Declined Patient Satisfaction in The Emergency Department

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Declining patient satisfaction in the emergency department (ED) demands urgent resolution. Aspects worsening patient experience at the ED are long waiting times, congestion at waiting rooms, long queues, and high rates of patients leaving without being treated. These aspects lead to poor service delivery, thereby damaging the reputation of the hospital’s ED. If the challenges remain unsolved, the hospital with a record-high rate of decreased revenue collection since the high number of patients leaving to seek services from other hospitals and cannot refer others to seek care from the hospital. The emergency department is the main source of the revenue collection of the hospital. There should be a computerized system to help patients avoid document loss, information leakage, and noncompliance to the ED’s clarence procedures. From a cultural perspective, respecting patients’ rights, their beliefs, and protecting confidentiality enhances patient satisfaction. The violation of patients’ rights and privacy make them unhappy with provided services. Policies are needed to ensure nurses and physicians observe culture and ethics to improve the satisfaction of patients. Most states in the U.S. have enacted laws on patient confidentiality to maintain legal compliance in the ED. A practice of audiovisual recording is unethical within the ED. There is a need to post precautions in the emergency room, waiting for the bay, and patient wards to discourage such acts. Emergency departments need to consider compliance with scientific, analytical, cultural, legal, and ethical demands to enhance patient satisfaction.

Keywords: patient satisfaction, the emergency department, confidentiality, policies



Declined Patient Satisfaction in The Emergency Department

In the 21st century, hospital emergency departments (EDs), along with healthcare providers working in these departments, are a crucial element of the United States (U.S.) healthcare system. For a half-century, EDs have emerged as a promising feature of transforming the U.S. healthcare system. As emergency care continues to evolve, patients, care workers, emergency care services, and facilities have experience evident changes because of the increasing daily number of patient visits. These patients are different and perceive the provision of services differently, an implication that healthcare providers need to consider ethical, cultural, and legal to satisfy patients’ needs. These diverse patients expect getting quality emergency care services without waiting for long, queuing, leaving without being treated, and crowding the ED. Congress affirmed the ED’s role as the key safety net for U.S. healthcare by enacting the Emergency Medical Treatment and Labor Act (EMTALA) in 1986. In the U.S., most states have passed laws on patient confidentiality which enable an individual to make part of interplay to record it because only consent from one party is needed to get care services in the ED. The increasing patient visits imply the EDs become overwhelmed, especially if the manual system is the only system for clearing and admitting patients. Declined patient dissatisfaction is a measure of the level of patients getting satisfied with offered emergence care services, including the consequences of the decline in terms of revenue generation and hospital reputation, all of which need a computerized system as a remedy to ensure increasing patient satisfaction.

The decreasing patient satisfaction scores in the hospital emergency department (ED) undermine patient experience who need urgent and immediate attention emergence care services. Many patients take a long time from arrival to admission to discharge, thereby forcing them not to make referrals to the hospital. For instance, suppose the hospital needs to hypothetically increase patient satisfaction scores from the 10th percentile to the 60th percentile and increase the patient volume by 10% from the mean of 7,000 patients per quarter to 8,000 patients per quarter. In that case, it must adopt a computerized clearance and admission system in the emergency room to ensure the work’s fast flow. This system will enhance workflow within the department and enhance the level at which patients get satisfied with provided services.

Patients’ declined satisfaction scores from the emergency department lead to damage to the hospital image and reputation in general. These declining scores imply increased rates of patients leaving without being treated who attribute the condition to poor emergency care services delivery (Vashi, Sheikhi, Nshton, Ellman, Rajagopal, & Asch, 2018). The main causes of patient dissatisfaction are length waits before getting admitted, and patients walking without being treated (Unwin, Nurs, Kinsman, Rigby, & Nurs, 2016). The emergency department’s policies determine the productivity of nurses in terms of clearing patients to receive emergency services. Many patients decide to leave to look for care services in other hospitals if their current healthcare facility cannot meet their care needs and demands. These incidences are the ones that significantly contribute to decreased patient satisfaction.

The improvement and enhancement of the ED operational efficiency facilitate the hospital to accommodate increased volume while enhancing the quality of care and satisfaction of the ED patients who have minimal additional resources, space, or staffing. In the United States, between 1995 to 2009, the yearly ED visits had increased from 96.5 million to 136.1 million (Sayah, Rogers, Devarajan, Kingsley-Rocker, & Lobon, 2014). This improvement was an increment of 41%, meaning the country’s healthcare system was supposed to have adequate healthcare facilities with enough ED resources to accommodate increased patient visits. Fortunately, the U.S. has witnessed decreasing lengthy ED waits, leaving without being treated, and increased quality care outcomes and patient satisfaction scores (Sayah et al., 2014). According to Sayah et al., (2014), in 2010, only 31% of American Emergency Departments had attained the required triage targets for their patients, and the other 48% healthcare facilities hospitalized their patients within 6 hours.

The impact of decreased patient satisfaction scores implies reduced revenue generation from the emergency department (ED). ED is the leading source and center for revenue collection in any hospital, which supports other departments’ operations. If patients leave without being treated, it means they do not make any payment to the ED; thus, revenue continues decreasing such that the hospital cannot meet its financial needs to operate. So, the impacts of reduced satisfaction scores directly affect the hospital’s ED and finance department in general.

Within the emergency department, various operational issues are leading to challenges such as IT system leaking patient charts and leaving them unprocessed and, therefore, payment left unaccounted, and patients leaving without treatment (LWOT) (Baker & Marco, 2020). From an analytical point of view, the loss of documents and charts represent revenue loss and increases incidences of non-compliance. For instance, the assumed analysis below explains how ED can experience revenue loss:

Annual patient visits are 100,000. Assuming that the lengthy waits lower the visits to 85,000 due to patients leaving without being treated (LWBT) and that professional fee reimbursement is $120 per patient visit, the impact of LWBT will be an annual loss of $1.8 million in professional-fee revenue due to low patient flow. If the ED has a yearly LWBT rate of 3%, it will incur a revenue loss of $375,000 in fee revenue.

The primary issues linked to decreasing satisfaction scores involve an unmet expectation of patients needing emergency care services and damage to reputation. The given emergence services should be patient-centered to ensure that the satisfaction scores remain high. The damage to the hospital’s reputation is one of the core areas that need greater attention. Also, the significance of meeting patient care needs may positively impact the reputation of nurses working at the ED. For every 100 patient visits, 50 patients leave before seeing the care provider. Assuming that each patient visit contributes $250, it means when 50 leave the ED, the hospital loses a revenue of $12,500.

Valid patient satisfaction scores motivated the ED to improve the delivery of quality care. If the scores decline, ED, physicians, and entire hospital are negatively affected. For instance, declining scores demotivates physicians or clinicians and affect their job satisfaction because the healthcare outcomes are discouraging and not motivating. In a study by Bachman (2016), 78% of nurses said patient satisfaction scores adversely impacted their work satisfaction in a negative way, and 28% said that the scores make them think of quitting. The manual system’s use to enter patient data, store, and retrieve is the major leading cause of slow patient workflow. Suppose nurses working at ED fail to meet patients’ expectations due to this manual system used to enter, store, and retrieve data. In that case, the outcome is overcrowding, lengthy waits, and leaving without being treated (Vashi et al., 2018). This manual system cause inconveniences that translate to declining patient satisfaction scores.

Patients expect getting quality emergency care services from ED. As a result, nurses and physicians should concentrate on observing cultural, ethical, legal, and regulatory guidelines to make legitimate decisions that do not lead to declined patient satisfaction scores. When providing treatment to ED patients, it is critical to consider their consent because any ED’s decision, contrary to their wish, is likely to decrease satisfaction scores. Various ethical, cultural, legal, and regulations determine the level of patient satisfaction at ED depending on how nurses put into practice such factors.

The American College of Emergency Physicians (ACEP) directs healthcare facilities to develop and implement regulations concerning patient audiovisual recording within the emergency department, involving limitations in areas with a justifiable expectation of confidentiality (Iserson, Allan, Geiderman, & Goett, 2019). Depending on the state and hospital, rules and regulations that restrict audiovisual recordings vary. For instance, healthcare centers such as Cedars Sinai in Los Angeles and Vail Medical Center in Colorado have implemented laws limiting most recordings that even family members of patients have granted a permission.

In many states, confidentiality legislation permits an individual making part of a discussion or interplay to record it because only consent from one party is required to receive treatment in the emergency department. That consent requirement implies that even if an individual is not a party to the discussion, for instance, family members overseeing interactions of a care provider with a sick person, they can record the interplay provided that one party gets participates in consent. From 2019, any audiovisual-based recording among ED patients without two-party consent became unlawful in more than eleven states, normally as part of their wiretapping legislation. For instance, according to Iserson et al., (2019), California law gives at most $2500 penalty and one-year imprisonment due to violation of audiovisual recording Act.

Iserson et al., (2019) review ethical and legal issues facing emergency departments that struggle to improve patient satisfaction scores. Through the research, audiovisual recording within emergency departments is unethical and illegal since it violates patient privacy and confidentiality rights. Since patients are not supposed to be recorded without their consent, nurses who record them continue to lower patient satisfaction since recording make patients’ experience hard (Iserson et al., 2019). In general, recording images and voices of ED patients raises legal and ethical concerns. Moskop et al., (2019) review ethical and moral consequences that result from overcrowding within the emergency department (Moskop, Geiderman, Marshall, McGreevy, Derse, Bookman, & Iserson, 2019). The article indicates that some of the significant moral and ethical outcomes of overcrowding are delivering poor patient outcomes, medication mistakes, and compromised patient privacy and confidentiality.

Hospitals have focused on discouraging illegal audiovisual recording by posting precautions at the admission rooms, waiting hall, and patient rooms. As a result of the varying privacy and confidential Acts, nurses at ED need to work as if they are ever being recorded, all the time keeping professionalism and communicating precisely. Taking patient photographs present a significant challenge. Because these photographs do not include audio recording, they are not restricted or prohibited, even in states requiring two-party consent, unless certain laws exist (Iserson et al., 2019). However, they can be illegal and prohibited in private healthcare centers with policies regarding photography. Offences may lead to a breach of the right of a person to confidentiality.

From the perspective of ethical theories, utilitarianism theory best explains the consequences of ED situations with long waits, overcrowding, and patients leaving without being treated. Under the context of utilitarianism, hospitals should predict patient satisfaction consequences if they decide to offer emergency care services in an environment that is not conducive for patients. When the ED becomes congested, experiences slow workflow, and many patients are leaving without treatment; it means that the hospital, ED, in particular, does not act in a way that benefits patients seeking emergency services (McCarthy, Mikkola, & Thomas, 2020). This act may increase death risks. As a result, patients feel unsatisfied with the offered services and may consider seeking emergency care services from other hospitals.

According to Govere & Govere, (2016), healthcare workers should consider cultural and ethical factors to enhance general patient satisfaction. According to the article, the United States experiences increased healthcare disparities and needs, minority groups, regulations, and ethical requirements (Govere, & Govere, 2016). Respecting a patient’s right, cultural beliefs, right to life, make a decision, and respect is critical for healthcare specialists to be culturally qualified to offer quality care and enhance satisfaction of patient, especially among marginalized populations.

Emergency departments experience tremendous issues and challenges when giving high-quality emergence care to patients of different backgrounds. There are shortages of linguistically and ethnically diverse nurses who can help in ameliorating ethnic disparities in ED. Cultural factors prevalent among ethnic groups are supportive and substitute medicine, health insurance‐related prejudice, racial concordance of a nurse and patient, and discrimination on age basis. Spirituality, the participation of a family of patient in making healthcare choices, and ethnicity‐based discrimination are unique to minority groups (Nápoles‐Springer, Santoyo, Houston, Pérez‐Stable, & Stewart, 2005). Experiences concerning the acceptance of nurses of complementary and alternative drugs are mixed among blacks, with most physicians at ED implying insensitivity to choices of patients receiving emergence care services.

Blacks feel that nurses are too fast to disregard their home medication or are not sensitive to cultural values and beliefs, such as forbid needle sticks. At ED, African American patients have a perception that nurses did not listen to them when they brought up for alternative emergence care treatment. As a result, such patients do not get satisfied with offered care services because they feel being disrespected to their beliefs. Spanish‐speaking patients reveal significant dissatisfaction with English‐speaking physicians working at the ED. As a result, these patients feel that they get low quality quality care services compared to their English‐speaking counterparts. Most Spanish‐speaking patients at ED experience delay because they fear that non‐Spanish‐speaking nurses are not committed to attending them. As a result, this delay becomes a barrier when accessing healthcare (Nápoles‐Springer et al., 2005). A dominant notion is that the ED staff is mostly not willing to help Spanish‐speaking patients. However, the presence of Spanish‐speaking nurses at ED enhance the workflow since the communication gets eased, and delivery of the services is fast due to a greater understanding of each other.

Among most African–American patients visiting the emergency department for healthcare services, the probability of being discriminated due to race and biasness exists during hospital admission with a racially discordant nurse. Depending on particular non‐verbal gestures, such as keeping nurse-patient physical distance or hesitating to come into contact with a patient when performing surgery, black patients perceive nurses as acting on prejudice (Nápoles‐Springer et al., 2005). As a result, they get some bad vibe, how a nurse or physician treats them. Patients, therefore, do not appreciate the services, and their satisfaction scores continue to decline.

Nurses and physicians should concentrate on observing cultural, ethical, legal, and regulatory guidelines to make legitimate decisions that do not lead to declined patient satisfaction scores. Healthcare providers consider cultural and ethical factors when providing care services to patients. Patients get satisfied when they feel their rights are respected, cultural beliefs recognized, and confidentiality protected. The violation of patients’ rights and privacy make them unhappy with the provided services. Healthcare facilities have implemented policies that ensure nurses and physicians observe culture and ethics to improve the satisfaction of patients. When providing treatment to ED patients, it is critical to consider their consent because any ED’s decision, contrary to their wish, is likely to decrease satisfaction scores.

In many circumstances at the ED, patients want to know and determine if the nurses or physicians they are dealing with them are prejudiced. For instance, some black patients think that nurses at some point assume that they are intellectually weak and not superior, or drug dealers depending on their race. Blacks perceive that nurses treat them as whites when they are involved in making decisions regarding their treatment (Nápoles‐Springer et al., 2005). For instance, a young adult, English‐speaking Latina women think that they are stereotyped by ED nurses as people who can withstand pain for some time, hence do not need emergency care.

Nurses at ED should fulfill their emergency care professional obligations to improve patient satisfaction with provided services. Under EMTALA law, they must offer emergency care services to all patients and enhance how patients can easily access care (Kraus, Moskop, Marshall, Bookman, & ACEP Ethics Committee, 2020). This law emphasizes the code of ethics for nurses on duty who must not engage in unethical practices such as causing injury and denying patients the right to quality emergence care services. As a result, compliance with the ethical and legal laws can describe responsible stewardship as a dual role to patients and communities to make prudent decisions on allocating resources depending on the urgency of the emergency medical. Generally, the fulfillment of the obligation leads to increased patient satisfaction scores in the ED.

The improvement of emergency care delivery will involve installing a computerized system, Emergency Department System Information (EDIS), that is associated with some economic impact. EDIS is costly and will require the hospital to invest in achieving the necessary change in ED. Once installed, the ED will increase the revenue generation since more patients will get cleared within the shortest time, indicating that many patients will pay more to get emergency services. The ED’s manual system is the main reason behind patients’ complaints about the dissatisfaction with emergency care services offered, which are associated with patients’ experience of long waits, overcrowding, and even leave without being attended (Emergency Care Report, 2020).

According to a study by Newgard, Zive, Jui, Weathers, & Daya (2012), the manual data processing and record abstraction in the ED cannot enhance efficiency in the workflow. Only ED using Electronic Health Records has attained increased effectiveness and efficiency in delivering emergency services that satisfy the needs of patients. The satisfaction scores continue to decline because the manual data processing that involves chart matching, data retrieval, and data entry by a nurse leads to medication errors. Nurses are aware of such declined scores because patients complain about an unclear prescription for medicine, which does not have clear labels. If the ED entirely implements the Electronic Health Record system, the emergency room will not experience overcrowding, and all patients will not leave without being treated.

The hospital continues to lose the revenue collected from ED because when more patients leave without being treated, it means they do not pay. Nurses working at the ED can witness patients’ complaints concerning the hospital’s poor systems that cannot ensure easy tracking of patients’ clinical data and information during admission and discharge. The slow search and retrieval lead to overcrowding since the processing takes long with the manual system. For instance, a nurse can take more than 10 minutes tracking and retrieving a single patient data from the manual data system and even if the data is retrieved, it has high chances of containing errors. These errors may mislead a nurse performing surgery because some nurses do not use explicit language that is clear to read and understand. With EDIS, the system can retrieve data for more than ten patients within 10 minutes, thereby increasing smooth and fast workflow (Newgard, Zive, Jui, Weathers, & Daya. 2012). This data does not contain any error unless it was entered wrongly during storage.

Conclusively, declining patient satisfaction determines the level at which patients get satisfied with offered emergence care services. This determination involves the consequences of the decline in terms of revenue generation and hospital reputation, all of which need a computerized system as a remedy to ensure increasing patient satisfaction. The increasing number of patients leaving the ED without being treated and overcrowding at the emergency rooms and waiting halls threaten the generation of revenue from. Cultural, legal, and ethical factors are critical determinants of the outcome of the level of patient satisfaction scores among patients at the ED. Audiovisual recording, privacy and confidentiality, cultural competency, and respect for patient choice are major issues that determine patient satisfaction within the ED. Nurses and physicians should acknowledge the potential value and usefulness of audiovisual recording in the ED and push for the hospital’s take on consistent specialty-broad and local regulations that stress safeguarding patient privacy to improve patient satisfaction. Cultural-associated issues such as discrimination, stereotypes, and language barriers undermine patients’ happiness at the emergency department. Overall, hospitals, through their emergency departments, should reconsider having culturally qualified healthcare workers who can comply with laws, ethics and practice a high level of professionalism when handling diverse patients to ensure increased patient satisfaction. Based on the main issue facing the ED, an automated system is needed to facilitate easy storage, tracking, and retrieval of data to enhance smooth work-flow at ED, thereby increasing patient satisfaction scores. It will also ensure an increase in revenue generation since more people visiting the ED will get admitted without any delay. In general, increased patient satisfaction scores rely on the used ED system that should be computerized rather than manual data processing.


















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