| | Patient Satisfaction as a Function of Emergency Department Previsit ExpectationsPresented as an abstract at the Society of Academic Emergency Medicine annual meeting, May 2007, Chicago, IL. Received 3 November 2007; received in revised form 10 June 2008, 29 July 2008 and 7 October 2008; accepted 26 January 2009. published online 13 March 2009. Study objectivesThis study measures the effect of meeting emergency department (ED) patients' expectations for diagnostic and therapeutic interventions on patient satisfaction. MethodsThis was a cross-sectional study of consecutive patients during block enrollment periods surveyed at the beginning and end of their ED visits. On arrival patients or their surrogates were surveyed about the specific interventions they expected during their visit. After completion of ED care, they were surveyed about their level of satisfaction with the entire encounter, assessment of their provider's interpersonal skills, impression of time spent waiting in the ED, and perceived waiting time. Satisfaction was assessed with categorical responses. The degree of concordance of interventions expected and interventions provided was analyzed to determine their effect on overall ED visit satisfaction. ResultsNine hundred eighty-seven patients presented during enrollment periods, 821 met inclusion criteria, and complete data were collected on 504 patient encounters. Twenty-nine percent had no previsit expectations of diagnostic or therapeutic interventions, 24% had a single reported expectation, 47% had multiple intervention expectations. After adjusting for potential confounders, we could not demonstrate a relationship between fulfillment of expectations and satisfaction. We did find a very strong relationship between highly ranked provider interpersonal skills and ED satisfaction (probability ratio of being “very satisfied” 8.6; 95% confidence interval 4.7 to 15.6). Other factors associated with high ED encounter satisfaction were adequate explanations for waiting times and perception of total time in the ED. ConclusionOverall satisfaction was strongly correlated with patient's assessment of the physician's interpersonal skills and was not correlated with whether the physician had met expectations about diagnostic and therapeutic interventions. Introduction  Background Emergency department (ED) practitioners are responsible for providing medically appropriate and cost-efficient care with the goals of patient satisfaction, optimal outcomes, and public health benefits. Patient satisfaction has been increasingly used as an outcome measure for health care system performance. ED patient satisfaction is an incompletely understood concept. Providers may find themselves carrying out activities to enhance satisfaction without fully knowing whether that activity does improve satisfaction. This is particularly problematic if actions taken to enhance satisfaction conflict with cost efficacy or public health responsibilities. Several determinants of ED patient satisfaction have been explored. Perceived waiting time (as opposed to actual waiting time) has been shown to be a factor in overall ED satisfaction.1, 2 Race and sex interactions are also related to satisfaction.3, 4 Younger patients, black patients, and those with lower triage acuity express lower satisfaction.5, 6 Likewise, language concordance may result in a closer relationship between patients and providers, positively affecting satisfaction.7, 8 Spahr et al found a relationship between the treating physician's awareness of parental expectations and overall encounter satisfaction.9 They also found a higher percentage of met expectation when providers were aware of the expectations. Though not directly explored, their study raises the question, did simply meeting parents' pre-encounter expectations improve overall satisfaction, or was the awareness of these expectations enough to initiate other behaviors among providers that improved parental satisfaction? Editor's Capsule SummaryWhat is already known on this topic Some patients come to the emergency department (ED) with specific expectations about their care. What question this study addressed This 504-patient, single-ED, observational study examined the relationship of patient satisfaction to whether patient expectations were met. What this study adds to our knowledge No important associations between meeting patient expectations for specific diagnostic and therapeutic interventions and patient satisfaction were found. As in other studies, satisfaction was associated with patient ratings of the quality of interpersonal skills and the time the provider spent with them. How this might change clinical practice This study reinforces that concept that tests and treatments should be ordered according to medical necessity and should not be done simply to meet patient expectations. Importance Physicians perceive that their patients have specific expectations during a clinical encounter, and there is a tendency for physicians to fulfill these expectations despite medical appropriateness.10, 11, 12, 13 Furthermore, physicians may misperceive patient expectations. For example, in a clinic setting with presumably well-established physician-patient relationships, treating physicians overestimated their patients' expectation of antibiotics for upper respiratory infections.14, 15 It is poor medical practice to provide unnecessary care, and particularly dysfunctional if mistakenly done so to enhance patient satisfaction. Goals of This Investigation The goal of this study was to determine the contribution of meeting a patient's previsit diagnostic and therapeutic expectations to overall satisfaction with an ED visit. We also sought to determine the relative effect of factors that other investigators have shown to influence satisfaction.1, 2, 3, 4, 5, 6 Materials and Methods Study Design We performed a cross-sectional study of patients during their visit to an ED. This study was approved by the sponsoring facility's institutional review board. Setting Our study was carried out in the ED of an urban academic teaching hospital with an emergency medicine residency. This ED has an annual census of 65,000 patient visits, with an admission rate of 20%. The hospital is a trauma and pediatric center for a population of 2.4 million urban, suburban, and rural inhabitants. Selection of Participants The study population consisted of consecutive patients treated in the ED during periods of block enrollment between June and September 2006. Blocks were defined by proportional allocation of discrete areas within the ED, as well as day, evening, week, and weekend periods. We excluded prisoners, the critically ill or injured, those who chose not to participate, and those who were unable to effectively communicate because of language. If a patient was unable to provide the necessary data (children, cognitively impaired, language barrier) and was accompanied by someone who could complete the collection of data, the person accompanying the patient, if willing, was used as a surrogate for the patient. We had no occurrences of repeated sampling of the same patient on different visits. We designed our survey to be anonymous and self-administered by the patient or their accompanying surrogate. If a respondent or patient required assistance in completing the survey, a research associate was available to help. The survey was developed and piloted during 16 hours of data collection. The effectiveness and readability of the survey were determined by the amount of input required of the research associate and incomplete responses on the survey. There were no formal outcome measures used for evaluating the instrument during the trial, but areas requiring clarification were identified and modifications were made. Our third draft appeared to be readable and required little input from the researchers for respondents to complete. Data collected with the third draft was included in our study analysis because this draft became the final survey instrument. Data were collected by one of the authors (G.T.) and trained research associates. ED providers were aware that a survey was taking place but were not aware of the nature of the survey. Data Collection and Processing For each patient visit, we collected data in 3 phases: patient expectations immediately on entry to the ED, patient impressions measured immediately after completion of care, and retrospective chart review. The initial contact took place before any encounter with a physician, nurse practitioner, or physician's assistant. During this period, the patient or his or her representative was surveyed to determine demographic features and specific expectations of diagnostic and therapeutic interventions. Responses were collected categorically (not sure, none, blood test[s], urine test[s], stool test[s], EKG, radiograph[s], ultrasonogram, computed tomography scan, magnetic resonance imaging, or specialty consultation, pain medications, medicine specific to your condition [eg, inhaled bronchodilators], antibiotics, intravenous fluids, hospital admission). Shortly after completion of ED care and before discharge or transfer to an inpatient unit, participants were surveyed to determine their overall satisfaction with the ED visit and other elements shown to be associated with satisfaction. These included satisfaction with the diagnostic and therapeutic procedures done in the ED, physician interpersonal skills, explanation of diagnosis and management, total time spent in the ED, explanation of the excessive waiting time (if any was perceived), and the perceived time spent by the provider with the patient. These responses were collected with a 5-point categorical scale (anchored by 1=very satisfied and 5=very dissatisfied). We also asked the patients whether they believed that they received unnecessary diagnostic or therapeutic interventions. The survey instrument is available in Appendix E1 (available online at http://www.annemergmed.com). Finally the ED medical record was reviewed shortly after the respondent left the ED to determine what interventions were performed or were scheduled through the ED. If questions arose, the patient's provider was approached to verify information from the chart. Other information collected from the chart included day of week and shift of the visit, the time spent in the ED from triage to disposition, the final patient disposition, and diagnostic category (medical or surgical). The sample size estimation was derived on a bivariate association between “expectation(s) met,” and being “highly satisfied” with the visit. We wanted a sample size sufficient to detect a modest strength of association that the probability of being highly satisfied when expectations were met would be 1.5 times higher than when expectations were not met. Our assumptions for carrying out the sample size calculation were that the probability of reporting “highly satisfied” with the ED visit would be 50% in the group with expectations met (P1=.5) and 33% in the group without met expectations (P2=.33). Assigning an α of .05 and seeking a power of 0.8, we calculated that we would require 143 patients per group. Anticipating effect modification and allowing for variations in percentage of patients whose expectations were entirely met, we planned to enroll 500 patients. Primary Data Analysis Data were entered into an EpiInfo (version 3.5; Centers for Disease Control and Prevention, Atlanta, GA) and imported into a SAS database (version 9.0; SAS Institute, Inc., Cary, NC). Our principle outcome measure was the level of satisfaction with the ED visit. From review of internal reports, we expected substantial patient satisfaction and thus planned to dichotomize satisfaction to “very satisfied” and “other.” Our analysis was designed to assess the association between expectations for interventions and overall satisfaction with the ED visit. Detailed bivariate analyses were conducted because expectation of interventions was a complex derived variable. First, the association for those expecting each specific intervention (regardless of other expectations) and satisfaction was computed. Second, the association between those expecting each specific intervention and satisfaction was computed, stratified by the number of interventions expected (0, 1, 2, 3, >3). Third, for those expecting 2 or 3 interventions, we reviewed the association between each exact combination of expectations and satisfaction. Although the numbers became very small, we focused on whether there was consistency in the direction of association or whether the relationship changed when different expectation combinations were viewed. We also looked for any evidence of effect modification. Although we had insufficient power to statistically detect effect modifiers that were not very strong, we visually inspected the data to identify evidence for moderate modification; none was observed. According to the findings, a summary of 2 perspectives was developed. First, for those who had only 1 expectation, the association between meeting the expectation and satisfaction for each specific expectation was studied. We then studied the association of satisfaction in meeting the expectation for all patients with any single expectation. Second, we studied the association of meeting the proportion expectations met with satisfaction in persons expressing multiple expectations. To assess the association between expectations met and overall ED satisfaction adjusted for potential confounders, we developed a model based on the satisfaction literature.2, 3, 4, 5, 6, 7, 8, 16 Factors included in the model were proportion of total expectations met (100%, 50% to 99.9%, 0.1 to 49.9%, 0%), and the following potential confounders: day and shift (8 am to 4 pm Monday to Friday, 4 pm to 8 am Monday to Thursday, 4 pm Friday to 8 am Monday), respondent (defined as either the patient, parent of a minor, or other), patient sex (male, female), age of respondent (18 to 21, 22 to 35, 36 to 50, 51 to 65, >65 years), race of respondent (white, black, Hispanic, other), health insurance (private insurance, no insurance, Medicare, Medicaid), education of respondent (high school and less, more than high school), and final patient disposition (admitted, discharged, other). Originally, a log-binomial model was selected for the analysis because the outcome (patient satisfaction) is mathematically common and thus the adjusted prevalence ratio must be estimated directly and not with an adjusted odds ratio (as is done with logistic regression). Because the log-binomial model did not converge, we analyzed the data with Poisson regression. The Poisson model with robust variance estimates also provides adjusted prevalence ratios with reasonable confidence intervals and test statistics.17, 18 Our analysis of the proportion of expectations met as a predictor of satisfaction was carried out only on those expressing at least 1 expectation. Significance was defined with an α of 0.05. Interaction terms were not included in the model because descriptive assessment of the data did not identify strong candidates and the sample size was not sufficient to identify modest effect modification. Model fit focused on the primary exposure factor of interest (proportion of total expectations met) and influence measures. Each covariate pattern was dropped individually and the model parameters were estimated to determine whether any individual or small group of individuals had undue influence on the estimated strength of association between expectations and satisfaction. None were observed. The similarities between estimated unadjusted prevalence ratios and adjusted prevalence ratios, and similarities between predicted probabilities and observed probabilities for covariate patterns with substantial numbers, suggested the model reasonably fit the data. All analysis was carried out with SAS version 9.0. Results Characteristics of Study Subjects There were 987 patients who came to the ED during 343 data collection hours; 821 (83%) met inclusion criteria and 504 (61%) participated in the study and had complete records (Figure). The characteristics of the study population and the presence or absence of expectations are shown in Table 1. Among all the respondents in the study, 29% reported having no expectations, 24% expected 1 diagnostic or therapeutic intervention, 26% expected 2 interventions, 11% expected 3 interventions, and 10% expected more than 3 interventions in the ED. Hispanics appeared to have had fewer previsit expectations. Of the 357 expressing at least 1 expectation, the most commonly mentioned diagnostic intervention was a blood test, followed by radiographs. Pain medicine was the most commonly expected therapeutic intervention. | | |  | Characteristics | Total, No.(%) | Those Without Expectations (N=146), No.(%) | Those With Expectations (N=358), No.(%) | |
|---|
| Day and shift of patient presentation | | | 8 am to 4 pm(Mon. to Fri.) | 257(52) | 70(27) | 187(73) | | | 4 pm to 8 am(Mon. to Thu.) | 91(18) | 24(26) | 67(74) | | | 4 pm Fri. to 8 am Mon. | 149(30) | 50(34) | 99(66) | | | Missing=7 | | | | | | Respondent | | | | | | Patient | 384(78) | 107(28) | 277(72) | | | Parent | 79(16) | 25(32) | 54(68) | | | Other | 31(6) | 11(35) | 20(64) | | | Missing=10 | | | | | | Sex of the respondent | | | | | | Male | 201(40) | 61(30) | 140(70) | | | Female | 296(60) | 83(28) | 213(72) | | | Missing=7 | | | | | | Age of the respondent, y | | | | | | 18–21 | 46(9) | 15(33) | 31(67) | | | 22–35 | 193(39) | 62(32) | 131(68) | | | 36–50 | 153(31) | 38(25) | 115(75) | | | 51–65 | 70(14) | 20(29) | 50(71) | | | >65 | 35(7) | 11(31) | 24(69) | | | Missing=7 | | | | | | Race of the respondent | | | | | | White | 298(60) | 93(31) | 205(69) | | | Black | 143(29) | 32(22) | 111(78) | | | Other | 28(6) | 8(29) | 20(71) | | | Hispanic | 28(6) | 13(46) | 15(54) | | | Missing=7 | | | | | | Primary health insurance of patient | | | Medicaid | 145(29) | 42(29) | 103(71) | | | Medicare | 62(12) | 21(34) | 41(66) | | | Private insurance | 228(46) | 60(26) | 168(74) | | | No insurance | 60(12) | 23(38) | 37(62) | | | Missing=9 | | | | | | Education level of respondent | | | High school and less | 229(46) | 73(32) | 156(68) | | | More than high school | 266(54) | 71(27) | 195(73) | | | Missing=9 | | | | | | | |
The distribution of overall satisfaction scores among the 504 respondents was 50% “very satisfied,” 41% “satisfied,” 4% “neither satisfied nor dissatisfied,” 3% “dissatisfied,” and 2% “very dissatisfied.” Forty-six percent of those who did not expect any interventions in the ED reported being “very satisfied,” whereas 51% of those who had expected at least 1 procedure were “very satisfied.” For those who expected only 1 diagnostic intervention, there was a suggestion of greater satisfaction when the expectation was met. There was no association between having a therapeutic intervention met and patient satisfaction. Although the numbers were small for specific expectations, there was nothing to suggest important associations (Table 2). There was no association with encounter satisfaction or absence of met expectations in those with multiple expectations. When specific combinations of expectations were explored (eg, radiograph and pain medication), we were unable to appreciate any association between receipt of expected interventions and satisfaction. However, the numbers involved with each combination were small. Bivariate analysis of the proportion of expectations met (in those with more than 1 expectation) did not show an association with satisfaction. Those provider factors associated with being “highly satisfied” included highly ranked interpersonal skills, clarity of explanation of the diagnosis, satisfaction with total ED time, and satisfaction with the time spent by the physician. On the other hand, the respondent factors of black race, Medicaid as primary insurance, admitted patients, and failure to complete high school were all associated with less satisfaction. The timing of presentation, whether the patient or a surrogate was surveyed, sex, and age had minimal or no association with satisfaction (Table 3). | | | | Variables | Total, No.(%) | Very Satisfied, No.(%) | Likelihood of Being Very Satisfied, RR(95% CI) | Multivariable Analysis Adjusted for Demographic and Operational Characteristics,* RR(95% CI) | |
|---|
| Proportion of expectations met, % | | | 100 | 157(44) | 84(54) | Ref | Ref | | | 50–99.9 | 114(32) | 58(51) | 0.9(0.7–1.2) | 0.9(0.7–1.2) | | | 0.1–49.9 | 30(8) | 13(43) | 0.8(0.5–1.2) | 0.9(0.6–1.3) | | | 0 | 56(16) | 29(52) | 1(0.7–1.3) | 1(0.7–1.4) | | | Day and shift | | | 8 am to 4 pm(Mon. to Fri.) | 187(53) | 100(53) | Ref | Ref | | | 4 pm to 8 am(Mon. to Thu.) | 67(19) | 30(45) | 0.8(0.6–1.1) | 0.92(0.7–1.2) | | | 4 pm Fri. to 8 am Mon. | 99(28) | 52(53) | 1(0.8–1.2) | 0.96(0.8–1.2) | | | Respondent | | | Patient | 277(79) | 144(52) | Ref | Ref | | | Parent of a minor | 54(15) | 29(54) | 1.(0.8–1.4) | 1.1(0.8–1.4) | | | Other | 20(6) | 9(45) | 0.9(0.5–1.4) | 0.9(0.6–1.4) | | | Sex of patient | | | Male | 140(40) | 76(54) | 1.1(0.9–1.3) | 1(0.8–1.3) | | | Female | 213(60) | 106(50) | Ref | Ref | | | Age of respondent, y | | | 18–21 | 3(9) | 13(42) | 0.8(0.5–1.3) | 0.9(0.6–1.3) | | | 22–35 | 131(37) | 68(52) | Ref | Ref | | | 36–50 | 115(33) | 60(52) | 1(0.8–1.3) | 1(0.8–1.3) | | | 51–65 | 50(14) | 26(52) | 1(0.7–1.4) | 1(0.7–1.3) | | | >65 | 24(7) | 14(58) | 1.1(0.8–1.6) | 1(0.6–1.5) | | | Race of respondent | | | White | 205(58) | 120(58) | Ref | Ref | | | Black | 111(32) | 43(39) | 0.7(0.5–0.9) | 0.8(0.6–1) | | | Other | 20(6) | 10(50) | 0.8(0.5–1.3) | 0.9(0.6–1.4) | | | Hispanic | 15(4) | 7(47) | 0.8(0.5–1.4) | 0.9(0.5–1.7) | | | Health insurance | | | Private insurance | 168(48) | 94(56) | Ref | Ref | | | No insurance | 37(11) | 22(59) | 1.1(0.8–1.4) | 1.1(0.7–1.7) | | | Medicare | 41(12) | 24(59) | 1(0.8–1.4) | 1.1(0.8–1.6) | | | Medicaid | 103(30) | 43(42) | 0.75(0.6–0.9) | 0.9(0.7–1.2) | | | Education of respondent | | | High school and less | 156(44) | 72(46) | 0.82(0.7–1) | 0.8(0.7–1.1) | | | More than high school | 195(56) | 110(56) | Ref | Ref | | | Final patient disposition | | | Discharged | 304(86) | 165(54) | Ref | Ref | | | Admitted | 42(12) | 14(33) | 0.6(0.4–0.9) | 0.7(0.5–1.1) | | | Other | 8(2) | 4(50) | 0.9(0.5–1.8) | 1(0.4–2.2) | | | Satisfaction with interpersonal skills of primary provider | | | Very satisfied | 239(67) | 174(73) | 8.6(4.7–15.6) | | | | Not very satisfied | 118(33) | 10(9) | Ref | | | | Satisfaction with explanation of the diagnosis | | | Very satisfied | 227(64) | 156(69) | 3.3(2.3–4.6) | | | | Not very satisfied | 128(36) | 27(21) | Ref | | | | Respondent's satisfaction with the total time spent in ED | | | Very satisfied | 116(32) | 105(90) | 2.7(2.3–3.3) | | | | Not very satisfied | 240(67) | 79(33) | Ref | | | | Respondent's satisfaction with the provider time | | | Very satisfied | 178(50) | 144(81) | 3.6(2.7–4.8) | | | | Not very satisfied | 179(50) | 40(22) | Ref | | | | | |
Multivariable analysis with Poisson regression also showed that the proportion of expected diagnostic or therapeutic interventions received did not improve the probability of a respondent reporting being “very satisfied” with the ED encounter (Table 3). Limitations Because we excluded patients deemed too ill to participate, our findings may not be valid for this group. Similarly, patients with inability to express themselves were also not sampled in our project. This subset of patients would generally be expected to report lower scores on satisfaction. Measurement of ED patient satisfaction is a complex endeavor. There are no widely accepted and validated instruments. Our measure of overall satisfaction was crude and may not fully capture all nuances of satisfaction. Nevertheless, our surveyed outcome measure resulted in findings similar to those of previous studies, including a skewed distribution toward high satisfaction and an association with provider interpersonal characteristics. Although our sample size may be inadequate to detect a small association between meeting patient expectations for diagnostic and therapeutic interventions and satisfaction, we believe that it was adequate to detect an important association. Last, we did not record provider-level characteristics and thus could not adjust for clustering of provider demographics. This likely resulted in smaller variances than would have been estimated had clustering been taken into account. Discussion This study provides evidence that although patients often present to an ED with pre-established diagnostic or therapeutic expectations for care, the effect of meeting these expectations is not associated with overall ED visit satisfaction. The features that showed meaningful influence on satisfaction were the respondent's report that they were “very satisfied” with the provider's interpersonal skills, receiving an explanation for time spent in the ED, receiving an explanation of the medical condition, and the perceived time the physician spent with the patient. The age, race, insurance status, and education levels of the respondent had a demonstrable, but possibly clinically insignificant, effect on satisfaction. We found, not surprisingly, that satisfaction is increased as perceived waiting times are reduced. Interestingly however, estimates of waiting time by patients may not be accurate.16, 19, 20 Our study reaffirms the findings that satisfaction is linked to waiting times and that adequate explanation for waits may be rewarded with higher encounter satisfaction. Education and insurance status, often considered surrogates of socioeconomic status, were strongly correlated with satisfaction. As those before us have found, markers of lower socioeconomic status were associated with lower satisfaction scores.21, 22, 23, 24 Additionally, ethnic discordance between patients and providers has been linked with lower encounter satisfaction.25 As is the case with most health care delivery settings, our provider group was heavily skewed toward nonblack and non-Hispanic ethnicities. Furthermore, our health care providers reside in the middle to upper middle socioeconomic strata. Though we did not demonstrate this, age may also be a factor in determining level of satisfaction. In our study, those aged between 18 and 21 years demonstrated a trend toward expressing lower satisfaction with their ED encounter. The characteristics most associated with high satisfaction with ED care were highly ranked provider interpersonal skills, explanation of the medical condition, and the length of time the provider spent with the patient, each a measure of the effectiveness of communication during the ED visit. Although, by design, we did not measure a provider effect in this study, differences in communications skills among providers likely affect satisfaction. This is important because interpersonal and communication skills can be enhanced through experience, training, and feedback.26, 27, 28, 29, 30 The findings of this study suggest that investing in the development of interpersonal and communication skills would be one way to improve patient satisfaction with ED encounters. The act of ordering diagnostic or therapeutic interventions, beyond those indicated for the presenting medical conditions, does not appear to be fruitful in achieving this goal. Appendix E1. Albany Medical Center patient satisfaction survey References 1. 1Hedges JR, Trout A, Magnusson AR. Satisfied Patients Exiting the Emergency Department (SPEED) study. Acad Emerg Med. 2002;9:15–21. MEDLINE |
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16. 16Thompson DA, Yarnold PR, Williams DR, et al. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28:657–665. Abstract | Full Text |
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a Albany Medical College, Department of Emergency Medicine, Albany, NY b University at Albany, School of Public Health, Albany, NY  Address for correspondence: Wayne Triner, DO, MPH, Albany Medical College, Department of Emergency Medicine, 47 New Scotland Avenue (MD-139), Albany, NY 12208; 518-262-3773, fax 518-262-3236
Supervising editors: J. Stephan Stapczynski, MD; David L. Schriger, MD, MPH Author contributions: GT collected data and WT oversaw the collection. GT, WT, and L-AM were responsible for study design. GT and L-AM were responsible for statistical analysis. L-AM was responsible for article review. WT takes responsibility for the paper as a whole. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Publication date: Available online March 12, 2009. Reprints not available from authors. PII: S0196-0644(09)00104-8 doi:10.1016/j.annemergmed.2009.01.024 © 2009 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved. | |
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