BEYOND THE WAIT - DETERMINANTS OF PATIENT SATISFACTION IN THE EMERGENCY DEPARTMENT.

 

An ED visit often represents the patient’s initial experience with a hospital system and thus a unique opportunity to establish a positive first impression. However, these visits frequently occur during times of stress and uncertainty for the patient and in an ED care environment that faces a myriad of challenges. Overcrowding, inadequate communication, a lack of patient privacy, poor pain control, and uncomfortable ED environments all continue to be issues that impact patients’ experiences of care and as a result remain areas of focus for ED leaders1,2,3,4,5. These deficiencies not only lead to unsatisfactory experiences for ED patients but have important downstream effects as well. The frequency of both patient complaints and lawsuits was related to factors that strongly influence the patient experience; time spent with patients by physicians, the perception of concern about patients’ questions, and physician courtesy were all strongly associated. Subsequent work has also demonstrated that patients’ ratings of their health care correlate more strongly with experience factors rather than with technical quality of care 6, 7.

 

Hospital administrators have come to accept the ED as the “front door to the hospital” and expect their emergency physicians and ED staff to take the issue of patient satisfaction seriously. Increasingly, emergency medicine consultant contracts are mandating that certain levels of patient satisfaction be met in order to retain the contract. Related benefits may include improved morale and job satisfaction in the ED, a reduced tendency for patients to seek further opinions, and a reduced incidence of complaints and litigation. There is also evidence of improved patient compliance 8,9,10. Beyond patient outcomes and malpractice risk, there also exists growing financial implications of poor patient experience in the ED. The development and deployment by the Centers for Medicare and Medicaid Services (CMS) of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey in 2006 has led to an increased emphasis on patient experience within inpatient medicine. Some of the 27 items comprising the survey being physician and nursing communication, responsiveness/attentiveness, adequacy of pain management, and hospital environmental factors. Starting in 2017, HCAHPS total performance scores were tied to a 2% incentive or penalty for Medicare reimbursement. Patient experience with emergency department care is a rapidly expanding area of research and focus for health-care leaders, and recent literature has demonstrated a strong correlation between high overall patient experience and improved patient outcomes, profitability, and other health-care system goals 11, 12, 13.

 

Since that time, the regulatory environment and systems of ED care have also evolved, leading to potentially new areas of focus and themes related to ED patient experience. With the corporate healthcare industry booming in India, not only as the gold standard of advanced super specialty care but also as the go-to destination for primary care needs owing to an ever-growing patient population falling under insurance coverage, determining factors which improve ED patient satisfaction is important towards improving ongoing care in ED, outcomes post ED disposition whilst also ensuring growth in revenue from the ED for the hospital. Hence, the aim of the study is to understand how wait times in the ED perform against structured emergency medicine care, the endpoint being overall patient satisfaction; whilst identifying emergency department processes of care and aspects of treatment dispensed by emergency medicine specialists and nurses associated with patient satisfaction.

Study Design and Setting

This cross-sectional study was conducted in the Department of Emergency Medicine of a tertiary care hospital in Delhi NCR. The study aimed to assess the selected study variables among patients presenting to the Emergency Department (ED) during the study period.

 

Study Duration

The study was carried out over a period of six months.

 

Sample Size and Sampling Technique

A total of 250 patients were included in the study. Participants were selected using a convenience sampling technique based on their availability and eligibility during the study period.

 

Study Population

The study population comprised adult patients attending the Emergency Department of the tertiary care hospital during the study period of six months.

 

Data Collection

Data were collected using a structured digital questionnaire administered to eligible participants after obtaining informed consent. The questionnaire was designed to capture relevant demographic and study-related information. Primary data were obtained directly from participants, while secondary data were gathered through a review of published literature from peer-reviewed journals, scientific databases, and relevant academic sources.

 

Inclusion Criteria

Participants meeting the following criteria were included in the study:

•              Age 18 years or older.

•              Patients presenting to the Emergency Department during the study period.

•              Willing and able to provide informed consent.

 

Exclusion Criteria

Participants meeting any of the following criteria were excluded from the study:

•              Age below 18 years.

•              Patients unwilling or unable to provide informed consent.

•              Patients referred from other healthcare facilities with prior intimation for higher-centre care.

 

Ethical Considerations

The study was conducted in accordance with the ethical principles outlined in the Indian Council of Medical Research (ICMR) guidelines. Written informed consent was obtained from all participants, and confidentiality and anonymity of the collected data were maintained throughout the study.

A. Demographics

The survey was completed by 250 patients. The sample was predominantly male (77.6%) with a mean age of 33.97 years (SD ± 9.06).

 

Table 1. Gender

 

Table 2. Groups

 

Table 3. Going to the Emergency Department

 

60.8% of patients presented with a new health problem, 25.6% had an accident or injury, and 13.6% had an ongoing health condition. 84.8% of patients arrived by ambulance. 40% of patients waited more than 20 minutes before being spoken to.

 

 

 

 

 

Table 4. During the Emergency Department Visit

 

 

Table 5. People Who Took Care of You

 

56% of patients felt nurses always treated them with courtesy and respect; 83% felt nursing staff were always or usually attentive. 88% felt nursing staff almost always or usually explained things clearly. For doctors, 70.8% of patients felt doctors always listened carefully — the highest single positive rating in this section.

 

Table 6. Leaving the Emergency Department

Table 7. Overall Experience

 

80% of patients rated their care 7–9 out of 10 (mean 6.96). 90% of respondents would probably or definitely recommend this ED to friends and family.

 

Table 8. Your Health Care

85.2% of patients use this ED as their primary contact point for all healthcare needs including primary, emergency and specialty care.

 

Table 9. About You

 

62.8% of patients rated their physical health as excellent and 66.4% rated their mental/emotional health as excellent. 49.6% of respondents had some college or a 2-year degree, and 28% had a 4-year college degree.

The study aimed to understand how wait times in ED perform against structured emergency medicine care, the endpoint being overall patient satisfaction; whilst identifying emergency department processes of care and aspects of treatment dispensed by emergency medicine specialists & nurses associated with patient satisfaction. The study was performed on 250 consenting patients at the Department of Emergency Medicine & Urgent Care located in Delhi NCR, India. The relevant data collected from the study subjects were recorded and analyzed. Principal findings of the study are discussed below with reference to studies for comparison & review.

 

Demographics

In the study it was found that the majority of the study subjects were male (77.6%). The mean age of the study subjects was 33.97±9.06 years. As per Aldaqal et al the average age of patients was 45.9 years, ranging from 15 to 83 years. In his study there was a strong relationship between the patient dissatisfaction and patient’s age (P value: 0.003), gender (P value: 0.001, with more female satisfaction) 14.Sun et al e determined that greater age predicted higher patient satisfaction, whereas all other variables correlated with lower patient satisfaction. It was found that the majority of the study subjects were male (67.4%). The mean age of the study subjects was 38 years 15. Messina et al in their study reported that majority of the study subjects belonged to age group 40-49 years with a majority of male study subjects (54.9%) 16. The mean age was 46.8±19.8 years, and 187 (62.3%) were female 17. In a review by Morgan et al., one of the factors contributing to higher patient satisfaction was age (patient’s ≥65 years); other factors included race/ethnicity (Non-Hispanic Black and Hispanic patients), Medicare insurance, and having a medication ordered in the ED18. Similarly, Ammo et al. reported that among other factors, educational level and patient–provider interactions during episodes of care also influenced outcomes19. Naseer et al it found young age to be associated with higher patient satisfaction. Other factors being female gender, literacy and high social class - the few patient characteristics influencing level of patient satisfaction 20.

 

ED Waiting Time              

It was observed in the study that only 20% of patients had someone who attended to them within 10 mins whilst 80% of patients were attended to beyond the 10 minute mark with a half of them being attended to after 20 minutes post ED door time. Despite the majority of the patients being treated beyond the ED wait time mark of 10 minutes & 14% patients receiving medical attention only after 30 minutes post ED presentation, there appears to be no relation of this metric with scores of overall patient satisfaction in this particular study. Dinh conducted a study to describe the relationship between waiting time and patient satisfaction, and to determine predictors of overall care rating in an emergency department (ED) fast-track setting. Waiting time was hence, found to be highly predictive of patient satisfaction in an emergency fast-track unit 21. Damghi et al aimed to evaluate patient satisfaction with emergency care, and to determine associated factors with patient satisfaction. It was concluded that one of the most important variables associated with greater satisfaction with ED care was waiting time less than 15 minutes22. Aldaqal et al it was found that the lowest level of satisfaction was for the waiting time in the emergency 14. Further, Huang et al. concluded that managing waiting time perceptions and providing discharge instructions may improve patient satisfaction among frequent ED users23. Additionally, a systematic review by Taylor identified perceived waiting times, interpersonal skills/staff attitudes, and provision of information and explanation as the most frequently reported service factors24.

 

Interpersonal Skills – Attentiveness, Efficient Counselling and Courtesy

In our study, 92.8% patients were asked about their medication history and 90% patients were administered drugs during their ED stay. 90% patients were counselled and informed about the therapeutic indication, side effects profile of the drugs administered to them; 89.2% patients got a diagnostic procedure done - radiological or pathological or both. 90% patients were content with the counselling done while 10% patients felt that they didn’t receive adequate information as per their expectations. 56% patients felt that they were always treated with courtesy & respect by the nursing staff while 34% felt that it was usually the case. ~ 9% patients felt that the courtesy was minimal, infrequent or absent altogether a resounding 83% patients felt that the nursing staff were always or usually attentive to their concerns/ queries while 17% patients felt that the nursing staff were sometimes or even never attentive to the patient’s concerns or queries. 88% of patients felt that the nursing staff almost always or usually explained things to the patient in a way they could comprehend while 12% of patients felt that it was sometimes or even never the case. 58.4% patients felt that they were always treated with courtesy & respect by the doctors while 29.2% felt that it was usually the case. ~ 12.4% patients felt that the courtesy was minimal, infrequent or absent altogether.  A resounding 88.4% patients felt that the doctors were always or usually attentive to their concerns/ queries while 11.6% patients felt that the doctors were sometimes or even never attentive to the patient’s concerns or queries. 90% of patients felt that the doctors almost always or usually explained things to the patient in a way they could comprehend while 10% of patients felt that it was sometimes or even never the case.  79.6% patients were informed of their discharge medicine to be taken at home by the doctors or nurses or both whilst 20.4% were not. Of the 199 respondents who were told to take medications at home- 88.4% patients were explained the need for the same by doctors/nurses whilst 11.6% were not. Among the patients, 39.6% were informed about their follow-up care by doctors and/or nurses, 55.6% were partially informed, while 4.8% were not informed at all. Additionally, 93.6% of patients were given information on how to obtain follow-up care by doctors and/or nurses, whereas 6.4% were not provided with this information appropriately.57.2% patients were informed about symptoms or health problems to look for at home by the doctor and/or nurse; 34.8% patients were partially informed whilst 8% were not informed at all. In another study it was concluded that a patient's perception of his or her clinic experience is heavily influenced by the attentiveness and coordination of the entire clinic care team 25. As per the study by Ammo et al., patient satisfaction was assessed with services provided in inpatient health care settings in Lebanon. It was concluded that patient satisfaction with hospital care is significantly influenced by patient’s provider interactions during the episodes of care 19. Schoenfelder et al conducted a study to identify key determinants of patient satisfaction. The results of the analysis showed that there are 10 determinants of Global patient satisfaction. The outcome of treatment was overall, the most salient predictor followed by nursing kindness as the second most important component 26. In another study, Glickman et al. examined clinical data on 6467 patients and found that satisfaction with nursing care was the most important determinant of overall patient satisfaction (P<0.001)27. Toma et al it was found that overall satisfaction was strongly correlated with patient’s assessment of the physician’s interpersonal skills and was not correlated with whether the physician had met expectations about diagnostic and therapeutic interventions 28. The survey validates the importance of previously identified determinants of patient satisfaction, poor explanation of problem, poor explanation of test indications & results, and not told when to return to the ED / discharge advice 15.

 

Overall Satisfaction

In the present study patients have responded affirmatively to the dimensions regarding their overall experience in the emergency department. In the sample of 250 respondents - 10% patients rated a lowly 3-4, 10% rated 5-6 and 80% gave a high rating of 7-9 for ED care with a score of 10 being best ED care possible. Majority of the study subjects (80%) seemed to be highly satisfied with the emergency department care given to them. However, 20% of the study subjects were still not happy with the emergency care provided to them, signifying possible scope for improvement.

 

Dinh 236 patients completed surveys (response rate of 74%). Of these, 84% rated their care as either very good or excellent 21. Damghi et al Sixty six percent of participants were satisfied with overall care, and 69.8% would return to their ED. The findings of this study suggest that doctor and nurse care, communication, courtesy and effective counselling in the ED significantly impact the patient satisfaction22. Yardan in their study reported that overall satisfaction was significantly related to the doctor's explanation, the nurse's attitude, teamwork, and technical quality of care. In addition, likelihood of the patient's willingness to return was related to the patient's overall satisfaction. In this study showed that about half of the patients stated that they would recommend their institution ED to their friends and family. The likelihood that a patient will recommend a service offered by a hospital is also dependent on factors beyond the ED’s scope of practise, most important possibly being costs incurred during ED stay17.

 

Limitations of the Study

The cross-sectional design of the study limits the ability to establish causal relationships between the variables studied and patient satisfaction outcomes. The findings represent associations observed at a single point in time and should therefore be interpreted with caution.

 

The study was conducted in a specific emergency department setting, which may limit the generalizability of the findings to other healthcare facilities, regions, or populations with different demographic and healthcare characteristics.

 

The study population may not be fully representative of all patients attending the emergency department, thereby introducing the possibility of selection bias and limiting the external validity of the results.

 

Patients who were extremely dissatisfied with the care and treatment received were often unwilling to provide consent for participation or left the emergency department before completion of their treatment. Consequently, their views and experiences could not be captured within the study.

 

The exclusion of highly dissatisfied patients may have resulted in an overestimation of overall patient satisfaction and limited the identification of factors contributing to dissatisfaction with emergency department services.

As patient satisfaction was assessed through self-reported responses, the findings may be subject to response bias, recall bias, and social desirability bias, potentially influencing the accuracy of the reported perceptions.

 

FUTURE RESEARCH

The complex relationship between individual aspects of care and overall patient satisfaction suggests that studies conducted at a local level are unlikely to demonstrate substantial improvements in overall satisfaction. Nevertheless, the existing literature indicates specific areas that warrant attention and provides guidance regarding approaches that may be explored in future research.

 

Three interventions worthy of further investigation are:

1.             Identifying additional factors that influence interpersonal communication in the Emergency Department (ED) and developing strategies for their improvement. Evidence suggests that short training programs focused on enhancing empathy and strengthening rapport with patients can be highly effective in improving communication and patient satisfaction.

2.             Providing patients with more comprehensive information, effective counselling, and evidence-based explanations regarding their diagnosis, treatment, and expected outcomes.

3.             Understanding whether the costs of care incurred by patients in the ED play a role in determining overall patient satisfaction, beyond the core functions of the emergency department, namely the provision of effective diagnostic and therapeutic care.

Future research should evaluate the impact of these and similar interventions on patient satisfaction and quality of care in the Emergency Department.

The majority of patients reported high levels of overall satisfaction with emergency department care. Interpersonal factors such as communication, attentiveness, courtesy, and counselling were key determinants of patient satisfaction. Waiting time alone did not significantly influence overall satisfaction in this study, although it remains an important factor in other studies. Gaps were identified in follow-up communication, discharge instructions, and patient awareness regarding post-Emergency department care. A patient-centered approach, along with improved communication and streamlined processes, is essential for enhancing patient satisfaction.

 

The present study demonstrates that patient satisfaction in the Emergency Department is multifactorial, with greater emphasis on the quality of interpersonal interactions and effective communication rather than operational factors alone. Although most patients expressed satisfaction with the care received, deficiencies in follow-up guidance and discharge-related communication highlight areas requiring targeted improvement.

 

Overall, strengthening patient–provider communication, enhancing counselling practices, and optimizing patient flow can significantly improve patient perceptions of care. The adoption of structured, patient-centered strategies is likely to result in improved satisfaction outcomes and a higher overall quality of emergency healthcare delivery.

1.       Welch SJ. Twenty years of patient satisfaction research applied to the emergency department: a qualitative review. American Journal of Medical Quality. 2010 Jan;25(1):64-72.

2.       Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Academic Emergency Medicine.2008Sep;15(9):825-31.

3.       Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, McCarthy M, John McConnell K, Pines JM, Rathlev N, Schafermeyer R. The effect of emergency department crowding on clinically oriented outcomes. Academic Emergency Medicine. 2009 Jan;16(1):1-0.

4.       Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Annals of emergency medicine. 1996 Dec 1;28(6):657-65.

5.       Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. The American journal of medicine. 2005 Oct 1;118(10):1126-33.

6.       Nairn S, Whotton E, Marshal C, Roberts M, Swann G. The patient experience in emergency departments: a review of the literature. Accident and emergency nursing. 2004 Jul1;12(3):159-65.

7.       Chang JT, Hays RD, Shekelle PG, MacLean CH, Solomon DH, Reuben DB, Roth CP, Kamberg CJ, Adams J, Young RT, Wenger NS. Patients' global ratings of their health care are not associated with the technical quality of their care. Annals of Internal Medicine.

8.       Thomas EJ, Burstin HR, O'Neil AC, Orav EJ, Brennan TA. Patient noncompliance with medical advice after the emergency department visit. Annals of emergency medicine. 1996 Jan 1;27(1):49-55.

9.       Murray MJ, LeBlanc CH. Clinic follow-up from the emergency department: do patients show up?. Annals of emergency medicine. 1996 Jan 1;27(1):56-8.

10.    Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D, Smee S, Eguale T, Winslade N, Girard N, Bartman I. Influence of physicians' management and communication ability on patients' persistence with antihypertensive medication. Archives of internal medicine.2010Jun28;170(12):1064-72.

11.    Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians' empathy and clinical outcomes for diabetic patients. Academic Medicine. 2011 Mar 1;86(3):359-64.

12.    Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLOS one. 2014 Apr 9;9(4):e94207.

13.    Richter JP, Muhlestein DB. Patient experience and hospital profitability: Is there a link?. Health Care Management Review. 2017 Jul 1;42(3):247-57.

14.    Aldaqal SM, Alghamdi H, AlTurki H, El-deek BS, Kensarah A. Determinants of patient satisfaction in the surgical ward at a University Hospital in Saudi Arabia. Life Science Journal. 2012;9(1):277-80.

15.    Sun BC, Adams JG, Burstin HR. Validating a model of patient satisfaction with emergency care. Annals of emergency medicine. 2001 Nov 1;38(5):527-32.

16.    Messina, G., Vencia, F., Mecheroni, S., Dionisi, S., Baragatti, L., &Nante, N. (2015). Factors affecting patient satisfaction with emergency department care: an Italian rural hospital. Global journal of health science, 7(4), 30

17.    Yardan T, Genc S, Baydin A, Aydinkal E, Sunter AT. Determinants of patient satisfaction with an emergency department observation unit. Hong Kong Journal of Emergency Medicine. 2012 May;19(3):151-61.

18.    Morgan MW, Salzman JG, LeFevere RC, Thomas AJ, Isenberger KM. Demographic, operational, and healthcare utilization factors associated with emergency department patient satisfaction. Western Journal of Emergency Medicine. 2015 Jul;16(4):516.

19.    Ammo MA, Abu-Shaheen AK, Kobrosly S, Al-Tannir MA. Determinants of patient satisfaction at tertiary care centers in Lebanon. Open Journal of Nursing. 2014 Dec 5;4(13):939

20.    Naseer M, Zahidie A, Shaikh BT. Determinants of patient's satisfaction with health care system in Pakistan: a critical review. Pakistan Journal of Public Health. 2012;2(2):52.

21.    Dinh MM, Enright N, Walker A, Parameswaran A, Chu M. Determinants of patient satisfaction in an Australian emergency department fast-track setting. Emergency Medicine Journal. 2013 Oct 1;30(10):824-7.

22.    .Damghi N, Belayachi J, Armel B, Zekraoui A, Madani N, Abidi K, Belabes Benchekroun A, Zeggwagh AA, Abouqal R. Patient satisfaction in a Moroccan emergency department. International archives of medicine. 2013 Dec;6(1):1-8.

23.    Huang JA, Lai CS, Tsai WC, Weng RH, Hu WH, Yang DY. Determining factors of patient satisfaction for frequent users of emergency services in a medical center. Journal-Chinese Medical Association. 2004 Aug 1;67(8):403-10

24.    Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emergency medicine journal.2004Sep1;21(5):528-32.

25.    Dragovich A, Beltran T, Baylor GM, Swanson M, Plunkett A. Determinants of patient satisfaction in a private practice pain management clinic. Pain Practice. 2017 Nov;17(8):1015-22.

26.    Schoenfelder T, Klewer J, Kugler J. Determinants of patient satisfaction: a study among 39 hospitals in an in-patient setting in Germany. International journal for quality in health care. 2011 Oct 1;23(5):503-9.

27.    Glickman SW, Boulding W, Manary M, Staelin R, Roe MT, Wolosin RJ, Ohman EM, Peterson ED, Schulman KA. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction. Circulation: Cardiovascular Quality and Outcomes. 2010 Mar;3(2):188-95.

28.    Toma G, Triner W, McNutt LA. Patient satisfaction as a function of emergency department previsit expectations. Annals of emergency medicine. 2009 Sep 1;54(3).