Complaints

Introduction

Complaints are inevitable in the setting of busy emergency departments (EDs). They may arise from poor quality of service or unmet patient expectations. Most senior ED staff are aware of what constitutes optimal care. Unfortunately, EDs are areas where there is little control over timing, volume or case presentations; that, combined with a mixture of staff with different levels of experience, long waits and multiple other reasons ( Box 30.7.1 ), means that complaints are common.

Advances in emergency medicine (EM) and nursing clinical care have resulted in new standards with which the public have become familiar. Patients and their relatives have much higher expectations of EDs than previously. They are better informed, more litigious and encouraged by marketing from legal firms. Nevertheless, most patients who may have legitimate cause for complaint do not formally complain; hence the frequency of complaints is not an accurate gauge of patient satisfaction.

Incidence

Complaint rates about ED care vary from 0.26 to 3.8 complaints/1000 patients. Some hospitals record only written complaints, whereas others also include verbal complaints in their data. Often the complaints refer to multiple issues. More complaints relate to paediatric patients and more are made by females and the literate.

In an analysis of complaints lodged by patients attending Victorian hospitals between 1997 and 2001; in comparison to other hospital departments, ED complaint rates were significantly lower (1.9/1000) than those in general wards (6.2/1000) and intensive care (5.9/1000).

In a further study of 2419 ED-related complaints from 36 hospitals over 5 years, 37% were made by the patient and 48% were from relatives. Friends accounted for 3%, and the rest included General Practitioners (GPs), specialists, government representatives and lawyers. ED complaints were 14.3% of the total 16,901 hospital complaints.

Reasons

In this study, there were four main categories for complaint: problems relating to care (inadequate treatment, diagnosis or follow-up—33%), communication (relaying information, rudeness and discourtesy—31%), access (26%) and administrative deficiencies (incorrect documentation, inability to obtain previous records, lack of privacy or confidentiality and loss of property—7%). In most other studies, communication is by far the highest category. In private hospitals, fees are an increasing source of complaint.

Clinical care

Approximately 50% of complaints claiming inadequate medical assessment and treatment are substantiated. Inadequate physical examination followed by a missed or delayed diagnosis is a frequent complaint and can only be refuted if good medical documentation exists.

Medicine is not an exact science, and early clinical features may be atypical. Explaining this to the anxious patient who wants a quick diagnosis and symptom relief can pose difficulties for a busy doctor.

Missed fractures are the most frequent ‘misdiagnosis’. Some ‘misdiagnoses’, as perceived by patients, result from poor communication, with lack of explanation by the treating doctor of the possible causes or what to do if there is no improvement.

Lack of treatment includes insufficient or no analgesia, lack of investigations or antibiotics (where an initial presentation, particularly in a child, may have suggested a viral illness with eventual progression to a bacterial infection) and lack of a splint for a ‘soft tissue injury’, which is subsequently diagnosed as a fracture.

Rough, unskilled or incompetent treatment still occurs despite advances in training of both doctors and nurses. A heavy workload is not an acceptable excuse. With the reduction in allowable weekly labour hours for hospital-employed doctors, EDs may rely to some extent on junior staff and locums under variable levels of senior supervision on some rosters.

Unprofessional conduct and refusal to refer to a specialist or to a previous treating doctor are unacceptable causes of complaint. Cases of sexual misconduct are very rare in EDs and should be referred to a medical board.

Communication

Effective communication is fundamental to good health care services. Poor or inadequate communication with consumers is the reason behind many complaints. Failure of doctors to introduce themselves and to explain the reasons for examination, investigations, treatment, disposition decisions, referrals or delays are all avoidable causes of complaints.

Abruptness, rudeness, discourtesy, insensitivity, absence of caring and other aspects of poor attitude used to be the main reason for complaints, but, perhaps as standards in general society have changed, this is no longer the case. However, in EDs, when people are rightfully anxious about their medical condition, such attitudes should not be tolerated. Lack of formality, addressing older patients by their given name, casual dress standards and incomplete identification have become the accepted norm in many Australasian hospitals but may still upset some of our senior citizens and immigrants.

Failure to obtain consent in the case of minors or to gain informed consent for procedures and to warn about risks occurs commonly in EDs, where it is assumed that attendance implies consent, but this can be challenged if the patient is brought to hospital by ambulance or other means.

Doctors may miss significant clues if they ignore aspects of a patient’s history which do not fit with a presumptive diagnosis. This may also occur if the history is rushed and overly brief. Incorrect documentation and poor clinical handover are common sources of complaint, particularly when it results in the wrong treatment.

Reliance on referring letters or ambulance sheets without interviewing the patient can result in transcribing incorrect past history, medication charts and allergies. It cannot be assumed that referral details or old case histories are correct. Objective evidence of diagnoses should be sought.

It can be difficult to identify a ‘source of truth’, when people do not have a regular physician. This can be compounded by ‘doctor shopping’, where patients attend the most convenient bulk-billing family medicine clinic, where their past history is unknown, hoping for a quick cure for acute problems, while reserving attendances at their usual general practitioner for more complicated ongoing illnesses.

Clinical staff in EDs are commonly faced with excessive communication loads. The combination of interruptions and multiple concurrent tasks resulted in 36 communication events an hour in one study, and this may produce clinical errors by disrupting memory processes.

Delays

Difficulty with access to health care is a worldwide problem, even in first-world countries, where economic rationalism and changing government policies have resulted in closure of hospital beds, mental health institutions and community resources. Lifestyle and industrial issues have decreased the numbers of medical and nursing staff in hospitals, particularly after hours.

Diminished outpatient services may mean that patients need to be referred to private consultants’ rooms where appointments may not be readily available. Fewer general practices open in the evenings or weekends. Some patients want a one-stop service for their medical consultation, their laboratory tests and their radiology. These social reasons make unnecessary use of scarce resources, despite strategies, such as telephone triage services and hospital-run after hours GP clinics. All the aforementioned have contributed somewhat to increased ED attendances.

Delays in triage, time seen by doctor, treatment, investigations, consultations, admission or discharge may therefore occur. Measures to decrease these are only partially successful because there is generally no excess of staff or resources to call upon when there are unexpected peaks in workload. Steps to improve waiting times, increase throughput of short-stay patients and decrease misdiagnosis of fractures have resulted in fewer complaints.

Particularly in the case of children and distressed patients, long delays cannot be easily tolerated, and a significant number ‘walk out’ without being seen. The elderly are less likely to complain but suffer in silence, such that any pain they have may be unrecognized and untreated until late in the management.

Administration

Incorrect documentation by clerical, nursing or medical staff, lack of privacy or confidentiality, loss of valuables, poor cleaning or other environmental issues and queries regarding billing in private hospitals comprise the majority of administrative complaints.

Errors can be made by doctors in giving advice regarding a patient’s right to claim compensation, because the full circumstances cannot easily be ascertained at the time of consultation. Doctors should not advise patients regarding entitlements to compensation but should complete the necessary documentation objectively.

Poor department design, lack of an accessible staff room or little adherence to departmental policy may cause complaints about staff socializing, eating or drinking. Their laughter may be seen by some patients as inappropriate but by others as a sign of good staff morale.

The Federal Privacy Act gives patients a general right of access to information held about them (see Chapter 28.4 ). Although patients have right of access, they must obtain consent from the doctors for further reproduction of the material, because the doctor still has ownership of clinical notes and specialists have legal rights over their reports. Relevant material must be made available to another doctor. Refusal of access must be based on reasonable grounds, such as that access would pose a serious threat to the life or health of any person. Conversely, information held by the doctor on the patient must not be divulged to third parties without patient consent, unless compelled by law, such as with mandatory reporting of child abuse.

Unmet expectations

Patient satisfaction surveys have ranked waiting times, symptom relief, a caring and concerned attitude and correct diagnosis as priorities when attending an ED. However, there is a mismatch when compared with staff who agree with the priorities but rank waiting time fourth.

Patients expect ED doctors to identify serious or dangerous conditions and to treat these appropriately. Explanation and reassurance are needed.

Responding to a complaint

Effectively responding to a complaint minimizes the likelihood of adversity and escalation. An effective response is early, supportive, open, even-handed and constructive. It should be backed up by a clear, accountable and outcome-driven complaints management process that is supported by hospital administration ( Box 30.7.2 ).