We conducted a three-armed, prospective, randomized controlled trial to assess the impact of provider knowledge of parental expectations on parent satisfaction for children with non-urgent visits to the ED. The Human Investigations Committee of Yale University approved this study.

The study was performed in an urban, tertiary care pediatric ED (annual census 35,000) over a one-year period from February 2014 to February 2015. A convenience sample of parents or guardians (hereafter referred to as parents) of children triaged as a non-urgent visit (Emergency Severity Index [ESI] level 4 or 5)¹⁶ were approached for enrollment upon arrival to the ED examination room. The ESI is a 5-level triage algorithm from 1 (most acute) to 5 (least urgent) based on patient acuity and anticipated resource needs, with levels 4 and 5 considered as low acuity visits.¹⁶ Parents were eligible for participation if their child was < 18 years old and presenting for a non-traumatic chief complaint (e.g. fever, cough, emesis, etc.). Parents were excluded if the child’s chief complaint was health maintenance related (e.g. vaccination), or if the parent was non-English speaking and/or could not read the English language surveys.

Eligible parents were enrolled by trained research assistants (RAs) during predetermined study blocks distributed throughout the 24 hours of the day and 7 days of the week, dependent on RA availability. Study packets were distributed to potentially eligible parents on arrival to the ED. An information sheet explained that consent was implied if the parent completed the enclosed surveys. Using block randomization, parents consenting for participation were randomly assigned using blocks of 80 into the three study groups: baseline, control, or intervention (Figure 1). RAs were blinded to the group assignment at the time of enrollment.

Parents assigned to the baseline group followed routine care, and no study procedures were conducted except completion of a satisfaction survey after the ED visit. Parents in the control and intervention groups were given an expectation survey immediately following enrollment. Upon survey completion, the RA collected the expectation survey. The control group expectation survey was placed back in the study packet and medical providers caring for the patient were blinded to survey responses. For the intervention group, the expectation survey was reviewed by the first treating provider (pediatric or emergency medicine resident, nurse practitioner, physician assistant, pediatric emergency medicine fellow or attending physician) prior to his or her initial evaluation of the patient. The first treating provider initialed the expectation survey to acknowledge review of the survey responses and returned the survey to the RA. We did not record whether a non-attending physician provider subsequently discussed the survey with an attending physician. Not every patient evaluated by a nurse practitioner or physician assistant in the ED is staffed with an attending physician, so an attending physician did not see all patients. Treating providers were not provided any further information about the study or outcomes being evaluated, and were not instructed as to how to consider the expectation survey responses. Parents in all groups were blinded as to whether the provider received written knowledge of their expectations.

Once the patient was ready for discharge, as deemed by the treating medical provider, the RA provided parents in all groups with a satisfaction survey that was completed prior to ED departure. The satisfaction survey was comprised of 3 questions that assessed parental satisfaction: 1) Overall rating of care received during your child’s visit, 2) likelihood of recommending our Emergency Department to others, and 3) staff’s sensitivity to your fears and concerns. These questions were derived from a survey supplied by vendor Press Ganey (Press Ganey Associates, Inc, South Bend, IN), a for-profit agency employed by our institution to benchmark the patient experience. Responses were indicated on a 5-point Likert scale from “very poor” (1) to “very good” (5). RAs were available to answer any questions throughout the parent’s ED stay.

The primary outcome was the proportion of ED visits resulting in a 5 out of 5 rating for satisfaction by parents. Differences in the percent receiving a 5 out of 5 rating for overall care between the intervention and control groups were compared. Secondary outcomes were the difference between the intervention and control groups in 1) parent’s likelihood of recommending the ED and 2) parent’s perception of the staff’s sensitivity to their fears and concerns, as measured in the satisfaction survey. To assess whether provider review of parental expectations increased time required for ED care, ED length of stay was also assessed as a secondary outcome measure.

There are no available, validated measures of parental expectations in the pediatric ED. The authors developed an expectation survey (Appendix Table 1) based on a survey previously utilized⁶ to address specific potential interventions expected by subjects (imaging, laboratory test, pain medication, antibiotics, intravenous fluids, prescription, thorough exam, other). Additionally, the expectation survey contained an open-ended question to assess what about the child’s illness most worried the parent. Twenty expectation surveys were distributed to parents in the ED during a pilot phase to determine understandability and feasibility of use in the ED. Parents were approached to identify any difficulties with survey items. The survey was then revised prior to use in the final study.

The responses to each expectation and satisfaction survey were entered into an electronic database. The date of visit, date of birth, triage level, chief complaint, time of arrival, time of discharge, gender, race, insurance provider, and expectation survey acknowledgement by the medical provider were also entered for each study child. All data was collected at the time of the clinical encounter except for time of discharge and insurance provider, which were obtained through medical record review.

We conducted a pilot of twenty satisfaction surveys to ascertain a baseline measurement of overall satisfaction, our primary outcome measure. Based on our pilot, we determined that 75% of subjects recorded the highest level of satisfaction (5 out of 5 response on the Likert scale) when evaluating overall rating of care specifically in non-urgent patients. Our hypothesis assumed that our intervention, knowledge of written expectations, would increase this proportion to 85%. Thus, we calculated our sample size using a 10% effect size between the intervention and control groups; assuming a β=0.20 and α=0.05, 250 subjects were necessary in each study group (baseline, control, intervention), for a total of 750 subjects. An interim analysis of data was planned after 1 year of enrollment.

Data were summarized using standard descriptive statistics. Comparative analyses for proportions were accomplished using chi-square tests among the three groups. Outcome data was dichotomized as a score of 5 out of 5 on the Likert scale and scores < 5. Continuous variables were compared using one-way ANOVA. Statistical significance was determined as a p-value <0.05. All analyses were performed using SPSS (v. 22.0, IBM Corp., Armonk, NY).

The study was stopped at our one-year interim analysis, after it was determined that a significant difference in our primary outcome between the intervention and control groups would be statistically futile. At the time of our interim analysis, 399 parents had been approached for enrollment: 38 refused participation and 15 were ineligible due to inappropriate chief complaint or triage level, or due to poor English literacy (Figure 2). An additional 42 enrolled parents had missing data or incomplete survey responses, leaving a total of 304 parents available for analysis (Figure 2).

The median age of enrolled children was 3.0 years (IQR 1.0–8.0), 49.3% were male, and 80.6% were publically insured. Fever was the most common chief complaint (26.1%), followed by rash (13.0%) and cough (8.8%). The three study groups did not differ substantially in age, race/ethnicity, gender, emergency severity index triage level, insurance type, location of care, time of enrollment, or disposition (Table 1). Children of parents that refused enrollment or who were excluded due to missing data were not statistically different than those enrolled across demographics, except that a higher proportion of the excluded parents were evaluated in the fast track area rather than in the main ED (26.1% vs. 12.7%, p <0.001).

Of the 104 expectation surveys completed in the intervention group, 97 were initialed and acknowledged by the treating provider: 60 (61.9%) were reviewed by a resident physician, 34 (35.1%) by a nurse practitioner or physician assistant, and 3 (3.1%) by an attending physician. Expectation survey responses were similar between the control and intervention groups, except for a larger proportion of parents in the control group expecting a prescription (Appendix Table 2). The most common expectations listed were a thorough exam by a provider (34.8%) followed by a desire for a prescription (33.8%). Antibiotics were expected by 31.3% of parents, while 28.4% expected a laboratory test to be performed and 21.4% anticipated receipt of pain medication. Additionally, 19.9% of subjects utilized the “other” category, writing in a specific expectation not previously listed; most commonly, whatever was necessary to make the child feel better and the diagnosis or reason for the child’s illness. The most frequent responses for the question “what about your child’s illness worries you the most” were fever, particularly height or duration of fever, and the child’s pain or discomfort.

Overall, parental satisfaction in the study was highly rated: 72.4% of parents reported a 5 out of 5 for “overall rating of care” and 95.6% reported a 4 or 5 out of 5 indicating “good” or “very good” for all three satisfaction questions across study groups (Appendix Figure 1).

There was no significant difference among the baseline, control, and intervention groups for any of the three satisfaction outcomes: “overall rating of care”, “likelihood of recommending the ED” and “staff sensitivity to fears and concerns” (Table 2). Additionally, in the intervention group, there were no significant differences in satisfaction for all 3 outcomes on sub-analysis based on first treating provider (data not shown). The outcome “staff sensitivity to fears and concerns” received the highest proportion of 5 out of 5 scores across all groups (baseline 78.6%, control 78.4% and intervention 78.8%). The median ED length of stay was similar among the study groups (104 vs. 106 vs. 107 minutes, p=0.98).