Client’s satisfaction towards emergency medical care at Ayder comprehensive specialized hospital, Mekelle, Ethiopia

Background: As assessing client’s experience are important guide towards services improvement, providers will need to fully understand patient satisfaction level and their determinants. This study was aimed to assess the level of satisfaction towards the emergency medical care and associated factors at emergency department of Ayder specialized comprehensive hospital, Mekelle, Ethiopia. Methods: A cross-sectional study was conducted from March 1–30, 2019. Systematic random sampling method was used to enroll study participants. Data was collected using a standard Brief Emergency Department Patient Satisfaction Scale questionnaire by trained data collectors. Data was entered into EpiData 3.1 then exported and analyzed by SPSS version 22. Binary and multiple logistic regression was used to assess the predictor’s patient satisfaction. Results: A total of 299 participants were enrolled in the study with a response rate of 99.3%. The overall client’s satisfaction was 81.9%. The lowest satisfaction rate was reported towards emergency room environment, and patient family satisfaction 37.5%, and 49.8% respectively. Educational status those who were able to read and write (AOR = 3.9, 95% CI: 1.4, 10, P = 0.008), those who arrived during the morning shift of the day (AOR = 3.6, 95% CI: 1.6, 8.7, p = 0.002), those who waited < 15 minutes to be seen by a doctor (AOR = 1.3, 95% CI: 1.003, 1.4), having felt discriminated (AOR = 1.5, 95% CI: 1.003, 1.4) were signi�cantly associated determinants of client satisfaction. Conclusions: The overall client’s satisfaction in this study was found to be good. There is a low satisfaction towards emergency room environment and patient’s family courtesy. It is important to readjust emergency room services to improve client’s courtesy, avoid feeling of discrimination by clients and overall to improve the quality of care in the emergency department.


Introduction
Satisfaction refers to patients' emotions, feelings and their perception of delivered healthcare services (1).
On the other hand, patient's satisfaction is de ned as a degree of congruence between patient expectations of ideal care and their perceptions of real care receive (2).
As the healthcare industry shifts toward patient-centered models, providers will need to fully understand patient satisfaction measures and how they affect their practices.Now a day, the healthcare regulators have shifted towards a market-driven approach of turning patient satisfaction surveys into a quality improvement tool for overall organizational performance (3).Measuring client or patient satisfaction has become an integral part of hospital/clinic management strategies across the globe (4).The emergency room is the main gateway for patients visiting the hospital and with the highest turnover of patients where they came with acute, life threatening medical need.Satisfaction within the emergency departments services could affects the overall satisfaction with hospitalization and the evaluation of the patient and companion satisfaction towards the ED as well as the institution (5,6).
Emergency medicine in Ethiopia is the newly developing department facing different di culties and with a promising progress over the past years (16) but studies on client's or patient's satisfaction are scarce.
This study was aimed to determine the level of satisfaction and factors associated with client's satisfaction at ED of Ayder comprehensive specialized hospital (ACSH).

Study design and study area
An institution-based cross-sectional study was conducted from March, 1-30, 2019, at ACSH, ED, Mekelle, Tigray, Ethiopia.ACSH is a tertiary care teaching university hospital, the main referral center in the Tigray region, with a catchment area of the Whole Tigray region and neighboring regions of Amhara and Afar.
The hospital is supposed to give service for more than 5 million peoples with in the catchment area and has the busiest emergency department due to the lack of nearby tertiary care giving hospitals.

Study participants
Study participants were recruited using a systematic random sampling method.Those with the ability to communicate in common regional language (Tigrigna) and agreed to participate were included in this study.

Sample size calculation
The sample size was determined using a single population proportion formula with the assumption of: 77% satisfaction level of the patients were considered from a study conducted in Jimma (17), 95% con dence level, and 5% margin of error.Including a 10% non-response rate, yielded a total 301patients.

Data collection tool
Data was collected using modi ed version of structured Brief Emergency Department Patient Satisfaction Scale (BEDPS) which was developed to assess patient satisfaction towards the services provided in the ED with 5 response options Likert scale questionnaire (18).Overall the questionnaire contains: Sociodemographic part, medical characteristics of the patient and BEDPS 20 questions divided into ve parts i.e.ED staff, ED environment, patient care satisfaction, general patient satisfaction, and patients family satisfaction.The English version questionnaire was translated into the local language (Tigrigna) rst then translated back into English.The patient satisfaction measure Likert scale questionnaire was graded as very dissatis ed "1", dissatis ed "2", fair/indifferent "3", satis ed "4", and very satis ed "5".Those scoring the mean or below were considered as dissatis ed while a score above the mean was labeled as satis ed.

Data collection procedure
The total sample was distributed into different working shifts considering, busy work hours, different providers, day of the week and the type of client complaint were considered to have had an effect on satisfaction level.The study subjects (the patient him/herself or if the patient was unconscious or in distress, the care takers) were interviewed face to face by three trained research assistants (graduating class Nursing Students) immediately after getting an emergency services i.e. while they are being admitted to the inpatient ward, consulted to respective specialty units or before they were discharged to home after getting emergency medical services.

Data analysis
Data was cleaned, coded, entered in to Epidata version 3.1.and then exported into SPSS version 22 for analysis.Descriptive statistics were used to determine the satisfaction level, calculate the sociodemographic characteristics and disease pro les.Bivariate and multivariate logistic regression was used to identify factors affecting the patient satisfaction.Level of signi cance was declared at p-value < 0.05.

Result
Out of the three hundred one participants approached 299 had completed the survey making a response rate of 99.3%.The mean ± SD age of the respondents was 35 ± 15 years and more than half (51.2%) of them were males.Majority of the respondent (54.2%) was their rst time visit to the hospital.One hundred sixty four (54.8%) of the participant had arrived at the ED during the night shift followed with evening 74 (24.7%) and morning shifts 61 (20.4%).Nearly two third (66.2%) of them were checked in the medical emergency OPD.With the degree of con dence they feel to get good service in the future 113 (37.8%) are con dent and 131 (43.8%) are very con dent.More than half (56.1%) of the patients were admitted to the inpatient ward after their ED checkup.The mean ± SD waiting time until seen by a doctor was 42 ± 66 minutes, ranging 5 minutes -3 hours [Table 1].

Determinants of patient satisfaction towards emergency medical care
On multiple logistic regression analysis educational status was signi cantly associated with the level of satisfaction.Where respondents who were able to read and write were 3.9 times more likely to be satis ed with the ED services compared to the degree and above holders (AOR = 3.9, 95% CI: 1.4, 10, P = 0.008).Patients who arrived during the morning shift of the day were 3.6 times more likely to be satis ed compared to their counterpart arriving at night (AOR = 3.6, 95% CI: 1.6, 8.7, p = 0.002).Another determinant was waiting time till seen by the doctor.Those who waited < 15 minutes to be seen by a doctor were 1.3 times more likely to be satis ed than those who waited greater than fteen minutes (AOR = 1.3, 95% CI: 1.003, 1.4).Whereas respondents who felt discriminated in the ED were less likely to be satis ed (AOR = 0.2, 95% CI: 0.1, 0.7) [Table 4].

Discussion
The recently advancing department in the country, emergency department has become the hospital's front door, with majority of admission to a hospital passing through it.The increased demand for the service much of it inappropriate to the site of care, has placed considerable strain on many facilities, leading to long wait times, crowded conditions, boarding patients in hallways, and increased ambulance diversions (23).Due to the fact that the ED is a unique department among other medical care services, understanding of the level of client's satisfaction and factors affecting it is essential (24).
Our study showed that the overall client's satisfaction level to the service given in the ED was good (81.9%).This is in line to the studies conducted in southern Ethiopia, Hawassa 86.7% (19), and Jimma 78%.But, higher compared to study conducted in Gondar 51.7% (7), and Morocco 66%, (20).The variation in the level of satisfaction might be attributed to the difference in the tool used to measure the level of satisfaction, difference in clinical characteristics (medical condition on arrival) of the patients (7,20).The present study showed that respondents had lower satisfaction with regards to the emergency department environment and patients' family handling at the ED, 37.5% and 49.8% respectively.Similarly, a study from Iran had also showed a lowest satisfaction towards pleasantness of the waiting area (21).
As it has been shown previously providing a comfort environment, interpersonal skills in terms of courtesy, respect by health care providers in addition to communication skills, explanation and clear information, which are more essential and in uential than other technical skills (12) should be promoted by health care providers at the ED.
There was a signi cant association with the morning shift admission of patients and level of satisfaction.Consistent with studies by Zohrevandi and press Ganey report (22,23) patients who arrived during the morning shift of the day were more likely to be satis ed compared to their counterparts arriving at the night shift.This might be due to the additional number of staffs (senior physicians, medical and nursing students) during the morning shift of the day may give an extra advantage to the regular working staffs since this is a teaching hospital.While during the night shift those extra staff members may not be assigned and majority of the patient (54.8%) had arrived to the ED at night shift, overcrowding of the ED might have also its own effect.
The mean waiting time for patients till seen by a doctor was 42 minutes which was similar with nding from Morocco 47.5 minutes (20) but, higher compared to the study from Iran 10 minutes (21).As reported from previous studies lengthy waiting time till seen by a doctor was negatively associated with client's level of satisfaction (8, 20,21,24) In line with this we found clients who waited < 15 minutes to be seen by a doctor were more likely to be satis ed than their counter parts of those who waited greater than fteen minutes.
Another determinant associated with patient satisfaction was educational status.Where those who were able to read and write were more likely to be satis ed than their counterpart of degree and above holders.But, in contrary in Damghi's study patients with a lower educational level were less satis ed, which was justi ed by their rescue was dependent on good management, despite uncomfortable conditions (20).
Having felt discriminated was negatively predictor of clients.Similarly, a study from Gondar also reported that those patients who felt discriminated were 2.5 times more likely to be dissatis ed with the ED services (7).

Conclusion
In conclusion, the overall patient satisfaction towards the emergency care was good.The lowest satisfaction level was recorded in the emergency department environment and patient family satisfaction measures.Being able to read and write, waiting < 15 minutes to be seen by the doctor, visiting time at the morning shift of the day, were signi cantly associated predictors of clients satisfaction.Whereas, having felt discriminated was negatively associated with the client's satisfaction.It is important to readjust emergency room services to improve client's courtesy, avoid feeling of discrimination by clients and overall to improve the quality of care in the emergency department.

Table 1
Socio-demographic characteristics and health services of the study participants at ED of ACHS (n = 299) Half of the study participants had a history of visits to the hospital before and majority (38.1%) of them had stayed in the emergency department for 3-6 hours [Table2].

Table 2
Medical condition characteristics of patients visiting the ED of ACSH (n = 299)The vast majority of respondents (81.9%) were satis ed with the emergency care services provided.In the ve categories of services they got, the respondents satisfaction rate to the emergency staff courtesy, emergency department environment, physician care, general patient satisfaction and patients family satisfaction were 80.3%, 37.5%, 75.9%, 70.9% and 49.8% respectively [Table3].

Table 3
The overall satisfaction rate of participant towards the ED services in ACSH (n = 299)

Table 4
Factors associated with client's satisfaction at the ED of TASH (n = 299)