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A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014
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RESPE-1017; No. of Pages 6
Available online at
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Original article
A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014 E´tude re´trospective des plaintes adresse´es au service des urgences d’un hoˆpital suisse entre 2009 et 2014 M.-N. Pfeil *, B. Yersin, L. Trueb, A.-S. Feiner, P.-N. Carron Emergency department, Lausanne university hospital, CHUV, rue du Bugnon 21, 1011 Lausanne, Switzerland Received 12 June 2016; accepted 25 August 2017
Abstract Objective. – Patient complaints are a valuable resource for monitoring and improving patient safety and quality of care. The purpose of this study was to analyze the complaint letters received at a Swiss academic emergency department (ED) over six years. Methods. – A retrospective study of all complaint letters sent to a Swiss academic ED between 2009 and 2014 was conducted. The following data were extracted: epidemiology items, reasons for complaints, hospital responses, follow-up, and severity of the events mentioned in the complaints. All complaint letters related to adult patients evaluated in the ED between 2009 and 2014 were included and a qualitative evaluation was performed based on a systematic taxonomy. Context, patient characteristics, mode of resolution and clinical severity of the related adverse event were evaluated. Results. – A total number of 156 complaints were recorded, corresponding to an annual complaint rate of 5.5 to 8.8 per 10,000 visits. The complaints concerned mostly three domains (clinical care, management and patient or caregiver relationship) with a slight predominance for organisation and logistics (39%) compared with 31.4% for standard of care and 29.6% for communication/relational complaints. The majority of complaints were sent within one month of the ED visit. Most complaints were resolved with written apologies or explanations. The consequences of 73.5% of the events in question were considered minor or negligible, 19% moderate, and 6.5% major. Only 1% (two cases) was related to situations with catastrophic consequences. Conclusion. – Complaint incidence in our ED was low and remained stable over the six-year observation period. Most of the complaints pertained to incidents that entailed negligible or minor consequences. As most complaints were due to inadequate communication, interventions targeting improvement of the doctor/patient communication are required. # 2017 Elsevier Masson SAS. All rights reserved. Keywords: Complaints; Emergency department; Patient safety; Satisfaction; Quality of care
Re´sume´ Introduction. – La me´decine d’urgence, en raison du flux souvent important et peu pre´visible de patients se pre´sentant pour des motifs varie´s, est re´gulie`rement expose´e aux critiques. Dans une vision d’ame´lioration de la qualite´, les plaintes des patients constituent une source d’information pre´cieuse pour e´valuer et ame´liorer leurs prises en charge. Objectif. – Analyser les plaintes adresse´es au service des urgences d’un hoˆpital tertiaire pour de´tecter et comprendre les dysfonctionnements d’un syste`me et tenter d’y apporter des solutions. Me´thode. – E´tude re´trospective monocentrique incluant toutes les lettres de plaintes adresse´es au Service des urgences du CHU de Lausanne entre 2009 et 2014. Les donne´es concernant l’e´pide´miologie des patients, les motifs des plaintes et les re´ponses donne´es ont e´te´ analyse´es pour chaque plainte. La se´ve´rite´ des e´ve´nements mentionne´s dans les plaintes a e´te´ analyse´e a` l’aide d’un outil valide´ « The National Patient Safety Agency ».
* Corresponding author. E-mail address: [email protected] (M.N. Pfeil). https://doi.org/10.1016/j.respe.2017.08.003 0398-7620/# 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003
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Re´sultats. – Au total, 156 plaintes ont e´te´ re´pertorie´es, correspondant a` un taux annuel de 5,5 a` 8,8 plaintes pour 10 000 consultations. Ces plaintes concernaient essentiellement les aspects organisationnels/logistiques (39 %), les soins (31,4 %) et le relationnel (29,6 %). La majorite´ (62 %) des plaintes ont e´te´ envoye´es dans le mois suivant la consultation aux urgences. La plupart (89 %) ont e´te´ re´solues par un courrier d’excuses ou d’explications. Quant a` la se´ve´rite´, 73,5 % des e´ve´nements mentionne´s dans les plaintes concernaient des situations juge´es ne´gligeables ou mineures, 19 % pre´sentaient des conse´quences mode´re´es, 6,5 % des conse´quences majeures et seulement 1 % (deux cas) concernaient des situations avec conse´quences juge´es catastrophiques. Conclusions. – Le taux de plaintes enregistre´es e´tait faible et est reste´ stable sur les six anne´es e´tudie´es. La majorite´ des plaintes (73,5 %) concernaient des cas avec des conse´quences ne´gligeables ou mineures. Nos re´sultats montrent que des strate´gies pour ame´liorer la communication entre me´decins et patients seraient be´ne´fiques. # 2017 Elsevier Masson SAS. Tous droits re´serve´s. Mots cle´s : Plaintes ; Service des urgences ; Se´curite´ des patients ; Satisfaction ; Qualite´ des soins
1. Introduction
2. Method
The number of patients treated each year in emergency departments (ED) worldwide is increasing. In Europe, ED handle approximately 20–25 visits per 100 inhabitants per year [1,2], compared to > 40 visits per 100 inhabitants in the USA [3]. This high activity is associated with an important risk of human errors and ED has therefore been described as ‘‘natural laboratories for the study of error’’ [4]. All ED tasks, such as registration, triage, medical assessment, transmission of medical information and coordination between the various partners are complicated by time constraints, interruptions and distractions [5,6]. Hence, emergency medicine is considered a ‘‘high risk’’ specialty, particularly prone to litigations and claims. Recent studies have shown that emergency medicine is now part of the top five specialties in terms of complaint frequency [7–9]. In this context, quality of care and patient safety are major issues in the ED. Analysis of several indicators, such as patient readmission rate, waiting times, rates of patients left without being seen, incident report systems, autopsy reports, or morbidity and mortality reviews have been used to monitor and improve the quality of healthcare in ED [10]. Analysis of complaint letters from patients and caregivers is part of these essential tools, providing valuable information about quality of care and patient satisfaction [9,11]. Patients and/or their relatives are able to identify specific dysfunctions in the healthcare system, which are frequently underestimated or not identified by traditional monitoring or incident reporting systems [10,11]. Information related to communication gap, waiting times or information failures are key elements in these complaints. Although the goals of individual complaints are many-fold (information, obtaining procedural modification, payment disputes, litigation), they explicit individual patients experiences and therefore complement other sources of quality monitoring. By analysing complaint rates, types and evolution over a 6-year period, the mode of resolution and complainants characteristics, this study aimed to identify specific shortcomings in the ED that could be targeted by quality of care improvement interventions.
2.1. Study design This study is a descriptive analysis of all complaint letters specifically related to patients admitted to the ED of the Lausanne University Hospital from January 1st 2009 to December 31st 2014. The Lausanne University Hospital is a 1500-bed public university hospital that provides primary care for the 300,000 inhabitants of the Lausanne area, as well as tertiary care for Western Switzerland (1.5 million population area). The Lausanne University Hospital ED receives 60,000 adult patients per year. Many patients ( 22,000) are admitted for specialized health problems (ophthalmology, gynaecology, psychiatry) and thus referred from the ED to these specialized clinics or to ambulatory primary care clinics. The remaining patients ( 38,000 patients/year) are admitted and treated in the ED. Patients admitted to the ED are initially registered in the ED software and evaluated by a triage nurse. They are triaged according to the presenting complaint and their vital signs, according to the Swiss Triage Scale [12]. The patients are then registered in the administrative information system unless their clinical condition warrants immediate attention. 2.2. Data sources We analysed all complaint letters from patients, their families or accompanying persons who visited the ED during the study period. At the Lausanne University Hospital, complaints addressed to the clinical departments, or specifically related to the medical activities of a clinical department, are managed by the department head. Complaints involving financial litigation or complaints related to the institution as a whole are managed by the Lausanne University Hospital management. Since April 2012, our hospital also provides an institutional complaints centre where patients can voice their concerns to mediators. Complaints addressed to the ED are managed by two senior physicians and all answers are validated by the ED medical director. For legal and administrative reasons, complaint letters
Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003
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addressed to the ED are archived for at least 10 years by the ED administrative office. Complaint letters addressed to the ED were compared with the complaints specifically addressed during the six years to the Lausanne University Hospital management and to the mediators of the institutional complaints centre. In this study, all written communications from patients or their representatives were included, whether directly addressed to the ED or through the hospital administration direction or the local State Health Authority. Complaint letters were excluded if the subject of complaint did not specifically concern patient management (for example loss of personal properties in the hospital, complaints about the cost of treatments, refusal to pay, etc.). Verbal complaints were not included in this study because rarely documented and recorded.
2.3. Data collection The following data were collected: patient age, gender, presenting chief complaint and initial triage category, according to the Swiss Triage scale. The complaints were analyzed for reasons, author of complaint (patient, relatives, treating general practitioner, or lawyer) and addressee (Head of the ED, Lausanne University Hospital management, State Healthcare Authority). The classification of the complaints was based on a recently published systematic taxonomy, which identifies three main types of complaints: clinical care, management and relationships [13]. Finally, the management and response to these complaint letters were evaluated. Assessment of the medical significance of the adverse events reported in the complaints was performed according to the specific tool from ‘‘The National Patient Safety Agency’’ [14]. This instrument scores consequences from 1 to 5 (1: negligible, 2: minor, 3: moderate, 4: major, 5: catastrophic). Two investigators scored each complaint independently. In case
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of disagreement, they reviewed the complaint together in order to reach a consensus. 2.4. Statistical analysis All individual data were anonymized and collected in a computerized database for statistical analysis. Descriptive statistics were generated, using mean and standard deviation (SD) for normally distributed data, and median as well as interquartile range for non-normally distributed data. Statistical analyses were performed using Stata Statistical Software Release 12.0. 3. Results A total of 156 complaints were recorded during the study period for a total of 219,787 ED visits, yielding a complaint rate between 5.5 and 8.8 per 10,000 visits each year. The annual number of complaints, as well as the number of consultations remained stable over the six consecutive years. The first year studied (2009) yielded the lowest complaint rate with 5.5 complaints per 10,000 visits. It remained stable during 2010 (6.4), then increased during 2011 and 2012 with a rate of respectively 8.8 and 8.3. It decreased to 6.3 and 6.6 in 2013 and 2014, respectively. Complaints were evenly distributed between the three domains (clinical care, management and relationships) with a slight predominance for organisation and logistics issues (39%) against 31.4% for quality of care and 29.6% for communication/relational. Moreover 17.9% of claims involved safety issues (Table 1). Patient characteristics are shown in Table 2. Most patients who complain were over 45 years old. The complaints involved male patients in 48%. About 75% of the complainants were patients triaged in the category 3 or 4 according to the Swiss Triage scale, corresponding to patients in a low risk category.
Table 1 Complaint categories. Domains
Categories
Number, n (%)
Clinical
Quality, including: inadequate patient examination; problems in the coordination of treatment between different services; substandard clinical/nursing care; poor, or unsuccessful, clinical treatment Safety, including: erroneous, missed or slow clinical diagnosis; errors in prescribing or administering medications; events or complications that threatened the safety of patients; deficiencies in the technical and non-technical skills of staff Institutional issues, including: problems with administrative policies and procedures; poor accommodation, hygiene or food; inadequate hospital staffing and resource levels Timing and access, including: lack of access to services or staff; delays in admission or access to treatment; early, late, or unplanned discharge from the hospital; problems in being referred to a healthcare service Communication, including: inadequate, delayed, or absent communication with patients; communication of wrong, inadequate, or conflicting information to patients; no listening to patients, lack of shared decision-making, conflict Humaneness/caring, including: rude, disrespectful or insensitive behaviours to patients; poor attitudes towards patients or their families Patients rights, including: physical, sexual or emotional abuse of patients; breaches of patient confidentiality; coercing or failing to obtain patient consent; discrimination against patients
46 (13.5)
Management
Relationships
61 (17.9)
50 (14.7) 83 (24.3)
45 (13.2)
46 (13.5) 10 (2.9)
Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003
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4 Table 2 Patient Characteristics. Characteristics
Categories
Number, n (%)
Age (years)
16–30 31–45 46–60 61–75 > 75 Male Female 1 2 3 4 (+ 5)a
27 35 28 31 35 75 81 6 40 78 32
Gender Triage scale
(17.3) (22.4) (18) (19.9) (22.4) (48) (52) (4) (29.5) (50) (20.5)
a Until late 2009, the triage scale used in the ED was a 5-level priority scale which was changed to the 4-level priority Swiss Triage Scale (STS) (in which the levels 4 and 5 were aggregated). Triage category 1 (patient requiring immediate medical evaluation) and 2 (patient requiring evaluation within 20 minutes) are considered as urgent. Semi-urgent category 3 (patient requiring evaluation within 120 minutes) and category 4 (non urgent conditions) complete the STS. Each patient is assigned a triage category based on the presumed urgency of the case.
The most frequent reasons for the ED visit were related to abdominal pain, neurologic disorders, chest pain and back pain. The majority (78%) of the complaints were written by the patients themselves or by their relatives (parents, children, husband/wife, or other relatives). A minority of complaints came from the treating physician (12%) or directly from a lawyer (4%). Two-thirds of all complaints were sent within the first month after the visit in the ED (62%). Letters were mainly addressed to the medical management of the ED (63%) and in a small percentage to the State Health Authority (8%). There was no statistical correlation between complaints and waiting times or days. All complaints received a written answer. Most issues were resolved with written apologies or explanations (91%). In a minority of cases, a meeting with the patient or his relatives was organised (6%). In two situations, out of court settlements, with financial associated compensations were necessary (1%) and one case was brought to court, where the claim was finally dismissed. The characteristics of the average complaint letter can be summarized as follows: patients older than 45 years, male or female, triaged in category risk 3 or 4 (less serious), involving one or two grievances, usually pertaining to time delays before medical assessment, access to treatment, inadequate management and delayed or absent information from caregivers. In terms of adverse event severity, 73.5% of the events mentioned in the complaints were considered negligible or with minor medical consequences; 19% with moderate consequences; 6.5% with major consequences and only 1% (i.e. two cases) were considered to have entailed catastrophic consequences. In the first case, an undiagnosed acute coronary syndrome led to a cardiac arrest, just after leaving the ED. Fortunately the patient benefited from immediate resuscitation procedures and coronary catheterization. The second case was a
missed diagnosis of an adhesion-induced small bowel obstruction with subsequent intestinal necrosis, requiring intestinal resection. Both of the patients survived. During the same period, a total of 1755 complaints (280–330 per year) were addressed directly to the Lausanne University Hospital management. The annual number of these complaint letters remained stable over the study period. This group of complaints were markedly different from those addressed to the ED, the majority (61%) pertaining to various types of financial claims. 4. Discussion Twenty to thirty-two written complaints were sent to the ED each year between 2009 and 2014. Compared with the 219,787 consultations achieved during this 6-year period, the global incidence of 6.9 letters per 10,000 visits is low and well within the range (from 4/10,000 visits to 14/10,000 visits) of previously published results [11,15–19]. The number of complaints remained stable over these six years and ED complaints represented only 9% of the total of complaints addressed to the hospital management during the same period (1755 complaints during the six years). Most complaints pertained to non-clinical (68.6%) issues (such as waiting time, logistics, poor communication), rather than clinical issues (31.4%). The most frequent cause was poor communication between staff and patients. According to the ‘‘National Patient Safety Agency’’ scoring system, the events recorded through the complaints had catastrophic consequences in only two cases (1%), and major consequences in 6.5%. Most of the complaints (73.5%) finally concerned negligible or minor consequences. Compared with our results, the five main reasons for complaints addressed to the mediators of our institutional complaints centre from April 2012 until February 2013 involved interpersonal relationship (43%), technical aspects of care (28%), health-care institution (18.5%), billing and insurance (6.5%), access to information (3%) [20]. Interestingly, in both studies, lack of communication clearly stands out. By analysing complaints rates and types, their evolution over a 6–year period, the mode of resolution and complainants characteristics, our study aimed at identifying specific shortcomings in the ED that could be targeted to improve quality of care and patient safety. We identified that lack of patient information remained a significant dissatisfaction factor amongst ED patients. Time constraints, stressful working conditions and numerous interruptions, frequently lead to lack of full and timely staff-to-staff and staff-to-patient communication [21]. Our results show that communication-improving interventions are clearly indicated. One of these includes courses targeting the clinical management of patients, as well as providing staff with adequate communication training. Improving communication relative to clinical management and logistics should positively affect both these complaint rates [22,23]. This is illustrated in a study by Taylor et al., which conclude that « significant improvements in a variety of patient
Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003
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satisfaction measures were achieved with an intervention comprising staff communication workshops (. . .) and a patient liaison nurse » [23]. Accordingly, results from our study and data from the complaints centre were presented to the emergency staff during a conference including doctors and nurses. Concomitantly, a project involving the Lausanne University Hospital is now underway to improve patients welcoming and communication during the hospital stay. Most complaints were resolved with a letter of explanation and/or apologies. In only one case, the conflict was brought to court and only two cases were settled by out of court financial agreements. These results are comparable to a French study [11], which obtained similar results. These results differ from studies made in the United States [24–26], where financial compensation is a frequent mode of resolution and where the amounts involved are much higher than in our experience. Interestingly, in our study most complaints were settled with explanations or apology letters, indicating that the aim of most complainants addressed to our hospital was primarily to be heard und understood, rather than to obtain financial compensation. Limitations of this study include the retrospective use of routinely collected data. In addition, data were limited to a sixyear period, resulting in a limited number of cases. Finally, data are reported from a single institution in a specific context and these results are not necessarily transposable to other healthcare systems. Strengths include the use of a previously validated taxonomy and the comprehensiveness on outcomes and management of all complaints.
5. Conclusion Albeit up to 30 complaint letters per year were sent to the ED of our tertiary care centre, the global incidence is low and remained constant over the last six years. Complaints mainly concern medical care, organizational aspects and staff-patient communication. As the majority of complaints are resolved with a letter of clarification and/or apologies, we can hypothesize that the principal aim of patients or their relatives is to inform the ED about dysfunctions. This information should be taken into account and can be used as a quality indicator to improve patient care. A special effort should be made to improve communication between staff and patients to better respond to patient expectations and increase patient satisfaction. Communication training should be part of staff education and a liaison nurse should be present to give better information and meet the patients increasing demand to be involved in the care and decision-making process. In addition, a brochure addressed to patients could be provided at admission, explaining the categories of triage, the reasons for waiting and the organisation of the emergency room. Another solution would be to install a real-time monitor screen displaying the expectable waiting time, as the majority of complainants pertained to patients in the non-urgent triage category 3 or 4.
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Ethical statement The study protocol was approved by the State Ethics Committee.
Disclosure of interest The authors declare that they have no competing interest.
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Available online at
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Original article
A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014 E´tude re´trospective des plaintes adresse´es au service des urgences d’un hoˆpital suisse entre 2009 et 2014 M.-N. Pfeil *, B. Yersin, L. Trueb, A.-S. Feiner, P.-N. Carron Emergency department, Lausanne university hospital, CHUV, rue du Bugnon 21, 1011 Lausanne, Switzerland Received 12 June 2016; accepted 25 August 2017
Abstract Objective. – Patient complaints are a valuable resource for monitoring and improving patient safety and quality of care. The purpose of this study was to analyze the complaint letters received at a Swiss academic emergency department (ED) over six years. Methods. – A retrospective study of all complaint letters sent to a Swiss academic ED between 2009 and 2014 was conducted. The following data were extracted: epidemiology items, reasons for complaints, hospital responses, follow-up, and severity of the events mentioned in the complaints. All complaint letters related to adult patients evaluated in the ED between 2009 and 2014 were included and a qualitative evaluation was performed based on a systematic taxonomy. Context, patient characteristics, mode of resolution and clinical severity of the related adverse event were evaluated. Results. – A total number of 156 complaints were recorded, corresponding to an annual complaint rate of 5.5 to 8.8 per 10,000 visits. The complaints concerned mostly three domains (clinical care, management and patient or caregiver relationship) with a slight predominance for organisation and logistics (39%) compared with 31.4% for standard of care and 29.6% for communication/relational complaints. The majority of complaints were sent within one month of the ED visit. Most complaints were resolved with written apologies or explanations. The consequences of 73.5% of the events in question were considered minor or negligible, 19% moderate, and 6.5% major. Only 1% (two cases) was related to situations with catastrophic consequences. Conclusion. – Complaint incidence in our ED was low and remained stable over the six-year observation period. Most of the complaints pertained to incidents that entailed negligible or minor consequences. As most complaints were due to inadequate communication, interventions targeting improvement of the doctor/patient communication are required. # 2017 Elsevier Masson SAS. All rights reserved. Keywords: Complaints; Emergency department; Patient safety; Satisfaction; Quality of care
Re´sume´ Introduction. – La me´decine d’urgence, en raison du flux souvent important et peu pre´visible de patients se pre´sentant pour des motifs varie´s, est re´gulie`rement expose´e aux critiques. Dans une vision d’ame´lioration de la qualite´, les plaintes des patients constituent une source d’information pre´cieuse pour e´valuer et ame´liorer leurs prises en charge. Objectif. – Analyser les plaintes adresse´es au service des urgences d’un hoˆpital tertiaire pour de´tecter et comprendre les dysfonctionnements d’un syste`me et tenter d’y apporter des solutions. Me´thode. – E´tude re´trospective monocentrique incluant toutes les lettres de plaintes adresse´es au Service des urgences du CHU de Lausanne entre 2009 et 2014. Les donne´es concernant l’e´pide´miologie des patients, les motifs des plaintes et les re´ponses donne´es ont e´te´ analyse´es pour chaque plainte. La se´ve´rite´ des e´ve´nements mentionne´s dans les plaintes a e´te´ analyse´e a` l’aide d’un outil valide´ « The National Patient Safety Agency ».
* Corresponding author. E-mail address: [email protected] (M.N. Pfeil). https://doi.org/10.1016/j.respe.2017.08.003 0398-7620/# 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003
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Re´sultats. – Au total, 156 plaintes ont e´te´ re´pertorie´es, correspondant a` un taux annuel de 5,5 a` 8,8 plaintes pour 10 000 consultations. Ces plaintes concernaient essentiellement les aspects organisationnels/logistiques (39 %), les soins (31,4 %) et le relationnel (29,6 %). La majorite´ (62 %) des plaintes ont e´te´ envoye´es dans le mois suivant la consultation aux urgences. La plupart (89 %) ont e´te´ re´solues par un courrier d’excuses ou d’explications. Quant a` la se´ve´rite´, 73,5 % des e´ve´nements mentionne´s dans les plaintes concernaient des situations juge´es ne´gligeables ou mineures, 19 % pre´sentaient des conse´quences mode´re´es, 6,5 % des conse´quences majeures et seulement 1 % (deux cas) concernaient des situations avec conse´quences juge´es catastrophiques. Conclusions. – Le taux de plaintes enregistre´es e´tait faible et est reste´ stable sur les six anne´es e´tudie´es. La majorite´ des plaintes (73,5 %) concernaient des cas avec des conse´quences ne´gligeables ou mineures. Nos re´sultats montrent que des strate´gies pour ame´liorer la communication entre me´decins et patients seraient be´ne´fiques. # 2017 Elsevier Masson SAS. Tous droits re´serve´s. Mots cle´s : Plaintes ; Service des urgences ; Se´curite´ des patients ; Satisfaction ; Qualite´ des soins
1. Introduction
2. Method
The number of patients treated each year in emergency departments (ED) worldwide is increasing. In Europe, ED handle approximately 20–25 visits per 100 inhabitants per year [1,2], compared to > 40 visits per 100 inhabitants in the USA [3]. This high activity is associated with an important risk of human errors and ED has therefore been described as ‘‘natural laboratories for the study of error’’ [4]. All ED tasks, such as registration, triage, medical assessment, transmission of medical information and coordination between the various partners are complicated by time constraints, interruptions and distractions [5,6]. Hence, emergency medicine is considered a ‘‘high risk’’ specialty, particularly prone to litigations and claims. Recent studies have shown that emergency medicine is now part of the top five specialties in terms of complaint frequency [7–9]. In this context, quality of care and patient safety are major issues in the ED. Analysis of several indicators, such as patient readmission rate, waiting times, rates of patients left without being seen, incident report systems, autopsy reports, or morbidity and mortality reviews have been used to monitor and improve the quality of healthcare in ED [10]. Analysis of complaint letters from patients and caregivers is part of these essential tools, providing valuable information about quality of care and patient satisfaction [9,11]. Patients and/or their relatives are able to identify specific dysfunctions in the healthcare system, which are frequently underestimated or not identified by traditional monitoring or incident reporting systems [10,11]. Information related to communication gap, waiting times or information failures are key elements in these complaints. Although the goals of individual complaints are many-fold (information, obtaining procedural modification, payment disputes, litigation), they explicit individual patients experiences and therefore complement other sources of quality monitoring. By analysing complaint rates, types and evolution over a 6-year period, the mode of resolution and complainants characteristics, this study aimed to identify specific shortcomings in the ED that could be targeted by quality of care improvement interventions.
2.1. Study design This study is a descriptive analysis of all complaint letters specifically related to patients admitted to the ED of the Lausanne University Hospital from January 1st 2009 to December 31st 2014. The Lausanne University Hospital is a 1500-bed public university hospital that provides primary care for the 300,000 inhabitants of the Lausanne area, as well as tertiary care for Western Switzerland (1.5 million population area). The Lausanne University Hospital ED receives 60,000 adult patients per year. Many patients ( 22,000) are admitted for specialized health problems (ophthalmology, gynaecology, psychiatry) and thus referred from the ED to these specialized clinics or to ambulatory primary care clinics. The remaining patients ( 38,000 patients/year) are admitted and treated in the ED. Patients admitted to the ED are initially registered in the ED software and evaluated by a triage nurse. They are triaged according to the presenting complaint and their vital signs, according to the Swiss Triage Scale [12]. The patients are then registered in the administrative information system unless their clinical condition warrants immediate attention. 2.2. Data sources We analysed all complaint letters from patients, their families or accompanying persons who visited the ED during the study period. At the Lausanne University Hospital, complaints addressed to the clinical departments, or specifically related to the medical activities of a clinical department, are managed by the department head. Complaints involving financial litigation or complaints related to the institution as a whole are managed by the Lausanne University Hospital management. Since April 2012, our hospital also provides an institutional complaints centre where patients can voice their concerns to mediators. Complaints addressed to the ED are managed by two senior physicians and all answers are validated by the ED medical director. For legal and administrative reasons, complaint letters
Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003
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addressed to the ED are archived for at least 10 years by the ED administrative office. Complaint letters addressed to the ED were compared with the complaints specifically addressed during the six years to the Lausanne University Hospital management and to the mediators of the institutional complaints centre. In this study, all written communications from patients or their representatives were included, whether directly addressed to the ED or through the hospital administration direction or the local State Health Authority. Complaint letters were excluded if the subject of complaint did not specifically concern patient management (for example loss of personal properties in the hospital, complaints about the cost of treatments, refusal to pay, etc.). Verbal complaints were not included in this study because rarely documented and recorded.
2.3. Data collection The following data were collected: patient age, gender, presenting chief complaint and initial triage category, according to the Swiss Triage scale. The complaints were analyzed for reasons, author of complaint (patient, relatives, treating general practitioner, or lawyer) and addressee (Head of the ED, Lausanne University Hospital management, State Healthcare Authority). The classification of the complaints was based on a recently published systematic taxonomy, which identifies three main types of complaints: clinical care, management and relationships [13]. Finally, the management and response to these complaint letters were evaluated. Assessment of the medical significance of the adverse events reported in the complaints was performed according to the specific tool from ‘‘The National Patient Safety Agency’’ [14]. This instrument scores consequences from 1 to 5 (1: negligible, 2: minor, 3: moderate, 4: major, 5: catastrophic). Two investigators scored each complaint independently. In case
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of disagreement, they reviewed the complaint together in order to reach a consensus. 2.4. Statistical analysis All individual data were anonymized and collected in a computerized database for statistical analysis. Descriptive statistics were generated, using mean and standard deviation (SD) for normally distributed data, and median as well as interquartile range for non-normally distributed data. Statistical analyses were performed using Stata Statistical Software Release 12.0. 3. Results A total of 156 complaints were recorded during the study period for a total of 219,787 ED visits, yielding a complaint rate between 5.5 and 8.8 per 10,000 visits each year. The annual number of complaints, as well as the number of consultations remained stable over the six consecutive years. The first year studied (2009) yielded the lowest complaint rate with 5.5 complaints per 10,000 visits. It remained stable during 2010 (6.4), then increased during 2011 and 2012 with a rate of respectively 8.8 and 8.3. It decreased to 6.3 and 6.6 in 2013 and 2014, respectively. Complaints were evenly distributed between the three domains (clinical care, management and relationships) with a slight predominance for organisation and logistics issues (39%) against 31.4% for quality of care and 29.6% for communication/relational. Moreover 17.9% of claims involved safety issues (Table 1). Patient characteristics are shown in Table 2. Most patients who complain were over 45 years old. The complaints involved male patients in 48%. About 75% of the complainants were patients triaged in the category 3 or 4 according to the Swiss Triage scale, corresponding to patients in a low risk category.
Table 1 Complaint categories. Domains
Categories
Number, n (%)
Clinical
Quality, including: inadequate patient examination; problems in the coordination of treatment between different services; substandard clinical/nursing care; poor, or unsuccessful, clinical treatment Safety, including: erroneous, missed or slow clinical diagnosis; errors in prescribing or administering medications; events or complications that threatened the safety of patients; deficiencies in the technical and non-technical skills of staff Institutional issues, including: problems with administrative policies and procedures; poor accommodation, hygiene or food; inadequate hospital staffing and resource levels Timing and access, including: lack of access to services or staff; delays in admission or access to treatment; early, late, or unplanned discharge from the hospital; problems in being referred to a healthcare service Communication, including: inadequate, delayed, or absent communication with patients; communication of wrong, inadequate, or conflicting information to patients; no listening to patients, lack of shared decision-making, conflict Humaneness/caring, including: rude, disrespectful or insensitive behaviours to patients; poor attitudes towards patients or their families Patients rights, including: physical, sexual or emotional abuse of patients; breaches of patient confidentiality; coercing or failing to obtain patient consent; discrimination against patients
46 (13.5)
Management
Relationships
61 (17.9)
50 (14.7) 83 (24.3)
45 (13.2)
46 (13.5) 10 (2.9)
Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003
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4 Table 2 Patient Characteristics. Characteristics
Categories
Number, n (%)
Age (years)
16–30 31–45 46–60 61–75 > 75 Male Female 1 2 3 4 (+ 5)a
27 35 28 31 35 75 81 6 40 78 32
Gender Triage scale
(17.3) (22.4) (18) (19.9) (22.4) (48) (52) (4) (29.5) (50) (20.5)
a Until late 2009, the triage scale used in the ED was a 5-level priority scale which was changed to the 4-level priority Swiss Triage Scale (STS) (in which the levels 4 and 5 were aggregated). Triage category 1 (patient requiring immediate medical evaluation) and 2 (patient requiring evaluation within 20 minutes) are considered as urgent. Semi-urgent category 3 (patient requiring evaluation within 120 minutes) and category 4 (non urgent conditions) complete the STS. Each patient is assigned a triage category based on the presumed urgency of the case.
The most frequent reasons for the ED visit were related to abdominal pain, neurologic disorders, chest pain and back pain. The majority (78%) of the complaints were written by the patients themselves or by their relatives (parents, children, husband/wife, or other relatives). A minority of complaints came from the treating physician (12%) or directly from a lawyer (4%). Two-thirds of all complaints were sent within the first month after the visit in the ED (62%). Letters were mainly addressed to the medical management of the ED (63%) and in a small percentage to the State Health Authority (8%). There was no statistical correlation between complaints and waiting times or days. All complaints received a written answer. Most issues were resolved with written apologies or explanations (91%). In a minority of cases, a meeting with the patient or his relatives was organised (6%). In two situations, out of court settlements, with financial associated compensations were necessary (1%) and one case was brought to court, where the claim was finally dismissed. The characteristics of the average complaint letter can be summarized as follows: patients older than 45 years, male or female, triaged in category risk 3 or 4 (less serious), involving one or two grievances, usually pertaining to time delays before medical assessment, access to treatment, inadequate management and delayed or absent information from caregivers. In terms of adverse event severity, 73.5% of the events mentioned in the complaints were considered negligible or with minor medical consequences; 19% with moderate consequences; 6.5% with major consequences and only 1% (i.e. two cases) were considered to have entailed catastrophic consequences. In the first case, an undiagnosed acute coronary syndrome led to a cardiac arrest, just after leaving the ED. Fortunately the patient benefited from immediate resuscitation procedures and coronary catheterization. The second case was a
missed diagnosis of an adhesion-induced small bowel obstruction with subsequent intestinal necrosis, requiring intestinal resection. Both of the patients survived. During the same period, a total of 1755 complaints (280–330 per year) were addressed directly to the Lausanne University Hospital management. The annual number of these complaint letters remained stable over the study period. This group of complaints were markedly different from those addressed to the ED, the majority (61%) pertaining to various types of financial claims. 4. Discussion Twenty to thirty-two written complaints were sent to the ED each year between 2009 and 2014. Compared with the 219,787 consultations achieved during this 6-year period, the global incidence of 6.9 letters per 10,000 visits is low and well within the range (from 4/10,000 visits to 14/10,000 visits) of previously published results [11,15–19]. The number of complaints remained stable over these six years and ED complaints represented only 9% of the total of complaints addressed to the hospital management during the same period (1755 complaints during the six years). Most complaints pertained to non-clinical (68.6%) issues (such as waiting time, logistics, poor communication), rather than clinical issues (31.4%). The most frequent cause was poor communication between staff and patients. According to the ‘‘National Patient Safety Agency’’ scoring system, the events recorded through the complaints had catastrophic consequences in only two cases (1%), and major consequences in 6.5%. Most of the complaints (73.5%) finally concerned negligible or minor consequences. Compared with our results, the five main reasons for complaints addressed to the mediators of our institutional complaints centre from April 2012 until February 2013 involved interpersonal relationship (43%), technical aspects of care (28%), health-care institution (18.5%), billing and insurance (6.5%), access to information (3%) [20]. Interestingly, in both studies, lack of communication clearly stands out. By analysing complaints rates and types, their evolution over a 6–year period, the mode of resolution and complainants characteristics, our study aimed at identifying specific shortcomings in the ED that could be targeted to improve quality of care and patient safety. We identified that lack of patient information remained a significant dissatisfaction factor amongst ED patients. Time constraints, stressful working conditions and numerous interruptions, frequently lead to lack of full and timely staff-to-staff and staff-to-patient communication [21]. Our results show that communication-improving interventions are clearly indicated. One of these includes courses targeting the clinical management of patients, as well as providing staff with adequate communication training. Improving communication relative to clinical management and logistics should positively affect both these complaint rates [22,23]. This is illustrated in a study by Taylor et al., which conclude that « significant improvements in a variety of patient
Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003
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satisfaction measures were achieved with an intervention comprising staff communication workshops (. . .) and a patient liaison nurse » [23]. Accordingly, results from our study and data from the complaints centre were presented to the emergency staff during a conference including doctors and nurses. Concomitantly, a project involving the Lausanne University Hospital is now underway to improve patients welcoming and communication during the hospital stay. Most complaints were resolved with a letter of explanation and/or apologies. In only one case, the conflict was brought to court and only two cases were settled by out of court financial agreements. These results are comparable to a French study [11], which obtained similar results. These results differ from studies made in the United States [24–26], where financial compensation is a frequent mode of resolution and where the amounts involved are much higher than in our experience. Interestingly, in our study most complaints were settled with explanations or apology letters, indicating that the aim of most complainants addressed to our hospital was primarily to be heard und understood, rather than to obtain financial compensation. Limitations of this study include the retrospective use of routinely collected data. In addition, data were limited to a sixyear period, resulting in a limited number of cases. Finally, data are reported from a single institution in a specific context and these results are not necessarily transposable to other healthcare systems. Strengths include the use of a previously validated taxonomy and the comprehensiveness on outcomes and management of all complaints.
5. Conclusion Albeit up to 30 complaint letters per year were sent to the ED of our tertiary care centre, the global incidence is low and remained constant over the last six years. Complaints mainly concern medical care, organizational aspects and staff-patient communication. As the majority of complaints are resolved with a letter of clarification and/or apologies, we can hypothesize that the principal aim of patients or their relatives is to inform the ED about dysfunctions. This information should be taken into account and can be used as a quality indicator to improve patient care. A special effort should be made to improve communication between staff and patients to better respond to patient expectations and increase patient satisfaction. Communication training should be part of staff education and a liaison nurse should be present to give better information and meet the patients increasing demand to be involved in the care and decision-making process. In addition, a brochure addressed to patients could be provided at admission, explaining the categories of triage, the reasons for waiting and the organisation of the emergency room. Another solution would be to install a real-time monitor screen displaying the expectable waiting time, as the majority of complainants pertained to patients in the non-urgent triage category 3 or 4.
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Ethical statement The study protocol was approved by the State Ethics Committee.
Disclosure of interest The authors declare that they have no competing interest.
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Please cite this article in press as: Pfeil M-N, et al. A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014. Rev Epidemiol Sante Publique (2018), https://doi.org/10.1016/j.respe.2017.08.003