Stephen L. Adams

Effects of Actual Waiting Time, Perceived Waiting Time, Information Delivery, and Expressive Quality on Patient Satisfaction in the Emergency Department

STUDY OBJECTIVE To determine the effects of actual waiting time, perception of waiting time, information delivery, and expressive quality on patient satisfaction. METHODS During a 12-month study period, a questionnaire was administered by telephone to a random sample of patients who had presented to a suburban community hospital emergency department during the preceding 2 to 4 weeks. Respondents were asked several questions concerning waiting times (ie, time from triage until examination by the emergency physician and time from triage until discharge from the ED), information delivery (eg, explanations of procedures and delays), expressive quality (eg, courteousness, friendliness), and overall patient satisfaction. RESULTS There were 1,631 respondents. The perception that waiting times were less than expected was associated with a positive overall satisfaction rating for the ED encounter (P < .001). Satisfaction with information delivery and with ED staff expressive quality were also positively associated with overall satisfaction during the ED encounter (P < .001). Actual waiting times were not predictive of overall patient satisfaction (P = NS). CONCLUSION Perceptions regarding waiting time, information delivery, and expressive quality predict overall patient satisfaction, but actual waiting times do not. Providing information, projecting expressive quality, and managing waiting time perceptions and expectations may be a more effective strategy to achieve improved patient satisfaction in the ED than decreasing actual waiting time.

Prospective evaluation of syncope

One hundred seventy patients with syncope presenting to an emergency department were studied prospectively. A checklist was used to supplement the physicians history and physical to ensure adequate recording of potentially useful data. Follow-up data were available in 89% of patients with a mean follow-up period of 6.2 months. Patients were categorized by presumed etiology using specific criteria. Typical vasovagal syncope occurred in 37.1% of patients. Other etiologies included first seizure (8.8%), orthostasis (7.6%), cardiac (4.1%), micturition (2.4%), hypoglycemia (1.8%), and psychogenic (0.6%). Syncope of unknown etiology accounted for 37.6% of the patients. The estimated duration of warning period was significantly shorter in patients with cardiac syncope compared to patients with vasovagal syncope. The yield of laboratory tests was low with the exception of the serum bicarbonate, which was decreased in 70% of our seizure patients. Recommendations regarding initial evaluation and admission are discussed.

Predicting patient satisfaction : A study of two emergency departments

To identify perceptions that predict overall patient (dis)satisfaction with Emergency Department (ED) care, we studied responses to a survey mailed to all discharged patients over a 6-month period (Academic Hospital), and to a telephone interview of a random sample of discharged patients over a 1-year period (Community Hospital). The survey and interview both assessed overall satisfaction, as well as satisfaction with perceived waiting times, information delivery, and expressive quality of physicians, nurses, and staff. Data for 1176 patients (training sample) and 1101 patients (holdout sample) who rated overall satisfaction as either “very good” or “very poor” (Academic Hospital), and for 856 patients (training sample) and 431 patients (holdout sample) who rated overall satisfaction as either “excellent” or “poor” (Community Hospital), were retained for analysis. For both hospitals, nonlinear tree models efficiently achieved overall classification accuracy exceeding 98% in training analysis and 95% in holdout analysis (all p < .0001). The findings suggest that overall patient (dis)satisfaction with care received in the ED is nearly perfectly predictable on the basis of patient-rated expressive qualities of ED staff, particularly physicians and nurses. Interventions designed to reinforce positive (and extinguish negative) expressive health-care provider behaviors may cut the number of extremely dissatisfied patients in half.

The Medicinal Leech: A Page from the Annelids of Internal Medicine

Leeches have been used in health care since ancient times by physician and layman alike. As just one of several methods of bloodletting, the leech became the focus of a science that included such subjects as indications, modes of attachment, complications, and relative contraindications. The popularity of leeching has varied immensely over the years. In the 19th century, this annelid saw its numbers decimated because of protean medicinal indications. The leech lost its hold on the practice of medicine in the early 20th century. Recently, the use of leeches has resurged in both the lay and the scientific communities.

How Accurate Are Waiting Time Perceptions of Patients in the Emergency Department

STUDY OBJECTIVE To assess the ability of patients to accurately estimate specific waiting times in the emergency department. METHODS A questionnaire was administered by telephone to a random sample of 776 patients (or parents or responsible caretakers, if appropriate) who had been treated within the previous 2 to 4 weeks in the ED of a suburban hospital. Respondents were asked their perceptions of two particular time frames: (1) the time elapsed from triage until initial examination by the emergency physician (physician waiting time [PWT]), and (2) the time elapsed from triage until departure from the ED (total waiting time [TWT]). Corresponding actual times were extracted from a computerized database. Time frames were divided into discrete periods for comparison. The correspondence between actual and perceived times was assessed by optimal data analysis. RESULTS Only 22.3% of the respondents accurately estimated PWT. Although this level of accuracy is statistically significant (P < .0001), it reflects only 11% of the theoretically possible improvement in accuracy beyond chance. More respondents overestimated than underestimated PWT (49.9% versus 27.8%, respectively). In contrast, TWT was accurately estimated by 36.6% of the respondents (P < .0001), reflecting 18% of the theoretically possible improvement in accuracy beyond chance. Fewer respondents overestimated than underestimated TWT (24.5% versus 38.9%, respectively). CONCLUSION Patients are not very accurate in their estimation of actual waiting times. Although fewer than one fourth of the respondents overestimated the TWT spent in the ED, almost half the respondents overestimated the PWT.

The full moon and ED patient volumes: Unearthing a myth

To determine if there is any effect of the full moon on emergency department (ED) patient volume, ambulance runs, admissions, or admissions to a monitored unit, a retrospective analysis of the hospital electronic records of all patients seen in an ED during a 4-year period was conducted in an ED of a suburban community hospital. A full moon occurred 49 times during the study period. There were 150,999 patient visits to the ED during the study period, of which 34,649 patients arrived by ambulance. A total of 35,087 patients was admitted to the hospital and 11,278 patients were admitted to a monitored unit. No significant differences were found in total patient visits, ambulance runs, admissions to the hospital, or admissions to a monitored unit on days of the full moon. The occurrence of a full moon has no effect on ED patient volume, ambulance runs, admissions, or admissions to a monitored unit.

Drugs that may exacerbate myasthenia gravis.

Myasthenia gravis is an uncommon disease. The emergency physician should be cautious when prescribing medications to myasthenics for problems not related to myasthenia gravis. We have discussed some of those agents (Figure 3) that are recognized to cause exacerbation of MG or that may have the potential to exacerbate MG. We recommend that management of any medical or surgical problem of the myasthenic be done in consultation with a managing neurologist, and that either early follow-up or admission is necessary when these agents are used in the patient with myasthenia gravis.

The Relationship Between Parental Income and Academic Performance of Medical Students.

Purpose To test the hypothesis that family financial status is associated with the academic performance of a medical student. Method The relationships between parental income and mean scores on the Medical College Admission Test (MCAT) and United States Medical Licensing Examination (USMLE) Step 1 were examined for the students in the 1994 and 1995 graduating classes at the UMDNJ–New Jersey Medical School who had applied for financial aid in 1991 and reported annual parental income. Pearson correlations were used to analyze separately the data for minority and majority students, for men and women, and for the four subgroups by gender and race–ethnicity. Results The final study cohort consisted of 192 students (55% of all students). Significant positive correlations were found between the (1) MCAT and USMLE Step 1 for the women, men, majority, and minority students, (2) MCAT and parental income for the subgroups of majority men and minority women, and (3) USMLE Step 1 and parental income for the subgroup of minority women. Conclusion Parental income was correlated significantly with performances on the MCAT and USMLE Step 1. These relationships may be particularly strong and persistent for minority women.

Methanol poisoning as a result of inhalational solvent abuse

We report an unusual presentation of solvent abuse. A 17-year-old boy was brought to the emergency department after he inhaled fumes from a rag soaked with a carburetor cleaner containing toluene, methylene chloride, and methanol. Considered to be intoxicated from the acute effects of sniffing toluene or methylene chloride, the patient remained lethargic and ataxic despite removal from exposure and administration of supplemental oxygen. Subsequently, he was found to have a toxic serum methanol level (23 mg/dL). Toluene, methylene chloride, and methanol are widely used in industry and carry potential occupational risks for exposure. These agents are also found in many products available for home use. The toxicology and management of each of the agents in this exposure are discussed.

Relative bradycardia in patients with isolated penetrating abdominal trauma and isolated extremity trauma

A relative bradycardia is sometimes seen in patients with hemorrhagic shock. The phenomenon of relative bradycardia in civilian patients with isolated penetrating abdominal trauma and isolated severe extremity trauma who presented to an urban trauma center was studied retrospectively. Relative bradycardia was defined as a pulse rate of less than 100 with a concomitant systolic blood pressure of less than 100 mm Hg. There were 256 patients with isolated penetrating abdominal trauma and 938 patients with isolated severe extremity trauma. The incidence of relative bradycardia was 3.1% (eight of 256) in the group with abdominal trauma and 1.8% (17 of 938) in the group with extremity trauma. A pulse rate less than 100 was documented in 35.2% of all patients presenting with a systolic blood pressure less than 100 mm Hg (25 of 71). A pulse rate of less than 100 was documented in 45.8% of all patients presenting with a systolic blood pressure less than 90 mm Hg (11 of 24). No increased mortality was seen in the patients who evidenced relative bradycardia. The effect of intraperitoneal bleeding on the normal tachycardic response to hemorrhage also was studied. After controlling for volume status using various operational definitions of shock, no statistically significant (P less than .01) difference in pulse rates was noted between patients with isolated penetrating abdominal trauma and isolated extremity trauma. This result suggests that the previously theorized vagal-mediated bradycardia unique to intraperitoneal bleeding may not exist.