Correspondence / American Journal of Emergency Medicine 33 (2015) 108–122 [2] Grover C, Elder J, Close R, Curry S. How frequently are “classic” drug-seeking behaviors used by drug-seeking patients in the emergency department? West J Emerg Med 2012;13(5):416–21. [3] Grover CA, Garmel GM. How do emergency physicians interpret prescription narcotic history when assessing patients presenting to the emergency department with pain? Perm J 2012;16(4):32–6. [4] Baehren DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med 2010;56(1):19–23.e1-3 [Epub 2010 Jan 4]. [5] Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR. Characteristics of opioid prescriptions in 2009. JAMA 2011;305(13):1299–301. [6] Kunins H, Farley T, Dowell D. Guidelines for opioid prescription: why emergency physicians need support. In the balance on www.annals.org; 2013. [7] Heins J, Heins A, Grammas M, Costello M, Huang K, Mishra S. Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department. J Emerg Nurs 2006;32(3):219–24. [8] Office of Diversion Control. State prescription drug monitoring programs; 2011 [Retrieved September 24, 2014, from http://www.deadiversion.usdoj.gov/faq/rx_ monitor.htm].

ED operational factors associated with patient satisfaction☆,☆☆ To the Editor, High patient satisfaction scores are associated with improved patient outcomes [1,2]. As such, patient satisfaction scores have become critical quality benchmarks for hospitals, are publically reported, and are often tied to financial incentives [3–6]. The emergency department (ED) is currently exempt from direct financial penalties in regard to patient satisfaction, although ED care affects inpatient satisfaction scores [7]. Whether financial payments will be tied to ED patient satisfaction in the future is unknown, but will likely occur given the link between ED care and inpatient satisfaction. Previous research demonstrates operational factors associated with patient satisfaction scores, such as the wait time to see a physician, patients' perceived wait time, treatment time, and length of stay greater than 6 hours in the ED [7–11]. However, these studies have been limited by small sample sizes, missing data, use of nonvalidated surveys, crosssectional study populations, or a focus on admitted patients. We conducted an exploratory analysis to determine operational factors and clinical characteristics associated with patient satisfaction scores over an 18-month period involving more than 2000 ED patients. We hypothesized that longer ED length of stay, door-to-doctor time, and prolonged wait time would be associated with lower patient satisfaction scores among discharged ED patients. This institutional review board–approved pilot study was conducted at an urban, academic ED with more than 85 000 annual visits. Per institutional protocol, 30% of discharged patients are randomly selected to receive the Press Ganey (PG) patient satisfaction survey, a psychometrically valid instrument, widely used to benchmark comparable institutions nationwide [12,13]. Press Ganey item questions are scored on a 5-point Likert scale (1 = very poor, 5 = very good). Data from the individual survey sections are aggregated and summarized on a 0-100 scale. The primary outcome of interest was the PG overall score (range, 0-100), dichotomized into very good scores (≥80) vs remaining scores (0-79). Only the “very good” designation was chosen, as these scores reflect top decile performance compared with similar institutions [14]. χ 2 Test and Wilcoxon rank sum test were used to evaluate for an association between very good PG scores (PG ≥ 80) and independent demographic and operational variables of interest (ie, patient demographics, ED volume, length of stay, triage acuity, and door-

☆ Conflict of interests: None. ☆☆ Author contributions: M.G. and P.S.P. conceived the study. M.G. drafted the manuscript, with D.M., M.S., J.A., and P.P. contributing substantially to its structure, form, revisions, and final draft. P.P. takes responsibility for the manuscript as a whole.

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to-doctor time). A regression analysis determined the best model for predicting very good PG scores. Backward selection, using the locked variables of sex and age, and a removal P value of .10, was performed to determine which variables of volume, time of day, door-to-doctor time, length of stay, and average daily wait time to include in the model. A total of 26981 surveys were mailed between January 2009 and July 2010. Six percent were undeliverable, whereas 2271 surveys were completed and returned (response rate of 13%). A total of 1799 discharged ED patients rated their experience as very good (≥80). Baseline characteristics, as well as differences between patients who reported very good vs others, are listed in Table 1. Multivariable analysis using threshold times (Table 2, demonstrated a door-to-doctor time less than 1 hour (Relative Risk (RR), 1.36; SE, 0.05; P b .001) and a length of stay less than 4 hours (RR, 1.12; SE, 0.04; P b .001) were more likely to give very good PG scores. Although no signs of multicollinearity were present, 2 other models (Table 2: models 2 and 3) were reviewed to determine if door-to-doctor times and length of stay continued to be significant predictors on their own. In model 2 (Table 2), those with a door-to-doctor time less than 1 hour were 1.40 times more likely to give a very good score than those with a door-todoctor time exceeding 1 hour (P b .001). In model 3 (Table 2), those with a length of stay less than 4 hours were 1.21 times more likely to give a very good score than those with a length of stay exceeding 4 hours (P b .001). When door-to-doctor and length of stay were analyzed continuously or broken up into 30-minute blocks (Tables 3 and 4), both scenarios

Table 1 Bivariate analysis for very good PG scores (PG ≥ 80) Characteristic

Age (y), mean (SD) Female (%) Acuity (%) Resuscitation Emergent Urgent Semiurgent Nonurgent Door-to-doctor (min), mean (SD) Door-to-doctor (no. of 30-min blocks), mean (SD) Door-to-doctor (%) 0-60 min N60 min Length of stay (min), mean (SD) Length of stay (no. of 30-min blocks), mean (SD) Length of stay (%) 0-240 min N240 min Mean wait time (min), mean (SD) Mean wait time (no. of 30-min blocks), mean (SD) Mean wait time (%) 0-30 min N30 min Time of day (%) 7:00 AM–7:00 PM 7:00 PM–7:00 AM Patient volume, mean (SD)

PG scores Total (n = 2721)

Less than very good (n = 922)

Very good or higher (n = 1799)

P

49.3 (18.8) 63.6

45.5 (17.7) 66.6

51.3 (19.0) 62.0

b.001 .02 .77

0.1 24.3 43.7 29.8 2.1 59.7 (55.0)

0.0 21.6 48.4 28.6 1.5 79.8 (65.8)

0.1 25.8 41.3 30.3 2.5 49.6 (45.4)

b.001

2.5 (1.8)

3.2 (2.2)

2.2 (1.5)

b.001

65.0 35.0 244.3 (180.6)

50.3 49.7 268.8 (185.4)

72.5 27.5 231.7 (176.7)

b.001

8.6 (6.0)

9.4 (6.2)

8.2 (5.9)

b.001

60.9 39.1 41.5 (17.6)

52.8 47.2 44.3 (18.6)

65.2 34.9 40.0 (16.8)

b.001

1.8 (0.7)

2.0 (0.7)

1.8 (0.6)

b.001

29.5 70.5

24.6 75.4

32.1 67.9

71.5 28.5 227.1 (20.4)

68.1 31.9 228.2 (19.3)

73.3 26.7 226.6 (20.9)

b.001

b.001

b.001

.005

.04

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Correspondence / American Journal of Emergency Medicine 33 (2015) 108–122

Peter S. Pang, MD, MSc Department of Emergency Medicine Northwestern University Feinberg School of Medicine, Chicago, IL Department of Emergency Medicine Indiana University School of Medicine, Indianapolis, IN Corresponding author. Department of Emergency Medicine Indiana University School of Medicine 702 Eskenazi Ave, FOB, 3rd Floor, Indianapolis, IN 46202 Tel.: +1 312 515 4025 E-mail address: [email protected]

Table 2 Log-link regression for very good PG scores (PG ≥ 80) with cut-point times Characteristic

Model 1, RR (SE) Model 2, RR (SE) Model 3, RR (SE)

Male Age Door-to-doctor (≤60 min) Length of stay (≤240 min)

1.05 (0.03) 1.01⁎⁎ (0.00) 1.36⁎⁎ (0.05) 1.12⁎⁎ (0.04)

1.05 (0.03) 1.00⁎⁎ (0.00) 1.40⁎⁎ (0.05)

1.06⁎ (0.03) 1.01⁎⁎ (0.00) 1.21⁎⁎ (0.04)

The variables door-to-doctor and length of stay were described in terms of significant cut points. Backward selection preferred model 3, using a removal P value of .10 and male and age as locked variables. ⁎ P b .05. ⁎⁎ P b .001.

http://dx.doi.org/10.1016/j.ajem.2014.09.051 Table 3 Log-link regression for very good PG scores (PG ≥ 80) with continuous times Characteristic

Model 1, RR (SE)

Model 2, RR (SE)

Model 3, RR (SE)

References

Male Age Door-to-doctor Length of stay

1.05 (0.03) 1.00⁎⁎ (0.00) 1.00⁎⁎ (0.00) 1.00 (0.00)

1.05 (0.03) 1.00⁎⁎ (0.00) 1.00⁎⁎ (0.00)

1.07⁎ (0.03) 1.01⁎⁎ (0.00)

[1] Kupfer JM, Bond EU. Patient satisfaction and patient-centered care: necessary but not equal. JAMA 2012;308(2):139–40. [2] Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say? Acad Emerg Med 2000; 7(6):695–709. [3] Schneider EC, Zaslavsky AM, Landon BE, Lied TR, Sheingold S, Cleary PD. National quality monitoring of Medicare health plans: the relationship between enrollees' reports and the quality of clinical care. Med Care 2001;39(12):1313–25. [4] de Bruin SR, Baan CA, Struijs JN. Pay-for-performance in disease management: a systematic review of the literature. BMC Health Serv Res 2011;11:272–86. [5] Robinson JC, Shortell SM, Rittenhouse DR, Fernandes-Taylor S, Gillies RR, Casalino LP. Quality-based payment for medical groups and individual physicians. Inquiry 2009; 46(2):172–81. [6] Goldfield N, Lamb V, Manton K, Vertrees J. Standardize concepts, not tools for quality improvement. J Ambul Care Manage 2007;30(2):116–9. [7] Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med 2008;15(9):825–31. [8] Boudreaux ED, O'Hea EL. Patient satisfaction in the emergency department: a review of the literature and implications for practice. J Emerg Med 2004;26(1):13–26. [9] Stearns CR, Gonzales R, Camargo Jr CA, Maselli J, Metlay JP. Antibiotic prescriptions are associated with increased patient satisfaction with emergency department visits for acute respiratory tract infections. Acad Emerg Med 2009;16(10):934–41. [10] Sun BC, Adams JG, Burstin HR. Validating a model of patient satisfaction with emergency care. Ann Emerg Med 2001;38(5):527–32. [11] Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med 1996;28(6):657–65. [12] Hall MF, Press I. Keys to patient satisfaction in the emergency department: results of a multiple facility study. Hosp Health Serv Adm 1996;41(4):515–32. [13] Associates P-G. Survey Development; 2008 [Available at: http://www.pressganey. com/cs/surveys_and_reports/survey_development]. [14] Clark PA, Drain M, Gesell SB, Mylod DM, Kaldenberg DO, Hamilton J. Patient perceptions of quality in discharge instruction. Patient Educ Couns 2005;59(1):56–68.

1.00⁎⁎ (0.00)

The variables door-to-doctor and length of stay were described in terms of minutes. Backward selection preferred model 3, using a removal P value of .10 and male and age as locked variables. ⁎ P b .05. ⁎⁎ P b .001. Table 4 Log-link regression for very good PG scores (PG ≥ 80) with 30-min block times Characteristic

Model 1, RR (SE)

Model 2, RR (SE)

Model 3, RR (SE)

Male Age Door-to-doctor Length of stay

1.05 (0.03) 1.00⁎⁎ (0.00) 0.89⁎⁎ (0.01) 1.00 (0.00)

1.05⁎ (0.03) 1.00⁎⁎ (0.00) 0.89⁎⁎ (0.01)

1.07 (0.03) 1.01⁎⁎ (0.00) 0.99⁎⁎ (0.00)

The variables door-to-doctor and length of stay were described in terms of 30-minute blocks. Backward selection preferred model 3, using a removal P value of .10 and male and age as locked variables. ⁎ P b .05. ⁎⁎ P b .001.

demonstrated that door-to-doctor and length of stay still appeared to be significant factors when examined separately in models 2 and 3. However, when both were included in the same model (model 1), door-todoctor seemed to matter, whereas length of stay dropped to insignificance, with no signs of multicollinearity present. Overall, we found that a lower door-to-doctor time and overall length-of-stay were significantly associated with the highest PG patient satisfaction scores. A door-to-doctor time less than 1 hour and a length of stay less than 4 hours were found to be ideal operational metric goals to target in order to improve patient satisfaction. Both door-todoctor time and length of stay are important; however, door-to-doctor time may have a slightly greater influence on patient satisfaction, suggesting that door-to-doctor may mediate the effects of length of stay. Ensuring efficient operations are critical to high ED patient satisfaction scores. Molly Goloback, MD Department of Emergency Medicine Colorado Permanente Medical Group, Denver, CO Danielle M. McCarthy, MD, MS Michael Schmidt, MD James G. Adams, MD Department of Emergency Medicine Northwestern University Feinberg School of Medicine, Chicago, IL

A field survey of spinal cord injury in bodyboarders☆,☆☆ To the Editor, During the summer, a large number of tourists visit Izu Peninsula, and our hospital is the only hospital capable of treating patients with acutephase spinal cord injuries on Izu Peninsula. Among the various marine sports, bodyboarding was the leading cause of spinal cord injury in subjects transported by the physician-staffed emergency helicopters in Izu peninsula [1]. Hence, we investigated the number of players of surfing, bodyboarding and obtained information using a questionnaire in a field. From July 26, 2014 to August 5, 2014, we asked bodyboarders at the beaches and our hospital on Izu Peninsula to complete a questionnaire. The items on the questionnaire were as follows: sex, age, hometown, years of experience, owner of the bodyboard, past history of head injury, past history of dysesthesia of the extremities, background of the event if ☆ Source(s) of support; none. ☆☆ The name of organization presented; none.

ED operational factors associated with patient satisfaction.

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