A Qualitative Study Exploring Patients Experience of Emergency Healthcare Utilisation during the Covid-19 Pandemic.

doi:10.21203/rs.3.rs-4655948/v1

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Research Article

A Qualitative Study Exploring Patients Experience of Emergency Healthcare Utilisation during the Covid-19 Pandemic.

https://doi.org/10.21203/rs.3.rs-4655948/v1

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Background

COVID-19 caused a global pandemic, disrupting healthcare services and contributing to significant mortality and morbidity worldwide. This necessitated high-quality care to be balanced with infection control in Emergency Department (ED) setting, compounding existing challenges for both healthcare professionals and patients. The aim of this study was to explore the experiences of adults who attended EDs across Ireland during the COVID-19 pandemic. Study findings will enhance understanding of patient’s experiences of ED attendance during COVID-19 and add to the evidence which explores the impact of Covid-19 on patient care.

Methods

This study utilises a subset of the Better Data Better Planning study [1] consisting of 46 interviews from 4 Regional Hospital Sites across Ireland. A qualitative research design comprising of semi-structured interviews was used for this study.

Results

Two key themes were produced from the data; Sense of reassurance in the ED during COVID-19 and COVID-19 impact on ED attendance and discharge experience.

Conclusions

This paper provides tangible insights into the experiences of ED patients during Covid-19 Notably, the importance of staff reassurance, where along with PPE use, reconfiguration of the ED environment and communication were found to alleviate patients concerns regarding exposure and transmission risks of Covid-19 while being present in the ED during the pandemic.

In 2020, COVID-19 resulted in a global pandemic which caused substantial disruption to health care services and systems and contributed to significant mortality and morbidity worldwide [2]. The sudden requirement for specialised and augmented health care services required high-quality care to be balanced with infection control management. This was particularly challenging in Emergency Department (ED) settings where the management of acutely ill patients, high staff turnover and time pressures are routine and exacerbated by the emergence of the pandemic. To date, research exploring the impact of COVID-19 has been limited to its effect on healthcare systems and services and on Health and Social Care Professionals (HSCPs). Research which is representative of the experience and perspective of all relevant stakeholders is required to inform healthcare strategy [3].

From an ED perspective, COVID-19 created additional challenges and complications to an already complex setting for both HSCPs and patients. COVID-19 saw the ED forced to respond to and navigate delivery of safe care amidst variable presentations from patients. Transmission concerns of presenting patients, a more unwell patient cohort, coupled with fragmented staffing, created variations across the ED health system during COVID-19. These changes were reflected in the research, with a UK study showing a significant decrease in common presenting complaints and primary diagnoses in the ED [4], with the mean length of ED stay during the first phase of the pandemic decreased from 3.8 hours to 3.1 hours. Additionally, a retrospective observational study in Ireland found significant decreases in ED attendances for abdominal pain, chest pain, headache, and trauma occurred during 2020 with respect to both pre- and post- COVID-19 lockdown periods [5]. The impact of COVID-19 on patients has been linked to a decrease in common ED presentations, fear of contracting and spreading the virus and patients delay in seeking health care during and after COVID-19 [1]. Furthermore, patient demographics and clinical characteristics changed during the COVID-19 lockdown period. A study conducted in the Netherlands looked at 1338 patient respondents who attended the ED during the COVID-19 pandemic, where 278 (20.8%) reported delayed emergency healthcare seeking behaviour; of those who delayed care, 126 (45.4%) reported the delay was related to COVID-19 concerns [6].

The experience in Ireland mirrored international trends, whereby COVID-19 public health restrictions significantly impacted health-seeking behaviour [1]. Not only did the length of stay in the ED decrease, but there were also observed differences in patient disposition as well as a decrease in likelihood for patients to attend the ED for reassurance, a second opinion, or to see a specialist [1]. Despite the decrease in likelihood of attendance to the ED, patients were often unaware of alternative pathways to care [7]. Similarly, psychiatry presentations to the ED decreased by 21% during the COVID-19 restrictions despite the significant increase in anxiety disorders during this period [8]. There are multiple possibilities as to why these decreases in hospital reports were seen given the likelihood of actual decreases in incident rates is unlikely. Decreases in hospital reports of common crises may be secondary to a population’s lack of seeking medical attention earlier in their crisis due to fear of contracting COVID-19 in a hospital setting. Many reports of delays of care to EDs have been documented since the pandemic in response to fear of contracting the disease in the ED [9]. The impact of COVID-19 heavily impacted on ED HSCPs, for whom both emotional and practical challenges were experienced [10], placing greater strain on an already stretched workforce with the potential to further impacts on the patient’s ED experience.

The aim of this study was to explore the experiences of adults who attended EDs across Ireland during the COVID-19 pandemic. Study findings will enhance understanding of patient’s experiences of ED attendance during COVID-19 and add to the evidence which explores the impact of Covid-19 on patient care. Furthermore, these findings provide valuable insight into patients’ decision-making process for attending the ED, participants' satisfaction with care provided and concerns pertaining to Covid-19. This study is part of a larger study, the Better Data, Better Planning (BDBP) Study, which collected demographic and clinical profiles of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland [1]. While extensive research has been undertaken to explore the impact of COVID-19 on health services globally, a paucity of research has been undertaken with a focus on the ED during COVID-19, particularly capturing the patient perspective.

This study is comprised of a subset of the BDBP study [1] consisting of 46 BDBP interviews from 4 Regional Hospital Sites across Ireland; 9 interviews from University Hospital Kerry, 12 interviews from St. James University Hospital, Dublin, 12 interviews from St. Vincent’s University Hospital, Dublin and 13 interviews from University Hospital Limerick. A sampling frame of 24 hours was used to recruit adult patients attending the ED.

Study design

A qualitative research design comprising of semi-structured interviews was used for this study. This approach allows qualitative researchers to employ interconnected interpretive practices to gain an in-depth understanding of the subject matter under scrutiny [11]. This ensured a bespoke evidence-based approach to protocol development and study application which ensured the in-depth exploration of patient experience. The interview guide was developed and piloted for this study, a copy of which is included in Appendix 1. To ensure rigour and limit bias, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for interviews to standardise the conduct and reporting of the study [12].

Ethical approval

The study was performed in accordance with the Declaration of Helsinki ethical principles for medical research involving human subjects [13]. Ethical approval was obtained from the UL Hospitals Group Research Ethics Committee (REC) at University Hospital Limerick (Ref. 122/19), HSE Midlands Area REC for MRHT (Ref: 231019CG), St. Vincent’s Healthcare Group Ethics and Medical Research Committee for St. Vincents University Hospital (Ref. RS20-004), Tallaght University Hospital / St. James’s University Hospital Joint REC for SJUH (Ref. 2020–04) and the Clinical REC of Cork Teaching Hospitals for University Hospital Kerry (Ref. ECM 4 (J)/ECM 4 (bb). Written, informed consent was obtained from all participants prior to enrolment in the study.

Study Settings

There are seven hospital groups organised around Ireland: Ireland East Hospital Group, RCSI Hospital Group, Dublin Midlands Hospital Group, UL Hospitals, South/Southwest Hospital Group, Saolta Hospital Group, and Children’s Health Ireland [14]. This study involved the EDs of four hospitals across Ireland: University Hospital Kerry (South/Southwest Hospital Group) Model 3, University Hospital Limerick (UL Hospital Group) Model 4, St. James University Hospital (Dublin Midland Hospitals) Model 4 and St Vincent's University Hospital (Ireland East Hospital Group) Model 4. Interviews took place during COVID-19 from March - December 2020. University Hospital Limerick averaged 180 ED presentations per day in 2020, and 5,585 presentations per month [15].

Model 4 Hospitals have an ED and Acute Medical Unit (AMU) which operates 24/7, these hospitals provide regular acute and elective inpatient and ambulatory care, managing high acuity procedures and major trauma patients, cancer care and single national surgical specialities [14]. Model 3 Hospitals admit undifferentiated acute medical patients, have an Acute Medical Assessment Unit and an ED on site and a category 1 or 2 ICU. The study settings represented in this study are inclusive of EDs with high attendance rates and diverse acute presentations. Consequently, this will ensure that study findings are representative of patient experience in emergency care settings with similar patient care structures and services offering a national perspective. Considering the emergency care pathways currently in place in EDs at a national level, many of which were streamlined during the Covid-19 pandemic, patients who were admitted or triaged in the ED and subsequently seen in an acute assessment unit were also suitable for inclusion in the study.

Participants

A total of 46 interviews of the 306 from [1] study was analysed for this study: 9 from University Hospital Kerry, 12 from St. James University Hospital, 12 from St. Vincent’s University Hospital, and 13 from University Hospital Limerick.

Recruitment and Sampling

The overall approach to participant recruitment adhered to a sampling frame of 24 hours to recruit adult patients attending the ED. Participant inclusion criteria comprised of: a) Individuals aged 18 years or older, b) considered medically stable using the Manchester Triage System (MTS) (categories 2-5), c) patient has capacity and willingness to provide informed consent. Exclusion criteria included: a) scheduled admissions to the ED, b) Mental health presentation, c) Patients with altered capacity due to drug or alcohol intoxication, d) Inability to communicate sufficiently in English to participate. A subset of 15-20% randomly selected participants were invited to participate in an interview 7-10 days following their ED visit to capture their in-depth experiences of attending the ED during the pandemic. The informed consent process within each ED was inclusive of consent to contact participants for a telephone interview following their ED visit. Participants were made aware of the purpose and content of the follow-up interviews prior to consent. Should a participant have a query, complaint or report an illness at the time of the interviews, structures were put in place at each site to provide support and follow-up care as appropriate. This was integrated as part of the study protocol after the pilot interviews and included patient advocacy services, the complaints process and linkage with both nursing and medical management at each site.

In order to stratify participants, participants were categorised by gender, age, whether from an urban or rural setting and whether they had a medical card, private health insurance or no coverage. Health insurance is categorised as private or public health insurance, which will depend on the income threshold. A medical card will cover the prescriptions an individual needs.

Once the strata were applied, the number of participants picked from the random sampling were dependent on the % representation from the overall number of participants from the site. The participants were contacted in sequence as they appeared in the randomised list on an excel document. In instances where participants refused or were unable to be contacted, the Research Nurse responsible for recruitment moved on to the next participant on the list in that grouping. Should a participant call back and wish to participate they were subsequently included. The informed consent process was repeated at the start of each phone call to ensure participants remained well informed of the risks and benefits of participating and made aware of the option to exit from the study. Four participants did not consent to contact after the ED visit. Two potential participants did not consent to telephone interview. One participant did not wish to discuss their experience as they were still unwell post ED attendance, the other participant had a negative outcome in the ED and, consequently, did not wish to discuss their experience. Both were offered support and follow-up care as appropriate and referred on to appropriate services.

The concept of information power was employed to ensure appropriate sample size. This process emphasises that the more relevant and in-depth the participant experience of the subject area is, the less participants are needed [16]. The participants interviewed had in-depth and current knowledge of their ED experience and could seamlessly report their experience to both clinical nurse researchers. Therefore, saturation was reached at 15-20% of the overall patients sampled at each site. Consequently, the sample size was evaluated at both the data collection and analysis stages and was deemed appropriate to address study aims and answer the research question posed.

Data Collection

Nine pilot interviews were carried out to refine the qualitative interview guide, consequently additional prompts were added to assist with the interview process. In addition, with the onset of the Covid-19 pandemic additional questions were added to facilitate in-depth exploration of patient’s experience. The interview schedule explored participants’ rationale for attending the ED and their experience within the ED. As outlined in the interview schedule, the Research Nurse used prompts to assist the participant in providing in-depth description of their experience and rationale for attendance.

The interviews were carried out by two Research Nurses over the telephone in accordance with public health guidance in place at the time of the study. The phone calls were undertaken in a private research room in the Clinical Research Support Unit (CRSU) of UHL where the research team were based. This ensured participant anonymity and facilitated a seamless uninterrupted interview process between the Research Nurse and participant. Nine pilot interviews were carried out in November and December of 2019 to refine the qualitative interview guide, with the onset of the Covid-19 pandemic additional questions were added to facilitate in-depth exploration of patient’s experience. Both Research Nurses (Clinical Nurse Manager 2 Grade) had previous experience conducting qualitative interviews. The first Research Nurse (GC) had 25+ years' experience working in acute medical services including the ED and 3 years working in research. The second Research Nurse (LB) had 15+ years' experience working in acute and medical services with 6+ years working in research. The Research Nurses conducting the follow-up interviews had initially administered surveys to recruited participants in each ED. Therefore, those interviewed were aware of the research nurse’s role and the purpose of the study as a result of the rigorous informed consenting process. As a result, the interviewers had built a professional rapport with study participants and this enhanced and underpinned the data collection process. Field notes were taken to note the time, date, and duration of interviews. The prompts used to enhance the interview process and emerging themes were also documented during the interview process to enhance and inform the data analysis process. This assisted with the initial coding of interview transcripts.

Rigour

To mitigate bias, methods of ensuring transferability, confirmability, credibility, and dependability were applied. These criteria, originally identified [17] are outlined in Table One and are highlighted in previous recommendations [18].

Table One: Criteria for Demonstrating Rigour in Qualitative Research

Criteria for Demonstrating Rigour in Qualitative Research	Methodology
Transferability	The transparent reporting of the study design, process and participant demographics provides sufficient detail for the recreation of the study. A well described, organised and purposeful method of sampling and recruitment was undertaken to ensure that rich data could be obtained from participants. The Research Nurses maintained detailed field notes to ensure rigorous documentation of the study process and adherence to the study protocol.
Confirmability	The demographics of participants were described in detail to give contextual relevance and depth to the data presented. This enhanced the generalisability and application of study findings. Direct quotations from participants were included to illustrate that findings were representative of data gathered and not biased by the researcher. The Research Nurses maintained detailed field notes to ensure rigorous documentation of the study process and adherence to the study protocol.
Credibility	Interviewers were experienced and skilled in interviewing research participants. A compassionate and empathetic approach to interviewing was employed to support participants. Participants were aware of the qualifications, role, and experience of interviewers to enhance credibility of approach. Participants were made aware of the overall aim of the study and the risks and benefits of being involved. This was undertaken at informed consent and before participating in the interview. Consequently, prior to commencing the interviews a rapport and trusting relationship was established to enhance participant willingness to exchange information. Participants were given ownership of the time and of the interview. Consequently, research nurses limited the impact of data collection on the participant. At the beginning and end of the interview, participants were encouraged to ask questions and interviewers ensured that they had contact details for the research team should any queries or problems arise. The research team were keenly aware that the ED experience for some participants may be difficult to discuss. Therefore, supports for participants were in place and included in the study protocol. These supports were offered to participants where appropriate by the Research Nurses. The informed consent process within each ED was inclusive of consent to contact participants for a telephone interview following their ED visit. Participants were made aware of the purpose and content of the follow-up interviews prior to consent. Should a participant have a query, complaint or report an illness at the time of the interviews, structures were put in place at each site to provide support and follow-up care as appropriate. This was integrated as part of the study protocol after the pilot interviews and included patient advocacy services, the complaints process and linkage with both nursing and medical management at each site.
Dependability	Via protocol development and field notes, an audit trail was established describing the study’s procedures and processes. Changes to the study were documented and accounted for e.g. Interview guide enhanced post pilot interviews.

Data Analysis

The semi-structured interview data were digitally audio-recorded and transcribed verbatim. The interviews varied in length from 12 to 50 minutes. Coding of the data for the current manuscript occurred in June 2022. Data were uploaded to NVivo to manage the data and support the data analysis process. The transcribed interview data were analysed following a reflexive thematic approach [19] through the production and analysis of themes. In the first instance, three interview transcripts were coded by two independent researchers (MB and CF) and subsequently discussed to explore different perspectives and insights from coders, as opposed to seeking consensus. All data were then coded by one researcher (MB). The six steps of thematic analysis described by Braun and Clarke were followed [19, 20]. The flexible nature of these steps is in line with the reflective thematic analysis approach utilised. The first step, involving data familiarisation, was achieved through analysis following transcription and reading of all data. The second step, involving generating initial codes systematically across the data set, had a particular focus on the research question. In the third step, overlapping codes were identified and preliminary themes defined. In the fourth step, these themes were reviewed with the research supervisors (RG, CF, NC) and in the fifth step they were refined and named. The final step involved preparation of the manuscript with quotes from the interview data to illustrate the themes identified. Upon application of the concept of information power, no further interviews were required to inform study findings.

Summary of Coding Tree/Overall Findings

Figure 1 provides an overview of themes produced. Participants described challenges in accessing supports upon ED referral during the pandemic, this was exacerbated by chronic waiting lists, the pausing or shutdown of routine healthcare services due to covid-19 outbreaks or surges and perceived inappropriate referrals. Many participants accessed private healthcare services due to stressors on the public health system. This was further exacerbated by the pandemic. Participants also discussed the supports available both in the acute and community services. Community services were bolstered during the pandemic, and this was clearly evident. Participants benefitted from healthcare provider supports post-ED and while recovering in the community. Participants were also heavily reliant on family support particularly when healthcare services were impacted by surges or healthcare-associated outbreaks of Covid-19. The unpredictability of Covid-19 surges and outbreaks often led to disjointed follow-up care and discharge planning; however, most participants described a concerted effort by healthcare workers (HCWs) to ensure appropriate follow-up. Participants experienced both effective and ineffective communication, those who were reassured, received appropriate education, and felt supported during their time in the ED reported a positive experience of interactions with HCWs. Participants who did not receive appropriate education, reassurance and support in a Covid-19 ED environment perceived a negative experience. Those who described receiving high-quality care not only attained appropriate diagnostics and intervention both within the ED and upon discharge, but were reassured, educated, and supported during their time in the ED. This was perceived as vital by participants particularly in a restructured and alien ED Covid-19 environment.

Due to the covid-19 pandemic, participants described feeling fearful of attending the ED and reluctant to access any healthcare services unless absolutely necessary and what they considered an emergency. Participants feared exposure to the virus when already unwell and were also apprehensive of how the pandemic may have altered the ED experience or how related healthcare services were delivered. Participants also described how ED staff made them feel safe and protected. Strict adherence to infection control precautions by both staff and other patients was routinely observed by participants which enhanced confidence in their safety within the ED environment. Participants described how Covid-19 had altered their expectations of the ED experience, participants did not expect the same level of timely intervention and follow-up and were understanding of ED stressors which were exacerbated by the pandemic. Participants who had a negative experience of the ED in a previous attendance had low expectations and were often surprised at the organised and timely manner in which care was delivered during the pandemic.

A total of 46 participants participated in this study. Two key themes were produced from the data; Sense of reassurance in the ED during COVID-19 and COVID-19 impact on ED attendance and discharge experience.

Sense of reassurance in the ED during COVID-19

A strong sense of reassurance was found across patient experiences in the ED during COVID-19. Participants spoke of how they were made feel reassured while in the ED during COVID-19 through communication efforts from ED staff:

“They have the place divided into COVID and non-COVID. I was seen even quicker than normal I have to be honest I normally would be waiting around a bit but I was seen very fast seen within 10 minutes of me arriving. There are people out on the hall this time it was far more, there was far more space there was a less frantic atmosphere” Participant 224

In addition to communication contributing to reassurance amongst patients, visibility of ED staff adhering to infection control measures also led to a sense of reassurance amongst participants:

“And then at the level of, I suppose, management, in terms of people washing their hands. That didn’t seem to be the case anymore. It was more strict and they were more aware.” Participant 319

“I felt very safe in there, I wore my mask all the time and there was distancing and the crowds were way less than I remember them being previously so no it was fine. With all the social distancing and there was plenty space I felt fine”. Participant 283

While some participants reported having some concerns regarding COVID-19 transmission while in the ED, there was an overarching sense of these fears being alleviated by infection control policies and public health measures that were implemented in the ED, particularly the re-adaptation of the ED environment for COVID-19 and non-COVID-19 zones:

“I got a bit anxious when I saw, you know where the cubicles used to be where it was all glass and everyone was in PPE that kind of thing like but then I was kind of relieved, that ok so everyone with COVID-19 symptoms is over there and not with me, so I was reassured by the way everything was organised even though it looked a bit daunting.” Participant 319

“They (ED staff) just couldn’t do enough, they would kindly advise us at times if we did go out into the corridor to make sure we had our masks back but when the doctors or nurses would come to you through courtesy you would put it back on you know just to eliminate any further say contamination”. Participant 371

In contrast, some participants who did not feel they received clear communication, or were not reassured, seemed to report a more negative experience around a lack of leadership in care planning while in the ED:

“It was really a bit disorientating because you were given a mask, you weren’t recognising people and that part of things, that was because of the covid, it’s understandable”. Participant 241

Several participants who had a pre-COVID-19 ED attendance spoke of how their experience during COVID-19 was found to have meaningful engagement with ED staff, an ED environment which was more structured in terms of organisation as well as reduced patient numbers leading to a more relaxed environment:

“I think it’s on everyone’s mind… I think it’s the first conversation everyone has had “have ye got any covid patients here in the hospital” and you know what’s the format and procedures but they advised us very quickly you know what their recommendations” Participant 371

“Anytime I go there’s always, there seems to be loads of people. In this place now, I was taken away and they ah took me to the urology place and looked after me and there wasn’t any hassle, I didn’t have to wait or anything.” Participant 268

For some participants, the restricted visitor / accompanying policy during COVID-19 was acknowledged positively, offering a quieter and less busy ED setting:

“And do you know – a thing I noticed that ah I’ve been in the hospital a few times, you wouldn’t believe this, it was a godsend not to have visitors and that I could rest” Participant 177

While others also recognised the visiting / accompanying restrictions and the impact this caused on the ED staff:

“Being in the times we are living in at the moment with the coronavirus and everything else and as family members and friends cannot visit their loved ones in the hospital and I think I think there is a bigger burden actually on the poor nurses and medical staff there to try and you know to try and console people and to counteract that balance” Participant 371

While largely the ED COVID-19 experience was that of patient’s satisfaction with the care received, some examples highlighted challenges in the additional time involved in adherence to PPE measures during their ED stay:

“No I wouldn’t say difficult to access, I was able to see who I needed to see but it just takes a way longer you know because you have to be seen on your own and everything has to be cleaned in between you know. Everything just takes longer.” Participant 192

COVID-19 impact on patient decision making; ED attendance, discharge and reattendance

ED attendance

The impact of COVID-19 on participants decision to attend the ED appeared minor, with patients reporting their health concerns taking precedence over transmission risks associated with the ED clinical environment:

“Ah well I suppose in the back of my mind I would but, but to tell you the truth if I had some other issue that wasn’t right in the body I would be going about it definitely I don’t think COVID-19 would stop me now.” Participant 297

“I don’t think COVID-19 would stop me, I would definitely go or attend if there was something not right. I would be dying for someone to see me, I don’t care, I wouldn’t care.” Participant 319

Numerous patients expressed that they would have refrained from visiting the ED unless faced with an emergency, or emphasised that their health worries were more significant than their concern about contracting COVID-19 at the hospital:

“Well I was actually so sick I didn’t even think about it and I was in so much pain. The pain was unmerciful so I had to yea I had no choice but to get help so it didn’t even cast me a thought”. Participant 318

Some participants acknowledged that COVID-19 created a delay in their decision to attend the ED due to COVI-19 exposure and transmission risks and concerns, illustrating how these concerns were alleviate on presentation to the ED:

“I think I would have and that was just something personally I would have done you know, due to the pandemic and due to the situation with COVID-19 but I think once you get in there and actually see it the hospital staff once you go in you have your COVID test before you are put to the ward but then you are kinda restricted to that ward and not much manoeuvring around the hospital so it is safe” Participant 371

ED discharge and reattendance

The challenges surrounding follow-up care and post discharge experiences were acknowledged. Variation in experiences illustrated a lack of clarity and consistency in the level of follow-up care received, with several examples of delays follow-up reported. Patients discussed the lack of a clear plan of post-discharge schedule of events, including follow up appointments, details of results and investigation outcomes and clarity on ED and GP communication:

“There is no correspondence made yet. There is a lot of stuff going on in the environment at the moment with, COVID-19.” Participant 241

In terms of potential reattendance to the ED during COVID-19, participants did not express that COVID-19 would be a deterrent to re-attending the ED if needed. Similar to attendance opinions, participants felt that if it was warranted based on health concerns, this would outweigh COVID-19 fears. Most individuals stated that they received timely care, and that they understood the stressors present in the ED. Even when many stated that they had long wait times, the individuals that felt they received proper and adequate care that they needed gave a positive rating of their ED experience:

“I was hanging around for a while, for the scan and to be seen by the doctor but it was worth it even though I was sick of hanging around. But when I did get up there for the scan they were very good they were very quick and thorough...I was very reassured.” Participant 190

Having experienced the ED environment during COVID-19, participants felt reassured that if they had to return, the COVID-19 measures in place would reassure them and not influence their decision to revisit, showing confidence in the ED setting during COVID-19:

“Oh I would not hesitate even if the pandemic got worse cos once you see the way they control things in there you know the way they work it. I think a lot of people don’t realise that all the services are still going and these people are still working under different environments and working under different regulations but I think there is a lot of people out there that think that don’t realise that everything is adequately and is operating adequately as good as it was just under restrictions you know” Participant 371

This paper provides tangible insights into the experiences of ED patients during Covid-19 Notably, the importance of reassurance within the ED was apparent, whereby patients highlighted how PPE use, ED environment physical layout and communication were found to alleviate patients concerns regarding exposure and transmission risks of Covid-19 while being present in the ED during the pandemic. A number of participants spoke of how reduced patient numbers provided a greater opportunity for ED staff to provide communication and build rapport, which led in some cases, to a more enhanced patient experience in the ED when compared to pre- Covid-19 ED patients experiences. However, this finding contrasts with previous research in this area, where patient experiences found the ED environment stressful and a sense of being disoriented and less reassured due to infection control measures [21] . While existing evidence has highlighted how lack of hospital flow may be linked to hospital overcrowding despite the decrease in hospital admissions during Covid-19 [22], our findings show the potential benefits of reduced patient numbers presenting to the ED in Ireland during COVID-19.

Study insights add to the evidence base for enhancing patient-centred care in the ED setting in terms of preparedness for managing potential adverse health events such as Covid-19. Findings offer valuable guidance for refining healthcare practices, emphasising the importance of maintaining effective communication strategies and adapting care environments to address patient needs and concerns.

The findings from this study offer key insights to inform clinical operational guidance, with tangible opportunities to implement and maintain patient reported factors and practices that have been shown to be central to alleviating patients' concerns regarding exposure and transmission risks of Covid-19 in the ED. The potential for adopting strategies observed during the pandemic to contribute to an improved overall patient experience in the ED beyond Covid-19 is also evident, contributing to an improved overall patient experience in the ED, emphasising the potential for adopting strategies observed during the pandemic to enhance healthcare delivery beyond Covid-19, warranting further investigation from staff ED staff perspectives [23].

Overall, patient experiences of the ED during Covid-19 captured the impactful role reassurance played, with factors such as PPE utilisation, ED reconfiguration, more time with ED staff acknowledged in contributing to a positive ED experience. Many participants stated they would re-attend the ED if faced with a similar scenario. The majority of participants stated that they received timely care - many stated they understood the stressors present in the ED. Even when participants stated that they had long wait times, the individuals who felt they received proper and adequate care that they needed gave a positive rating of their ED experience.

Participants who acknowledged feeling a sense of reassurance highlighted clear and open communication from ED staff as a key influencer of their overall ED experience. Conversely, those that did not feel they received sufficient communication, or were not reassured, reported a less satisfied experience. While many reported having a small-significant fear of Covid-19 in the hospital, most reported feeling safe while in the hospital system due to PPE, ED organisation, and infection control measures.

This study highlights the fragmented nature of follow-up care and experiences around ED discharge. While some participants reported receiving follow-up care after their ED visit, a significant number mentioned a lack of having received a clear follow-up plan. Patients frequently expressed confusion about the next steps in their care plan, lack of awareness of a clear timeline for receiving results, and whether the ED had communicated with their GP.

In terms of decision-making surrounding ED attendance, findings highlighted how patients balanced their health needs with concerns about Covid-19. Several patients indicated that they would have avoided the ED unless it was an emergency, where their health concerns surpassed worries about contracting Covid-19 at the hospital. Only a small number reported delays in seeking ED care due to Covid-19 or other reasons, contrary to the anticipation that more individuals might have postponed care due to fears of contracting the virus.

Though many participants reported Covid-19 not unduly impacting on their decision to attend the ED, there were reports on the increasing difficulty receiving standard care. This was most prevalent in the context of the outpatient perspective. Participants who had ED experience across pre and post Covid-19 spoke of considerably different experiences at these two time points, associated with PPE use, organisation and restrictions.

Ethics approval and consent to participate:

The study was performed in accordance with the Declaration of Helsinki ethical principles for medical research involving human subjects (JAMA 2013). Ethical approval was obtained from the UL Hospitals Group Research Ethics Committee (REC) at University Hospital Limerick (Ref. 122/19), HSE Midlands Area REC for MRHT (Ref: 231019CG), St. Vincent’s Healthcare Group Ethics and Medical Research Committee for St. Vincents University Hospital (Ref. RS20-004), Tallaght University Hospital / St. James’s University Hospital Joint REC for SJUH (Ref. 2020–04) and the Clinical REC of Cork Teaching Hospitals for University Hospital Kerry (Ref. ECM 4 (J)/ECM 4 (bb). Written, informed consent was obtained from all participants prior to enrolment in the study.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

University of Limerick School of Medicine Medical Education Liaison Groups (MELG) Student Research Bursary Award

Authors' contributions

CF and MB analysed data. CF and MB drafted initial manuscript. LB, GC, CD conducted data collection, analysed data. NC, LB, DR and RG, reviewed and edited the manuscript. GC, LB, FC, CD coordinated data collection fieldwork. All authors read and approved the final manuscript.

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A Qualitative Study Exploring Patients Experience of Emergency Healthcare Utilisation during the Covid-19 Pandemic.

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