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The aim of this study was to examine the effectiveness of the seamless model of management on the quality of care for emergency department (ED) patients. This was a pre- and postintervention study of comparing post intervention data with the baseline on several variables of interest. The intervention was the seamless model of ED management, designed and implemented as a response to the challenge of increasing work load at the ED. Information on patients' waiting times, critical care performance, patients' satisfaction and staff morale was collected at baseline and postintervention for comparison. The results indicated significant improvements on all outcome measures were found postintervention. The average waiting time reduced by 40%, from 92.1 to 55.3 min, as well as the time to craniotomy from 120 to 45 min for more severe patients. Complaints from patients were reduced by 80% and staff morale had improved with a 48% reduction in sick days and a 80% reduction in staff resignations. Ambulatory patients presenting to the department saw a 20% improvement in their waiting time. We report a successful restructuring process that used routinely collected clinical and administrative data to highlight problems. Using these data and through a systematic planning process, appropriate strategies for restructuring were developed by emergency staff in partnership with the hospital executive. Significant improvements in waiting time and patient care were clearly demonstrated.

Objective: To investigate the characteristics and outcomes of patients who walked out from a tertiary children's hospital emergency department (ED) without seeing a medical officer. Methods: A prospective study of patients who walked-out from the ED of a children's hospital, without seeing a medical officer. Information collected at triage included demographics, presenting problems, time of arrival, time of departure and reason for leaving. Charts were reviewed and those at high risk of serious illness or adverse outcome were contacted by telephone within 24 h. Further information collected during follow up included outcome, such as adverse events and admission to hospital. Data were analysed by comparing the walk-out and non-walk-out groups with regard to demographic variables, presenting problems and outcomes. Results: Over a 29 week period, 1037 (5.5%) patients walked out from the ED of the hospital without seeing a medical officer. Comparisons between the walk-out and non-walk-out patients indicated no differences in terms of demographics. However, significant differences were found between the triage categories, presenting problems and arrival time. Of these, 829 (79.9%) were followed up by telephone. This revealed the predominant presenting problem was non-urgent and infectious in nature and no adverse events occurred. The admission rate for walk-out patients (1.5%) was significantly lower in comparison with the non-walk-out group (6.9%; odds ratio 0.2; 95% confidence interval 0.1–0.3). Walk-out patients who were eventually hospitalized had a shorter mean length of stay than non-walk-out patients (20.4 vs 34.8 h, respectively; t = 17.78, P < 0.0001). Conclusions: Medical resources are limited and, therefore, some extended waiting in the ED is necessary. Paediatric patients who walk-out of the ED without seeing a medical officer have simple illnesses that resolve without medical intervention or adverse events.