Patient Satisfaction in the Emergency Department and the Use of Business Cards by Physicians

Background

Emergency departments (EDs) across the country become increasingly crowded. Methods to improve patient satisfaction are becoming increasingly important.

Objective

To determine if the use of business cards by emergency physicians improves patient satisfaction.

Methods

A prospective, convenience sample of ED patients were surveyed in a tertiary care, suburban teaching hospital. Inclusion criteria were limited to an understanding of written and spoken English. Excluded patients included those with altered mental status or too ill to complete a survey. Patients were assigned to receive a business card on alternate days in the ED from the treating physician(s) during their patient introductions. The business cards listed the physician’s name and position (resident or attending physician) and the institution name and phone number. Before hospital admission or discharge, a research assistant asked patients to complete a questionnaire regarding their ED visit to determine patient satisfaction.

Results

Three hundred-twenty patients were approached to complete the questionnaire and 259 patients (81%) completed it. Patient demographics were similar in both the business card and non-business-card groups. There were no statistically significant differences for patient responses to any of the study questions whether or not they received a business card during the physician introduction.

Conclusion

The use of business cards during physician introduction in the ED does not improve patient satisfaction.     

Emergency Department Patient Satisfaction: Examining the Role of Acuity

OBJECTIVES: To explore the relationships between patient acuity, perceived and actual throughput times, and emergency department (ED) patient satisfaction. The authors hypothesized that high-acuity patients would be the most satisfied with their throughput times, as well as the overall ED visit. The authors also expected overall ED satisfaction to be more strongly associated with perceived throughput times compared with actual throughput times, regardless of acuity. METHODS: This was a prospective survey of 1,865 ED patients at a large, inner-city hospital during a one-month period. Data were collected on patient demographics, acuity of patient illness, actual waiting time for evaluation by a physician, and actual overall length of stay. Patient satisfaction with various throughput times (i.e., perceived throughput time) and overall ED visit was assessed by using a seven-point scale (1 = poor, 7 = excellent). Analysis of variance, analysis of covariance (ANCOVA), and correlations were conducted to explore the hypotheses. RESULTS: Patients with "emergent" acuity perceived their throughput times more favorably and were more satisfied with their overall ED visit compared with "urgent" and "routine" patients (all p < 0.01). Once the effects of perceived throughput time were controlled for by using an ANCOVA, acuity no longer predicted overall ED satisfaction. Correlations showed that overall ED satisfaction was more closely linked to perceived throughput times than to actual throughput times (average r = 0.62 vs. -0.12). CONCLUSIONS: "Emergent" patients are more satisfied than "urgent" and "routine" patients with their ED visits. "Emergent" patients perceived their throughput times more favorably than other patients, especially their wait for physician evaluation. Changing perceptions of throughput times may yield larger improvements in satisfaction than decreasing actual throughput times, regardless of patient acuity.     

Predictors of Emergency Department Patient Satisfaction: Stability over 17 Months

OBJECTIVES: The contradictory findings reported in the emergency department (ED) patient satisfaction literature may be due to methodologic differences between studies, as well as actual differences in predictors. The authors examined the stability of predictors of ED patient satisfaction across multiple assessments over 17 months. METHODS: All patients who presented for emergency care to the authors' hospital during four designated time periods spanning 17 months were eligible. The participants were contacted by telephone and the following were assessed: demographics, visit characteristics, perceived waiting times, subjective quality of care indicators, and overall satisfaction. The authors computed logistic regressions to predict overall satisfaction for each of the four periods. They compared the results across the assessments, both visually and using an aggregated logistic regression, to determine the consistency of the final equations. Interpretations based on traditional p-value cut-offs and odds ratios (ORs) were compared. RESULTS: When using a p-value cut-off strategy of p < 0.05, notable discrepancies in the predictors of overall satisfaction were common. Six indicators, including age, perceived wait before bed placement, perceived wait before physician evaluation, physician care, discharge instructions, and waiting time satisfaction, were statistically associated with satisfaction for only one of the four assessments. In contrast, examining the size of the ORs associated with each predictor showed far fewer discrepancies. Only physician care appeared to have large differences in the strength of its relation to overall satisfaction. This trend was confirmed by the aggregated logistic regression analysis. CONCLUSIONS: Using p-value cut-offs as the sole criterion for interpreting which variables are most important in determining ED patient satisfaction is ill-advised, and may lead to spurious conclusions of discrepant findings. Nevertheless, some determinants of ED satisfaction likely differ meaningfully based on the cohort that is being examined. Overgeneralizing conclusions derived from a single ED patient satisfaction study should be avoided, especially those studies that are cross-sectional and use a single site.     

The Effect of Emergency Department Crowding on Patient Satisfaction for Admitted Patients

Objectives: The objective was to study the association between factors related to emergency department (ED) crowding and patient satisfaction. Methods: The authors performed a retrospective cohort study of all patients admitted through the ED who completed Press‐Ganey patient satisfaction surveys over a 2‐year period at a single academic center. Ordinal and binary logistic regression was used to study the association between validated ED crowding factors (such as hallway placement, waiting times, and boarding times) and patient satisfaction with both ED care and assessment of satisfaction with the overall hospitalization. Results: A total of 1,501 hospitalizations for 1,469 patients were studied. ED hallway use was broadly predictive of a lower likelihood of recommending the ED to others, lower overall ED satisfaction, and lower overall satisfaction with the hospitalization (p < 0.05). Prolonged ED boarding times and prolonged treatment times were also predictive of lower ED satisfaction and lower satisfaction with the overall hospitalization (p < 0.05). Measures of ED crowding and ED waiting times predicted ED satisfaction (p < 0.05), but were not predictive of satisfaction with the overall hospitalization. Conclusions: A poor ED service experience as measured by ED hallway use and prolonged boarding time after admission are adversely associated with ED satisfaction and predict lower satisfaction with the entire hospitalization. Efforts to decrease ED boarding and crowding might improve patient satisfaction.     

Incorporating Hourly Rounding to Increase Emergency Department Patient Satisfaction: A Quality Improvement Approach

ProblemPatient satisfaction is an important factor that influences the perceived quality of care delivered. In an effort to meet patient expectations, a process improvement initiative involving hourly rounding was implemented to improve low patient satisfaction scores.MethodsThis project took place over 23 months and consisted of 4 phases (baseline, intervention I, break, and intervention II). During the intervention phases, self-reported hourly rounding was tracked on a daily basis. Compliance with rounding and patient satisfaction results were provided to staff during unit meetings and were displayed on a visual tracker board. Weekly 5-minute customer service training was provided to all staff. During the baseline and break phases, hourly rounding was not tracked. However, patient satisfaction data were still collected through the Interactive Customer Evaluation system. Three variables were measured using a 5-point Likert scale: overall patient satisfaction, patient perception of staff attitude, and whether the health care team answered all patient questions/concerns.ResultsHourly rounding compliance was 39% during intervention I and 51% during intervention II. Approximately 0.01% of patients submitted satisfaction data. From baseline to conclusion of intervention II, overall patient satisfaction increased from 52% to 73%; perception of staff attitude increased from 70% to 84%; and whether the health care team answered all patient questions/concerns increased from 63% to 81%.DiscussionThere is a positive relationship between hourly rounding and patient satisfaction scores. Despite low compliance with hourly rounding, patient satisfaction increased for all 3 variables measured. To achieve a change in culture with hourly rounding compliance, nurse managers must consistently monitor staff compliance with hourly rounding.     

Patient Satisfaction in the Emergency Department—A Survey of Pediatric Patients and Their Parents

OBJECTIVES: To assess and compare overall satisfaction in pediatric emergency department (ED) patients and their accompanying parents. To identify aspects of health care delivery that influence satisfaction in these groups. METHODS: Pediatric patients (ages 5-17 years) and their parents (or guardians) seen at a university hospital pediatric ED were eligible. A convenience sample of English-speaking subject pairs (n = 101 pairs) was enrolled. Questionnaires were administered to both children and their parents at the completion of their ED care. The survey instruments used a modified Wong-Baker FACES Pain Rating Scale and a six-point interval scale. Factors measured included overall satisfaction, perceptions of pain and fear, and other characteristics of the ED visit. Data were analyzed using paired Wilcoxon signed-rank tests, Spearman rank correlation coefficients, and Fischer's exact chi-square tests (alpha = 0.05) where appropriate. RESULTS: Parent satisfaction was associated with the quality of provider-patient interactions (R = 0.54, p = 0.0001), the adequacy of information provided (R = 0.47, p = 0.0001), and shorter waiting room times (R = -0.24, p = 0.01). Child satisfaction was associated with the quality of provider-patient interactions (R = 0.24, p 0.04), adequacy of information provided (R = 0.51, p = 0.003), and resolution of pain (R = 0.25, p = 0.03). Parent estimates were similar to children's initial pain scores; however, children reported greater resolution of pain than appreciated by their parents (p = 0.006). CONCLUSIONS: Satisfaction can be validly and reliably measured in pediatric patients using a visual scale instrument. Factors that influence patient satisfaction were similar among both children and their parents. The influence of pain resolution on pediatric ED satisfaction is a novel finding, which demonstrates the importance of appropriate pain and anxiety assessment and treatment in children.     

Learning from Patient Safety Incidents in the Emergency Department: A Systematic Review

BackgroundPatient safety incidents are commonly observed in critical and high demanding care settings, including the emergency department. There is a need to understand what causes patient safety incidents in emergency departments and determine the implications for excellence in practice.ObjectiveOur aim was to systematically review the international literature on patient safety incidents in emergency departments and determine what can be learned from reported incidents to inform and improve practice.DiscussionPatient safety incidents in emergency departments have a number of recognized contributing factors. These can be used as groundwork for the development of effective tools to systematically identify incident risk. Participation in efforts to diminish risk and improve patient safety through appropriate incident reporting is critical for removing barriers to safe care.ConclusionsThis review enhances our awareness of contributing factors to patient safety incidents within emergency departments and encourages researchers from different disciplines to investigate the causes of practice errors and formulate safety improvement strategies.     

Where to Focus Efforts to Improve Overall Ratings of Care and Willingness to Return: The Case of Tuscan Emergency Departments

Objectives: Both regression and optimization models were used to identify an efficient combination of aspects of care (e.g., comfort of waiting room) necessary to improve global emergency department (ED) patient satisfaction. The approach, based on patient survey data, tends to favor aspects of care with large regression coefficients and those whose current performance is low, because improvements produce a greater effect on global satisfaction. Methods: The authors used ED patient satisfaction survey data collected between September and October 2007 from a random sample of 5,277 adult patients who visited 43 EDs in Tuscany, Italy. Ordinal logistic regression models were run to predict overall ratings of care and willingness to return using 20 independent variables (i.e., aspects of care). An optimization model was run to increase these two global items to a maximum of 15%. This model minimizes the total combined percentage increase of the aspects of care. Models using all cases (n = 5,277), cases from local hospitals (n = 4,264), and cases from teaching hospitals (n = 1,013) were run. Results: Four aspects selected by the optimization algorithm were in all models: “satisfaction with waiting time,”“comfort of the waiting room,”“professionalism of physicians” (technical skills), and “level of collaboration between physicians and nursing staff.” Most aspects needed a 15% increase to comply with the percentage increases set for the global satisfaction items. The model found that to increase overall ratings of care by 1, 2, or 8%, hospitals would need to focus only on one aspect: “level of collaboration between physicians and nursing staff.” The total number of variables increased to six when the improvement in overall ratings of care was set at 15%. To increase 3 or 5% willingness to return, the optimization algorithm found that 6 or 14 aspects, respectively, are needed. An increase of 6% or more was unfeasible. Conclusions: This approach is only somewhat efficient, as a cost structure is absent. The optimization model assumes that the cost to increase each aspect by 1% is equivalent. By applying this modeling technique we have demonstrated that, at least, two elements are important to consider when developing efficient improvement strategies to increase global satisfaction: 1) the current level of satisfaction of the aspects of care and 2) the importance ascribed to the aspects of care. A third element, the cost to increase the aspects of care, might also be important. However, the impact of this element on the optimal solution is currently unknown.     

A Method for Assessing Emergency Department Performance Using Patient Outcomes

Abstract. Objective:TO determine the rates of correct patient disposition after an ED evaluation.
Methods:In a university pediatric hospital, a 25% random sample of ED patients for 4 consecutive months was reviewed, after exclusion of minor injuries and patients triaged to the nonurgent clinic. Patients were categorized into one of 4 outcomes on the basis of inpatient resource use: appropriate admission, inappropriate admission, appropriate release, or inappropriate release. A 10% random sample of released patients was contacted by telephone to detect patients who sought care elsewhere after ED release.
Results:642 of 2,682 ED patients (23.9%) were admitted; 159 (24.7%) were inappropriately admitted, and 26 (1.3%) were inappropriately released. The correct identification of the need for hospitalization (sensitivity) was 94.9%, and for release (specificity) 92.7%. Overall, the correct classification rate was 93.1%. Inappropriate admissions were associated with diagnoses of trauma, seizures, and burns.
Conclusion:Inappropriate admissions occur at a substantial rate and occur more commonly than inappropriate releases. The correct disposition of patients is a practical and meaningful outcome-based measure of the quality of ED care. This methodology is suitable for use in other EDs.     

Hourly Rounding in the Pediatric Emergency Department: Patient and Family Safety and Satisfaction Rounds

Background

Methods of increasing patient and family involvement in and understanding of their medical care are plentiful, and hourly rounding specifically has shown benefit in several clinical settings. Although the approach has shown a variety of advantages in other areas, its use in urgent care pediatric settings is not well described.

Objectives

This study evaluates the institution of patient satisfaction and safety rounding (“hourly rounding”) in the pediatric emergency department (ED) setting.

Methods

Hourly rounding was instituted in a tertiary care, urban pediatric ED using a formal mnemonic, after staff education, training, and observation to ensure standardization of approach. Pre- and postintervention data were collected, including frequency and type of nursing call bell usage, family discharge opinion survey, and vendor-collected survey results.

Results

Two weeks of nursing call bell activation data and 200 pre- and postintervention family discharge opinion surveys were collected, evenly divided between pre- and postimplementation data. Call bell activations prior to and after hourly rounding institution were 102 and 150 respectively, with accidental activations comprising the majority. Additionally, vendor-collected patient satisfaction data were analyzed. There were no changes in patient scoring when pre- and postimplementation data were compared.

Conclusions

This model of hourly rounding shows no measurable improvement in patient satisfaction or provider–patient communication using call bell data, family discharge opinion surveys, or vendor-collected patient satisfaction data. Further studies may be indicated to identify different methods of analyzing the effects of this method, and to examine alternative methods of improving these outcomes in the pediatric ED setting.     

The Impact of a Brief Expectation Survey on Parental Satisfaction in the Pediatric Emergency Department

Objectives
To determine the effect of physician knowledge of parental expectations on satisfaction with emergency department (ED) care.
Methods
This was a prospective, controlled, interventional trial involving parents of children presenting to a children's hospital ED. Parents completed an expectation survey on arrival, which was either immediately placed back in the enrollment envelope (control) or shown to the physician caring for the child (intervention). The physician was instructed to initial the expectation survey to acknowledge receipt of the survey. Parents then completed a satisfaction survey at discharge. The primary outcomes were differences in satisfaction with physician review of the expectation survey, as measured by 1) parental ratings of overall care and 2) their willingness to recommend the ED to others. A third (baseline) group completed only a satisfaction survey at discharge.
Results
A total of 614 (66%) of the 930 enrolled parents completed the study. Intention-to-treat analysis did not show a significant increase in parental satisfaction ratings for either overall care or recommend the ED; however, only 42% of the intervention group surveys had documented physician review. When these initialed surveys were compared with the control group in a per-protocol analysis, there was a significant improvement in parental satisfaction. There were no differences between the control and baseline groups, indicating no effect of the expectation survey completion on satisfaction.
Conclusions
Physician knowledge of written parental expectations may improve parental satisfaction during an ED visit. Further work is needed to overcome the barriers to physician review of the expectation survey to maximize parent satisfaction.     

The Intubating Laryngeal Mask Airway: Suggestions for Use in the Emergency Department

With the increased use of rapid-sequence induction and its potential complications, emergency physicians need a rescue device for unexpected difficult intubations. The intubating laryngeal mask airway (ILMA) is an ideal rescue airway since it can be placed quickly and can provide adequate ventilation in nearly all patients. It can then be used as conduit for endotracheal intubation, while ventilation is ongoing. The authors review the current literature on the ILMA. In conjunction with their experience using the ILMA in the emergency department (ED), a modification of the American Society of Anesthesiologists difficult airway algorithm was derived for use in the ED. The ILMA appears to be valuable for managing difficult airways.     

Point-of-Care Ultrasound to Diagnose Colitis in the Emergency Department: A Case Series and Review of the Literature

BackgroundColitis refers to an inflammatory process of the colon, composed of a variety of different etiologies including inflammatory bowel disease, infectious colitis, ischemic colitis, and allergic colitis. Usually, abdominal computed tomography (CT) is the gold standard in diagnosing the various forms of colitis. However, by the use of point-of-care ultrasound (POCUS), one may occasionally be able to discern wall thickening, pericolic fluid, and adjacent hyperechoic mesenteric fat. One may also see abscesses, fistulae, or ascites.Case SeriesThis is a series of 6 patients who had findings consistent with colitis seen on POCUS performed by an emergency physician. These were confirmed by abdominal CT with contrast. Early detection by POCUS was able to lead to a rapid diagnosis and to expedite treatment.Why Should an Emergency Physician Be Aware of This?The ability to detect findings of colitis by POCUS can be quickly learned by the emergency physician with a strong background in basic ultrasound. For many of the different subtypes of colitis, the initial treatment in the emergency department is the same: i.v. antibiotics, i.v. fluids, and “bowel rest” by maintaining the patient in nothing-by-mouth status. For the stable patient with high clinical suspicion of an infectious etiology of colitis, ultrasound can help confirm the diagnosis and rule out other etiologies. This may be especially important in certain populations such as children and young women, where one can avoid a significant amount of radiation being directed toward the pelvic area.     

The Impact of Post-discharge Patient Call Back on Patient Satisfaction in Two Academic Emergency Departments

Background

Patients’ satisfaction is a common parameter tracked by health care systems and Emergency Departments (EDs).

Objectives

To determine whether telephone calls by health care providers to patients after discharge from the ED was associated with improved patient satisfaction.

Methods

Retrospective analysis of Press Ganey (PG; Press Ganey Associates, South Bend, IN) surveys from two EDs operated by the University of California San Diego Health System. Responses to the YES/NO question, “After discharge, did you receive a phone call from an ED staff member?” was compared to the responses to the question “likelihood of recommending this ED to others” (LR). This variable could be ranked with a score of 1 (very poor) to 5 (very good). Responses were dichotomized into two groups, 1–4 and 5. Chi-squared was performed to assess LR between those answering YES vs. NO to the call back question. Differences in proportion, 95% confidence interval (CI), and p-value are reported. Rankings for percentage of 5s across all EDs in the PG database were compared based upon YES/NO responses.

Results

In the 12-month study period, about 30,000 surveys were mailed and 2250 (7.5%) were returned. Three hundred forty-seven (15.4%) checked off YES for the call back question. Percentage of 5s for LR for NO call back was 51.1% and for YES call back was 70.6% (difference = 19.5; 95% CI 14.0–24.6; p < 0.001).These values correlated with an ED ranking of 14^th and 85^th percentile, respectively.

Conclusion

This retrospective study demonstrated a strong association between post-visit patient call back and LR. Further prospective study with control for co-variables is warranted.     

The Relationship Between Mindfulness,Triage Accuracy,and Patient Satisfaction in the Emergency Department: A Moderation-Mediation Model

IntroductionIndividual and collective mindfulness attracts growing research attention, yet reports of their impact on health care professionals’ work behaviors are scarce, especially in the emergency department. The aim of the current study was to explore whether the association between trait mindfulness and triage accuracy is moderated by the emergency workload environment, and whether this association promotes patient satisfaction subject to levels of collective mindfulness.MethodsA prospective consecutive nested design was conducted. Data were collected from ED teams (nurses and physicians, N = 96) on individual characteristics and trait mindfulness. Data were also collected on triage accuracy, triage team characteristics, collective mindfulness, workload, and patient satisfaction (N = 960) at a specific patient–ED team encounter.ResultsFindings indicated that ED workload environment (b = 0.24, P < 0.01), trait mindfulness (b = 1.80, P < 0.01), and their interaction (b = −0.04, P < 0.05) were associated with triage accuracy. Triage accuracy (b = 1.81, P < 0.001), collective mindfulness (b = 1.29, P < 0.001), and their interaction (b = −0.32, P < 0.001) were associated with patient satisfaction. The moderated-mediation model was significant under high, but not under extreme, levels of ED workload environment and all levels of collective mindfulness.DiscussionTrait and collective mindfulness are relevant to ED triage and patient satisfaction, but their effects are bounded by workload. The beneficial gain of nurses’ trait mindfulness on triage accuracy and collective mindfulness on patient satisfaction is demonstrated only under high-workload environments but limited under extreme-workload environments.     

External Causes of Pediatric Injury-related Emergency Department Visits in the United States

OBJECTIVES: To characterize the types and external causes of pediatric injury-related visits (IRVs) to emergency departments (EDs), in particular, sports-related injuries. To compare the characteristics of children with IRVs with those with non-IRVs, specifically, differences in IRV rates by race and ethnicity and by health insurance. METHODS: This was a stratified random-sample survey of EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS), including all IRVs for patients less than 19 years of age in 1998 (n = 2,656). National estimates of pediatric IRVs were obtained using the assigned patient visit weights in the NHAMCS databases and SUDAAN analyses. Measures of association between predictor variables (patient and health insurance characteristics) and whether a child had an IRV were calculated using multivariate logistic regression analyses to determine adjusted odds ratios with 95% confidence intervals. RESULTS: Pediatric IRVs accounted for more than 11 million ED visits annually. The most common diagnoses for IRVs were open wounds, contusions, sprains and strains, and fractures and dislocations. The leading external causes of IRVs were sports-related injuries, accidental falls, being struck by objects, and motor vehicle collisions. Children with IRVs differed from those who presented for non-IRVs in many characteristics: they were more likely to be male, to be older, to be of white race, and to have private insurance, and less likely to be of Asian or Hispanic ethnicity. CONCLUSIONS: Sports and recreation are the leading external causes of pediatric IRVs to EDs in the United States. There are different patterns of IRVs according to gender, age, race, ethnicity, and insurance. Identification of specific patterns of injury is necessary for the design of effective prevention strategies.