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Med. J. Cairo Univ., Vol. 80, No.

2, March: 5-15, 2012

Efficiency of Care and Satisfaction for Head Injury Patients at

Emergency Department in Mansoura Emergency Hospital
1,3,4 1,2
The Departments of Nursing Administration , Critical Care Nursing2, Faculty of Nursing, Mansoura University &
the Department of Nursing Administration, Damnhour University 3 and Alexandria University 4

Abstract Key Words: Efficiency of care Patients' satisfaction

Emergency department Head injury.
Introduction: In modern societies, the quality of medical
care plays an important role in building up patients positive Introduction
perception and satisfaction. Patient satisfaction has become
an established outcome indicator of the quality and the effi- TODAY, quality, efficiency and patient satisfaction
ciency of the healthcare system and can be an important tool are increasingly used as indicators for consumers
to improve the quality of services in the Emergency Department
(ED). and for insurers for selecting health care providers
[1] . The emergency department (ED) is one of the
This Study Aimed: To assess the efficiency of care and major entryways to hospitals for a significant
satisfaction for head injury patients at Emergency Department
in Mansoura Emergency Hospital. number of patients and often provides the patients
first impression of the hospital experience. When
Methods: A descriptive study was carried for 7 months patients enter ED with undiagnosed life-threatening
from December (2008) to June (2009) using 100 head injury
patients who were entered ED with mild, moderate, and severe
conditions, their survival depends on how fast and
conditions. Data were collected through two tools were 1- accurately the staffers diagnose and treat their
Emergency Department Patient Data Flow Sheet to assessing problems without making people wait for several
the efficiency of care provided for head injury patient from hours [2] .
arrival till disposition from emergency department, and 2-
Patient Satisfaction Questionnaire to determine overall patients' As the demand for emergency medicine service
satisfaction in relation to care process.
increases, emergency departments are compelled
Results: The results of the present study revealed that, to become more efficient at providing optimal
the majority of patients studied suffered from mild head patient care, this optimal care should be delivered
injuries (80%). The mean waiting time through different time to the right person, at the right time, in the right
intervals increased with decrease severity of head injury. The
study findings indicated that, the severe and moderate head place, in the right way, and by the right provider
injury patients had the more efficient care process because [3] . The efficiency of public health care system is
the total length of stay in ED of them was less than 4 hours. reflected in the utilization of the services by the
The severe patients had the highest mean difference for people for whom they are intended. In general
satisfaction (=15.89 at p<0.000). There was a relation with
satisfaction level and waiting time; those who waited longer
economic terminology, efficiency means absence
were less satisfied. of waste, or using the resources as effectively as
possible to satisfy people's needs and desires [4] .
Conclusions: There was a negative correlation coefficient
between length of stay (LOS) in ED and satisfaction for head The more efficient emergency departments were
injury patients. There were statistical significant differences
for satisfaction variance analysis between head injury patients
in reducing patient turnaround time. Patient turn-
(mild, moderate, and severe). And severe patients had the around time defined as the time that elapses be-
highest mean difference for satisfaction (=15.89 at p<0.000). tween the arrival and discharge of a patient. In
This was an association with satisfaction level; those who addition, it is a key performance measure of quality
waited longer were less satisfied. and efficiency of service at the ED [5] . The ED
Correspondence to: Dr. Hind Abdulla Mohamed, process is critical for any hospital. Short wait times
The Department of Nursing Administration, Critical Care and a positive experience represent important
Nursing, Faculty of Nursing, Mansoura University drivers of patient satisfaction [6] .

6 Efficiency of Care & Satisfaction for Head Injury Patients

Patient satisfaction is an important consideration the three shifts morning, evening, and night (100
that is closely related to patient care efficiency. patients according to the sample equation).
Patient satisfaction defined as a summation of all 2
the patients' experiences in the hospital. It derived Sample Size (n) = PQXz (Kish and Lesle, 1965)
from the patients' evaluation of how well the pro-
vider meets his or her personal and emotional as Where:
well as physical needs [7] . Now, patient satisfaction P = The estimated proportion of head injury
is increasingly being used as an outcome measure patients in Mansoura emergency hospital last year
for hospital and its personnel performance, and it = (7.95%).
is affected by multiple factors in the emergency
department as provision of information, technical Q = 1-P = 0.205.
skills, and perceived waiting times [6] . Z = A percentile of standard normal distribution
There is a relationship between how long pa- determined by 95% confidence level =1.96.
tients have to wait in ED to receive care and the A = The width of the confidence interval = P/10=
outcome. Critical Injuries as head injuries that 0.0795.
need medical and nursing intervention are time
0.795 X 0.205 X (1.96) 2
sensitive. The longer the wait, the more damage Sample size (n) = = 100 patients
occurs because there is a loss and/or deprivation (0.0795) 2
of basic needs for survival, such as oxygen, blood, Tools of data collection:
electrolytes (potassium, sodium, etc.), sugar, water,
immunity, and skin integrity. Therefore, ED team After approval by the hospitals administrative
is responsible for a complex situation; they must authority for the protection of human subjects, an
quickly form an opinion about the patients' condi- investigator explain clearly the aim of the study
tion and make satisfactory assessment [8] . to the ED staff and patients included in the study.
An investigator record review of retrospective
For this reason, the emergency department team estimation of number of head injury patients during
who care for head injury must understand the need year (2007). A pilot study will be carried out to
for timely evaluation and treatment of head injuries assess the clarity and the applicability of the tool.
and the possible long-term problems, and the ap- It will be conducted on 10% of sample size, which
propriate management of head injury patient is will not include in the study.
important to minimize complication [9] . So efficient
emergency department management requires a team The efficiency of care provided for all head
of providers know what they are doing, why they injury patients was assessed by Emergency Depart-
are taking certain measures, and what action has ment Patient Data Flow Sheet (time flow sheet)
to be taken to achieve a satisfactory outcome [10] . which developed by Dawood in 2004.

Aim of the study: The time flow sheet consists of the following parts:
This study was conducted to assess the efficien- 1- Patient general characteristics which include
cy of care and satisfaction for head injury patients (demographic data, pre hospital management,
at Emergency Department in Mansoura Emergency history and causes of head injury, nature of
Hospital. injury, and discharge state).
2- Primary assessment and intervention which
Material and Methods include (airway, breathing, circulation and dis-
Design: ability).
A descriptive study. 3- Secondary Assessment which include (all phys-
ical examination).
Setting: 4- Activities related to delegated medical order as
The study was conducted at the emergency (consultation, investigation and procedures).
department of Mansoura Emergency Hospital. This 5- Head Trauma Patient Care Intervention Checklist
department consists of two areas, reception room which include (resuscitation phase and preven-
(RR) and emergency department (ED) inpatient tion of secondary injuries).
Will be assessed the care provided for all head
Subject: injury patients from arrival till disposition from
All patients admitted to emergency department emergency department through the six time inter-
with head injury (mild, moderate, severe) through vals of patient flow in ED; these intervals represent
Hind A. Mohamed, et al. 7

the main phases of patient evaluation and treatment scored as 1 for done, 0 for not done, and activity
through the care process (Tool I). These time were not applicable was excluded. The perfor-
intervals, were: mance score was done through:
1- Time from arrival to emergency till physician Sum of scores obtain for
assessment. all required activities
Performance score = 100
2- Time spent from physician assessment till de- Maximum score from
applicable items
parture to radiology department.
3- Time spent in radiology department till return Time of activity: Recording the time of start and
to ED. end of each activity and notes was taken of time
for nothing being done within or between activ-
4- Time spent waiting for consultation and opera-
5- Time spent from discharge decision till departure Each item of the PSQ scored as 2 for Yes, 1 for
from ED. Sometimes, and 0 for No.
6- Time spent in way from ED to ED inpatient unit Logistic regression analysis was carried out to
or another unit. The time spent for each time study the variables affecting patient satisfaction
interval was calculated, and the total length of in ED. A P-value of less than 0.05 was considered
stay was calculated for each patient. Any reason statistically significant.
for delay during these six time intervals will be
identified. Results

Patients' perception related to care process was Table (1) demonstrate the percentage distribu-
assessed by Patient Satisfaction Questionnaire (PSQ) tion of the head injury patients according to their
which developed by Dawood (2004). The Patient general characteristics, results revealed that the
Satisfaction Questionnaire consists of 2 parts were, most of patients were male (84%). The mean age
the demographic data, and patient perception in ED of patients was 22.36 17.22. As regard the nature
toward care process. This PSQ investigates: of injury, findings revealed that the most of cases
had concussion (65.0%) followed by laceration
1-Patient satisfaction of waits for different activities.
(26.0%). Concerning the cause of injury and dis-
2- Satisfaction of communication with staff and charge status, the findings revealed that, the main
about operation. cause of injury was an accident for (49.0%) of
3- Satisfaction of relationship with ED staff (phy- cases follow by falls for (38.0%) of cases, while
sician, nurses, and orderlies). the least cause is sports about (4.0%) in cases of
4- Satisfaction of ED environment. head injury. Also table showed that, the all severe
cases were transfer to intensive care unit, 81.81%
5- The overall patient satisfaction in emergency
of moderate patients were admitted to inpatient
department. The PSQ has 38 items, plus addi-
ED unit, while 71.25% of mild cases discharge at
tional one question designed to list the reasons
of unsatisfaction.
Fig. (1) portrays the percentage distribution of
Patient who will be entered emergency depart-
patients according to severity of head injury. It
ment were interviewed after having all needed
was found that the majority of the patients (80%)
treatment and investigation to determine overall
were admitted with diagnosis of mild head injury,
patients' satisfaction in relation to care process
while the minority (9.0%) has severe head injury.
(Tool II).
Table (2) illustrates the percentage performance
Statistical analysis:
score for different components of management to
Data were recorded on standard study forms, and patients. Pre-hospital management was limited to
then entered into the SPSS statistical software Airway and Circulation assessment for moderate
(SPSS Base version 10.0) for Windows (SPSS and severe patients, and the severe patients have
Inc, Chicago). Patient demographics, head injury the highest score of care components (52.0%,
levels, time intervals and selected variable rela- 13.2%). Primary assessment illustrate that, severe
tionships were described using descriptive statistics patients has the highest score of component of
as Means, standard deviations, and percentages. assessment and intervention. The performance
Performance score was calculated for the areas score for preventive measures (Nutrition, Commu-
of performance that includes several activities nication, Activity, Pain, and Simulation) was very
provided to the head injury patients. Each activity low for head injury patients.
8 Efficiency of Care & Satisfaction for Head Injury Patients

Table (1): Percentage distribution of patients according to characteristics.

Head injury
Mild n=80 Moderate n=11 Severe n=9 Total n=100
Patients characteristics
No. % No. % No. % No. %
Male 71 88.75 7 63.63 6 66.66 84 84
Female 9 11.25 4 36.36 3 33.33 16 16
<15 16 20 4 36.36 7 77.77 27 27
15- 55 68.75 7 63.63 2 22.22 64 64
>45 9 11.25 0 0.0 0 0.0 9 9
Mean ageSD 24.47 17.53 19.67 15.44 7.396.51 22.36 17.22
Nature of injury:
Contusion 0 0.0 1 9.1 0 0.0 1 1
Laceration 24 30 2 18.18 0 0.0 26 26
Concussion 56 70 8 72.73 1 11.11 65 65
Skull fracture 0 0.0 0 0.0 2 22.22 2 2
Based skull fracture 0 0.0 0 0.0 3 33.33 3 3
Intracranial hemorrhage 0 0.0 0 3 33.33 3 3
Causes of head injury:
Falls 31 38.75 4 36.36 3 33.33 38 38
Accident 36 45 7 63.63 6 66.66 49 49
Sports 4 5 0 0.0 0 0.0 4 4
Others 9 11.25 0 0.0 0 0.0 9 9
Discharge summary:
Discharge at home 57 71.25 1 9.1 0 0.0 58 58
Transfer to another unit 23 28.75 9 81.8 0 0.0 32 32
Transfer to I.C.U 0 0.0 1 9.1 9 100 10 10

Table (3) indicate the mean duration (minutes) hour-4.30 hours) for mild patients followed by the
of different time intervals of care process in emer- mean of total length of stay for moderate patients
gency department according to severity of head 1.65 hour ranged between (1.10-2.35 hours), while
injury. Regarding time interval I the highest mean the lowest mean of total length of stay was 1.47
of time from arrival to ED till assessment by phy- hour ranged between (1.10-2.10 hours) for severe
sician was 4.24 minutes for mild patients, and the patients.
lowest mean for severe patients was 0.33 minutes.
Concerning time interval II, the highest mean of Table (4) shows the satisfaction level of patients
time spent from physician assessment till departure in regard to aspect of care process. Items with a
to radiology department was 17.45 minutes for high level of satisfaction included: Time from
mild patients. In time interval III, the lowest mean arrival to ED till seen by physician (78%), skills
of time spent was 10.22 minutes for severe patients. of ED physicians (77%), time from order of radi-
Concerning time interval IV, the highest mean of ology investigation till departure to X-ray depart-
time spent waiting for operation was 40.5 minutes ment (70%), cleanness and ventilation of ED (52%).
for moderate patients. Time interval IV also indi- While the lowest level of satisfaction refers to the
cated that, the highest mean of time spent waiting following items: Speed of orderlies response to
for consultation was 23.32 minutes for mild pa- request (20%), speed of nurse response request to
tients. In time interval V, the lowest mean was 1.66
call doctor (18%), nurses answer questions (16%),
minutes for severe patients. As regard time interval
speed of nurse response to calling (16%), explana-
VI, the highest mean of time spent in way from
tion of test result and treatment by physicians
ED to ED inpatient unit or another unit was 5.69
minutes. (13%), ED is calm (13%), giving an explanation
about follow up on discharge (12%), giving an
As regard the total Length of stay (LOS) in ED explanation of reason for admission (11%), giving
Fig. (2) shows that, the highest mean of total length information about any delay (10%), and provision
of stay in ED was 2.36 hours ranged between (1.10 of privacy during care provided (6%).
Hind A. Mohamed, et al. 9

Table (2): Percentage of performance score for different components of management for head injury patients according
to severity.
Management of head injury
Mild 80 Moderate 11 Severee 9
(I) Pre-hospital management:
Airway 0.0 45.3 52.0
Breathing 0.0 0.0 0.0
Circulation 0.0 11 13.2
Primary assessment and intervention
Airway 0.0 17.8 70.0
Breathing 0.0 44.5 55.0
Circulation 22.0 37.3 85.2
Disability 0.0 65.0 100.0
Exposure 5.0 4.0 35.0
(II) Secondary assessment and intervention:
A) Resuscitation phases
Fluid and electrolytes assessment 7.0 49.2 65.0
Aeration 0.0 25.4 63.7
(B) Prevention of secondary injury phases:
Nutrition 0.0 3.0 12.0
Communication 12.0 15.5 17.3
Activity 0.0 0.0 0.0
Pain 0.0 0.0 0.0
Simulation 0.0 3.0 12.0
Skin integrity 17.5 35.0 33.0

Table (3): Duration (minutes) of different time intervals of care process in emergency department according to severity of head

Head injury

Time intervals (in minutes) Mild (n=80) Moderate (n=11) Severe (n=9)

Range MeanSD Range MeanSD Range Mean SD

Time interval (I):

Time from arrival to ED till physician (0-20) 4.243.955 (0-15) 3.33 1.723 (0-5) 0.330.5000
Time interval (II):
Time spent from physician assessment (1-80) 17.45 17.703 (1-15) 5.752.988 (6-30) 16.009.301
till departure to radiology department
Time interval (III):
Time spent in radiology department till (6-53) 26.92 10.022 (6-30) 19.254.769 (6-15) 10.222.728
return to ED
Time interval (IV):
Time spent waiting for operation (36-45) 40.56.731 (25-35) 30.09.928 *NA *NA
Time spent waiting for consultation (1-180) 23.32 15.743 (4-48) 19.329.928 (1-12) 7.435.92
Time Interval (V):
Time spent from discharge decision till (1-30) 10.087.675 (6-20) 8.663.366 (1-5) 1.66 1.000
departure from ED
Time Interval (VI):
Time spent in way from ED to ED (4-15) 5.694.277 (4-15) 5.504.101 (4-10) 4.770.666
inpatient unit or another unit

*NA : (Not applied). ED : (Emergency Department)

10 Efficiency of Care & Satisfaction for Head Injury Patients

Table (4): Patient satisfaction in regard to aspect of care process in ED according to severity of head injury.

Head injury

Items Mild n=80 Moderate n=11 Severe n=9 Total n=100

No. % No. % No. % No. %

Satisfaction with waits for different

Time from arrival to ED till seen 60 75 9 81.81 9 100 78 78
by physician is long.
Time from order of radiology 59 73.75 7 63.63 4 44.44 70 70
investigation till departure to X-
ray department is long.
Time spent within X-ray depart- 31 38.75 6 54.54 9 100 46 46
ment is long.
Time from return to ED after done 35 43.75 7 63.63 9 100 51 51
X-ray till receiving results is
Time from operation order till 2 2.5 2 2
departure to operating room is

Satisfaction with communication and

about operation:
Giving explanation about what 29 36.25 5 .45 3 33.33 37 37
will be done to you.
Giving information about any 5 6.25 3 27.27 2 22.22 10 10
Giving explanation of reasons for 21 26.25 2 18.18 2 22.22 25 25
Giving you answer about your 29 36.25 4 36.36 6 66.66 39 39
Giving you explanation of reason 10 12.5 1 9.1 11 11
for admission.
Giving you an explanation about 11 13.75 1 9.1 12 12
follow-up on discharge.

Satisfaction with nurses and order-

Respect and courtesy to you by 39 48.75 6 54.54 5 5.55 50 50
Nurses keep you informed about 30 37.5 6 54.54 2 22.22 38 38
Nurses answer your questions. 10 12.5 2 18.18 4 44.44 16 16
Skills of ED nurses is good. 17 21.25 4 36.36 5 55.55 26 26
Respect and courtesy shown to 29 36.25 4 36.36 7 77.77 40 40
you by orderlies.

Satisfaction with speed of nurses and

Speed of nurse response to your 11 13.75 2 18.18 3 33.33 16 16
calling is rapid.
Speed of nurse response to your 13 16.25 2 18.18 5 55.55 20 20
request is rapid.
Speed of nurse response to your 13 16.25 2 18.18 3 33.33 18 18
request to call doctor is rapid.
Speed of response to your request 20 25.0 4 36.36 4 44.44 28 28
to evacuations rapid.
Speed of orderlies response to 22 27.5 4 36.36 5 55.55 31 31
your calling is rapid.
Speed of orderlies response to 13 16.75 3 27.27 4 44.44 20 20
your request is rapid.
Hind A. Mohamed, et al. 11

Table (4): Count.

Head injury
Items Mild n=80 Moderate n=11 Severe n=9 Total n=100
No. % No. % No. % No. %
Satisfaction with physicians:
Respect and courtesy shown to 21 26.25 5 45.45 4 44.44 30 30
you by physician.
Skills of physicians is good 60 75.0 9 81.81 8 88.88 77 77
Physicians available when you 22 27.5 4 36.36 9 100.0 35 35
need them.
Physicians informs you about 30 37.5 6 54.54 7 77.77 43 23
your condition.
Physicians answer your questions 35 43.75 5 45.45 6 66.66 46 46
about your condition.
Physicians explains your test re- 6 7.5 2 18.18 5 55.55 13 13
sult and treatment.
Physicians explains what will be 13 16.25 6 54.54 6 66.66 25 25
done to you.

Satisfaction with ED environment:

ED staff provide privacy to you 2 27.5 1 9.1 3 33.33 6 6
during care provided.
ED is noisy. 10 12.5 1 9.1 2 22.22 13 13
ED environment is clean and 41 51.25 6 54.54 5 55.55 52 52
well ventilated.

Overall satisfaction with ED visit:

Your rating of your ED visit is 48 60 7 63.63 3 33.33 58 58
If you need Ed you would come 40 50 6 54.54 8 88.88 54 54
Would you recommended ED to 30 37.5 4 36.36 6 66.66 40 40
your family if they need it.

Table (5): Reasons of dissatisfaction for head injury patients Table (6): The correlation coefficient between total length of
with Emergency Department. stay (LOS) and satisfaction of severity of head
injury patient according to the mean total score for
Percentage of head injury each of them.
patients (n=100)
Reasons of patients Satisfaction
dissatisfaction with ED % of reasons
No. % Mild (n=80) Moderate (n=11) Severe (n=9)
(n=523) Items
r p-value r p-value r p-value
No privacy 81 81 15.5 Length of -0.48 0.001* -0.91 0.001* -0.90 0.001*
Noise 66 66 12.6 stay
r : Correlation coefficient. * Significant
Long waiting time for consul- 59 59 11.3
Over crowding 57 57 10.9 9% Mild
No response to questions 43 43 8.3 Moderate
Miss communication with 43 43 8.3 Severe
staff of ED
Long waiting time in CT unit 31 31 5.9
Long waiting time in x -ray 29 29 5.5 80%
Small size of ED 28 28 5.3
Not enough of ED resources 28 28 5.3
Low level of cleanliness 10 10 1.9 Fig. (1): Percentage distribution of patients according to Severity
of head injury.
12 Efficiency of Care & Satisfaction for Head Injury Patients

2.5 by equal percentage for moderate and severe head

injury accounts for 10% of all head injury patients
2 [12] .
1.5 As regards the main cause of injury was an
accident for (49.0%) of patients, while the least
1 cause is sports about (4.0%) in patients. This was
in congruence with Turner (2010) in United States,
0.5 who illustrated that the common causes of head
injuries were motor vehicles which account for
0 almost half of the patients, follow by falls, assaults,
Mild Moderate Severe and sports [13] .
Fig. (2): Mean duration (hours) of the total length (LOS) in
emergency department according to severity of head The study result also reveled that majority of
injury. the patients had concussion (65.0%), while only
(1.0%) of all patients has contusion. This finding
Table (5) shows frequency distribution of rea- is compatible with Shanon Medical Center (2010)
sons of dissatisfaction for head injury patients with in England, who reported that approximately half
ED, results indicates that the most frequent reasons of all the ED visits for concussions patients [14] .
with a high level of dissatisfaction included: No
privacy (81%), followed by noise in ED (66%), According to discharge status, all severe patients
long waiting time for consultation (59%), over- were transfer to intensive care unit, the majority
crowding (57%), no response to questions and bad of moderate patients were admitted to hospital
communication with staff of ED were have equal (81.81%), while the majority of mild patients
percentage (43%), long waiting time in CT unit (71.25%) were discharge at home. The findings
(31%), long waiting time in X-ray department was supported by McNett et al., (2010) who con-
(29%). cluded that most patients of mild head injury rarely
they require a hospital admission, and the majority
Table (6) demonstrate that, there is a negative of head injury hospitalizations are for patients with
relation between total length of stay (LOS) in ED severe injuries necessitating critical care monitoring
and satisfaction of head injury patients. There were [15] .
a statistical significant difference observed at
p<0.001, those with longer LOS were less satisfied. The findings of the study revealed that the
severe patients has the highest score of all compo-
Discussion nent of assessment and intervention, followed by
performance score of moderate patients, while the
Emergency Departments (EDs) are a vital com- lowest score for mild patients. This result similar
ponent of any hospital, providing a wide variety to the result reported by Dawood (2004) who found
of medical services around the clock. Typically, that sever and moderate patients had the highest
an ED is designed to provide high quality medical score of care component of assessment and inter-
treatment, with the immediate availability of critical vention [16] . Also, according to Presciutti (2006)
resources to the patients in need of emergent and the responsibilities of ED team for severe head
urgent care [5] . In modern societies, the quality of injury include monitoring patient physiological
medical care plays an important role in building parameters and ensuring hemodynamic stability,
up patients positive perception and satisfaction. performing serial neurological examinations, pre-
With the emerging role of patients as important venting secondary injury, and providing emotional
medical care partners, it is critical to understand support for patients [17] .
their expectations for care. Obtaining patient feed-
back can provide valuable into the quality of clinical Chande et al. (1991), reported that prolonged
practice and hospital programs [11] . waiting time was the reason for 33% of the com-
plaints lodged against the ED of the Kings College
Findings of the present study showed that the Hospital and for 60% of the patients leaving the
majority of studied patients admitted to ED with Toronto Hospital ED without being seen by a
head injuries was classified as mild head injury physician. Shortening waiting time may improve
80%, followed by 11% as moderate and the minor- ED satisfaction for about 75% of patients (18). In
ity of patients was 9% as sever. This classification our study, the patients and their families also
is consistent with Costello et al. (2007), who found complained of waiting time for consultation, wait-
that the mild head injury account (80.0%) followed ing time in CT unit, and in X-ray department (59%,
Hind A. Mohamed, et al. 13

43%, and 37%). However, according to Hedges et tient satisfaction has been shown to be influenced
al. (2002) study emphasized that efforts to improve by length of waiting time and total time spent in
ED patient satisfaction should focus primarily on the emergency department [23] . This goes in agree-
improving patients perceptions that wait intervals ment with Boudreaux et al. (2009) study which
are appropriate, and secondarily on shortening the found the satisfaction level was higher in those
wait intervals [19] . with serious illnesses or emergency needs. In this
study they suggested that the reduction in average
The present study illustrate that the longest waiting time was an important factor to increase
mean of time spent from arrival to ED till seen by the satisfaction level [24] .
physician was 4.3 minutes for mild patients, while
the lowest mean of time spent was 0.3 minutes for According to Press Ganey's (2009) report that
sever patients. This result is supporting by the patients who spent more than 2 hours in the emer-
result of Yoon et al. (2003) at Alberta Hospital in gency department reported less overall satisfaction
Canada stated that, the mean minutes of ED reg- with their visits than those who were there for less
istration to triage assessment was 2.8 minutes for than 2 hours. Since much of the time in the ED is
triage level 1, triage level 2 was 2.6, while triage spent waiting-in the waiting room, in the exam
level 3 was 7.7 minutes [20] . area, for tests, for discharge-reducing waiting times
should have a direct positive impact on patient
The findings of the present study revealed also satisfaction [25] .
that, the highest mean of time waited to be seen
by specialist in ED was 23.3 minutes for mild Other common reasons for dissatisfaction in
patients, followed by the mean time 19, 3 minutes the present study are: No privacy, noise, overcrowd-
for moderate patients, while the lowest mean of ing, and no response to patient questions. Walsh
time was 7.4 minutes for sever patients. There was and Knott (20 10) study supports our results which
an association with satisfaction level; those who emphasized that privacy, noise, comfort, modern-
waited longer were less satisfied at p<0.000. This isms of equipment, Cleanliness, communication,
finding is consistent with Soleimanpour et al. and food have been identified as important envi-
(2011), which find that, the average time a patient ronmental elements that affect patient satisfaction.
waited to be seen by a specialist or a resident in Most of these are very basic human needs that
emergency medicine was 24.15min. There was an would be expected to rate highly important in most
association with satisfaction level; those who waited settings [26] .
longer were less satisfied [21] . From the viewpoint of patients in the present
Considering the mean of total length of stay in study, the reasons of dissatisfaction related to ED
ED, it was found that mild patients were spent staff were no response to questions and bad com-
munication with ED staff. Also our observation
2.36 hours followed by 1.65 hours for moderate
results confirmed that communication between
patients; while the lowest mean of total length of
staff (physician and nurses) and patient was poor.
stay was 1.47 for sever patients. This finding
illustrate that, the mild head injury patients had Benger and Taylor (2004) & Kaushal et al.
the longest mean of time spent in all time intervals (2005), stated that the interpersonal skills/staff
in ED than moderate and sever patients. This goes attitudes, provision of information/explanation,
in consistence with Finamor and Turris (2009) who and the increasing information on ED arrival are
reported that emergency patients having the longest factors has a significant effect on patients' percep-
waits are those who present with less urgent symp- tions of the quality of care and overall satisfaction
toms [22] . Moreover Costello et al. (2007) claimed [27,28] . This was supported by findings of Taylors
that the evaluating, diagnosing, and treating minor et al. (2006) study which revealed that staff orien-
head trauma is more difficult than moderate or tation with an educational film and workshop on
severe injury, so mild head injury need more time how to communicate effectively with patients and
than others [12] . having a nurse to explain the diagnostic and treat-
ment processes to patients improved the patients
In study found that there are a negative corre- satisfaction levels [29] .
lation between length of stay in ED and satisfaction
for head injury patients. Those who waited longer On other hand, items with a high level of satis-
were less satisfied. Other studies have also shown faction included were: Time from arrival to ED
that there are a negative association between in- till seen by physician, skills of ED physicians, time
creased waiting time and patient satisfaction [21- from order of radiology investigation till departure
26] . Also Downey and Zun (2010) stated that, pa- to X-ray department, cleanliness and ventilation
14 Efficiency of Care & Satisfaction for Head Injury Patients

of ED, time from return to ED after done X-ray department-a qualitative study. International Jourmnal of
till receiving results, and respect and courtesy nursing studies. July, 44 (5): 714-22. 10-1-2010, 2007.
shown by nurses. 9- DRIES JD.: Initial evaluation of the trauma patiemnt.
Emerg. Medicin. J., 4 (1): 67-73, 2001.
Thus, according to the findings of this study
and similar ones, EDs need to define their processes WULLSCHLEGER M., BURKI L. and ZIMMERMANN
very clearly, especially those processes related to H.: Strategies Emergency Department Design: An Ap-
triage, registration, diagnosis, treatment, admission, proach To Capacity Planning In Health Care Provision
and discharge from ED, and the use of patient input In Overcrowded Emergency Rooms. Journal Of Trauma
(complaints and compliments) to decrease length Management and Outcomes, 17 November, 2 (11): 321-
327, 2008.
of stay, improve efficiency and raise the satisfaction
A.M. and HEPNER D.L.: Improving efficiency and patient
satisfaction in a Tertiary Teaching Hospital Preoperative
Conclusion: Clinic, the American Society of Anesthesiologists, 112
The study findings indicated that, the severe (1): 66-72, 2010.
and moderate head injury patients had the more 11- COSTELLO H.H. and PANG P.S.: Managing Closed Head
efficient care process because the total length of Injury. Emerg. Med., 39 (6): 22, 2007.
stay in ED of them was less than 4 hours. There 13- TURNER K.: Nursing a patient with a severe head injury:
was a negative correlation coefficient between A case study, retrieved from
length of stay (LOS) in ED and satisfaction for, 2010.
head injury patients. There were statistical signif- 14- Shanon Medical Center.: Head Injury-facts and symptoms,
icant differences for satisfaction variance analysis 2010.
between head injury patients (mild, moderate, and
severe). And severe patients had the highest mean 15- MCNETT M. and GIANAKIS A.: Nursing interventions
for critically ill traumatic brain injury patients. Journal
difference for satisfaction (=15.89 at p<0.000). of Neuroscience Nursing, April, 42 (2): 71-77, 2010.
This was an association with satisfaction level;
16- DAWOOD N.I.: Efficiency of Care and patient satisfaction
those who waited longer were less satisfied. at Emergency Department in Alexandria Main University
Hospital, published master thesis, in Nursing Administra-
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