A Comprehensive View of Parental Satisfaction With Pediatric Emergency Department Visits

doi:10.1016/j.annemergmed.2013.04.025

Annals of Emergency Medicine

Volume 62, Issue 4, October 2013, Pages 340-350

https://doi.org/10.1016/j.annemergmed.2013.04.025 Get rights and content

Study objective

We develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric emergency department (ED) visits, using both quantitative and qualitative data.

Methods

This was a retrospective observational study using data from an institution-wide system to measure patient satisfaction. For this study, 2,442 parents who brought their child to the ED were interviewed with telephone survey methods. The survey included closed-ended (quantitative) and open-ended (qualitative data) questions, in addition to a cognitive interview–style question.

Results

Overall parental satisfaction was best predicted by how well physicians and nurses work together, followed by wait time and pain management. Issues concerning timeliness of care, perceived quality of medical care, and communication were raised repeatedly by parents in response to open-ended questions. A cognitive interview–style question showed that physicians and nurses sharing information with each other, parents receiving consistent and detailed explanations of their child's diagnosis and treatments, and not having to answer the same question repeatedly informed parent perceptions of physicians and nurses working well together. Staff showing courtesy and respect through compassion and caring words and behaviors and paying attention to nonmedical needs are other potential satisfiers with emergency care.

Conclusion

Using qualitative data to augment and clarify quantitative data from patient experience of care surveys is essential to obtaining a complete picture of aspects of emergency care important to parents and can help inform quality improvement work aimed at improving satisfaction with care.

Introduction

The Institute of Medicine report Emergency Care for Children: Growing Pains¹ emphasizes the importance of delivering patient- and family-centered care in pediatric emergency medicine. Although parental satisfaction with care is an important patient- and family-centered care outcome, providing such care can be challenging, given the nature of the emergency care experience. These challenges include emergency department (ED) crowding, the acute nature of the visit, lack of established relationships between health care providers and patients or parents, and the occasional absence of parents or guardians.² ED crowding has been negatively associated with satisfaction with care.³ Furthermore, interactions with health care providers are often short and intense, leaving little room to address emotional, psychological, and social needs.2, 4, 5

Given these challenges, improving the delivery of patient- and family-centered care in an ED setting requires a comprehensive view of health care provider behaviors and system characteristics that drive satisfaction with the visit. In the adult emergency care literature, the following have been shown to be drivers of overall satisfaction: timeliness of care6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17; information provided about the diagnosis, care, and treatment9, 11, 14, 15, 16, 17, 18, 19; caring and empathy7, 11, 17, 19, 20; the degree to which the staff was organized¹¹; the perceived technical quality of care7, 9, 17, 21; the quality of interpersonal interactions9, 15, 22; explanations of delays in care14, 19; feelings of safety and security⁷; understandable discharge instructions7, 14; health care provider courtesy¹⁰; thoroughness of the physician¹⁰; and pain management.17, 19

The few published studies that address satisfaction with pediatric emergency care have shown that provider interactions,²³ pain management,23, 24, 25 information and explanations provided,23, 25 ability to stay with the child,²⁵ staff attitude,²⁵ and wait time24, 26 are associated with overall satisfaction with care. Almost all the published studies used quantitative data resulting from surveys administered to patients or parents. To our knowledge, only 1 study of adolescents' perceptions of emergency care augmented quantitative data from close-ended questions with qualitative data from open-ended questions. The objective of that study was to identify factors associated with adolescent satisfaction with emergency care. Using quantitative methods, interpersonal communication and respect were found to be associated with overall satisfaction. In addition, an open-ended question was used to elicit what adolescents would have liked to change about the care they received, which resulted in 4 themes: no changes were necessary, enhance interpersonal communication, improve comfort of stay, and shorter length of stay.²⁷

Satisfaction with care has been associated with improved adherence to medical regimens and health-related outcomes in other populations.5, 28, 29 A comprehensive view of the drivers of overall parental satisfaction with care in pediatric emergency care is an important step toward improving the delivery of quality patient- and family-centered care. Using quantitative survey data alone, however, may not provide a comprehensive view of drivers of overall satisfaction with care. Aspects of care important to parents may be missed if not included in close-ended survey questions. Also, close-ended questions often do not provide adequate detail about specific health care provider behaviors or system characteristics needed to inform quality improvement work. The use of both quantitative and qualitative data can provide a more robust view of aspects of care important to parents associated with overall satisfaction.

The objective of this study was to develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric ED visits, using both quantitative and qualitative data.

Section snippets

Study Design

This was a retrospective observational study using data from a telephone survey used to measure parental satisfaction with care received in a pediatric ED. The survey is part of ongoing institution-wide efforts to improve satisfaction with care. This study was approved by the hospital's institutional review board and was determined to be exempt from ongoing board oversight.

Setting

This study was conducted at a large, urban, tertiary care, pediatric teaching hospital. The ED has a patient census of

Characteristics of Study Subjects

The response rate for this survey was, on average, 50%. During the study period 2,442 parents completed the survey. Table 2 summarizes characteristics (age, sex, race, insurance, admitted to hospital) of the study sample compared with those of the study population.

Main Results

All but 8 parents provided an overall satisfaction rating. Of those providing a rating, 9% rated their overall satisfaction 0 to 6; 23%, 7 to 8; and 68%, 9 to 10. Figure 1 summarizes which aspects of care exhibit the highest potential

Limitations

This study has several limitations. First, it is a single site study in a large academic setting, which may not be generalizable to other settings or regions.

Second, there are inherent biases in telephone surveys. The nonresponse rate was approximately 50% and we do not know whether nonresponders would have answered differently. Table 2, however, indicates that the demographic characteristics of the sample were very similar to that of the population of patients who visited our ED.

Third, the

In Retrospect

The qualitative data in this study have shown that the drivers of overall satisfaction are multifaceted and not mutually exclusive. The use of both quantitative and qualitative data elucidated the complex nature of these drivers and the relationships between them, enabling us to develop a more comprehensive picture of what is important to parents of children who visit an ED.

The quantitative data showed that the most important drivers of overall parent satisfaction were how well physicians and

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Do Pediatrician Interpersonal and Personality Characteristics Affect Patient Experience?
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In our sample, EM pediatricians were significantly more likely to receive a low rating. The EM pediatrician ratings in our study were comparable to rates reported in other pediatric studies.40 Factors unique to the emergency setting including long wait times, visit acuity, and lack of an established relationship with the EM pediatrician could challenge patient care experiences ratings41 and may have affected the current study results.
Previous studies have demonstrated associations between patient experience scores and physician's demographic characteristics such as gender and race. There is a paucity of data, however, on the effect of broader pediatrician characteristics on caregivers’ experience of their children's care. This study assessed pediatric caregiver experience of care ratings within a children's hospital and examined the effects of pediatricians’ interpersonal and personality traits on caregiver experience ratings.
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The odds of caregivers of Spanish-speaking children to provide a high physician rating were 75% higher than the odds for non-Spanish-speaking patients. At the physician level, lower agreeableness (odds ratio [OR] = 0.63, P = .002), and lower narcissistic perfectionism (OR = 0.98, P = .016) were associated with an increased likelihood of a high care experience rating. The odds of nonemergency medicine pediatricians receiving high ratings were approximately 4.17 times higher than that of EM pediatricians.
Current results may inform future interventions that address pediatrician personality characteristics associated with caregivers of children experience outcomes.
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Patient satisfaction measures of their care are not necessarily associated with the provision of care consistent with accepted standards of care [27,28]. Asking pediatric patients about their experiences is essential [29]. Although an important first step in identifying families' priorities in pediatric ED trauma care, this tertiary care single center study's results may not be applicable to all settings.
Despite growing interests in patient-reported outcomes, youth and families are rarely involved in designing quality improvement measures. Few quality indicators exist for the care of children with injuries in the Emergency Department (ED) and extremity fractures are among the most common injuries in children. This study's aim was to identify both parents' and youth's perspectives about ED care in the context of a suspected long-bone fracture.
Youth (10–18 years old) and their parents were surveyed prospectively during their ED visit. Participants were asked: 1) to identify their main concerns, 2) to identify quality measures that were most important to them, and 3) to evaluate the ED care they received. Descriptive analyses present participants' responses. Continuous data was analyzed using a Student t-test and categorical data using a Chi-square test.
Over 15 months, 350 families met eligibility criteria and were approached to participate, of which 300 participants consented and 249 surveys were completed (71% response rate): 148 parents and 101 youth (median age: 12) completed their respective surveys. Participants placed a high importance on several themes: pain management, short length of stay, and quality interactions with ED clinicians. Youth as a group prioritized their overall wellbeing and the ED environment (e.g., waiting room comfort, signage), while parents focused on accurate diagnoses and treatments. The following items were less prioritized: that radiology be close to the ED, to see the radiograph, to have access to a wheelchair, to know the identities of clinicians on the team, and to have access to entertainment. Parents and youth within the same family often did not share the same priorities. Ninety-two percent of parents reported their child's pain was treated, while 81% and 63% of youth reported their pain was treated sufficiently and quickly, respectively.
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: Please see page 341 for the Editor's Capsule Summary of this article.

: Supervising editor: Robert L. Wears, MD, PhD

: Author contributions: TLB conceived and designed the study, obtained research support, worked with the James M. Anderson Center for Health Systems Excellence to procure the data, conducted the quantitative data analysis, and drafted the article. All authors participated in the qualitative data analysis and contributed substantially to article revision. TLB takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The work was supported by the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center. The James M. Anderson Center managed and oversaw the data collection.

: Publication date: Available online June 17, 2013.

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Pediatrics/original researchA Comprehensive View of Parental Satisfaction With Pediatric Emergency Department Visits

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design

Setting

Characteristics of Study Subjects

Main Results

Limitations

In Retrospect

Am J Emerg Med

J Emerg Med

Ann Emerg Med

Ann Emerg Med

J Emerg Med

Ann Emerg Med

Ann Emerg Med

J Natl Med Assoc

J Emerg Med

Ann Emerg Med

Am J Emerg Med

Committee on the Future of Emergency Care in the United States Health System. Emergency Care for Children: Growing Pains

Rising to the challenge of family-centered care in emergency medicine

Acad Emerg Med

The effect of emergency department crowding on patient satisfaction for admitted patients

Acad Emerg Med

Patient- and family-centered care and the role of the emergency physician providing care to a child in the emergency department

Pediatrics

Patient- and family-centered care of children in the emergency department

Pediatrics

A patient satisfaction theory and its robustness across gender in emergency departments: a multigroup structural equation modeling investigation

Am J Med Qual

Emergency department patient satisfaction: examining the role of acuity

Acad Emerg Med

Waiting time and assessment of patient satisfaction in a large reference emergency department: a prospective cohort study, France

Eur J Emerg Med

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

Acad Emerg Med

Twenty years of patient satisfaction research applied to the emergency department: a qualitative review

Am J Med Qual

A multifaceted intervention improves patient satisfaction and perceptions of emergency department care

Int J Qual Health Care

Predicting patient satisfaction: a study of two emergency departments

J Behav Med

Patient satisfaction as a function of emergency department previsit expectations

Ann Emerg Med

Patient satisfaction in the emergency department—a survey of pediatric patients and their parents

Acad Emerg Med

Pediatrics/original research
A Comprehensive View of Parental Satisfaction With Pediatric Emergency Department Visits