Here’s a magic trick for you: How do you improve emergency department (ED) wait-time metrics while simultaneously seeing fewer patients? Simple. You wait until they leave, then don’t count them.
Recently, I wrote about euphemisms used in health care to downplay systemic failure. Let’s take a closer look at one of those: Left Without Being Seen (LWBS) – the statistical escape hatch that’s become Canadian emergency medicine’s dirtiest little secret.
The vanishing act
Let’s start with the raw numbers, because they’re genuinely breathtaking.
In 2018-19, British Columbia recorded 76,157 LWBS patients. By 2024-25? That number hit 141,961 – an 86 per cent increase in just seven years. To put that in perspective, B.C.’s population grew by roughly 11 per cent during the same period, meaning LWBS rates increased nearly eight times faster than population growth.
For context, pre-pandemic LWBS rates varied by hospital type: academic/teaching EDs averaged 3.7 per cent, regional EDs 3.4 per cent, and urban EDs 3.2 per cent. Those rates now look quaint.
Quebec managed an astounding 11.5 per cent LWBS rate in 2024-25, representing 428,676 people who walked out of EDs. Across the country, LWBS rates ranged between 4.9 per cent (Ontario) and 14 per cent (P.E.I).
But here’s where it gets interesting. These patients vanish from our performance metrics entirely. They don’t count against “time to physician initial assessment” targets. They actually improve the statistics.
Can’t meet your wait time benchmarks? No problem. Just wait a little longer. Eventually, the problem walks itself out the door.
‘Don’t worry, it’s just people with colds’
The standard reassurance has always been that LWBS patients are low-acuity – people with sniffles who got impatient. Minor stuff.
The data says otherwise.
According to the Canadian Triage and Acuity Scale (CTAS), patients are categorized from Level 1 (resuscitation – you’re dying right now) to Level 5 (non-urgent – maybe you shouldn’t be here). CTAS 2 patients are classified as “emergent” – think heart attacks, strokes, severe trauma (technically referred to as “a potential threat to life or limb”). Yet, 7 per cent of CTAS 2 patients leave without being seen – the very patients we built emergency departments to serve. For CTAS 3 (urgent) patients, 8.7 percent are gone. These aren’t people with hangnails. These are genuine emergencies, and nearly one in 10 are walking out before anyone sees them.
But sure, let’s keep pretending this is a patient behaviour problem rather than a system collapse.
The death study
In December 2024, ICES Ontario published a study that should have triggered alarm bells across every health ministry in the country. It didn’t.
Researchers compared the outcomes of Ontario adults who left emergency departments without being seen (LWBS) in 2022-23 to those from 2014-2020. Same behaviour (leaving), different time periods. The question: Are outcomes getting worse?
Answer: Yes. Significantly.
Patients who left without being seen in 2022-23 had:
- 14 per cent higher risk of death or hospitalization within seven days compared to pre-pandemic LWBS patients
- 5 per cent higher risk at 30 days.
Let that sink in. We’re not comparing LWBS patients to patients who stayed and got care. We’re comparing recent LWBS patients to earlier LWBS patients. The same action – leaving – now carries substantially higher risk of death or hospitalization within a week.
The patient profile? Median age 41; few prior hospitalizations. These aren’t frequent flyers gaming the system. These are healthy people having actual emergencies who gave up and left.
The math game
Let’s say the target is to see 90 per cent of patients within a benchmark time. Here’s how the trick works in practice:
Scenario A: 100 patients arrive. You see 85 within target. Performance: 85 per cent. FAIL.
Scenario B: 100 patients arrive. 10 leave without being seen. You see 75 of the remaining 90 within target. Performance: 83 per cent. FAIL.
Scenario C: 100 patients arrive. 20 leave without being seen. You see 72 of the remaining 80 within target. Performance: 90 per cent. SUCCESS!
Same hospital. Same staffing. Fewer patients actually seen. Better metrics.
The sicker the system gets, the more patients leave, the better our statistics look.
The sicker the system gets, the more patients leave, the better our statistics look. We’ve created a performance indicator that rewards failure.
Hospital boards and Chief Executive Officers love seeing green dashboards and meeting targets – the inconvenient truth that people may be leaving amid chest pain and dying at rates 14 per cent higher gets statistically vaporized from existence.
We’ve invented a performance measurement system where the sicker it gets, the more patients abandon hope, the shinier our metrics become. It’s not a bug; it’s a feature with a body count.
The acceleration
Ontario’s LWBS rates tell the story of a system in freefall:
- Pre-pandemic peak: 4 per cent;
- 2020-2023: Exceeded 4 per cent in 42 per cent of months;
- 2022-2023: Exceeded 4 per cent in 75 per cent of months.
This isn’t a blip. It’s a trend. And it’s getting worse.
Vancouver Island saw LWBS patients increase from 11,513 in 2018-19 to 29,997 in 2024-25 – a staggering 160 per cent increase. These aren’t statistical anomalies. This is what system collapse looks like when you measure it honestly.
The normalization
The most disturbing aspect isn’t the numbers themselves – it’s how we talk about them. LWBS has been transformed from a crisis indicator into a routine operational metric. We track it like bed occupancy or hand hygiene compliance. Just another data point in the dashboard.
We’ve created entire categories of analysis: LWBS by time of day, by day of week, by triage level, by chief complaint. We study it. We trend it. We present it at conferences.
What we don’t do is treat it like what it actually is: systemic ED care failure.
When hospitals began systematically tracking LWBS around 2010, it was meant to identify problems. Instead, we normalized them. A 3.6 per cent national rate became the baseline. Then 5 per cent. Now we’re flirting with double digits in some provinces, and the response is . . . more tracking.
The disappeared
Here’s what we know: More than 1.2 million Canadians gave up on emergency care in 2022-23 alone. Some percentage of them – we don’t know exactly how many – will die or be hospitalized within a week, at rates 14 per cent higher than just a few years ago.
We don’t follow up with most of them. We don’t track their outcomes systematically. They leave; they disappear from our metrics; our performance numbers improve.
It’s brilliant, really. We’ve turned “we failed to provide care” into a statistical category that makes us look better.
As long as patients continue to cooperate and leave without being seen, the statistics stay green, the dashboards glow and hospital boards sleep soundly. The only request is that they have the decency to die somewhere else – preferably off-site, off-record and off the quarterly report.
Collapse in the parking lot if you must, just not in the waiting room where it becomes a data problem.
Excellent article but doesn’t mention the CDU patient times that “disappear” from the metrics if the patient is discharged. As ER physicians we’re allowed to put patients in a Clinical Decision Unit to await further testing such as troponins or CT scans, etc. If the patient is discharged, their time waiting in the cdu disappears. (can be up to 23 hours) If they are admitted, the time remains but if more than 20 % of cdu patients get admitted, you get penalized. Bizarre metrics begets bizarre behaviour.
Another great topic and extremely well written from Dr. Marotta.
As an allied Healthcare Professional it truly is difficult to see how healthcare has declined over that past 30 years. The focus of the organizations are truly number driven in all aspects of care with the “Do More in less time” and implement this without increasing staff. It seems that running like an assembly line has now turned into healthcare practices. I’m pretty sure all levels of healthcare professionals share similar feelings.
I feel the strain both sides of the fence, as a worker as well as a patient. So many things contribute to this pressure on Emergency departments, yet there are no blue skies imagined for the future. Family doctor shortage, Specialists overwhelmed, 2 year wait list, so as an individual that needs care with things that are typically “Not high level Emergencies” are now presenting in Emergency. Then the domino effect comes into place. Last resort is to go to Emergency for some sort of care, wait and wait and wait, then become one of these LWBS statistics. I’m certain that there is a high percentage of patients out there that feel this exact way. The outlook is dismal.
Typically, Emergency means just that, a serious, unexpected, and often dangerous situation requiring immediate action. However, this doesn’t mean that certain symptoms other than those that meet the eye aren’t also Emergency. Yet here we are bursting at the seams and hiding metrics instead of dealing with the problem that affects so many people. The entire system is broken when “numbers” with false statistics (or should I say creative interpretation) is more important than what Healthcare is for: Providing Care to people.
The only way to improve at this point, in my opinion, is to have the Good, the Bad and the Ugly approach. Assess them all, INCLUDE them all and start fixing. STAT !!!
You’ve really hit on something important here—that moral injury healthcare workers feel when they can’t provide the care they know patients deserve. That gap between what you’re trained to do and what the system allows creates a real ethical wound. It affects everyone: providers who are trying their best and patients who aren’t getting what they need. Naming this disconnect honestly might be the first step toward actually fixing things. RM
Another excellent article by Dr.Marotta shedding light on critical issues in healthcare purposely kept out of the spotlight.It is shameful the administrators of medicine play the ‘smoke & mirrors’ tactic to conceal data that casts a negative shadow on their management of healthcare that has dangerous consequences on patient outcomes.Perhaps there needs to be more transparency revealing these administrative
metrics. As a cardiologist for over 35 years, it deeply concerns me that patients with high risk cardiovascular disease leave the emergency room before being assessed because of system deficiencies and do not receive the acute care they deserve and have paid for with their tax dollars.This can only result in increased morbidity and mortality for this patient cohort.
Thank you for your comments as a cardiologist. It must be alarming to know that CTAS 2 and 3 patients are leaving the emergency department – 7% of CTAS 2 (emergent) patients and 8.7% of CTAS 3 (urgent) patients leave without being seen. These are the very patients who would ultimately benefit from your care and expertise. Some of them end up dying. Some come back with greater morbidity.
RM
Another great piece that throws some much-needed light on an under-recognized and (even when it is recognized) often misunderstood problem.
I especially appreciated the point that not many of those who leave without being seen are in level 5, i.e., people who don’t need emergency care and, in the view of many, shouldn’t be there. Why most of those who are in level 5 show up in emergency departments (EDs) is worth its own article. It’s clear to me (given the many problems with access to primary care, especially at certain times, on particular days, e.g., Sundays, and in many areas) that no more than a tiny number of people in level 5 go to EDs because they are attention-seekers who have nothing better to do.
What strikes me every time I am in an ED either as a patient or a caregiver is how needlessly opaque the system is and how much might be gained by making it a whole lot less opaque through sharing certain information with patients and caregivers who may never be in another situation where they are as eager to be informed. Begin by telling people at triage what the initial assessment of their condition is or means, what the different levels are, how being placed in one level or another will determine where they will be sent, how long–at least roughly–they are likely to wait to be seen by a doctor (or another nurse), whether or how they will be monitored, and what to do if their condition seems to be worsening. And especially in light of the data cited by Dr. Marotta, patients and caregivers should be informed about the risks of leaving without being seen by someone other than the triage nurse. Will this unnecessarily or dangerously frighten patients? Not very likely if the person providing the information is skilled at doing so. Those who go to EDs are almost always already worried.
Once inside the gates of the ED, patients often wonder why things are taking so long. Is it because certain lab results take extra time or because there is only one radiologist rather than the usual two, or because many ED staff have been required to treat people seriously injured in a large car crash, because many nurses or technicians are off work because of sickness, or because tight budgets mean there are never enough physicians, or nurses or … ? It’s very easy when sitting in an uncomfortable chair or lying on a bed by oneself in a treatment room for one, two, three, or four hours to begin to feel that one has been forgotten or regarded as “low priority.” I have discovered from reading over reports of my ED “visit” that, sometimes at least, a great deal was happening “behind the scenes”: urine and blood test results being reviewed, images being examined in great detail, conversations happening between specialists about my condition, etc. But while I was in the ED all I heard (after pushing the call button and waiting for the nurse) was that the doctor would be by “pretty soon, we hope.”
Patients, caregivers, and members of the public generally would be much better able to advocate for-change if they knew more about why things are the way they are. In the absence of accurate information candidly shared, misinformation and false assumptions flourish. I suspect that replacing opacity with transparency would result in fewer people leaving EDs without being seen and maybe some real efforts to address the problems that are now, it seems, being so cynically camouflaged.
Thank you so much for taking the time to share such a thoughtful and candid response. Your firsthand observations as both a patient and caregiver add an essential perspective that data alone can’t capture, and I’m grateful you’ve articulated these experiences so clearly.
You’re absolutely right that transparency and communication represent significant failures in how we deliver emergency care. The opacity you describe – patients left wondering, waiting, and often assuming the worst – is both unnecessary and harmful. Your point about people being most receptive to information precisely when they’re most anxious is particularly astute. We miss a critical opportunity every time we fail to explain triage levels, expected wait times, and the risks of leaving.
That said, while better communication would undoubtedly improve the patient experience and might reduce some LWBS cases, I worry we risk mistaking a symptom for the disease. The core issue isn’t that we’re failing to explain the system adequately – it’s that the system itself is fundamentally broken.
We could achieve perfect transparency tomorrow – every patient fully informed about their triage level, every delay explained, every behind-the-scenes activity communicated – and we’d still have 141,961 people walking out of B.C. emergency departments. We’d still have CTAS 2 patients leaving before being seen. We’d still have that 14% increased risk of death or hospitalization within seven days.
The brutal truth is that no amount of better communication fixes insufficient capacity, inadequate staffing, or a healthcare structure that’s collapsing under its own weight. Small tweaks – improved signage, better triage explanations, wait-time boards – might smooth some rough edges, but they won’t address the systemic failure that’s causing people to abandon emergency care in record numbers.
We need both, of course. Patients deserve transparency and communication as basic standards of care. But we can’t let those achievable improvements distract from the much harder conversation about fundamental structural reform.
Thank you again for sharing your insights – they’re a valuable reminder that behind every statistic is a human being trying to navigate an increasingly impossible system.
RM