The acute medical assessment unity (AMAU) is a relatively new concept in Ireland’s medical system.¹ It was designed to decongest the increasing demands on emergency departments in tertiary healthcare institutions.^1,2 Patients are triaged based on their referral from their general practitioner with the aim of getting a comprehensive medical assessment and appropriate investigations. An NCHD assigned to the AMAU carries out the initial assessment of the patient, who, based on the working and differential diagnoses, arranges the appropriate investigations. The consultant on call at the AMAU reviews these patients with the relevant test results and formulates a management plan. The aim is to reach a diagnosis, formulate a treatment plan and/or refer on to the appropriate specialist centre.² Within this framework, the AMAU in Kerry General Hospital strives to discharge patients not requiring admission within the 9am-5pm working hours.  

An initial satisfaction survey was carried out in 2012 in the antecedent AMAU facilities where patients and their accompanying carers rated the AMAU services. The AMAU relocated to a bigger and better equipped facility since the initial survey and the aim was to evaluate if there was a change in the level of satisfaction at the new location and identify the strongest and weakest areas of participants’ satisfaction.

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Methods

Setting 

The AMAU was upgraded in 2013 to an eight-bedded facility with more space between cubicles and a waiting area beside the facility for accompanying carers. The nursing station is now larger with two computer systems and working space for doctors and nurses to carry out medical and administrative work. The new facility provides a toilet for patients within the AMAU and two additional toilets near the waiting area. In the new AMAU, an NCHD is assigned to work there for a week, which allows for continuity and a good rapport between staff. The addition of an office space for the clinical nurse manager (CNM) in the department ensures smoother running of the AMAU and a more private setting for sensitive discussions with patients and carers. 

Study population and survey 

In 2012 and 2015, 100 random participants (50 patients and 50 carers) in each cycle answered an eight-question survey, which rated their experience in the AMAU according to how prompt their access to the AMAU was, and how helpful was the verbal and written information given. They rated the cleanliness, facilities, nursing care, medical care and overall experience. Each question was rated on a scale of excellent, good, fair, poor or no answer. There was a section for additional comments.

Participants were approached randomly and were included based on those who gave their verbal consent to participate in the survey. Participants filled in the questionnaires away from AMAU staff and then dropped the completed forms into an unmarked box.  

The AMAU patient population is based on the guidelines from the National Acute Medicine Programme (NAMP) which states that: “Any adult patient (aged 16 years and older) whom a GP determines requires immediate medical admission or urgent medical assessment, may be considered suitable for AMU/AMAU/MAU referral, unless alternative pathways are considered more appropriate.”²

Patients who are not suitable for the AMU/AMAU/MAU have been clearly outlined by the NAMP as:  

• Patients requiring ED-based resuscitation, eg. patients who are clinically or physiologically unstable or are considered at high risk for sudden life-threatening clinical deterioration
• Patients from other hospitals requiring direct admission to ICU, CCU, HDU or other critical or high dependency areas
• Initial assessment of patients with acute behavioural problems 
• Patients with acute mental health problems should be seen promptly in an appropriate clinical environment 
• Trauma patients
• Patient with undiagnosed abdominal pain/haematemesis
• Patients with acute decrease in level of consciousness 
• Patients with exceptional isolation requirements, which cannot be met in an AMU/AMAU/MAU setting.²
• The study used the term ‘carer’ for any individual accompanying patients. This included, but was not limited to relatives, home helps, friends, neighbours and care assistants. 

Analyses 

Descriptive statistics 

The eight questions were assessed in both time points where we compared the percentage of all participants who answered excellent, good, fair, poor or provided no answer to the survey questions. Given that at each time point, there were 100 participants (50 patients and 50 carers), the numbers given corresponds to the percentages. We also looked at the areas that attained the highest percentage of excellent, poor ratings and no answer. An inference for the difference in proportion of participants, who answered excellent and good to each of the eight questions at the two time points, was assessed using a z-statistic for proportions.³

For instance, in Question 1, the difference in proportion of participants who answered excellent would hold the null hypothesis H01: P1E – P2E = 0. It states that there is no difference between the proportions of participants who answered excellent to Question 1 in 2015 compared to 2012. The corresponding alternative hypothesis is given as HA1: P1E – P2E =/ 0; hypothesises that difference in the proportion of patients who answered excellent in 2015 compared to 2012 is not zero. 

Where: H01 is the null hypothesis for Question 1; HA1 is the alternate hypothesis for Question 1; P1E is the proportion of participants in 2015 that answered excellent to Question 1; P2E is the proportion of participants in 2012 that answered excellent to Question 1 and α is set at 0.05.

For this test to be valid, the proportion of patients was only compared when there was > 5 participants in each category being compared. All eight questions had high proportions of excellent and good responses given, these two categories were used for our sub-analysis. Categories for fair and poor did not meet the minimum of > 5 participants and were therefore not included in the sub-analysis. 

Results

Descriptive analyses

Figure 1 and Figure 2 give an overall view of how patients and carers answered to each question in both surveys. From the figures, one can see that the patients and carers answered the survey questions in a similar pattern. This reduces any concern about combining the carers and patients into a single participant population pool when comparing the two time points.

When analysing the percentages of participants who answered each question, we found that 79% answered excellent to ‘How prompt was your access to the AMAU?’ in 2012 compared to 78% in 2015. In 2012, 10% answered good compared to 20% in 2015; 10% answered fair in 2012 compared to 2% in 2015; in 2012, only 1% answered poor compared to 0% in 2015. None of the participants gave ‘no answer’. 

The verbal information was deemed excellent by 91% in 2012 compared to 78% in 2015; 6% rated it good in 2012 compared to 21% in 2015; 3% rated it fair in 2012 compared to 1% in 2015. No one answered poor or gave no answer. 

The lowest ratings were noted when looking at the written information, 59% found it excellent in 2012 compared to 53% in 2015; 9% found it good in 2012 compared to 25% in 2015; 0% of participants rated this fair compared to 2% in 2015; 2% rated the written information poor compared to 0% in 2015. A high percentage of participants gave no answer to this question (30% in 2012 and 20% in 2015). The remarks in the comment section highlighted that the majority of participants did not receive the written information.

The AMAU got excellent ratings for its cleanliness (75% in 2012 and 90% in 2015); 24% rated it good in 2012 compared to 9% in 2015; 1% answered fair in 2012 and 1% in 2015. None of the participants rated it poor or gave no answer.

The fifth question asked patients how they rate the facilities and 65% rated this excellent in 2012 compared to 86% in 2015. In 2012, 28% found the facilities good compared to 14% in 2015; 4% found it fair in 2012 compared to 0% in 2015; 1% found it poor in 2012 compared to 0%; 2% gave no answer in 2012 and 0% in 2015. 

The nursing care was the highest rated service in the AMAU survey. In 2012, 97% found the care excellent and 92% in 2015; 3% rated the service good in 2012 and 8% in 2015. None of the participants rated this service fair, poor or gave no answer. 

The rating of the medical care was not far behind that of the nursing care. This service was found to be excellent by 89% of participants in 2012 compared to 84% in 2015; 9% in 2012 found it good compared to 13% in 2015; 2% rated it fair in 2012 with 2% in 2015; none of the participants rated this service poor and no answer was given by 1% in 2015. 

The questionnaire concluded by asking how participants rated their overall experience. We found that 88% rated it excellent in 2012 and 83% in 2015; 11% deemed it good in 2012 compared to 14% in 2015; 1% marked their experience fair in 2012 with 2% in 2015. None of the participants rated their overall experience poor but one participant gave no answer in 2015. 

Sub-analysis

The sub-analyses calculated the z-statistic, which represents the critical value from the standard normal distribution. Since all two sided p-values were greater than 0.05, we can neither reject the null hypothesis that there is a significant difference between proportions of patients who answered excellent to the survey questions in 2015 compared to 2015, nor a difference in proportion of patients who answered good (see Table 1).

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Discussion

From the descriptive analyses, one can see that there is no substantial difference in the participants’ ratings of each question in the two time points. The sub-analyses did not support any statistically significant difference in the proportion of excellent or good ratings. 

The improvement in the location and facilities in the AMAU did not seem to translate into a higher level of satisfaction. A change in these structures may not necessarily be perceived by patients as an improvement in services offered. Our analysis lies on the assumption that the participants in both surveys were independent and hence might not identify the changes implemented in the AMAU.

The 2012 survey was new to Ireland. This follow up survey of 2015 serves as encouragement for the department to maintain the high standards already set. The results of 2012 and 2015 highlight the high level of carer and patient satisfaction with the medical and nursing care received in the AMAU. 

The survey identified areas of improvement such as a deficiency in patients receiving the written information before their AMAU appointment so that first time attenders know what to expect when they visit the department. We hope that this study sets the ball rolling for future research into improving the services provided by AMAUs nationwide.

The subjective nature of surveys means that the responses are based on the perceptions of participants and authors. This makes it difficult to certify exactly what is being measured. For instance, Question 1 asks, ‘How prompt was your access to the AMAU?’ One might interpret this as the length of waiting time from GP referral until receiving an AMAU appointment while another might understand the question to mean the waiting time from AMAU arrival to being seen by the nurse, NCHD or consultant. 

In future studies, we hope to make the questions and answers more specific and objective. Our results show similarities in the way carers and participants responded to the survey questions, as there was no instruction pertaining to not divulging the responses to each other. We hope to consider ways to eliminate this influence in future surveys.

Conclusion

Improvement in AMAU structural facilities did not result in an improved participant satisfaction according to our findings. The perception of better healthcare provision could be influenced by other factors such as good communication, participants’ expectations being met and their concerns being addressed during their visit in the AMAU.⁴ The knowledge of a diagnosis and a structured follow-up plan might also play a crucial role.⁵ These are areas that should be incorporated in future surveys.

References

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2. O’Neill S, Carroll J, Geary U et al. Report of the National Acute Medicine Programme (2010) 
3. Royal College of Physicians of Ireland Irish Association of Directors of Nursing and Midwifery Therapy Professions Committee Quality and Clinical Care Directorate, Health Service Executive. Available www.hse.ie/eng/about/Who/clinical/natclinprog/acutemedicineprogramme /report.pdf (accessed Dec 6, 2015)
4. Harvard School of Public Health Quantitative Methods Lecture Slides. Chapter 8: Inference for Proportions. Available at: http://isites.harvard.edu/fs/docs/icb.topic1097638.files/Unit%2008%  20-%20Inference%20for%20Proportions%20-%201%20per%20page.pdf (accessed Dec 6, 2015)
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