Original article 1
Patient satisfaction in out-of-hospital emergency care: a multicentre survey Agnes Neumayra, André Gnirkec, Joerg C. Schaeubled, Michael T. Ganterd, Harald Sparrb, Adolf Zollb, Adolf Schinnerla, Matthias Nueblinge, Thomas Heideggerc and Michael Baubina Background There is only limited information on patient satisfaction with emergency medical services (EMS). The aim of this multicentre survey was to evaluate patient satisfaction in five out-of-hospital physician-based EMS in Austria and Switzerland. Methods The psychometrically tested and standardized questionnaire ‘patient satisfaction in out-of-hospital emergency care’ was used for this survey. The recruitment of the patients was carried out on the basis of inclusion and exclusion criteria. All questionnaires were sent together with an invitation letter and a prepaid return envelope, followed by a reminder 2 weeks later. The descriptive statistical analysis was carried out by an external organization to maintain anonymity. Results The response rate of all EMS was 46.7%. High satisfaction rates were achieved for the four quality scales ‘emergency call, emergency treatment, transport and hospital admission’. A significant difference was found between the Swiss and the Austrian dispatch centres in the judgement of the call takers’ social skills. Patient satisfaction with the emergency treatment, for example, reduction of pain, was high in all EMS, independent of whether the EMS is physician (Austria) or physician and emergency medical assistant based (Switzerland). Lowest satisfaction rates were found for items of social skills.
Introduction Quality indicators for patient satisfaction in hospital medical care in respect of patient’s values and expressed needs are coordination and integration of care, information, communication, physical comfort, emotional support, alleviation of fear and involvement of family and friends [1–3]. Patient satisfaction surveys in anaesthesia have shown that information, communication and involvement in decision-making are the most important quality indicators to ensure high patient satisfaction in the perioperative period [4–8]. Standardized questionnaires surveying patient satisfaction in out-of-hospital emergency care are rather scarce and cross-national surveys are missing [1,2]. From our previous pilot study, we know that from the perspective of the emergency patients or their relatives, time-critical patient-centered care, fast reduction of pain, clear and adequate information and sensitive social and emotional skills of all health care 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Conclusion Patient satisfaction in out-of-hospital physician-based EMS is generally high. There is room for improvement in areas such as the social skills of dispatchers and EMS-team members and the comfort of the patients during transport. A checklist should be developed for basic articles that patients should take along to hospital and for questions on responsibilities for children, dependent people or pets. European Journal of Emergency Medicine 00:000–000 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 00:000–000 Keywords: emergency medical services, multicentre study, patient satisfaction a Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, bDepartment of Anaesthesia and Critical Care Medicine, General Hospital Dornbirn, Dornbirn, Austria, cDepartment of Anaesthesia, Spitalregion Rheintal Werdenberg Sarganserland, Grabs, dInstitute of Anaesthesiology and Pain Medicine, Kantonsspital Winterthur, Winterthur, Switzerland and eEmpirical Consulting (GEB mbH), Denzlingen, Germany
Correspondence to Dr Agnes Neumayr, Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstr 35, A-6020 Innsbruck, Austria Tel: + 43 512 504 81535; fax: + 43 512 504 25744; e-mail: [email protected] Received 19 December 2014 Accepted 12 February 2015
professionals during the entire emergency process play an important role in increasing patient satisfaction [1,2]. The aim of this multicentre survey was to evaluate patient satisfaction in terms of emergency call, emergency treatment, transport and admission to hospital in physicianbased emergency medical services (EMS) in Austria or physician and emergency medical assistant-based EMS in Switzerland.
Methods Construction of the standardized questionnaire
The psychometrically tested and standardized questionnaire ‘patient satisfaction in emergency care’ was developed and psychometrically validated in a former research project [1]. Because of the ‘emergency patient pathway’, the questionnaire is divided into four chronological sections assessed by four corresponding quality scales: (A) emergency call, (B) emergency treatment, (C) DOI: 10.1097/MEJ.0000000000000264
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
2 European Journal of Emergency Medicine 2015, Vol 00 No 00
transport and (D) hospital admission. Each section finishes with a question on satisfaction with this topic. Altogether, 48 quality indicators are placed within the four quality dimensions. Sociodemographic characteristics (age, sex, type of insurance, etc.) of the patient (section F) and, if applicable, of the individual who completed the questionnaire (section G) are also recorded. Compared with the validation study for the multicentre survey, one new question was included, in which patients or relatives are asked to estimate the waiting period till the ambulance arrived in minutes. The questionnaire of the two EMS of Switzerland was additionally modified insofar as satisfaction was not only assessed in terms of the treatment by an emergency physician but also by an emergency medical assistant (as both professions form the emergency team in Switzerland). Multicentre survey design
From June to July 2013, the multicentre survey was carried out in the EMS of Innsbruck (Austria), Kufstein (Austria), Dornbirn (Austria) and Winterthur (Switzerland) and Rheintal/Werdenberg/Sarganserland (Switzerland) (Table 1). The five ground-based EMS were included to represent different aspects such as urban and rural areas, different countries, dispatch systems using Advanced Medical Priority Dispatch System (AMPDS) or a self-developed in-house tool and physician-based or emergency medical assistant-based EMS. The mismatches between population of districts and emergency incidents can be explained by the fact that the EMS are not bound to district borders. The AMPDS that is used in Tyrol provides a tool for calltakers to process emergency calls in a standardized manner. It includes chief complaint/incident-type protocols that enable dispatchers to obtain vital information to send the appropriate response. The other three EMS use self-developed in-house tools for emergency calls. Inclusion criteria
Patients treated by EMS, between 18 and 90 years, severity grading between National Advisory Committee for Aeronautics (NACA) score III and V, hospital admission within the 3 months of the recruiting period, and patients discharged from hospital were included. The patients had to fulfil every inclusion criterion. NACA I–II patients were not included in the survey. In Table 1
general, these patients do not necessarily need an emergency physician´s treatment and are mainly not hospitalized. Thus, they are not assessed in the four quality scales of the questionnaire. Patients with NACA score VI–VII are usually not able to judge their emergency treatment as they were resuscitated or died on scene. Patients with medical disorder or trauma were included. Exclusion criteria
Glasgow Coma Scale less than 13, interhospital transfer, known psychiatric illness, patient’s death. The criteria known psychiatric illness, patient’s death were required by the Ethics Committee. We excluded patients with a Glasgow Coma Scale less than 13 to avoid the inclusion of patients with pre-existing or acute neurological disorders. Data were obtained from EMS records and the databases of the hospitals. Timeline for the survey
After the approval of each regional Ethics Committee, the consecutive recruiting of emergency patients according to inclusion and exclusion criteria was started. Patients had to be discharged from hospital and treated by EMS within an exact period of 3 months within an overall timeline of February–May 2013. In early June, all questionnaires were sent to the emergency patients together with an invitation letter and a prepaid return envelope, followed by a reminder 2 weeks later. The EMS Innsbruck and Kufstein had to obtain approval from all relevant patients before sending the questionnaire because of a specification of the regional Ethics Committee. Statistical analysis
All quality indicators (48 items) were assessed in a range from 0 to 100 points: 90–100 points: very high satisfaction; 81–89: high satisfaction; 61–80: moderate satisfaction; and 0–60: low satisfaction. The four scale values (A–D) were calculated as the mean value of the single indicators in the respective dimension; analogously, the overall quality measure was constructed as the mean of all 48 quality indicators. Psychometrical analysis of the questionnaire was replicated (factor analysis, reliability analysis, validity analysis) as described in the validation study, yielding the same results (not shown
Participating EMS
EMS, region, country Innsbruck, Tyrol, Austria Kufstein, Tyrol, Austria Dornbirn, Vorarlberg, Austria Winterthur, Zürich, Switzerland Spitalregion Rheintal/Werdenberg/Sarganserland, Switzerland
Population of district
Emergency incidents of EMS 2013
Dispatch system type
115 000 102 000 80 000 200 000 133 000
3691 1346 1599 4163 3981
AMPDS of dispatch centre Tyrol
AMPDS, Advanced Medical Priority Dispatch System; EMS, emergency medical services.
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In-house tool In-house tool In-house tool
Patient satisfaction in emergency care Neumayr et al. 3
Table 2
Results of patient satisfaction for the four quality scales (A–D)
EMS Centre 1 2 3 4 5 Total (n/MV)
Emergency call (A) (MV)
Treatment (B) (MV)
Transport (C) (MV)
Admission (D) (MV)
Total satisfaction (core of 48 quality items) (MV)
95.6 93.8 93.6 91.3 90.5 393/93.1
92.0 92.3 91.3 91.7 91.6 482/91.8
88.8 87.2 88.1 87.7 87.3 476/87.7
93.0 91.2 95.2 93.0 91.9 453/92.8
92.3 91.4 91.6 90.8 90.3 514/91.2
EMS, emergency medical services; MV, mean value.
Table 3
Results on important items of the four quality scales (A–D) Valid answers/mean value of satisfaction
Quality criteria (scales and items) Did you really want an EMS physician? Extent of the conversation Feeling at the end of the conversation Kept on the line until the ambulance arrived Judgement of the calltaker concerning medical skills Concerning emotional skills Concerning active listening and being taken seriously Concerning social skills Concerning politeness Concerning friendliness Subjective estimation of the waiting time, till emergency team arrived Objective estimation of the duration of waiting time Did other noninvolved persons bother you? Introduction of the EMS physician Was the handling of medical devices professional? Did you get pain relief fast enough? Were questions answered comprehensively enough? Was information withheld from you? Were you treated without being given any information? Were your suggestions respected adequately? Were you involved in decisions? Were you treated with regard to your cultural needs? Was your anxiety reduced by the EMS-team? Was your privacy given sufficient consideration? Was the patient taken to the ambulance? Judgement of the safety of transport to the ambulance Estimation of the duration of treatment on scene Was the transport to the hospital necessary? Did relatives accompany the patient by the transport? Were the seat belts fastened for the transport? How safe did you feel during drive? Were you cold during the transport? Were you covered with a blanket during the transport? Was the bedding in the ambulance comfortable? Were you told to which hospital you were being taken? Were your relatives told to which hospital you were taken? Were you told which basic articles you should immediately take with you to the hospital? Were you advised to lock the door to your flat? Questions relating to your social situation Delivery of medical information to the hospital Delivery of social information to the hospital Did the rescue team say goodbye to you?
Centre 1 Austria
Centre 2 Austria
A: Emergency call 58/93.1 98/93.8 63/98.4 102/97.0 63/98.4 102/94.1 62/100 104/97.1 56/89.3 99/86.9 49/91.2 94/89.0 49/92.5 93/87.5 43/90.7 83/87.6 55/92.8 100/95.7 57/93.0 99/94.9 B. Emergency treatment 68/60.8 106/63.3 68/92.6 69/95.6 64/89.0 57/96.4 46/93.4 50/99.0 70/94.2 71/92.9 35/88.5 27/96.3 10/95.0 71/92.9 70/97.1 73/97.2 74/94.5 60/98.3 63/100 63/88.8 66/96.2 67/98.5 65/81.4 67/88.8 67/95.5 68/95.5 59/94.9 60/43.3
106/94.3 109/100 108/91.6 87/100 68/95.5 90/95.0 109/87.6 107/85.5 64/92.1 60/98.3 19/89.4 115/96.9 112/98.2 C. Transport 117/94.8 115/97.3 100/98.0 108/96.3 106/80.1 112/98.6 114/99.1 113/84.9 114/85.0 110/95.4 110/88.1 93/91.4 105/45.7
52/92.3 87/93.1 57/42.1 92/39.1 D. Admission to hospital 55/94.5 93/91.4 46/89.1 70/92.8 57/96.4 99/94.9
Centre 3 Austria
Centre 4 Swiss
Centre 5 Swiss
Total (5 centres)
66/93.9 77/94.8 75/98.6 71/98.5 69/87.0 64/83.4 67/87.1 61/83.1 71/95.8 71/95.8
101/89.1 111/98.2 104/97.1 105/98.1 93/82.6 87/79.0 89/82.5 76/77.3 97/88.4 98/89.1
24/95.8 27/100 27/100 26/84.6 25/81.5 23/79.8 22/80.5 20/73.5 23/88.5 26/87.3
347/92.5 380/97.3 371/97.0 368/97.2 342/85.8 317/84.8 320/86.3 283/83.3 346/92.7 351/92.6
79/58.7
145/45.2
45/40.6
443/53.9
79/91.1 82/98.7 79/87.3 67/98.5 47/93.6 61/97.5 80/88.7 78/88.4 52/96.1 43/90.7 17/94.1 83/93.3 81/97.5
138/94.9 157/98.7 153/94.7 126/98.4 95/95.7 109/96.3 155/90.9 150/91.6 78/89.7 63/92.0 22/93.1 155/93.5 150/99.3
38/78.9 47/100 46/95.6 38/100 29/100 32/96.8 50/93.0 49/95.9 24/95.8 18/94.4 7/100 49/95.9 49/97.9
429/92.3 464/98.7 450/92.0 375/98.6 285/95.4 342/96.6 464/90.5 455/90.3 253/92.0 211/94.3 75/93.3 473/94.5 462/98.2
81/96.3 82/99.3 74/98.6 78/97.4 80/85.0 80/96.2 82/96.3 79/84.8 80/88.1 81/92.5 80/92.5 75/89.3 72/51.3
141/90.7 140/97.5 133/96.9 136/99.2 152/92.7 145/97.5 152/95.7 151/91.3 144/87.5 149/96.6 152/90.1 134/91.0 133/40.6
42/95.2 44/97.7 43/100 51/96.0 52/84.6 47/97.8 51/99.0 52/94.2 50/92 51/96.0 52/88.4 44/93.1 45/44.4
454/94.2 455/97.3 410/98.0 436/97.9 453/86.9 450/97.4 466/97.4 460/87.6 455/87.6 458/95.4 462/90.6 405/91.6 415/44.5
64/92.1 63/39.6
96/93.7 134/43.2
23/91.3 41/26.8
322/92.8 387/39.7
66/98.4 52/100 71/95.7
114/94.7 89/89.8 130/97.6
44/95.4 30/93.3 44/95.4
372/94.6 287/92.6 401/96.2
Bold questions show a significant difference, P < 0.05. EMS, emergency medical services.
here) [1]. The methods used in this paper were univariate frequencies including calculation of mean values (Tables 2 and 3) and SDs, and comparison of mean
(analysis of variance and multiple comparisons of mean). Statistical significance was defined as P value less than 0.05 (two tailed).
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4 European Journal of Emergency Medicine 2015, Vol 00 No 00
Results Altogether, 531 of 1137 contacted emergency patients of the five EMS participated in the survey, which yielded a response rate of 46.7% (Table 4). Sample characteristics (n = 531)
In all, 49% of the survey participants were men and 40% women; 11% did not specify their sex. The question on the current health condition of the emergency patients was answered by 74% as ‘very well to sufficient’; 13% reported ‘less well’ and 2% reported ‘bad’. 41% were treated by the emergency physician for the first time, 37% had already used the EMS 2–5 times and 10% had used the EMS more than five times. In all, 66% of the patients completed the questionnaire alone and 19% completed the questionnaire with the help of relatives. Twelve percent of questionnaires were completed only by relatives and 1% by other individuals such as nurses. Eight percent of the participants stated a foreign language as their mother tongue (not German). Quality scales and overall satisfaction
Table 2 shows the results of patient satisfaction for the four quality scales (A–D) for the five EMS centres. Results of important items of the four quality scales (A–D)
Table 3 shows survey data of important questions. Bold marked raws show a significant difference in the data between the five EMS centres.
Discussion In this multicentre survey, we found high satisfaction rates with the EMS in all areas ‘emergency call, emergency treatment, transport and hospital admission’ and on the whole. There was almost no difference either among the two different EMS in their staff (physicianbased EMS in Austria vs. combined physician and emergency medical assistant-based EMS in Switzerland) or among the EMS involved within the countries. This high grade of patient satisfaction in emergency care is well-known [4,5,7–9]. Table 4
Participating patients and response rate
EMS
Contacted patients
Valid questionnaire
Response rate (%)
306 228 120 343 140
128 88 75 181 59
41.8 38.6 62.5 52.8 42.1
654 483 1137
291 240 531
44.5 49.7 46.7
Innsbruck, Austria Kufstein, Austria Dornbirn, Austria Winterthur, Switzerland Spitalregion Rheintal Werdenberg Sarganserland, Switzerland Total Austria Total Switzerland Total EMS, emergency medical services.
The results of the study, however, vary on examining the four scales of the questionnaire. There was no general difference in the patient satisfaction between the dispatch centre using the AMPDS (EMS Innsbruck and Kufstein) and centres using inhouse tools (Dornbirn, Winterthur, Spitalregion Rheintal Werdenberg Sarganserland). We found a significant difference between the Swiss and the Austrian dispatch centres in the judgement of the call takers’ emotional and social skills, active listening and being taken seriously, friendliness and politeness. In Switzerland, the patients rated their satisfaction with the call takers’ soft skills significantly lower than in Austria. In both Swiss dispatch centres, AMPDS is not used. During the emergency call, the call taker uses the in-house tool to lead the emergency call. In contrast, in Austria, there was no significant difference in satisfaction between the dispatch centre with the AMPDS and the one without. Although the questions in the AMPDS are more ‘technical’ and less empathic or emotional, the results are better compared with the Swiss dispatch centres. As the two Austrian dispatch centres with and without AMPDS did not show much difference, there is no evidence that AMPDS provides better results in terms of patient satisfaction. The national or sociocultural background may probably explain this effect. In all EMS included, the general satisfaction with the emergency treatment was rated very high (91.7%). Although the patients reported the waiting time as long, the duration of waiting time was still rated high. In hospital emergency departments, the perceived waiting time is one of the most important parameters of patient satisfaction [10]. The requirements for the arrival time at the emergency scene are 15 min in 90% in the Tyrolean EMS compared with 80% in Switzerland. However, this difference in requirements did not exert any effects on patient satisfaction. Accurate timely administration of pain relief medication and reduction of fear are very important aspects of satisfaction. These aspects showed high satisfaction in all EMS included. There was no difference in the two countries, although the EMS and the requirements are different. In contrast to Austria, the Swiss EMS works regularly with specialized emergency medical assistants with medical competences such as basic airway management, application of opiates and invasive medical techniques. Thus, there are many emergency cases where emergency medical assistants treat patients without a specialized EMS physician and therefore the number of EMS physicians is lower in Switzerland. In terms of patient satisfaction with reduction of pain and fear, there was no difference between physicians and emergency medical assistants.
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Patient satisfaction in emergency care Neumayr et al. 5
The questions in the quality scale for transport were generally rated lower, but still with high satisfaction (87.8%). One reason for the lower satisfaction is the impossibility of relatives to accompany the transport, often because of the limited seating capacity of the ambulance. Also, patients rated satisfaction lower as they felt cold during transport (e.g. not being covered with a blanket). To pay attention to the comfort of the patient during transport could probably raise the satisfaction rate. In particular, severely burned, injured or intubated patients and children who cannot communicate their needs require special attention. Lowest satisfaction rates were assigned to two items on soft skills: the question ‘Which articles should be taken to the hospital’ and the question on the social situation of the patient (i.e. taking care of children and domestic animals, informing neighbours or relatives). In emergency medicine, social skills and motivated staff are important factors for patient satisfaction [10]. Although we found high and very high satisfaction rates in items such as information provision, patient satisfaction can notably be improved by better training in empathic behaviour and soft skills of the EMS team [11]. Some limitations must be taken into account. First, the overall response rate of our survey was moderate. The obligation of the Ethics Committee of two Austrian centres to obtain written consent from the patients before sending them the questionnaire may explain this to some extent. All the patients included from these two Austrian centres agreed to complete the questionnaire. Second, our results are not simply applicable to countries or EMS that are strictly paramedic based. However, a comparison with those systems would be interesting. A further limitation of this survey is that we have just one dispatch centre with an AMPDS, which dispatches the EMS Innsbruck and the EMS Kufstein. A patient selection bias may be caused because of the subjective judgement of the NACA Score. Conclusion
In general, patient satisfaction in out-of-hospital emergency care is very high, irrespective of which EMS is judged, the strictly physician-based EMS in Austria or the combined physician and emergency medical assistantbased EMS in Switzerland. There is no general difference
in the patient satisfaction between the dispatch centre using the AMPDS and centres using the in-house tool. To improve the social skills of dispatchers and EMS-team members, special communication training is recommended. Furthermore, during transport, emergency medical assistants should focus on the comfort of the patients, for example, asking whether they need a blanket. A checklist should be developed for basic articles that patients should take along to hospital and for questions on responsibilities for children, dependent people or pets.
Acknowledgements This study is part of a dissertation at the Department of Anaesthesiology and Pain Therapy, University Hospital Bern, Switzerland. The authors would like to thank Robert Greif, Professor of Anaesthesiology, Department of Anaesthesiology and Pain Therapy, University Hospital Bern, Switzerland, for his support. Conflicts of interest
There are no conflicts of interest.
References 1
Baubin M, Neumayr A, Eigenstuhler J, Nuebling M, Lederer W, Heidegger T. Patient satisfaction in out-of-hospital emergency care. Development of a standard questionnaire [in German]. Notfall Rettungsmed 2012; 15:225–233. 2 Neumayr A, Eigenstuhler J, Baubin M. Qualitative research methods in preclinical emergency medicine. Significance of focus group interviews [in German]. Notfall Rettungsmed 2011; 14:220–225. 3 Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL. Through the patient’s eyes. San Francisco, CA: Jossey-Bass; 1993. 4 Heidegger T, Saal D, Nübling M. Patient satisfaction with anaesthesia – Part 1: satisfaction as part of outcome – and what satisfies patients. Anaesthesia 2013; 68:1165–1172. 5 Nübling M, Saal D, Heidegger T. Patient satisfaction with anaesthesia – Part 2: construction and quality assessment of questionnaires. Anaesthesia 2013; 68:1173–1178. 6 Heidegger T, Nuebling M, Saal D, Kreienbuehl G. Patient-centred outcomes in clinical research: does it really matter? Br J Anaesth 2008; 100:1–3. 7 Heidegger T, Saal D, Nuebling M. Patient satisfaction with anaesthesia care: what is patient satisfaction, how should it be measured, and what is the evidence for assuring high patient satisfaction? Best Pract Res Clin Anaesthesiol 2006; 20:331–346. 8 Heidegger T, Nuebling M, German R, Borg H, Flueckiger K, Coi T. Patient satisfaction with anaesthesia care: information alone does not lead to improvement. Can J Anesth 2004; 51:801–805. 9 Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say? Acad Emerg Med 2000; 7:695–709. 10 Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg Med J 2004; 21:528–532. 11 Baubin M, Resch R, Neumayr A. Continuous quality improvement in prehospital emergency medicine. The plan-do-check-act (PDCA) cycle [in German]. Notfall Rettungsmed 2011; 14:117–124.
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Patient satisfaction in out-of-hospital emergency care: a multicentre survey Agnes Neumayra, André Gnirkec, Joerg C. Schaeubled, Michael T. Ganterd, Harald Sparrb, Adolf Zollb, Adolf Schinnerla, Matthias Nueblinge, Thomas Heideggerc and Michael Baubina Background There is only limited information on patient satisfaction with emergency medical services (EMS). The aim of this multicentre survey was to evaluate patient satisfaction in five out-of-hospital physician-based EMS in Austria and Switzerland. Methods The psychometrically tested and standardized questionnaire ‘patient satisfaction in out-of-hospital emergency care’ was used for this survey. The recruitment of the patients was carried out on the basis of inclusion and exclusion criteria. All questionnaires were sent together with an invitation letter and a prepaid return envelope, followed by a reminder 2 weeks later. The descriptive statistical analysis was carried out by an external organization to maintain anonymity. Results The response rate of all EMS was 46.7%. High satisfaction rates were achieved for the four quality scales ‘emergency call, emergency treatment, transport and hospital admission’. A significant difference was found between the Swiss and the Austrian dispatch centres in the judgement of the call takers’ social skills. Patient satisfaction with the emergency treatment, for example, reduction of pain, was high in all EMS, independent of whether the EMS is physician (Austria) or physician and emergency medical assistant based (Switzerland). Lowest satisfaction rates were found for items of social skills.
Introduction Quality indicators for patient satisfaction in hospital medical care in respect of patient’s values and expressed needs are coordination and integration of care, information, communication, physical comfort, emotional support, alleviation of fear and involvement of family and friends [1–3]. Patient satisfaction surveys in anaesthesia have shown that information, communication and involvement in decision-making are the most important quality indicators to ensure high patient satisfaction in the perioperative period [4–8]. Standardized questionnaires surveying patient satisfaction in out-of-hospital emergency care are rather scarce and cross-national surveys are missing [1,2]. From our previous pilot study, we know that from the perspective of the emergency patients or their relatives, time-critical patient-centered care, fast reduction of pain, clear and adequate information and sensitive social and emotional skills of all health care 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Conclusion Patient satisfaction in out-of-hospital physician-based EMS is generally high. There is room for improvement in areas such as the social skills of dispatchers and EMS-team members and the comfort of the patients during transport. A checklist should be developed for basic articles that patients should take along to hospital and for questions on responsibilities for children, dependent people or pets. European Journal of Emergency Medicine 00:000–000 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 00:000–000 Keywords: emergency medical services, multicentre study, patient satisfaction a Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, bDepartment of Anaesthesia and Critical Care Medicine, General Hospital Dornbirn, Dornbirn, Austria, cDepartment of Anaesthesia, Spitalregion Rheintal Werdenberg Sarganserland, Grabs, dInstitute of Anaesthesiology and Pain Medicine, Kantonsspital Winterthur, Winterthur, Switzerland and eEmpirical Consulting (GEB mbH), Denzlingen, Germany
Correspondence to Dr Agnes Neumayr, Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstr 35, A-6020 Innsbruck, Austria Tel: + 43 512 504 81535; fax: + 43 512 504 25744; e-mail: [email protected] Received 19 December 2014 Accepted 12 February 2015
professionals during the entire emergency process play an important role in increasing patient satisfaction [1,2]. The aim of this multicentre survey was to evaluate patient satisfaction in terms of emergency call, emergency treatment, transport and admission to hospital in physicianbased emergency medical services (EMS) in Austria or physician and emergency medical assistant-based EMS in Switzerland.
Methods Construction of the standardized questionnaire
The psychometrically tested and standardized questionnaire ‘patient satisfaction in emergency care’ was developed and psychometrically validated in a former research project [1]. Because of the ‘emergency patient pathway’, the questionnaire is divided into four chronological sections assessed by four corresponding quality scales: (A) emergency call, (B) emergency treatment, (C) DOI: 10.1097/MEJ.0000000000000264
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
2 European Journal of Emergency Medicine 2015, Vol 00 No 00
transport and (D) hospital admission. Each section finishes with a question on satisfaction with this topic. Altogether, 48 quality indicators are placed within the four quality dimensions. Sociodemographic characteristics (age, sex, type of insurance, etc.) of the patient (section F) and, if applicable, of the individual who completed the questionnaire (section G) are also recorded. Compared with the validation study for the multicentre survey, one new question was included, in which patients or relatives are asked to estimate the waiting period till the ambulance arrived in minutes. The questionnaire of the two EMS of Switzerland was additionally modified insofar as satisfaction was not only assessed in terms of the treatment by an emergency physician but also by an emergency medical assistant (as both professions form the emergency team in Switzerland). Multicentre survey design
From June to July 2013, the multicentre survey was carried out in the EMS of Innsbruck (Austria), Kufstein (Austria), Dornbirn (Austria) and Winterthur (Switzerland) and Rheintal/Werdenberg/Sarganserland (Switzerland) (Table 1). The five ground-based EMS were included to represent different aspects such as urban and rural areas, different countries, dispatch systems using Advanced Medical Priority Dispatch System (AMPDS) or a self-developed in-house tool and physician-based or emergency medical assistant-based EMS. The mismatches between population of districts and emergency incidents can be explained by the fact that the EMS are not bound to district borders. The AMPDS that is used in Tyrol provides a tool for calltakers to process emergency calls in a standardized manner. It includes chief complaint/incident-type protocols that enable dispatchers to obtain vital information to send the appropriate response. The other three EMS use self-developed in-house tools for emergency calls. Inclusion criteria
Patients treated by EMS, between 18 and 90 years, severity grading between National Advisory Committee for Aeronautics (NACA) score III and V, hospital admission within the 3 months of the recruiting period, and patients discharged from hospital were included. The patients had to fulfil every inclusion criterion. NACA I–II patients were not included in the survey. In Table 1
general, these patients do not necessarily need an emergency physician´s treatment and are mainly not hospitalized. Thus, they are not assessed in the four quality scales of the questionnaire. Patients with NACA score VI–VII are usually not able to judge their emergency treatment as they were resuscitated or died on scene. Patients with medical disorder or trauma were included. Exclusion criteria
Glasgow Coma Scale less than 13, interhospital transfer, known psychiatric illness, patient’s death. The criteria known psychiatric illness, patient’s death were required by the Ethics Committee. We excluded patients with a Glasgow Coma Scale less than 13 to avoid the inclusion of patients with pre-existing or acute neurological disorders. Data were obtained from EMS records and the databases of the hospitals. Timeline for the survey
After the approval of each regional Ethics Committee, the consecutive recruiting of emergency patients according to inclusion and exclusion criteria was started. Patients had to be discharged from hospital and treated by EMS within an exact period of 3 months within an overall timeline of February–May 2013. In early June, all questionnaires were sent to the emergency patients together with an invitation letter and a prepaid return envelope, followed by a reminder 2 weeks later. The EMS Innsbruck and Kufstein had to obtain approval from all relevant patients before sending the questionnaire because of a specification of the regional Ethics Committee. Statistical analysis
All quality indicators (48 items) were assessed in a range from 0 to 100 points: 90–100 points: very high satisfaction; 81–89: high satisfaction; 61–80: moderate satisfaction; and 0–60: low satisfaction. The four scale values (A–D) were calculated as the mean value of the single indicators in the respective dimension; analogously, the overall quality measure was constructed as the mean of all 48 quality indicators. Psychometrical analysis of the questionnaire was replicated (factor analysis, reliability analysis, validity analysis) as described in the validation study, yielding the same results (not shown
Participating EMS
EMS, region, country Innsbruck, Tyrol, Austria Kufstein, Tyrol, Austria Dornbirn, Vorarlberg, Austria Winterthur, Zürich, Switzerland Spitalregion Rheintal/Werdenberg/Sarganserland, Switzerland
Population of district
Emergency incidents of EMS 2013
Dispatch system type
115 000 102 000 80 000 200 000 133 000
3691 1346 1599 4163 3981
AMPDS of dispatch centre Tyrol
AMPDS, Advanced Medical Priority Dispatch System; EMS, emergency medical services.
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In-house tool In-house tool In-house tool
Patient satisfaction in emergency care Neumayr et al. 3
Table 2
Results of patient satisfaction for the four quality scales (A–D)
EMS Centre 1 2 3 4 5 Total (n/MV)
Emergency call (A) (MV)
Treatment (B) (MV)
Transport (C) (MV)
Admission (D) (MV)
Total satisfaction (core of 48 quality items) (MV)
95.6 93.8 93.6 91.3 90.5 393/93.1
92.0 92.3 91.3 91.7 91.6 482/91.8
88.8 87.2 88.1 87.7 87.3 476/87.7
93.0 91.2 95.2 93.0 91.9 453/92.8
92.3 91.4 91.6 90.8 90.3 514/91.2
EMS, emergency medical services; MV, mean value.
Table 3
Results on important items of the four quality scales (A–D) Valid answers/mean value of satisfaction
Quality criteria (scales and items) Did you really want an EMS physician? Extent of the conversation Feeling at the end of the conversation Kept on the line until the ambulance arrived Judgement of the calltaker concerning medical skills Concerning emotional skills Concerning active listening and being taken seriously Concerning social skills Concerning politeness Concerning friendliness Subjective estimation of the waiting time, till emergency team arrived Objective estimation of the duration of waiting time Did other noninvolved persons bother you? Introduction of the EMS physician Was the handling of medical devices professional? Did you get pain relief fast enough? Were questions answered comprehensively enough? Was information withheld from you? Were you treated without being given any information? Were your suggestions respected adequately? Were you involved in decisions? Were you treated with regard to your cultural needs? Was your anxiety reduced by the EMS-team? Was your privacy given sufficient consideration? Was the patient taken to the ambulance? Judgement of the safety of transport to the ambulance Estimation of the duration of treatment on scene Was the transport to the hospital necessary? Did relatives accompany the patient by the transport? Were the seat belts fastened for the transport? How safe did you feel during drive? Were you cold during the transport? Were you covered with a blanket during the transport? Was the bedding in the ambulance comfortable? Were you told to which hospital you were being taken? Were your relatives told to which hospital you were taken? Were you told which basic articles you should immediately take with you to the hospital? Were you advised to lock the door to your flat? Questions relating to your social situation Delivery of medical information to the hospital Delivery of social information to the hospital Did the rescue team say goodbye to you?
Centre 1 Austria
Centre 2 Austria
A: Emergency call 58/93.1 98/93.8 63/98.4 102/97.0 63/98.4 102/94.1 62/100 104/97.1 56/89.3 99/86.9 49/91.2 94/89.0 49/92.5 93/87.5 43/90.7 83/87.6 55/92.8 100/95.7 57/93.0 99/94.9 B. Emergency treatment 68/60.8 106/63.3 68/92.6 69/95.6 64/89.0 57/96.4 46/93.4 50/99.0 70/94.2 71/92.9 35/88.5 27/96.3 10/95.0 71/92.9 70/97.1 73/97.2 74/94.5 60/98.3 63/100 63/88.8 66/96.2 67/98.5 65/81.4 67/88.8 67/95.5 68/95.5 59/94.9 60/43.3
106/94.3 109/100 108/91.6 87/100 68/95.5 90/95.0 109/87.6 107/85.5 64/92.1 60/98.3 19/89.4 115/96.9 112/98.2 C. Transport 117/94.8 115/97.3 100/98.0 108/96.3 106/80.1 112/98.6 114/99.1 113/84.9 114/85.0 110/95.4 110/88.1 93/91.4 105/45.7
52/92.3 87/93.1 57/42.1 92/39.1 D. Admission to hospital 55/94.5 93/91.4 46/89.1 70/92.8 57/96.4 99/94.9
Centre 3 Austria
Centre 4 Swiss
Centre 5 Swiss
Total (5 centres)
66/93.9 77/94.8 75/98.6 71/98.5 69/87.0 64/83.4 67/87.1 61/83.1 71/95.8 71/95.8
101/89.1 111/98.2 104/97.1 105/98.1 93/82.6 87/79.0 89/82.5 76/77.3 97/88.4 98/89.1
24/95.8 27/100 27/100 26/84.6 25/81.5 23/79.8 22/80.5 20/73.5 23/88.5 26/87.3
347/92.5 380/97.3 371/97.0 368/97.2 342/85.8 317/84.8 320/86.3 283/83.3 346/92.7 351/92.6
79/58.7
145/45.2
45/40.6
443/53.9
79/91.1 82/98.7 79/87.3 67/98.5 47/93.6 61/97.5 80/88.7 78/88.4 52/96.1 43/90.7 17/94.1 83/93.3 81/97.5
138/94.9 157/98.7 153/94.7 126/98.4 95/95.7 109/96.3 155/90.9 150/91.6 78/89.7 63/92.0 22/93.1 155/93.5 150/99.3
38/78.9 47/100 46/95.6 38/100 29/100 32/96.8 50/93.0 49/95.9 24/95.8 18/94.4 7/100 49/95.9 49/97.9
429/92.3 464/98.7 450/92.0 375/98.6 285/95.4 342/96.6 464/90.5 455/90.3 253/92.0 211/94.3 75/93.3 473/94.5 462/98.2
81/96.3 82/99.3 74/98.6 78/97.4 80/85.0 80/96.2 82/96.3 79/84.8 80/88.1 81/92.5 80/92.5 75/89.3 72/51.3
141/90.7 140/97.5 133/96.9 136/99.2 152/92.7 145/97.5 152/95.7 151/91.3 144/87.5 149/96.6 152/90.1 134/91.0 133/40.6
42/95.2 44/97.7 43/100 51/96.0 52/84.6 47/97.8 51/99.0 52/94.2 50/92 51/96.0 52/88.4 44/93.1 45/44.4
454/94.2 455/97.3 410/98.0 436/97.9 453/86.9 450/97.4 466/97.4 460/87.6 455/87.6 458/95.4 462/90.6 405/91.6 415/44.5
64/92.1 63/39.6
96/93.7 134/43.2
23/91.3 41/26.8
322/92.8 387/39.7
66/98.4 52/100 71/95.7
114/94.7 89/89.8 130/97.6
44/95.4 30/93.3 44/95.4
372/94.6 287/92.6 401/96.2
Bold questions show a significant difference, P < 0.05. EMS, emergency medical services.
here) [1]. The methods used in this paper were univariate frequencies including calculation of mean values (Tables 2 and 3) and SDs, and comparison of mean
(analysis of variance and multiple comparisons of mean). Statistical significance was defined as P value less than 0.05 (two tailed).
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4 European Journal of Emergency Medicine 2015, Vol 00 No 00
Results Altogether, 531 of 1137 contacted emergency patients of the five EMS participated in the survey, which yielded a response rate of 46.7% (Table 4). Sample characteristics (n = 531)
In all, 49% of the survey participants were men and 40% women; 11% did not specify their sex. The question on the current health condition of the emergency patients was answered by 74% as ‘very well to sufficient’; 13% reported ‘less well’ and 2% reported ‘bad’. 41% were treated by the emergency physician for the first time, 37% had already used the EMS 2–5 times and 10% had used the EMS more than five times. In all, 66% of the patients completed the questionnaire alone and 19% completed the questionnaire with the help of relatives. Twelve percent of questionnaires were completed only by relatives and 1% by other individuals such as nurses. Eight percent of the participants stated a foreign language as their mother tongue (not German). Quality scales and overall satisfaction
Table 2 shows the results of patient satisfaction for the four quality scales (A–D) for the five EMS centres. Results of important items of the four quality scales (A–D)
Table 3 shows survey data of important questions. Bold marked raws show a significant difference in the data between the five EMS centres.
Discussion In this multicentre survey, we found high satisfaction rates with the EMS in all areas ‘emergency call, emergency treatment, transport and hospital admission’ and on the whole. There was almost no difference either among the two different EMS in their staff (physicianbased EMS in Austria vs. combined physician and emergency medical assistant-based EMS in Switzerland) or among the EMS involved within the countries. This high grade of patient satisfaction in emergency care is well-known [4,5,7–9]. Table 4
Participating patients and response rate
EMS
Contacted patients
Valid questionnaire
Response rate (%)
306 228 120 343 140
128 88 75 181 59
41.8 38.6 62.5 52.8 42.1
654 483 1137
291 240 531
44.5 49.7 46.7
Innsbruck, Austria Kufstein, Austria Dornbirn, Austria Winterthur, Switzerland Spitalregion Rheintal Werdenberg Sarganserland, Switzerland Total Austria Total Switzerland Total EMS, emergency medical services.
The results of the study, however, vary on examining the four scales of the questionnaire. There was no general difference in the patient satisfaction between the dispatch centre using the AMPDS (EMS Innsbruck and Kufstein) and centres using inhouse tools (Dornbirn, Winterthur, Spitalregion Rheintal Werdenberg Sarganserland). We found a significant difference between the Swiss and the Austrian dispatch centres in the judgement of the call takers’ emotional and social skills, active listening and being taken seriously, friendliness and politeness. In Switzerland, the patients rated their satisfaction with the call takers’ soft skills significantly lower than in Austria. In both Swiss dispatch centres, AMPDS is not used. During the emergency call, the call taker uses the in-house tool to lead the emergency call. In contrast, in Austria, there was no significant difference in satisfaction between the dispatch centre with the AMPDS and the one without. Although the questions in the AMPDS are more ‘technical’ and less empathic or emotional, the results are better compared with the Swiss dispatch centres. As the two Austrian dispatch centres with and without AMPDS did not show much difference, there is no evidence that AMPDS provides better results in terms of patient satisfaction. The national or sociocultural background may probably explain this effect. In all EMS included, the general satisfaction with the emergency treatment was rated very high (91.7%). Although the patients reported the waiting time as long, the duration of waiting time was still rated high. In hospital emergency departments, the perceived waiting time is one of the most important parameters of patient satisfaction [10]. The requirements for the arrival time at the emergency scene are 15 min in 90% in the Tyrolean EMS compared with 80% in Switzerland. However, this difference in requirements did not exert any effects on patient satisfaction. Accurate timely administration of pain relief medication and reduction of fear are very important aspects of satisfaction. These aspects showed high satisfaction in all EMS included. There was no difference in the two countries, although the EMS and the requirements are different. In contrast to Austria, the Swiss EMS works regularly with specialized emergency medical assistants with medical competences such as basic airway management, application of opiates and invasive medical techniques. Thus, there are many emergency cases where emergency medical assistants treat patients without a specialized EMS physician and therefore the number of EMS physicians is lower in Switzerland. In terms of patient satisfaction with reduction of pain and fear, there was no difference between physicians and emergency medical assistants.
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Patient satisfaction in emergency care Neumayr et al. 5
The questions in the quality scale for transport were generally rated lower, but still with high satisfaction (87.8%). One reason for the lower satisfaction is the impossibility of relatives to accompany the transport, often because of the limited seating capacity of the ambulance. Also, patients rated satisfaction lower as they felt cold during transport (e.g. not being covered with a blanket). To pay attention to the comfort of the patient during transport could probably raise the satisfaction rate. In particular, severely burned, injured or intubated patients and children who cannot communicate their needs require special attention. Lowest satisfaction rates were assigned to two items on soft skills: the question ‘Which articles should be taken to the hospital’ and the question on the social situation of the patient (i.e. taking care of children and domestic animals, informing neighbours or relatives). In emergency medicine, social skills and motivated staff are important factors for patient satisfaction [10]. Although we found high and very high satisfaction rates in items such as information provision, patient satisfaction can notably be improved by better training in empathic behaviour and soft skills of the EMS team [11]. Some limitations must be taken into account. First, the overall response rate of our survey was moderate. The obligation of the Ethics Committee of two Austrian centres to obtain written consent from the patients before sending them the questionnaire may explain this to some extent. All the patients included from these two Austrian centres agreed to complete the questionnaire. Second, our results are not simply applicable to countries or EMS that are strictly paramedic based. However, a comparison with those systems would be interesting. A further limitation of this survey is that we have just one dispatch centre with an AMPDS, which dispatches the EMS Innsbruck and the EMS Kufstein. A patient selection bias may be caused because of the subjective judgement of the NACA Score. Conclusion
In general, patient satisfaction in out-of-hospital emergency care is very high, irrespective of which EMS is judged, the strictly physician-based EMS in Austria or the combined physician and emergency medical assistantbased EMS in Switzerland. There is no general difference
in the patient satisfaction between the dispatch centre using the AMPDS and centres using the in-house tool. To improve the social skills of dispatchers and EMS-team members, special communication training is recommended. Furthermore, during transport, emergency medical assistants should focus on the comfort of the patients, for example, asking whether they need a blanket. A checklist should be developed for basic articles that patients should take along to hospital and for questions on responsibilities for children, dependent people or pets.
Acknowledgements This study is part of a dissertation at the Department of Anaesthesiology and Pain Therapy, University Hospital Bern, Switzerland. The authors would like to thank Robert Greif, Professor of Anaesthesiology, Department of Anaesthesiology and Pain Therapy, University Hospital Bern, Switzerland, for his support. Conflicts of interest
There are no conflicts of interest.
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