key: cord-0874924-bn39rpo9
authors: Grissom, Maureen O.; Farra, Morgan; Cruzen, Eric S.; Barlow, Erin; Gupta, Sanjey
title: What can COVID‐19 teach us about patient satisfaction in the emergency department? A mixed‐methods approach
date: 2021-04-29
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12436
sha: c2717572d503fd820aec6f3e150d5c8f746711ab
doc_id: 874924
cord_uid: bn39rpo9

OBJECTIVE: The current study explored improved patient satisfaction scores at a single emergency department (ED) during the early phase of the COVID‐19 pandemic (March to May 2020). METHODS: A mixed‐methods design, integrating qualitative and quantitative data analyses, was employed to explore a total of 289 patient satisfaction survey ratings and 421 comments based on care that took place in the ED during the initial phase of the COVID‐19 epidemic. This allowed for comparisons to a more typical time period in the ED along with the emergence of novel categories of influence. RESULTS: The ED census was 31% lower during 2020 (COVID‐19) than the previous year, and a significantly greater percentage of patients in 2020 indicated that they would “definitely recommend” the ED compared with 2019. Wait time was mentioned in >40% of dissatisfied patient comments in 2019 but <20% of dissatisfied patient comments in 2020. General negative comments were proportionately greater than general positive comments in 2019, whereas in 2020 the reverse pattern held. Other categories did not differ significantly across 2019 and 2020. CONCLUSIONS: The general circumstances surrounding the early stages of the COVID‐19 pandemic included a lower census in the ED and higher reported satisfaction among patients. A comparison of the content of patient comments revealed less concern about wait times and a more positive overall view toward receiving care during the first 3 months of the pandemic.

Patient satisfaction in the emergency department (ED) has been associated positively with patient compliance 1 and negatively associated with burnout on the part of ED staff 2 as well as being considered

an indicator of quality of care and a factor in pay-for-performance models. 1, 3 Factors associated with patient satisfaction in the ED have been relatively consistent during the past 2 decades, falling into the following broad categories: (1) interpersonal skills and attitude of staff (eg, courtesy, caring, concern, respect), (2) communication or providing explanations and information to patients (eg, providing instructions at discharge or explaining test results or the cause of a patients symptoms), (3) wait times, and (4) perceived standards of care. 4, 5 Other studies have had similar findings 6, 7 and have added factors related to the environment of the ED (eg, cleanliness, privacy). 8, 9 King et al. recently linked overcrowding in the ED to lower patient satisfaction. 10 Although during the early stages of COVID-19 pandemic (March to May 2020), some hospitals in New York City (NYC)

were overrun with patients, some EDs saw a decrease in patients likely due to a combination of patients with non-COVID-19-related concerns staying away from the hospital, a decrease in ED visit drivers (eg, decreases in communicable diseases and motor vehicle collisions due to adherence to masking/distancing measures and stay-at-home orders), and rapid adjustments to outpatient practice patterns, including expanded availability of telehealth and clinical call centers. Thus, paradoxically, some EDs in the New York metro area may have seen fewer patients during the early COVID-19 surge than during more typical times. 11

This study addresses the following 2 important concepts in emergency medicine: COVID-19 and its potential effects on patient satisfaction.

The current study was prompted by a review of Press Ganey patient satisfaction surveys that revealed an improvement in overall ratings during first wave of COVID-19 (March to May 2020) in 1 ED in a suburb of NYC. This begged the following questions: What contributed to improvement in patient satisfaction during the early COVID-19 surge, and what can we learn from this going forward?

Consistent with the uncertainty of the early pandemic, the approach to analyzing patient satisfaction during the advent of COVID-19 must be one of allowing for the unknown. A simple review of pre-COVID-19 Likert-scale ratings might miss important factors that previous research and assessment instruments had no basis to consider. 12 A qualitative approach to analyzing patient comments on the Press Ganey survey would allow for the discovery of novel contributors to

The COVID-19 pandemic brought many unknowns, including the impact on emergency department patient satisfaction.

Using a combination of quantitative (Press Ganey) and qualitative data, the authors found improved satisfaction scores based on the redirection of emphasis from wait times to gratitude for care.

(and detractors from) patient satisfaction as identified in patients' own words and based on their own experiences. 12 This qualitative exploration was followed with a descriptive analysis of the proportion of comments in various categories. The findings of the 2 methods were integrated to determine the meaning and potential implications of the differences and similarities across 2019 and 2020 and across satisfied and dissatisfied patients. Although hospitals and health systems continued to struggle for at least a year after this, this early period differed in its sense of uncertainty and panic. The NY metro area was termed the "epicenter" for the United States with citizens and medical personnel unsure of the mode of transmission and most effective treatments. 13, 14 The Press Ganey self-report survey at the institution in the current study was sent to ≈30% of patients discharged from the ED via postal mail within 1 to 2 weeks of their ED visit, and the remainder of patients received an email with a link to a survey to their email on file. Surveys were not sent to patients who were admitted, transferred, left without being evaluated, or who died in the ED.

Press Ganey ratings were based on care provided in the ED at a sin- 

The patient satisfaction survey is a 4-page, 50-item instrument 

Of the 5 authors, 4 took part in a directed content analysis using the following 5 predetermined broad categories identified in the extant literature on patient satisfaction in the ED: 4-10 (1) communication, (2) staff attitude, (3) wait time/efficiency, (4) level of care, and (5) ED environment. Individual comments were categorized into all appropriate categories (eg, the comment "I was in and out so quickly and every person was so concerned and polite" was categorized as a comment about wait time as well as staff attitude). Some comments fit into just 1 category, whereas others were coded into as many as 4 categories.

However, a small number of items arose that did not appear to fit into predetermined categories. When 10 or more comments that did not fit in predetermined categories were agreed to represent some additional concept, another category was created. Consequently, 2 additional categories ("specific staff" and "general positive or negative comment") were added for a total of 7 categories compared across 2019 and 2020. An eighth category, "covid-19 specific," was created for 2020 comments. 

The frequencies of comments across the 8 categories (staff attitude, level of care, wait time, specific staff, communication, general positive or negative, ED environment, and COVID-19 specific) were tabulated for surveys with the responses "definitely recommend" and "definitely not recommend" for 2019 and 2020. Comments from respondents who indicated "probably recommend" or "probably not recommend" were not analyzed as it was felt that clear satisfaction or dissatisfaction could not be established based on these probable responses (see Figure 1 ).

Because of the categorical nature of the quantitative data, nonparametric tests were used to compare the breakdown between "definitely recommend" and "definitely not recommend" from 2019 to 2020. Chi square tests were used to compare the overall number of surveys across 2019 and 2020 in the "definitely recommend" and "definitely not recommend" groups. 

As shown in Figure 1 , the total ED patient census was 31% lower for the 3 months of 2020 (the COVID-19 surge) than the same 3 months in 2019. Press Ganey surveys were available for 281 patients in 2019 and for 148 patients in 2020 (sampling 1.52% and 1.15% of total patients, respectively). As noted previously, surveys with rating of "definitely recommend" and "definitely not recommend" were selected for analysis, bringing the total number of surveys reviewed to 289. In addition to fewer patients treated in the ED in 2020, those patients were more likely to indicate that they would "definitely recommend" (subsequently referred to as "satisfied patients") the ED (47% in 2019 vs 70%

in 2020) and less likely to indicate they would "definitely not recommend" (subsequently referred to as "dissatisfied patients") the ED (15% in 2019 vs 9% in 2020). This difference across 2019 and 2020 was statistically significant (χ 2 = 7.422, P = 0.006). Table 1 and are demonstrated graphically in Figure 2 . Table 1 

This was not a predetermined category and was derived from the openended survey question, "Is there any caregiver you would like to recognize for the excellent care he or she provided during your visit?" We noted several specific mentions by name or caregiver role description and determined a need for this additional category.

Comparison in this category did not reach statistical significance, and it is important to note that this category was not mentioned by any dissatisfied patients in 2020 and in only 1 patient comment in 2019.

However, specific staff were noted in the comments of 28% of satisfied patients in 2019 and more than one fifth of satisfied patients in 2020.

This category was added to capture comments that did not provide a clear description of what was exceptional or poor such as "Everyone was excellent!" or "Terrible experience." Patterns were opposite across the 2 years at a statistically significantly level (Fisher's exact P = 0.003). In 2019, general negative comments were proportionately greater than general positive comments, whereas in 2020, general positive comments were a greater proportion. 

The team had initially considered a separate category of "crowding/privacy," but found so few of these comments (4 in total) that this was subsumed under the general ED environment. Comments in this domain ranged from physical aspects of the ED space to the more general milieu (eg, music, refreshments, cleanliness) of the ED. Similar to the specific staff category, this category was not mentioned by any dissatisfied patients in 2020.

This final (understandably 2020 only) category was composed of comments that referred to words including "COVID," "COVID-19,"

"corona," "coronavirus," "the virus," and "the pandemic." Other less TA B L E 2 Exemplars of positive and negative comments in individual patient satisfaction categories

Staff attitude "As I was eating my lunch, a staff member who was sweeping the floor, leaned his broom against the wall and went into another cubicle and brought me a tray on wheels, so I could place my tray on it. . . he was very considerate since I had my food tray on the bed. I had told the nurse it was fine, but it really wasn't and I did not want to bother her again. He saw something he could fix, didn't ask questions and fixed it."

"When you push the button for a nurse and you see them all sitting and laughing with each other instead of working."

Communication "The doctor who explained my results/diagnosis to me told me in a way I could understand."

"Listen to the client and/or caregiver who is actually experiencing the problem that brought them in. . . after all there must have been a significant reason that person felt warranted an emergency room visit at that time of night."

Wait time "Nurse in ER was quick to get my test results so that I could be discharged quickly and safely."

"I waited 5 hours without food or water. I left the hospital after this and went home. Not acceptable."

ED environment "The area in the emergency room where I was taken for IV drip was incredible! Reclining seating, privacy, and an iPad!"

"The door to the bathroom should be made wider. . . I had to use the bathroom frequently. Since I didn't bring my walker and couldn't maneuver a wheelchair (door needs widening and door jamb needs to be level with the floor) I had to rely on staff to take me back and forth."

Specific staff "Dr.

[X]came across as a very kind & compassionate human being, and a good doctor as well." "Dr.

[X] come in the room and told my child he was caring for people who were near death and he had 100 patients. My daughter was so upset."

Perceived level of care "The doctor considered different explanations for my symptoms based on a discussion we had about my medical history and took steps to rule them out: A very scientific approach."

"Don't suggest that I don't need anything when my blood pressure was way above normal and my primary doctor sent me to the ER."

General positive or negative comment "I couldn't ask for better." "Emergency room caregivers were all terrible."

COVID-19 specific (2020 only)

"We appreciate EVERYTHING that was done at the time of the visit.

We know what a difficult time it is for everyone now."

"I was sent to ER by (another doctor) for COVID-19 but no check swab test or blood test and told me I have COVID-19?"

pointed comments such as "stay safe" or "healthcare heroes," although not specifically denoting COVID-19, were interpreted to be related to the pandemic, and they appeared to become part of the vernacular related to the pandemic. 16 Although there was no opportunity for quantitative statistical 

The authors had hoped to reveal precisely what contributed to "Wait time" was not a frequent comment category for satisfied patients in either 2019 or 2020, but among dissatisfied patients, it was mentioned twice as much 2019 than in 2020. It is possible that due to the lower census, there simply was not as much waiting in 2020 or alternatively, patients were willing to overlook this issue during COVID-19, as suggested by the content of some comments.

In 2019, the general negative comments were proportionately greater than the general positive comments, whereas in 2020, the reverse pattern held. This is likely affected by the higher level of reported patient satisfaction in 2020, but we theorize, based on comments in the "COVID-19 specific" category, that patients may have held a generally more positive view of and appreciation for receiving any care at all during the first 3 months of the pandemic.

Some patterns remained stable across 2019 and 2020. For instance, dissatisfied patients tended to comment on concerns about their perceived level of care more than satisfied patients during both years, and satisfied patients tended to name specific staff in their comments to a greater extent than dissatisfied patients in 2019 and 2020.

Across years and satisfaction levels, the ED environment did not emerge as a strong contributor to satisfaction as was expected based on the literature review. However, the ED in the current study had been renovated in 2017 with an eye toward making it comfortable and functional for patients and staff. One possibility is that the ED environment might be noticed if it was consistently poor but is less notable when its condition is adequate or better. In the same vein, there were not as many comments about crowding as expected, but the renovation involved tripling the square footage of the ED in 2017.

Review of the contents of the COVID-19-specific comments suggested, for satisfied patients, a tendency to be grateful for care and the tendency to overlook some concerns. For dissatisfied patients, the COVID-19-specific comments suggested that they might have been feeling particularly vulnerable, and a large percentage of dissatisfied patient comments related to staff attitude. It is not possible to ascertain whether this was due to patients' own apprehension afftecting their interpretation of staff atittude, staff apprehension in the midst of a pandemic truly affecting staff attitude, or a combination of both.

Regardless, this suggests that it is important to keep in mind that this is likely a time of heightened emotions for both healthcare workers and patients.

In summary, COVID-19 appeared to have had a positive effect on the overall level of patient satisfaction possibly due to, at least in part, a decrease in total ED census. Consistent with this, dissatisfied patients in 2020 did not note wait time as frequently as dissatisfied patients in 2019. The breakdown of patient comments revealed that many aspects remained relatively stable in their importance across 2019 and 2020.

However, in 2020, patient general comments tended to be more positive. This makes intuitive sense in the context of COVID-19 specific comments that suggested an overall gratitude for care in the early stage of the pandemic. It is hoped that the COVID-19 pandemic will soon be resolved, but this information may hold potential importance for patient satisfaction going forward in unforseen times of stress and uncertainty.

The authors declare no conflict of interest. 

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PhD, is a clinical associate professor in the Department of Behavioral and Social Sciences at the University of Houston College of Medicine

What can COVID-19 teach us about patient satisfaction in the emergency department? A mixed-methods approach