Emergency Department Patient Experience Research Articles

Strategies to Improve Care in the Emergency Department for Culturally and Linguistically Diverse Adults: a Systematic Review.

The emergency department (ED) is an important gateway into the health system for people from culturally and linguistically diverse (CALD) backgrounds; their experience in the ED is likely to impact the way they access care in the future. Our review aimed to describe interventions used to improve ED health care delivery for adults from a CALD background. An electronic search of four databases was conducted to identify empirical studies that reported interventions with a primary focus of improving ED care for CALD adults (aged ≥ 18years), with measures relating to ED system performance, patient outcomes, patient experience, or staff experience. Studies published from inception to November 2022 were included. We excluded non-empirical studies, studies where an intervention was not provided in ED, papers where the full text was unavailable, or papers published in a language other than English. The intervention strategies were categorised thematically, and measures were tabulated. Following the screening of 3654 abstracts, 89 articles underwent full text review; 16 articles met the inclusion criteria. Four clear strategies for targeting action tailored to the CALD population of interest were identified: improving self-management of health issues, improving communication between patients and providers, adhering to good clinical practice, and building health workforce capacity. The four strategies identified provide a useful framework for targeted action tailored to the population and outcome of interest. These detailed examples show how intervention design must consider intersecting socio-economic barriers, so as not to perpetuate existing disparity. PROSPERO registration number: CRD42022379584.

Designing and developing a digital equity dashboard for the emergency department.

Disparities in diagnosis, treatment, and health outcomes of racial minorities are well documented in the emergency department (ED). Although EDs may provide broad departmental feedback on clinical metrics, lack of up-to-date monitoring and data availability present significant challengesto identifying and addressing patterns of inequitable care. To address this issue, we developed an online "Equity Dashboard," incorporating data that is updated daily from our electronic medical record to highlight demographic, clinical, and operational variables, stratified by age, race, ethnicity, and language, and sexual orientation, gender identity. Through an iterative design thinking process, we created data visualizations for an interactive interface that tells a story about the ED patient's experience and enables any staff to explore up-to-date trends in patient care. To assess and improve usability of the dashboard, we conducted a survey of end-users using custom questions, as well as the System Usability Scale and Net Promoter Score, both of which are validated health technology use instruments. The Equity Dashboard is of particular use for quality improvement initiatives, as it reflects common departmental challenges including delays in clinician events, inpatient boarding, and throughput metrics. This digital tool further helps demonstrate how these operational factors differentially affect our diverse patient population. The dashboard ultimately enables the ED team to measure current performance, to identify our vulnerabilities, and to design targeted interventions to address disparities in clinical care.

Improving Emergency Department Patient Experience Through an Organizational Values-Aligned Standardized Behavioral Model.

Patient experience in the setting of the emergency department (ED) is an area of strategic priority forall healthcare facilities. Patient experience can be affected by several factors that encompass the cultural, behavioral, and psychological domains of the healthcare organization. Al Hada Armed Forces Hospital, in its efforts to achieve the strategic objectives of continuously improving the patient experience at scale, implemented an ED-basedbehavioral model of service behaviors that was adapted to match the local community needs and practiced by the frontline healthcare staff at the ED during Q2-2021. A pre-experimental and postexperimental design was used for our patient experience quality improvement project. The Institute for Healthcare Improvement model for improvement plan-do-study-act was used to implement the quality improvement initiative. Our work is reported in accordance with the SQUIRE (Standards for Quality Improvement Reporting Excellence for Education) 2.0 guidelines from the EQUATOR network. The ED patient experience mean score improved during the postimplementation phase by 5.23 points (8% increase) in Q1-2022 and reached a sustainability level during Q3-2022. This quality improvement project in patient experience at our ED provides strong evidence for adopting organizational values-aligned standardized service behaviors to improve the patient experience at scale across ED settings.

The impact of follow-up calls after a pediatric emergency department visit

Pediatric emergency department (ED) visits can be a stressful time for patients and their caregivers. This high stress environment can lead to questions and needed clarifications post-discharge. We implemented a post-discharge callback system to resolve these concerns for a focused subset of patients who historically have provided the most negative comment feedback on ED patient experience surveys. We hypothesized that comment types would shift to more positive than negative and the themes of the comments received would change. We developed a discharge callback process that focused on patients who were triaged as ESI level 4 during their emergency department visit. Over a 6-week period, patients were called the day after discharge and asked if they had questions regarding their recent ED visit in addition to questions regarding current health, post-discharge instructions, prescriptions, or follow-up instructions if applicable. A maximum of 3 discharge calls were made if needed in order to contact the patient or family. Any questions regarding health care needs were followed up by a licensed healthcare provider within 24 hours with a maximum of 3 attempts. At the end of the project timeframe we analyzed comments received from our patient experience surveys to identify if there was a shift in comment types and their themes. In addition, we analyzed ED return rates within 72 hours of discharge. During the 6-week period, 2710 calls were made to contact 1618 patients’ caregivers. Follow up was requested by 149 families with a healthcare provider. There was no significant change in the number of comment types received. Thematic analysis of the patient experience survey comments received during this time period, revealed a reduction in questions regarding the recent ED visit and post discharge needs. There was no significant change in 72-hour ED return rates. The institution of an ED discharge callback system can effectively reduce patients’ and families’ questions regarding post-discharge care by providing an opportunity to clarify care after they have left the emergency department.

Media and technology usage and attitudes in emergency department patients.

Digital health technologies are increasingly being used in emergency medicine, many of which utilize smartphones and computers. Patient willingness to use these modalities is an important factor in successful implementation. Therefore, this study aimed to assess emergency department (ED) patients' use of and attitudes towards technology. This was a pooled sub-analysis of ED patients (≥18 years old) that were enrolled in two studies evaluating the ED patient experience in response to novel technological interventions. Participants completed the Media and Technology Usage and Attitudes Scale (MTUAS) that assessed computer and smartphone ownership; frequency of use of phone calls, texting, email, and smartphones; and anxiety and dependence attitudes on these technologies. One hundred and forty-four participants completed the survey. Mean age was 47.2 years (SD 17.94); 61.8% were female; and 61.1% were white. There was high usage of smartphones (93.1%) and computers (74.3%). Participants most frequently used phone calling and texting and least commonly used email. Participants had a positive attitude (mean 3.9/5, SD 0.68) towards the use of these technologies. ED patients reported high ownership of smartphones and computers, had a positive attitude towards their use, and had varying frequency with which they used different technologies. Future studies can use this information to inform the development of digital health interventions that utilize technologies that patients find most acceptable.

Assessing patient satisfaction with emergency department care delivery using a patient experience framework

Patient satisfaction with their experience during an emergency department (ED) visit is affected both by the quality of the clinical care received and the process of care delivered. This study adapts the generic quality framework developed by Golder, Mitra, and Moorman (2012) (GMM) with a Patient Experience Framework (PEF) tailored to the specific nature of ED care delivery, to systematically review research about ED patient experience. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, this review examines a range of medical publications that reported process interventions to improve patient satisfaction, and retained sixty-five studies. This extant research was then analyzed using the GMM framework as a theoretical lens: while every study considered the emergency care delivery process, only two studies investigated the patient experience process, four studies examined how patients evaluate the care received, and only one study considered all three processes. The review identifies areas for future research on patient satisfaction with their ED experience, which needs to expand its reach beyond processes of care delivery. Quality managers should focus on how patients experience the services performed and how that experience, along with prior expectations, affects a priori expectations and subsequent evaluation of the care received.

Establishing the content validity of a new emergency department patient-reported experience measure (ED PREM): a Delphi study

BackgroundPatient-reported experience measures aim to capture the patient’s perspective of what happened during a care encounter and how it happened. However, due to a lack of guidance to support patient-reported experience measure development and reporting, the content validity of many instruments is unclear and ambiguous. Thus, the aim of this study was to establish the content validity of a newly developed Emergency Department Patient-Reported Experience Measure (ED PREM).MethodsED PREM items were developed based on the findings of a systematic mixed studies review, and qualitative interviews with Emergency Department patients that occurred during September and October, 2020. Individuals who participated in the qualitative interviews were approached again during August 2021 to participate in the ED PREM content validation study. The preliminary ED PREM comprised 37 items. A two-round modified, online Delphi study was undertaken where patient participants were asked to rate the clarity, relevance, and importance of ED PREM items on a 4-point content validity index scale. Each round lasted for two-weeks, with 1 week in between for analysis. Consensus was a priori defined as item-level content validity index scores of ≥0.80. A scale-level content validity index score was also calculated.ResultsFifteen patients participated in both rounds of the online Delphi study. At the completion of the study, two items were dropped and 13 were revised, resulting in a 35-item ED PREM. The scale-level content validity index score for the final 35-item instrument was 0.95.ConclusionsThe newly developed ED PREM demonstrates good content validity and aligns strongly with the concept of Emergency Department patient experience as described in the literature. The ED PREM will next be administered in a larger study to establish its’ construct validity and reliability. There is an imperative for clear guidance on PREM content validation methodologies. Thus, this study may inform the efforts of other researchers undertaking PREM content validation.

Social and structural determinants and their associations with patient experience in the emergency department

BackgroundImproving patient experience and satisfaction in the emergency department (ED) is challenging but beneficial. Previous studies have shown an association between social and structural factors and patient satisfaction. This study examined the structural and social factors related to the ED patient experience among Jewish and Arab patients in a Jerusalem hospital. MethodsA cross-sectional study was conducted among ED patients in a Jerusalem hospital. Data were collected via questionnaires. The sample included 257 Jewish patients and 170 Arab patients. The outcome variable was a positive or negative ED experience. ResultsJewish and Arab patients had different factors related to ED experience. Cultural differences, including a language barrier and access to information, were associated with a negative experience among Arab patients. Among Jewish patients, frequent use of community health services was associated with a negative ED patient experience. ConclusionThis study shows an association between social and structural factors and patient experience, illustrating gaps for and vulnerability of different ethnic groups that affect their experience with healthcare services. Understanding these issues and implementing solutions formulated at the institutional and national levels can promote equity by providing structurally competent care.

ED Patient Experience: Does Day of the Week or Time of the Day Matter?

The effect of the arrival day of the week, arrival time of the day, or discharge time of the day on emergency department (ED) patient experience (PE) scores has not been well studied. We performed a retrospective analysis of ED patients between July 1st, 2018 through March 31st, 2021. We recorded demographics, PE scores, arrival day, arrival and discharge times, and total ED and perceived ED times. We performed univariate and multivariable analyses. We sent 49,849 surveys and received back 2423 that we included in our study. The responding patients' median age was 52, with a majority of female gender (62%) and white race (57%). The average arrival time was 1:40 PM, and the average discharge time 2:38 PM. The average total ED time was 261 minutes, while the average perceived ED time was 540 minutes. We found a statistical association between worse PE scores and longer actual ED time but not longer perceived time. A later arrival time was significantly associated with worse PE scores on 4 out of 6 domains of the PE questionnaire. The discharge time and the day of the week were not significantly associated with PE scores. Conclusion: Actual longer ED time was significantly associated with worse PE scores, but not perceived time. Later arrival time was associated with worse PE scores, but not later discharge time. The arrival day of the week was not statistically associated with differences in PE. Further studies are needed to confirm these findings.

The Emergency Department Patient Experience: In Their Own Words.

In this paper, the authors review the verbatim comments from patients’ post-emergency department discharge survey results and highlight the impact that doctors and nurses have on the patient's experience. This paper also explores the benefits of delivering a positive experience on patients, clinicians, and healthcare systems. Many interventions that have worked are simple to implement and do not tend to require significant capital investment while having the potential of improving emergency department encounters for all those involved. There are always limitations, selection biases, and issues with generalizability in reviewing retrospective and subjective survey response data.

390 A Telemedicine Emergency Provider in Triage Improves Patient Experience, Staff Satisfaction, and Operational Metrics

Emergency department (ED) patient volume surge can prolong waiting room (WR) times which delays care and disposition. A telemedicine emergency provider (EP) in triage can initiate care without the limitations of physically placing one in the WR -- space, repeat interviewing, and EP availability. This study compared telemedicine EP in triage to standard WR operations during surge periods in terms of ED patient experience, ED staff satisfaction, and operational metrics.

Development and validation of a patient experience of care survey for emergency departments.

To (1) develop a survey to assess the patient experience of care in hospital-based emergency departments (ED) and (2) evaluate the reliability and validity of composite measures of patient experience using data collected through the experimental implementation of the newly developed Emergency Department Patient Experience of Care (EDPEC) Discharged to Community (DTC) Survey. 4893 adult patients were treated in the ED of 16 hospitals across the United States in 2018. The study utilized a cross-sectional survey. Survey development activities included a literature review, focus groups, and cognitive interviews with recently discharged ED patients, technical expert panels, and multiple field experiments. Survey development resulted in a 34-item instrument; the analysis reported here focuses on 18 items on patient experience of care. Using data from the EDPEC DTC Survey in the 2018 Feasibility Test, we performed confirmatory factor analysis to group 15 evaluative survey items into composite measures. We examined internal consistency reliability, interunit reliability, and associations between each composite measure and patients' overall rating and willingness to recommend the ED. Analyses of 15 evaluative items identified four composite measures: Getting Timely Care, How Well Doctors and Nurses Communicate, Communication about Medications, and Communication about Follow-up. Patient-level internal consistency reliability exceeded 0.75 for two of four composites; ED-level internal consistency reliability exceeded 0.83 for all four composites. Interunit reliability estimates indicated that 450 survey completes per ED results in at least 0.70 reliability for all composites. Higher scores on each composite were associated with higher overall ratings and willingness to recommend the ED. The composite measures derived from the EDPEC DTC Survey are statistically reliable and valid. These results provide guidance for EDPEC DTC Survey adopters on how to construct meaningful and psychometrically-sound composite measures for monitoring the quality of care they provide.

Factors associated with the experience of patients presenting in pain to the emergency department.

This study aims to examine the association between person, environment, health and illness factors, pain care and the patient experience in the emergency department, guided by symptom management theory. Current outcome measures of pain care in the emergency department focus on process measures such as the time taken to deliver analgesic medication. Patient-reported outcomes of pain care are rare in emergency department literature and predominantly focus on patient satisfaction. Measuring overall patient experience is common, with extensive surveys undertaken in the United Kingdom, United States of America and Australia; however, these are not used as an outcome of pain care. Prospective cohort study. One hundred and ninety patients arriving at a large, inner-city adults-only emergency department in moderate to severe pain were recruited to answer a modified version of the emergency department patient experience of care survey. Fifteen factors were identified as influencing the patient experience of care when presenting in pain. These influences of patient experience included the emergency department environment, time to first analgesic medication and the provision of analgesic medication. In addition to pain care factors, there is a significant association between the emergency department environment-especially workload, throughput and patient placement-and the experience of patients who present in pain to the emergency department. This study demonstrated an association between time to first analgesic medication and the patient experience of care. Providing timely care, including pain care, in emergency departments is difficult, but necessary to improve the patient experience of care.

Racial/Ethnic Differences in Emergency Department Utilization and Experience.

BackgroundPrevious work has demonstrated racial/ethnic differences in emergency department (ED) utilization, but less is known about racial/ethnic differences in the experience of care received during an ED visit.ObjectiveTo examine differences in self-reported healthcare utilization and experiences with ED care by patients’ race/ethnicity.DesignAdult ED patients discharged to community (DTC) were surveyed (response rate: 20.25%) using the Emergency Department Patient Experience of Care (EDPEC) DTC Survey. Linear regression was used to estimate case-mix-adjusted differences in patient experience between racial/ethnic groups.Participants3122 survey respondents who were discharged from the EDs of 50 hospitals nationwide January–March 2016.Main MeasuresSix measures: getting timely care, doctor and nurse communication, communication about medications, receipt of sufficient information about test results, whether hospital staff discussed the patient’s ability to receive follow-up care, and willingness to recommend the ED.Key ResultsBlack and Hispanic patients were significantly more likely than White patients to report visiting the ED for an ongoing health condition (40% Black, 30% Hispanic, 28% White, p<0.001), report having visited an ED 3+ times in the last 6 months (26% Black, 25% Hispanic, 19% White, p<0.001), and report not having a usual source of care (19% Black, 19% Hispanic, 8% White, p<0.001). Compared with White patients, Hispanic patients more often reported that hospital staff talked with them about their ability to receive needed follow-up care (+7.2 percentile points, p=0.038) and recommended the ED (+7.2 points, p=0.037); Hispanic and Black patients reported better doctor and nurse communication (+6.4 points, p=0.008; +4 points, p=0.036, respectively).ConclusionsHispanic and Black ED patients reported higher ED utilization, lacked a usual source of care, and reported better experience with ED care than White patients. Results may reflect differences in care delivery by staff and/or different expectations of ED care among Hispanic and Black patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06738-0.

Emergency Department Patient Experiences During the COVID-19 Pandemic.

Emergency department (ED) utilization changed notably during the coronavirus disease 2019 (COVID-19) pandemic in the United States. The purpose of the study was to gain a more thorough understanding of ED patient experience during the early stages of the COVID-19 pandemic. This study used the consensual qualitative approach to analyze open-ended responses from post-ED patient experience surveys from February through July 2020. Comments were included in the analysis if they pertained to care during the pandemic (eg, mentioned “the virus,” “masks,” “PPE”). A total of 242 COVID-specific comments from 192 unique patients were analyzed (median age 49 years; 69% female). Six themes were identified: visually observed changes, experiences of process changes, expressions of understanding or appreciation, sense of security, COVID-19 disease-specific comments, and “classic” satisfaction comments that align with previous literature on patient experience. The COVID-19 pandemic has challenged health care systems across the world in unique and unprecedented ways. This study identified six themes that better elucidate ED patient experience during an unprecedented public health crisis.

Changing Culture to Drive Nurse Engagement and Superior Patient Experience

Brandon "Kit" Bredimus was the recipient of AONL's 2018 Pamela Austin Thompson Early Careerist Award. He helped to develop and implement the program detailed below, which improved nurse engagement and patient experience scores.

Methods for Improving Response Rates in an Emergency Department Setting – A Randomized Feasibility Study

Standard single survey mode approaches, such as mail-only or telephone-only, generally produce lower response rates than sequential mixed mode (SMM) approaches. SMM approaches may be particularly important when lower response propensities and/or poor contact information exist, as with emergency department (ED) patients. Results were examined from a randomized feasibility study testing five survey administration modes among ED patients who are discharged-to-community. A total of 4,017 discharged patients from eight EDs during February 2016 were randomized in equal numbers to five modes: on-site distribution of a paper survey; mail notification of a web survey; email notification of a web survey; two-stage SMM (mailed survey with telephone follow-up); and three-stage SMM (email notification of a web survey with mail follow-up and then telephone follow-up). Sampled patients received a 43-item instrument focusing on ED patient experience. The two-stage SMM, commonly used for other patient experience surveys, was the reference mode. Three-stage SMM had a higher response rate (30.7%) than two-stage SMM (25.3%); the other three experimental modes had significantly lower response rates (0.8–9.6%; p<0.001 for all comparisons). On-site distribution was difficult to operationalize, possibly promoting selection bias. Valid email capture rates ranged from 4.0% to 48.3% by hospital and 30.1% overall, even though participating hospitals reported capture rates of at least 20%; the odds of having a valid email address were significantly lower for older and male patients. Findings highlight the limitations of web-only and on-site approaches, and identify SMM with a web-based component as a promising approach for survey administration in the ED setting.

Improving Emergency Department Patient Experience Through Implementation of an Informational Pamphlet.

Objective:Patient satisfaction is emerging as a new health-care metric. We hypothesized that an emergency department (ED) informational pamphlet would significantly improve patient understanding of ED operations and ultimately improve patient satisfaction.Methods:We performed a prospective study of patients presenting to a single tertiary care center ED from April to July 2017. All patients were given a pamphlet on alternating weeks with regular care on opposite weeks and were surveyed upon ED discharge. The primary outcome was patient satisfaction with ED care. Secondary outcomes included patient understanding of various wait times (test results, consultants), discharge process, who was on the care team and what to expect during the ED visit.Results:Four hundred ninety-four patients were included in this study and 266 (54%) were in the control group. Of 228 (46%) patients who were given the pamphlet, 116 (51%) were unaware they received it. Of the remaining 112 (49%) patients who remembered receiving the pamphlet, 43 (38%) stated they read it. Among those reading the pamphlet, only two statements were significant: knowing what to expect during the ED visit (88% vs 71%; P = 0.012) and waiting time for test results (95% vs 75%; P = 0.003) when compared to those who did not receive or read the pamphlet.Conclusion:An ED informational pamphlet, when utilized by patients, does improve patient understanding of some aspects of the ED visit but does not appear to be the best tool to convey all information. Ultimately, sustained improvement in patient satisfaction is a complex and dynamic issue necessitating a multifactorial approach and other methods should be explored.

Emergency department patient experience: Same location, same provider, different scores by different survey methods.

Recent findings on emergency department (ED) patient experience surveys and concerns for the low response rates challenge the quality and reliability of the survey reports. We assessed the consistency of an ED patient experience survey report and identified the effects of patient demographics on ED patient experiences. We conducted a prospective, cross-sectional study at a university-based ED from July to December 2017. We obtained ED patient experience scores from an institutional version (IS) survey and the Press Ganey Associates-distributed survey (PGA). We compared top box scores from the two reports using frequency analysis and performed multivariable logistic regressions to identify associations between IS patient demographics and scores. We obtained 289 PGA and 234 IS responses. The IS reported significant, higher top box scores in doctor-specific patient questions compared to PGA (all four P-values < 0.01). Female, Christian and White patients were more likely to give top box scores (OR 3.07, OR 2.22 and OR 2.41, P-value < 0.05, respectively). We found significant differences in ED patient experience scores between the IS and PGA surveys. We recommend that healthcare providers consider patient demographic variables when interpreting ED experience score reports. Multiple survey techniques and distribution methods may be adopted to best capture ED patient experiences.

National Testing of the Emergency Department Patient Experience of Care Discharged to Community Survey and Implications for Adjustment in Scoring.

The emergency department (ED) setting is unique and measuring quality of care in the ED requires the development of ED-specific tools. The Emergency Department Patient Experience of Care Discharged to Community Survey was designed to measure patient experience in the ED setting. Describe results from the Emergency Department Patient Experience of Care Discharged to Community Survey including respondent characteristics and reported patient experience, and examine factors, including mode of survey administration, associated with response propensity and response patterns. In total, 16,006 discharges were sampled from 50 hospitals nationwide to receive the survey using a mode experiment design. Logistic regression modeled response propensity; linear regression examined associations between response patterns and patient characteristics and mode. In total, 3122 survey respondents. Measures of patient experience. Patients reported that hospitals consistently informed them of the purpose of any new medications (84% yes, definitely), but did not consistently explain their possible side effects (53%). Age, education, health, and arrival by ambulance were significantly associated with response patterns. There were significant differences in response rate by mode: 29% mixed mode, 22% telephone only and 14% mail only. Mode of administration was significantly associated with response patterns whereby patients surveyed using telephone-only or mixed mode tended to respond more positively than those surveyed using mail only. There is room for improvement in terms of patient experience in the ED setting. Effects of patient characteristics and survey mode on responses were large enough to necessitate appropriate adjustments if hospitals are to be compared in the future.