Patient satisfaction investigations and the emergency department: what does the literature say?

BACKGROUND: Patient satisfaction is an indicator of the quality of care provided by emergency department (ED) personnel. It is this perception of satisfaction that becomes the basis for future ED choice or the recommendation of a specific ED to other potential patients. OBJECTIVE: To perform an evidence-based literature review to: 1) characterize measures of "patient satisfaction"; 2) identify factors that have been associated with overall ED patient satisfaction; 3) critique the methods used to assess patient satisfaction in the literature; and 4) address how this information can be beneficial to those reading the satisfaction literature or designing a satisfaction survey instrument. METHODS: The MEDLINE database was searched for studies addressing ED patient satisfaction, from January 1976 through July 1999, using MeSH terms and a text word search. Bibliographies of manuscripts also were searched for additional relevant articles and each clinical study was used as a search criterion in Science Citation Index, from the date of publication through July 1999. RESULTS: Multiple measures have been used to evaluate overall patient satisfaction. Sixteen studies were found associating ED patient satisfaction with service and patient factors. Most studies are observational and of these, most are cross-sectional. Hence, cause-and-effect determination of factors responsible for patient satisfaction cannot be resolved using the current literature. CONCLUSIONS: Despite considerable methodologic variability, key themes (e.g., association of satisfaction with patient information, provider-patient interpersonal factors, and perceived waiting time) emerge from review of the ED patient satisfaction literature. To standardize future investigations, clinicians and investigators should use a common definition for the state of overall patient satisfaction, e.g., when the patient's own expectations for treatment and care are met (or exceeded). This common definition should be incorporated into the instrument used to measure overall ED patient satisfaction.

First-postgraduate-year resident clinical time use on three specialty rotations.

OBJECTIVE: To compare in-hospital time uses by first-postgraduate-year (PGY1) residents during rotations in emergency medicine (EM), internal medicine (IM), and surgery (S). This article reports the clinical components of residency time use. METHODS: A cross-sectional, observational study of the clinical activities of EM PGY1 residents was performed while the residents were on duty during the three specialty rotations. The activities were recorded by an observer using a log with predetermined categories for clinical activities. A time-blocked, convenience sample of resident shifts was observed for each service rotation. The sample was proportional to the total number of hours for which a PGY1 resident was expected to be in the hospital during a rotation on that service. No attempt was made to sample the same resident at all time periods or on all rotations. Proportions were compared by chi2; alpha = 0.0001. RESULTS: Twelve PGY1 residents were observed for a total of 166 hours on S, 156 hours on IM, and 120 hours on EM. These hourly amounts were representative of a typical two-week span of service on each rotation for the residents. On average, the residents spent 57% of their time on clinical or service-oriented activities. During EM and IM rotations, the residents spent most of their time performing clinical information gathering and engaging in case management and data synthesis (52% of total clinical effort). Within this category, residents on EM were more involved with case discussion and review of ancillary test results than on IM (34% vs 20% of time in this category). Conversely, proportionately less time in this category was devoted to documentation on the EM vs IM rotation (56% vs 80%; p < 0.0001). The greatest opportunity to perform procedures was on the S rotation (31% of total clinical time vs 6% for other specialties; p < 0.0001). CONCLUSION: Awareness of the clinical activities performed on PGY1 rotations can help residency directors anticipate educational needs to balance their residents' experience. Since 29% and 42% of total clinical time on PGY1 EM and IM rotations, respectively, is focused on documentation, efforts to enhance charting skills and efficiency are warranted. Also, efforts to enhance PGY1 procedural experience outside of the S rotation appear warranted.

Resident educational time study: a tale of three specialties.

OBJECTIVE: To compare amounts of in-hospital time use by PGY1 residents during rotations in emergency medicine (EM), internal medicine (IM), and surgery. This article reports the general study methodology and focuses on the educational aspects of residency time use. METHODS: A cross-sectional, observational study of the activities of EM PGY1 residents was performed while the residents were on duty during the 3 specialty rotations. The activities were recorded by an observer using a log with predetermined categories for clinical/service, educational, and personal areas. A time-blocked, convenience sample of resident shifts was observed for each service rotation. The sample was proportional to the total number of hours for which a PGY1 resident was expected to be in the hospital during a rotation on that service. No attempt was made to sample the same resident at all time periods or on all rotations. RESULTS: Twelve PGY1 residents were observed for a total of 166 hours on surgery, 156 hours on IM, and 120 hours on EM. These hourly amounts were representative of a typical 2-week span of service on each rotation for the residents. On average, the residents spent 57% of their time on clinical or service-oriented activities, 24% on educational activities, and 19% on personal activities. The proportions of time devoted to the 3 major areas were similar for the 3 rotations. In all 3 rotations, the largest proportion of time was spent on patient-focused education (81% to 92% of total educational time). Only 2% to 11% of educational time was devoted to self-education. Within the patient-focused education category, proportionately less resident time with faculty occurred on the surgery rotation than on the EM and IM rotations (18% vs 30% and 27%, respectively). CONCLUSION: The general breakdowns of clinical/service, educational, and personal time use by PGY1 residents are proportionately similar for the 3 service rotations. Patient-focused education is the primary mode of education for all services. In-hospital, self-education time is limited. Clinical teaching is largely by nonfaculty. The educational implications of these findings are discussed.

Follow-up compliance after emergency department evaluation.

STUDY OBJECTIVE: To identify factors associated with outpatient follow-up of emergency department visits. DESIGN: A retrospective review of 587 ED charts meeting strict criteria was performed. The following variables were identified: method used to arrange follow-up, age, sex, consultant contacts, distance from patient's residence to hospital, previous physician, recommended time to clinic return, and funding source. Compliance was assessed using the outpatient registration computer data base. SETTING: ED and outpatient clinics of an urban university teaching hospital. PARTICIPANTS: Inclusion criteria were age between 18 and 75 years, patient released to outpatient care, and instructions specifying a university hospital clinic or ED follow-up and a time period within which this appointment was to occur. Follow-up options included patients being asked to return to the ED on a specific day (group 1), being given a specific clinic appointment (group 2), or being given the clinic telephone number and instructed to call for an appointment (group 3). RESULTS: Compliance rates, defined as follow-up within seven days of the recommended date, were group 1, 51%; group 2, 65%; and group 3, 46%. Significant confounding factors adversely affecting follow-up as determined by multiple logistic regression analysis were decreasing age (P < .05), absence of insurance (P < .01), and no ED consultation with follow-up clinic physician (P < .01). Controlling for these factors and the reason for follow-up showed that having the patient schedule their own follow-up was associated with poor follow-up compliance (P < .001). CONCLUSION: Compliance with follow-up is multifactorial. Consultant contact at the time of initial patient evaluation and provision of a return visit appointment at the time of ED release should improve compliance in a university hospital setting.

Torsade de pointes after inhaled pentamidine.

The case of a 40-year-old HIV-positive man who had multiple episodes of torsade de pointes is presented. The patient's history was pertinent for the use of inhaled pentamidine the day before admission. His episodes of torsade de pointes were refractory to the usual therapy. His presentation, laboratory work, echocardiography, computed tomography scan, and treatment are reviewed. Physicians should be aware of the association of pentamidine with torsade de pointes.

Faculty attrition among three specialties.

STUDY OBJECTIVES: To survey faculty attrition in emergency medicine and compare it with faculty attrition in the specialties of orthopedic surgery and cardiology. DESIGN: Chairmen of the three departments were surveyed regarding faculty attrition, work hours, and motivation for leaving. Those emergency physicians having left also were surveyed. MAIN RESULTS: Responses were obtained from 67 of 68 emergency medicine programs, 53 of 58 orthopedic programs, and 47 of 54 cardiology programs. Overall, there were 670 total faculty in emergency medicine, of which 67 (10%) left their positions during 1988-38 to enter private practice, 18 to take another academic position, and 11 to do something unidentified. There was no difference in faculty attrition among the three specialties or in what the physicians left to do (P = .75). Both the orthopedists and the cardiologists worked more total hours each week (P = .001) but fewer night hours (P = .03) than the emergency physicians. Among the 67 emergency medicine programs, 28 reported no attrition; 39 reported one or more physicians leaving the program. These two groups of programs did not differ in terms of faculty size, hours worked, or night hours worked.

Massive levothyroxine ingestion. Conservative management.

The clinical course of a 29-month-old girl who was referred for evaluation after ingesting ninety 0.2-mg tablets of levothyroxine is reported. Despite an initial thyroxine (T4) level of 282 micrograms/dl and a triiodothyronine (T3) level of 1,837 ng/dl at 48 hours postingestion, her symptoms were mild and included irritability, vomiting, tremor, and tachycardia. Treatment was limited to activated charcoal and propranolol. Thyroid hormone levels fell to normal by 13 days postingestion. The child's clinical course was benign. Even after massive acute ingestions of levothyroxine, children's symptoms are usually mild and may be controlled with propranolol. This conservative approach should be considered before expensive and potentially dangerous therapies are undertaken.

Cimetidine-induced cutaneous vasculitis.

A rash developed in a man consistent with urticarial vasculitis as demonstrated by biopsy on each of two occasions that he was exposed to cimetidine. The vasculitis resolved on discontinuation of the drug. This is the first report demonstrating by biopsy and rechallenge that oral cimetidine therapy may cause type III hypersensitivity.