Introduction

Satisfaction refers to the good feeling that you have when you have achieved something or when something that you wanted to happen does happen [1]. The emergency room (ER) is the main gateway for patients visiting the hospital and with the highest turnover of patients where they came with acute, life-threatening medical needs. Satisfaction with emergency departments (ED) affects the overall satisfaction with hospitalization and the evaluation of patient satisfaction is a measurement of the quality of care in the ED [2, 3].

Although we couldn’t keep all patients and their companions satisfied we can increase their satisfaction by working on the related indicators and trying to improve them [4, 5]. Among the factors to have affected patient satisfaction levels were: perceived waiting time, interpersonal skills/staff attitudes, provision of information/explanation, cleanliness of the emergency area, patient courtesy, nursing care, and patient-nurse communication [6–9].

Health care in developing countries has not traditionally focused on emergency medical care [10]. Emergency medicine is the newly developing department in the country facing different difficulties and with promising progress over the past years [11]. Since no previous studies were conducted in the ED of Ayder comprehensive specialized hospital (ACSH), assessing the patient level of satisfaction towards the emergency services provided and its determinants in will provide important input for identifying the gap and strengthening the potential area of opportunity [12].

Material and methods

Results

Socio-demographic characteristics of the respondents

From 301 participants approached 299 have completed the interview, making a response rate of 99.3% in which only two participant did not complete the interview due to unexplained reason. More than half 154 (51.2%) of them were males and the mean (SD) age of the study participants was 35 (15) years. For majority of the respondent 162 (54.2%) it was their first time visit to the hospital. Concerning their educational status being able to read and write 95 (31.8%) outnumbers the rest. The emergency department provided service in three shifts with more than half 164 (54.8%) of the study participants arrived at the ED during the night shift followed with evening and morning shifts, 74 (24.7%) and 61 (20.4%) respectively. Regarding the outpatient department (OPD) site visited in the ED, a majority 198 (66.2%) of them were checked in the medical emergency OPD. More than half (55.2%) of the interviewees were the patient themselves. With regard to the degree of confidence they feel to get good service in the future majority of them are confident and very confident, 113 (37.8%) and 131 (43.8%) respectively. One hundred twenty-seven (41.5%) of the patients were managed in the emergency department the rest 168 (56.1%) were admitted to the inpatient ward. The mean (SD) waiting time till seen by a doctor was 43 (67) minutes’ ranging from 5 minutes to 3 hours [Table 1].

Table 1

Socio-demographic characteristics and health services of the study participants at emergency OPD of ACHS (n = 299).

Variables	Groups		N (%)
Sex	Male		154 (51.5)
	Female		145 (48.5)
Age (years)	1–10		33 (11)
	11–20		30 (10)
	21–30		116 (38.8)
	31–40		52 (17.4)
	41–50		27 (9.05)
	51–64		27 (9.05)
	≥ 65		14 (4.7)
Educational status	Illiterate		66 (22.1)
	Able to read and write		95 (31.8)
	Primary school		18 (6)
	Secondary school		45 (15)
	Diploma		34 (11.4)
	Degree		41 (13.7)
Time of visit	Morning		61 (20.4)
	Evening		74 (24.7)
	Night		164 (54.9)
Frequency of visit	First time		162 (54.2)
	Two and more		137 (45.8)
Respondent	Patient him self		165 (55.2)
	Attendant		134 (44.8)
OPD site visited	Medical emergency		198 (66.2)
	Surgical emergency		64 (21.4)
	Pediatrics emergency		37 (12.4)
Subsequent management decision	Managed in the ED		127 (42.5)
	Admitted		168 (56.1)
	Transferred		4 (1.4)
Degree of confidence to get good service in the future	Very confident		113 (37.8)
	Confident		131 (43.8)
	Somewhat confident		53 (17.7)
	Not confident		2 (0.7)
Do you feel discriminated	Yes		29 (9.7)
	No		270 (90.3)
Residency	Urban		197 (65.9)
	Rural		102 (40.1)
Waiting time till seen by Dr.(Mean ± SD in minutes)		43 ± 67 minutes

Medical condition of the patients

Half of the study participants had a history of visits to the hospital before and 114 (38.1%) of the patients had stayed in the ED for 3–6 hours after getting emergency care [Table 2].

Table 2

Medical condition characteristics of patients visiting the emergency department of ACSH (n = 299).

Medical characteristics	Category	N (%)
Presence of any past illness	Yes	121 (40.5)
	No	178(59.5)
Emergency visit before	Yes	150(50.2)
	No	149 (49.8)
Duration of stay in the ED after examination	1–2 hours	28 (9.4)
	3–6 hours	114 (38.1)
	7–13 hours	38 (12.7)
	14–23 hours	22 (7.4)
	≥ 24 hours	97 (32.4)
History of admission to hospital	Yes	139 46.5)
	No	160 (53.5)
Previous chronic illness	Yes	153 (51.2)
	No	146 (48.8)
	Hypertension	14 (4.7)
	Cardiac problem	22 (7.4)
	Cancer	17 (5.7)
	Diabetes mellitus	24 (8)
	Asthma	24 (8)
	Others	52 (17.4)

Patient’s satisfaction towards the ED services

The vast majority of respondents (81.9%) were satisfied with the emergency care services provided. In the five 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 [Table 3].

Table 3

The overall satisfaction rate of study participant towards the emergency medical services in ACSH (n = 299).

Questions	Satisfied (%)	Dissatisfied (%)
The overall satisfaction of ED staff courtesy	240(80.3)	59(19.7)
The overall satisfaction of ED environment	112(37.5)	187(62.5)
The overall satisfaction of physician care	227(75.9)	72(24.1)
The overall score of general patient satisfaction	212(70.9)	87(29.1)
The overall satisfaction patient’s family care	149(49.8)	150(50.2)
Total overall satisfaction level of the patients towards the ED services	245(81.9)	54(18.1)

Determinants of patient satisfaction towards emergency medical care

On binary logistic regression analysis variables like educational status, waiting time till seen by a doctor, visiting time of the day and were significantly associated with patient satisfaction. On the multiple logistic regression analysis educational status was found to be associated with the level of satisfaction. Where the odd of individuals who are able to read and write, reporting to be satisfied were 88% less likely compared to the degree and above holders (AOR = 0.12, 95% CI: 0.03, 0.5, p = 0.002). Visiting time of the day had also an effect on the satisfaction of patients with emergency care provided (p < 0.0001). Where patients who arrived during the morning shift of the day, reporting to be satisfied were 4.8 times compared to their counterparts arriving at night shift (AOR = 4.8, 95% CI: 2.08, 11.4). Another vital determining factor of patient satisfaction was the waiting time till seen by the doctor. For every minute decrease in waiting time to be seen by a doctor, there is an increase in patient satisfaction by 1.3 times more (AOR = 1.3, 95% CI: 1.003, 1.4) [Table 4].

Table 4

Logistic regression analysis of factors associated with patient satisfaction at the emergency OPD in ACSH (n = 299).

Variables	Level of satisfaction		OR (95% CI)		P–value
	Satisfied	Not satisfied	Crude	Adjusted
Educational status					0.001*
Illiterate	66	22.1	1.6(0.6, 4.1)	0.7 (0.2,1.9)	0.741
Able to read & write	95	31.8	0.1(0.03, 0.4)	0.12 (0.03,0.5)	0.002*
Primary school	18	6	0.7(0.2,2.8)	0.8 (0.2,3.5)	0.875
Secondary school	45	15	1.6(0.6, 4.1)	2.0 (0.7,5.8)	0.131
Diploma	34	11.4	0.6(0.1, 1.7)	0.8 (0.2,2.8)	0.999
Degree & above	41	13.7	1	1
Time of visit					0.001*
Morning	61	20.4	5.2 (2.5, 10.8)	4.8 (2.08, 11.4)	<0.0001*
Evening	74	24.7	2.5 (1.19, 5.4)	2.2 (0.9, 5.2)	0.061
Night	164	54.8	1	1
Waiting time till seen by doctor(mean± SD)	43 ± 67 minutes		1(1.004,1.035)	1.3(1.003,1.4)	0.002*

*p- value < 0.05, OR: odds ratio, COR: crude odds ratio, AOD: adjusted odds ratio, SD: standard deviation, CI: confidence interval

Discussion

In the present study the overall patient satisfaction towards the emergency medical service provided in ACSH was assessed using 20 questions containing brief emergency department patient satisfaction scale. Where 81.9% of respondent have reported to be satisfied and factors like educational status of being able to read and write, arrival time at the morning shift of the day and waiting time till seen by a doctor were the determinants of patient satisfaction.

Majority (54.8%) of the patients had arrived in the emergency department during the night time of the day, which is similar to the study conducted in Gondar [6], whereas the data from study conducted in Hawassa showed that the majority of the cases had arrived during the morning shift of the day [15]. The mean waiting time till seen by a physician in the ED was 43 minutes, ranged 5 minutes—6 hours, which is in line with a study conducted in central Saudi Arabia, Morocco and Imam Raza hospital [16–18], but found to be higher when compared to the study conducted in Iran 10.7± 6.1 minutes [19]. The lengthy waiting time in the current study might be due to the burden of the high patient flow to the hospital since this is the only referral hospital with a wide catchment area.

The overall satisfaction score of the patients with the services rendered at ACSH, ED majority (81.9%) of them were satisfied, which is similar to the studies conducted in southern Ethiopia, Hawassa 86.7%, and Jimma 78% [13, 15]. Whereas, higher compared to the study conducted in Gondar, 51.7%, [6] and Morocco 66% [16]. This difference in level of satisfaction might be due to the difference in the tool used to measure patient satisfaction, and difference in clinical characteristics (medical condition on arrival) of the patients.

With regards to the five domains of patient satisfaction measurement, the respondents have lower satisfaction in the emergency department environment and patients’ family satisfaction 37.5% and 49.8% respectively. Similarly, a study from Iran had also showed a lowest satisfaction towards pleasantness of the waiting area [19]. This shows a potential area of weakness and the hospital management should work in this area to improve the quality of care. As it has been stated in other studies providing a comforting 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 influential than other technical skills such as clinical competency and hospital equipment [19, 20].

The time of the day where the patient arrives in the ED had an association with patient satisfaction. Where patients who arrived during the morning shift of the day were 4.8 times more likely to be satisfied compared to their counterparts arriving at night. In line with this a study by Zohrevandi [21], and press Graney report [22] found that patients who arrived during the morning shift of the day were more likely to be satisfied 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 to the night shift, and as the majority of the patient (54.8%) had arrived to the ED at nightshift overcrowding of the ED might have also its own effect.

This study revealed that a patient’s waiting time till seen by a doctor was found to be negatively affecting patient satisfaction. For every minute decrease in patients waiting time to see the doctor, the satisfaction level will be increased by 1.3 times. This is similar to other studies and working on minimizing the waiting time could enhance patient satisfaction at the ED [16, 18, 23, 24].

Another determining factor associated with patient satisfaction was educational status were those patients with lower educational status (able to read and write) were less likely to be satisfied than their counterparts of degree and above holders which is in line to the study conducted in Morocco which was justified as patients with higher educational status might have a better understanding, able to settle medical debates easily and had accepted their care was dependent on good management [16].

Conclusion

In summary, the majority of patients (81.9%) were satisfied with the overall emergency medical care received at the ED. The lowest satisfaction level was recorded in the emergency department environment and patient family satisfaction measures domains. Determinant factors of patient satisfaction identified were: educational status, waiting time till seen by the doctor and the time of the day visited (morning). The hospital management and staff at the ED should work together to minimize the waiting time.