Med. J. Cairo Univ., Vol. 80, No.
2, March: 5-15, 2012
www.medicaljournalofcairouniversity.com
Efficiency of Care and Satisfaction for Head Injury Patients at
Emergency Department in Mansoura Emergency Hospital
1
HIND ABDULLA MOHAMED, D.N.Sc. ; NAYERA MOHAMED TANTAEWY, D.N.Sc. 2 ;
NEAMAT MOHAMED EL-SAID, D.N.Sc. 3 and MAGDA ELWY NASSAR, D.N.Sc. 4
1,3,4
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
Introduction: In modern societies, the quality of medical
care plays an important role in building up patients positive
perception and satisfaction. Patient satisfaction has become
an established outcome indicator of the quality and the effi-
ciency of the healthcare system and can be an important tool
to improve the quality of services in the Emergency Department
(ED).
This Study Aimed: To assess the efficiency of care and
satisfaction for head injury patients at Emergency Department
in Mansoura Emergency Hospital.
Methods: A descriptive study was carried for 7 months
from December (2008) to June (2009) using 100 head injury
patients who were entered ED with mild, moderate, and severe
conditions. Data were collected through two tools were 1-
Emergency Department Patient Data Flow Sheet to assessing
the efficiency of care provided for head injury patient from
arrival till disposition from emergency department, and 2-
Patient Satisfaction Questionnaire to determine overall patients'
satisfaction in relation to care process.
Results: The results of the present study revealed that,
the majority of patients studied suffered from mild head
injuries (80%). The mean waiting time through different time
intervals increased with decrease severity of head injury. The
study findings indicated that, the severe and moderate head
injury patients had the more efficient care process because
the total length of stay in ED of them was less than 4 hours.
The severe patients had the highest mean difference for
satisfaction (=15.89 at p<0.000). There was a relation with
satisfaction level and waiting time; those who waited longer
were less satisfied.
Conclusions: There was a negative correlation coefficient
between length of stay (LOS) in ED and satisfaction for head
injury patients. There were statistical significant differences
for satisfaction variance analysis between head injury patients
(mild, moderate, and severe). And severe patients had the
highest mean difference for satisfaction (=15.89 at p<0.000).
This was an association with satisfaction level; those who
waited longer were less satisfied.
Correspondence to: Dr. Hind Abdulla Mohamed,
The Department of Nursing Administration, Critical Care
Nursing, Faculty of Nursing, Mansoura University
5
1,2
&
Key Words: Efficiency of care Patients' satisfaction
Emergency department Head injury.
Introduction
TODAY, quality, efficiency and patient satisfaction
are increasingly used as indicators for consumers
and for insurers for selecting health care providers
[1] . The emergency department (ED) is one of the
major entryways to hospitals for a significant
number of patients and often provides the patients
first impression of the hospital experience. When
patients enter ED with undiagnosed life-threatening
conditions, their survival depends on how fast and
accurately the staffers diagnose and treat their
problems without making people wait for several
hours [2] .
As the demand for emergency medicine service
increases, emergency departments are compelled
to become more efficient at providing optimal
patient care, this optimal care should be delivered
to the right person, at the right time, in the right
place, in the right way, and by the right provider
[3] . The efficiency of public health care system is
reflected in the utilization of the services by the
people for whom they are intended. In general
economic terminology, efficiency means absence
of waste, or using the resources as effectively as
possible to satisfy people's needs and desires [4] .
The more efficient emergency departments were
in reducing patient turnaround time. Patient turn-
around time defined as the time that elapses be-
tween the arrival and discharge of a patient. In
addition, it is a key performance measure of quality
and efficiency of service at the ED [5] . The ED
process is critical for any hospital. Short wait times
and a positive experience represent important
drivers of patient satisfaction [6] .
6 Efficiency of Care & Satisfaction for Head Injury Patients
Patient satisfaction is an important consideration
that is closely related to patient care efficiency.
Patient satisfaction defined as a summation of all
the patients' experiences in the hospital. It derived
from the patients' evaluation of how well the pro-
vider meets his or her personal and emotional as
well as physical needs [7] . Now, patient satisfaction
is increasingly being used as an outcome measure
for hospital and its personnel performance, and it
is affected by multiple factors in the emergency
department as provision of information, technical
skills, and perceived waiting times [6] .
There is a relationship between how long pa-
tients have to wait in ED to receive care and the
outcome. Critical Injuries as head injuries that
need medical and nursing intervention are time
sensitive. The longer the wait, the more damage
occurs because there is a loss and/or deprivation
of basic needs for survival, such as oxygen, blood,
electrolytes (potassium, sodium, etc.), sugar, water,
immunity, and skin integrity. Therefore, ED team
is responsible for a complex situation; they must
quickly form an opinion about the patients' condi-
tion and make satisfactory assessment [8] .
For this reason, the emergency department team
who care for head injury must understand the need
for timely evaluation and treatment of head injuries
and the possible long-term problems, and the ap-
propriate management of head injury patient is
important to minimize complication [9] . So efficient
emergency department management requires a team
of providers know what they are doing, why they
are taking certain measures, and what action has
to be taken to achieve a satisfactory outcome [10] .
Aim of the study:
This study was conducted to assess the efficien-
cy of care and satisfaction for head injury patients
at Emergency Department in Mansoura Emergency
Hospital.
Material and Methods
Design:
A descriptive study.
Setting:
The study was conducted at the emergency
department of Mansoura Emergency Hospital. This
department consists of two areas, reception room
(RR) and emergency department (ED) inpatient
unit.
Subject:
All patients admitted to emergency department
with head injury (mild, moderate, severe) through
the three shifts morning, evening, and night (100
patients according to the sample equation).
2
Sample Size (n) = PQXz (Kish and Lesle, 1965)
2
Where:
P = The estimated proportion of head injury
patients in Mansoura emergency hospital last year
= (7.95%).
Q = 1-P = 0.205.
Z = A percentile of standard normal distribution
determined by 95% confidence level =1.96.
A = The width of the confidence interval = P/10=
0.0795.
0.795 X 0.205 X (1.96) 2
Sample size (n) = = 100 patients
(0.0795) 2
Tools of data collection:
After approval by the hospitals administrative
authority for the protection of human subjects, an
investigator explain clearly the aim of the study
to the ED staff and patients included in the study.
An investigator record review of retrospective
estimation of number of head injury patients during
year (2007). A pilot study will be carried out to
assess the clarity and the applicability of the tool.
It will be conducted on 10% of sample size, which
will not include in the study.
The efficiency of care provided for all head
injury patients was assessed by Emergency Depart-
ment Patient Data Flow Sheet (time flow sheet)
which developed by Dawood in 2004.
The time flow sheet consists of the following parts:
1- Patient general characteristics which include
(demographic data, pre hospital management,
history and causes of head injury, nature of
injury, and discharge state).
2- Primary assessment and intervention which
include (airway, breathing, circulation and dis-
ability).
3- Secondary Assessment which include (all phys-
ical examination).
4- Activities related to delegated medical order as
(consultation, investigation and procedures).
5- Head Trauma Patient Care Intervention Checklist
which include (resuscitation phase and preven-
tion of secondary injuries).
Will be assessed the care provided for all head
injury patients from arrival till disposition from
emergency department through the six time inter-
vals of patient flow in ED; these intervals represent
Hind A. Mohamed, et al.
the main phases of patient evaluation and treatment
through the care process (Tool I). These time
intervals, were:
1- Time from arrival to emergency till physician
assessment.
2- Time spent from physician assessment till de-
parture to radiology department.
3- Time spent in radiology department till return
to ED.
4- Time spent waiting for consultation and opera-
tion.
5- Time spent from discharge decision till departure
from ED.
6- Time spent in way from ED to ED inpatient unit
or another unit. The time spent for each time
interval was calculated, and the total length of
stay was calculated for each patient. Any reason
for delay during these six time intervals will be
identified.
Patients' perception related to care process was
assessed by Patient Satisfaction Questionnaire (PSQ)
which developed by Dawood (2004). The Patient
Satisfaction Questionnaire consists of 2 parts were,
the demographic data, and patient perception in ED
toward care process. This PSQ investigates:
1-Patient satisfaction of waits for different activities.
2- Satisfaction of communication with staff and
about operation.
3- Satisfaction of relationship with ED staff (phy-
sician, nurses, and orderlies).
4- Satisfaction of ED environment.
5- The overall patient satisfaction in emergency
department. The PSQ has 38 items, plus addi-
tional one question designed to list the reasons
of unsatisfaction.
Patient who will be entered emergency depart-
ment were interviewed after having all needed
treatment and investigation to determine overall
patients' satisfaction in relation to care process
(Tool II).
Statistical analysis:
Data were recorded on standard study forms, and
then entered into the SPSS statistical software
(SPSS Base version 10.0) for Windows (SPSS
Inc, Chicago). Patient demographics, head injury
levels, time intervals and selected variable rela-
tionships were described using descriptive statistics
as Means, standard deviations, and percentages.
Performance score was calculated for the areas
of performance that includes several activities
provided to the head injury patients. Each activity
7
scored as 1 for done, 0 for not done, and activity
were not applicable was excluded. The perfor-
mance score was done through:
Sum of scores obtain for
all required activities
Performance score = 100
Maximum score from
applicable items
Time of activity: Recording the time of start and
end of each activity and notes was taken of time
for nothing being done within or between activ-
ities.
Each item of the PSQ scored as 2 for Yes, 1 for
Sometimes, and 0 for No.
Logistic regression analysis was carried out to
study the variables affecting patient satisfaction
in ED. A P-value of less than 0.05 was considered
statistically significant.
Results
Table (1) demonstrate the percentage distribu-
tion of the head injury patients according to their
general characteristics, results revealed that the
most of patients were male (84%). The mean age
of patients was 22.36 17.22. As regard the nature
of injury, findings revealed that the most of cases
had concussion (65.0%) followed by laceration
(26.0%). Concerning the cause of injury and dis-
charge status, the findings revealed that, the main
cause of injury was an accident for (49.0%) of
cases follow by falls for (38.0%) of cases, while
the least cause is sports about (4.0%) in cases of
head injury. Also table showed that, the all severe
cases were transfer to intensive care unit, 81.81%
of moderate patients were admitted to inpatient
ED unit, while 71.25% of mild cases discharge at
home.
Fig. (1) portrays the percentage distribution of
patients according to severity of head injury. It
was found that the majority of the patients (80%)
were admitted with diagnosis of mild head injury,
while the minority (9.0%) has severe head injury.
Table (2) illustrates the percentage performance
score for different components of management to
patients. Pre-hospital management was limited to
Airway and Circulation assessment for moderate
and severe patients, and the severe patients have
the highest score of care components (52.0%,
13.2%). Primary assessment illustrate that, severe
patients has the highest score of component of
assessment and intervention. The performance
score for preventive measures (Nutrition, Commu-
nication, Activity, Pain, and Simulation) was very
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. %
Sex:
Male 71 88.75 7 63.63 6 66.66 84 84
Female 9 11.25 4 36.36 3 33.33 16 16
Age:
<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)
of different time intervals of care process in emer-
gency department according to severity of head
injury. Regarding time interval I the highest mean
of time from arrival to ED till assessment by phy-
sician was 4.24 minutes for mild patients, and the
lowest mean for severe patients was 0.33 minutes.
Concerning time interval II, the highest mean of
time spent from physician assessment till departure
to radiology department was 17.45 minutes for
mild patients. In time interval III, the lowest mean
of time spent was 10.22 minutes for severe patients.
Concerning time interval IV, the highest mean of
time spent waiting for operation was 40.5 minutes
for moderate patients. Time interval IV also indi-
cated that, the highest mean of time spent waiting
for consultation was 23.32 minutes for mild pa-
tients. In time interval V, the lowest mean was 1.66
minutes for severe patients. As regard time interval
VI, the highest mean of time spent in way from
ED to ED inpatient unit or another unit was 5.69
minutes.
As regard the total Length of stay (LOS) in ED
Fig. (2) shows that, the highest mean of total length
of stay in ED was 2.36 hours ranged between (1.10
hour-4.30 hours) for mild patients followed by the
mean of total length of stay for moderate patients
1.65 hour ranged between (1.10-2.35 hours), while
the lowest mean of total length of stay was 1.47
hour ranged between (1.10-2.10 hours) for severe
patients.
Table (4) shows the satisfaction level of patients
in regard to aspect of care process. Items with a
high level of satisfaction included: Time from
arrival to ED till seen by physician (78%), skills
of ED physicians (77%), time from order of radi-
ology investigation till departure to X-ray depart-
ment (70%), cleanness and ventilation of ED (52%).
While the lowest level of satisfaction refers to the
following items: Speed of orderlies response to
request (20%), speed of nurse response request to
call doctor (18%), nurses answer questions (16%),
speed of nurse response to calling (16%), explana-
tion of test result and treatment by physicians
(13%), ED is calm (13%), giving an explanation
about follow up on discharge (12%), giving an
explanation of reason for admission (11%), giving
information about any delay (10%), and provision
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.
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
injury.

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
assessment
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

activities:
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
long.
Time from operation order till 2 2.5 2 2
departure to operating room is
long.

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
delay.
Giving explanation of reasons for 21 26.25 2 18.18 2 22.22 25 25
delay.
Giving you answer about your 29 36.25 4 36.36 6 66.66 39 39
questions.
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-

lies:
Respect and courtesy to you by 39 48.75 6 54.54 5 5.55 50 50
nurses.
Nurses keep you informed about 30 37.5 6 54.54 2 22.22 38 38
treatment.
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

orderlies:
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
enough.
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
satisfactory.
If you need Ed you would come 40 50 6 54.54 8 88.88 54 54
again.
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
tation
Over crowding 57 57 10.9 9% Mild
11%
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%
Department
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
2.5
2.364
2 [12] .
1.645
1.477
1.5
1 cause is sports about (4.0%) in patients. This was
0.5
0 almost half of the patients, follow by falls, assaults,
Mild Moderate Severe
Fig. (2): Mean duration (hours) of the total length (LOS) in
emergency department according to severity of head
injury.
Table (5) shows frequency distribution of rea-
sons of dissatisfaction for head injury patients with
ED, results indicates that the most frequent reasons
with a high level of dissatisfaction included: No
privacy (81%), followed by noise in ED (66%),
long waiting time for consultation (59%), over-
crowding (57%), no response to questions and bad
communication with staff of ED were have equal
percentage (43%), long waiting time in CT unit
(31%), long waiting time in X-ray department
(29%).
Table (6) demonstrate that, there is a negative
relation between total length of stay (LOS) in ED
and satisfaction of head injury patients. There were
a statistical significant difference observed at
p<0.001, those with longer LOS were less satisfied.
Discussion
Emergency Departments (EDs) are a vital com-
ponent of any hospital, providing a wide variety
of medical services around the clock. Typically,
an ED is designed to provide high quality medical
treatment, with the immediate availability of critical
resources to the patients in need of emergent and
urgent care [5] . In modern societies, the quality of
medical care plays an important role in building
up patients positive perception and satisfaction.
With the emerging role of patients as important
medical care partners, it is critical to understand
their expectations for care. Obtaining patient feed-
back can provide valuable into the quality of clinical
practice and hospital programs [11] .
Findings of the present study showed that the
majority of studied patients admitted to ED with
head injuries was classified as mild head injury
80%, followed by 11% as moderate and the minor-
ity of patients was 9% as sever. This classification
is consistent with Costello et al. (2007), who found
that the mild head injury account (80.0%) followed
Efficiency of Care & Satisfaction for Head Injury Patients
by equal percentage for moderate and severe head
injury accounts for 10% of all head injury patients
As regards the main cause of injury was an
accident for (49.0%) of patients, while the least
in congruence with Turner (2010) in United States,
who illustrated that the common causes of head
injuries were motor vehicles which account for
and sports [13] .
The study result also reveled that majority of
the patients had concussion (65.0%), while only
(1.0%) of all patients has contusion. This finding
is compatible with Shanon Medical Center (2010)
in England, who reported that approximately half
of all the ED visits for concussions patients [14] .
According to discharge status, all severe patients
were transfer to intensive care unit, the majority
of moderate patients were admitted to hospital
(81.81%), while the majority of mild patients
(71.25%) were discharge at home. The findings
was supported by McNett et al., (2010) who con-
cluded that most patients of mild head injury rarely
they require a hospital admission, and the majority
of head injury hospitalizations are for patients with
severe injuries necessitating critical care monitoring
[15] .
The findings of the study revealed that the
severe patients has the highest score of all compo-
nent of assessment and intervention, followed by
performance score of moderate patients, while the
lowest score for mild patients. This result similar
to the result reported by Dawood (2004) who found
that sever and moderate patients had the highest
score of care component of assessment and inter-
vention [16] . Also, according to Presciutti (2006)
the responsibilities of ED team for severe head
injury include monitoring patient physiological
parameters and ensuring hemodynamic stability,
performing serial neurological examinations, pre-
venting secondary injury, and providing emotional
support for patients [17] .
Chande et al. (1991), reported that prolonged
waiting time was the reason for 33% of the com-
plaints lodged against the ED of the Kings College
Hospital and for 60% of the patients leaving the
Toronto Hospital ED without being seen by a
physician. Shortening waiting time may improve
ED satisfaction for about 75% of patients (18). In
our study, the patients and their families also
complained of waiting time for consultation, wait-
ing time in CT unit, and in X-ray department (59%,
Hind A. Mohamed, et al.
43%, and 37%). However, according to Hedges et
al. (2002) study emphasized that efforts to improve
ED patient satisfaction should focus primarily on
improving patients perceptions that wait intervals
are appropriate, and secondarily on shortening the
wait intervals [19] .
The present study illustrate that the longest
mean of time spent from arrival to ED till seen by
physician was 4.3 minutes for mild patients, while
the lowest mean of time spent was 0.3 minutes for
sever patients. This result is supporting by the
result of Yoon et al. (2003) at Alberta Hospital in
Canada stated that, the mean minutes of ED reg-
istration to triage assessment was 2.8 minutes for
triage level 1, triage level 2 was 2.6, while triage
level 3 was 7.7 minutes [20] .
The findings of the present study revealed also
that, the highest mean of time waited to be seen
by specialist in ED was 23.3 minutes for mild
patients, followed by the mean time 19, 3 minutes
for moderate patients, while the lowest mean of
time was 7.4 minutes for sever patients. There was
an association with satisfaction level; those who
waited longer were less satisfied at p<0.000. This
finding is consistent with Soleimanpour et al.
(2011), which find that, the average time a patient
waited to be seen by a specialist or a resident in
emergency medicine was 24.15min. There was an
association with satisfaction level; those who waited
longer were less satisfied [21] .
Considering the mean of total length of stay in
ED, it was found that mild patients were spent
2.36 hours followed by 1.65 hours for moderate
patients; while the lowest mean of total length of
stay was 1.47 for sever patients. This finding
illustrate that, the mild head injury patients had
the longest mean of time spent in all time intervals
in ED than moderate and sever patients. This goes
in consistence with Finamor and Turris (2009) who
reported that emergency patients having the longest
waits are those who present with less urgent symp-
toms [22] . Moreover Costello et al. (2007) claimed
that the evaluating, diagnosing, and treating minor
head trauma is more difficult than moderate or
severe injury, so mild head injury need more time
than others [12] .
In study found that there are a negative corre-
lation between length of stay in ED and satisfaction
for head injury patients. Those who waited longer
were less satisfied. Other studies have also shown
that there are a negative association between in-
creased waiting time and patient satisfaction [21-
26] . Also Downey and Zun (2010) stated that, pa-
13
tient satisfaction has been shown to be influenced
by length of waiting time and total time spent in
the emergency department [23] . This goes in agree-
ment with Boudreaux et al. (2009) study which
found the satisfaction level was higher in those
with serious illnesses or emergency needs. In this
study they suggested that the reduction in average
waiting time was an important factor to increase
the satisfaction level [24] .
According to Press Ganey's (2009) report that
patients who spent more than 2 hours in the emer-
gency department reported less overall satisfaction
with their visits than those who were there for less
than 2 hours. Since much of the time in the ED is
spent waiting-in the waiting room, in the exam
area, for tests, for discharge-reducing waiting times
should have a direct positive impact on patient
satisfaction [25] .
Other common reasons for dissatisfaction in
the present study are: No privacy, noise, overcrowd-
ing, and no response to patient questions. Walsh
and Knott (20 10) study supports our results which
emphasized that privacy, noise, comfort, modern-
isms of equipment, Cleanliness, communication,
and food have been identified as important envi-
ronmental elements that affect patient satisfaction.
Most of these are very basic human needs that
would be expected to rate highly important in most
settings [26] .
From the viewpoint of patients in the present
study, the reasons of dissatisfaction related to ED
staff were no response to questions and bad com-
munication with ED staff. Also our observation
results confirmed that communication between
staff (physician and nurses) and patient was poor.
Benger and Taylor (2004) & Kaushal et al.
(2005), stated that the interpersonal skills/staff
attitudes, provision of information/explanation,
and the increasing information on ED arrival are
factors has a significant effect on patients' percep-
tions of the quality of care and overall satisfaction
[27,28] . This was supported by findings of Taylors
et al. (2006) study which revealed that staff orien-
tation with an educational film and workshop on
how to communicate effectively with patients and
having a nurse to explain the diagnostic and treat-
ment processes to patients improved the patients
satisfaction levels [29] .
On other hand, items with a high level of satis-
faction included were: Time from arrival to ED
till seen by physician, skills of ED physicians, time
from order of radiology investigation till departure
to X-ray department, cleanliness and ventilation
14
of ED, time from return to ED after done X-ray
till receiving results, and respect and courtesy
shown by nurses.
Thus, according to the findings of this study
and similar ones, EDs need to define their processes
very clearly, especially those processes related to
triage, registration, diagnosis, treatment, admission,
and discharge from ED, and the use of patient input
(complaints and compliments) to decrease length
of stay, improve efficiency and raise the satisfaction
level.
Conclusion:
The study findings indicated that, the severe
and moderate head injury patients had the more
efficient care process because the total length of
stay in ED of them was less than 4 hours. There
was a negative correlation coefficient between
length of stay (LOS) in ED and satisfaction for
head injury patients. There were statistical signif-
icant differences for satisfaction variance analysis
between head injury patients (mild, moderate, and
severe). And severe patients had the highest mean
difference for satisfaction (=15.89 at p<0.000).
This was an association with satisfaction level;
those who waited longer were less satisfied.
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