In emergency departments around the country, many of the patients who show up needing help never get it — and leave before ever seeing a doctor. According to the General Accounting Office, leave-without-being-seen rates may be as high as 7 percent nationally, and some experts say individual hospitals may have an unexplained departure rate as high as 15 percent. For many patients, crowded ED departments have made the wait for a doctor simply too long to be endured. "There were increasingly long stays for a number of reasons," says Dr. Ted Chan, who works in the ED at the University of California, San Diego, Medical Center, where the average wait times for emergency patients hits two hours during peak demand periods. And it wasn't possible just to expand the amount of space given to the department, either. Says Dr. Chan: "We were limited geographically." So Dr. Chan and his colleagues focused on improving the ED's processes instead. They published their results recently in the Annals of Emergency Medicine. "What we saw was that there were a number of redundant steps, where you had to queue up," says the emergency care doctor. And each step created a potential bottleneck. It might take 10 minutes to register when there was no backlog of patients, but 50 minutes if you were at the back of a line of five. And different snags in the process could multiply the waiting period. But Dr. Chan and his colleagues found some simple ways to cut out the queues. New information technology allowed incoming ER patients to be quickly identified and tagged with a bar code linked to a new medical record. Rather than try to create a full medical record, patients were directed to the nearest available emergency room bed immediately after they were triaged. And the system was changed to allow tests and other medical interventions to take place before a patient was fully registered in the hospital. For patients unable to find a bed, tests were begun immediately. And an extra technician was assigned to the ED during its busiest times in order to make sure that the tests could be completed more quickly. To make sure they were comparing apples to apples, Dr. Chan and his colleagues gathered data on emergency admissions in the first half of 2003 and then set up the new procedure for use in the first half of 2004. Despite a substantial increase in the numbers of incoming ER patients, to 3,112 per month in 2004, leave without being seen patients fell by 42 percent - to 823 of the 18,673 people who came looking for emergency care. "By combining computer systems integration and patient bar code tracking with staff cultural and process changes, we were able to improve our ED entry process for patients and eliminate duplicative and redundant processes," reported the ER group. "Patients were moved more quickly to open ED beds, and when beds were not available, care was initiated at triage with ancillary testing as indicated without the delay often associated with full patient registration. Our leave before being seen rate decreased by almost 50 percent, suggesting that relatively small improvements in wait times, length of stay, and the initiation of care processes at triage can have a large impact on this patient population." Changes are needed, says Dr. Chan. The problem has grown worse around the country as the number of uninsured in the country has swelled past the 45 million mark. "For a certain population," says Dr. Chan, "the ED is the provider of last resort." Dr. Chan noted that some physicians believe that leave without being seen rates may reflect a rough kind of triage in itself, with patients leaving because they don't really need the services of the ER. But Dr. Chan goes on to note a Los Angeles hospital with an 8.2 percent departure rate that found that almost half of those patients were in urgent need of an evaluation and that 29 percent needed care in the next 24 to 48 hours. More than a third of patients did come back and 11 percent required hospitalization. "It's hard to know exactly why they leave and why they stay," says Dr. Chan. "On the other hand, waiting eight hours to get into an ED isn't something you'd want to do."