Digital Commons Network^™

Association Between Clinicians’ Average Patient Length Of Stay And Patient Experience Scores, Diane Kuhn, Thomas Lardaro, Katherine Pollard, Carl Pafford, Steven K. Roumpf, Christian C. Strachan, Julia Vaizer, Nancy K. Glober, Benton R. Hunter

Patient Experience Journal

Objective: Given the current emphasis on patient-centered care, emergency physicians are seeking ways to improve patients’ experience in the emergency department (ED). Length of stay (LOS) in the ED has previously been associated with patient experience ratings, however there is limited literature on this relationship at the clinician level. The objective of this study was evaluate the association between ED clinicians’ mean LOS and their individual patient experience scores. Methods: This was a cross-sectional observational study of 240 ED clinicians’ average LOS and patient experience scores which took place across a regional healthcare system in the United States …

Does Patient Experience Change With Age? Exploring Associations Between Patient Experience, Gender And Age, Corey Adams, Ramya Walsan, Anthony Schembri, Anurag Sharma, Ramesh Walpola, Reema Harrison

Patient Experience Journal

Patient experience measurement is important for healthcare organizations to support the provision of high-quality care. Although previous research suggests age and gender may influence patient experiences, a thorough analysis of these associations remains unexplored. To address this gap, our research investigates the association of age and gender on patient experience ratings, using data from two widely used assessment tools: the Net Promoter Score (NPS) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Data analysis was performed on a total of 19,228 survey responses, collected from 2018 to 2022, in a public metropolitan hospital in Sydney, Australia. Our …

Covid-19 Vaccine Perception And Hesitancy Among Uninsured Free Clinic Patients, Samin Panahi, Brenda Spearman, Justine Sundrud, Mason Lunceford, Akiko Kamimura

Patient Experience Journal

There are many complexities regarding the acceptance of COVID-19 vaccines, mainly because the COVID-19 vaccine had a fast track of development compared to vaccines developed in the past years. The purpose of this study is to understand COVID-19 vaccine perception and hesitancy among uninsured free clinic patients using the theory of planned behavior. This study had seven focus groups with 37 total participants, including 19 Spanish speakers. Free clinic adult patients (over the age of 18) participated in four focus groups during Summer of 2021. The average age of the participants was 44.7, and the majority of the participants self-identified …

Evaluation Of Online Patient Complaints Regarding City Hospitals In Türkiye During The Covid-19 Pandemic: A Content Analysis Study, Canan Çınar, Elif Erbay, Gökçen Çeliker, Ahmet Selçuk Yıldırım

Patient Experience Journal

The COVID-19 pandemic put tremendous pressure on healthcare systems worldwide, which led to heightened scrutiny of the medical services offered by hospitals. This article aims to evaluate complaints about city hospitals in Türkiye during the COVID-19 pandemic using the Healthcare Complaints Analysis Tool, which includes three main domains and seven problem categories. The complaints submitted by users on the site via “sikayetvar.com” were systematically collected. Document analysis was used as the data collection method, and 925 complaints were included in the analysis. The most common motive for complaining was “just to express” and problems occurred at the stage of admission, …

The Mental Health Journey Of Healthcare Workers Returning To Work After Covid-19 In Pakistan: Recovery And Resilience, Fahad Ahmed, Ayesha Iqbal, Talal Khurshid, Hidayat Ullah, Sundas Sahar, Khurram Iqbal, Muhammad Ahmed Ali, Rija Rizvi

Patient Experience Journal

Since the beginning of the COVID-19 pandemic various studies have reported that healthcare workers (HCWs) are not only at risk of exposure but also experiencing psychological distress. However, less is known about the mental health outcome of HCWs after their clinical recovery from COVID-19 infection. This study addresses a critical gap in our understanding by focusing on the mental health outcomes of HCWs in Pakistan after their clinical recovery from COVID-19 infection and the resumption of their duties. This cross-sectional, study was conducted among 272 HCWs who had recovered COVID-19 infection. The symptoms of depression were assessed by Patient Health …

Acceptability Of A New Remote Monitoring Service For Patients With Covid-19 Infection Using Wearable Biostickers™: A Mixed Methods Study, Lynne Maher Dr, Lisa K. Blake Mrs, Karol J. Czuba Dr, Mary E. Seddon Dr

Patient Experience Journal

The COVID-19 pandemic saw rapid adoption of telehealth, including remote patient monitoring (RPM). There is limited evidence about how patients and staff experience such services in New Zealand. This study aimed to understand the acceptability of the RPM experience, particularly for Maori and Pacific peoples, and identify strengths, gaps, and limitations to inform future delivery of services. A mixed methods study was undertaken between 4 July and 11 September 2022 in Auckland. We conducted telephone surveys with patients and semi-structured interviews with patients and staff. Survey, and clinical and administrative data were analysed descriptively using SPSS. Interviews were analysed using …

Refining Successful Implementation Strategies For The Surgical Safety Checklist In High-Income Contexts: Results Of An International Mixed Methods Study, Meagan E. Elam, Christopher J. Louis, Jonathan Woodson, Nathan Turley, Denisa Urban, Mary E. Brindle, Jacey A. Greece

Patient Experience Journal

The WHO Surgical Safety Checklist (SSC) continues to show inconsistent success in reducing surgical complications in high-income settings. Previous implementation research identified potential barriers and facilitators to success, but it primarily consists of qualitative studies with small sample sizes in limited geographic areas. We conducted a multi-country mixed-methods study of barriers and facilitators to SSC implementation to better inform policies and practices for improving SSC buy-in and use to maximize its impact. This convergent parallel mixed-methods study utilized survey and interview data from surgical team members practicing in five countries. Survey data were analyzed using χ² analysis or Fisher’s …

Helping Patients Navigate The Emergency Department: Assessing The Utility Of A Poster Illustrating The Patient Journey, Lynette D. Krebs, Cristina Villa-Roel, Maria B. Ospina, Brian R. Holroyd, Brian H. Rowe

Patient Experience Journal

Patients often have limited understanding of the emergency department (ED) care process, which can increase anxiety, frustration, and confusion. This study implemented and assessed the usefulness of a poster explaining the ED care process. A large wall-mounted poster illustrating the patient journey was developed; two different data collection techniques were used. First, a QR code/URL was used to passively collect patient reactions to the poster in 15 EDs. Due to limited response, a paper survey was developed and delivered by research assistants in three study sites using a consecutive sampling method. A total of 67 responses were collected from the …

Healthcare Team Members’ Views On Social Determinants Of Health Screening And Referral Practices In A Pediatric Emergency Department, Jadelynn Nagy, Natalie J. Tedford, Sahlil Ahmed, Sofia Thoms, Akiko Kamimura, Maija Holsti

Patient Experience Journal

We aimed to explore the healthcare team members’ (HTMs) views on social determinants of health (SDH) screening and referral processes in a pediatric emergency department (PED). We conducted a cross-sectional, mixed-methods study to explore PED HTMs’ views on social care practices at a quaternary-level children’s hospital. The survey was created using a goal identification framework. The survey gathered quantitative and qualitative data by assessing SDH screening practices, comfort and personal habits in screening, prioritization of SDH domains, workflows to perform screening, and perceived barriers to screening. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using thematic analysis …

Informed Consent In Surgical Practice With Patients’ Experiences: A Cross-Sectional Study, Seda Kumru, Pakize Yiğit, Meryem Demirtaş, Hüseyin Fındık

Patient Experience Journal

This study aims to evaluate patients' experiences and perspectives regarding informed consent in surgical practice. Data for this cross-sectional study were collected from 276 patients using a questionnaire developed by Falagas et al. Descriptive statistics were employed for all questions. Statistical tests such as the Mann-Whitney U test, Kruskal-Wallis test, and Spearman's rank correlation analysis were performed, and Cohen's effect sizes were reported. IBM SPSS 23.0 was used for all analyses, and p<0.05 was considered statistically significant. A high score on both The Delivered Information Index and The Patient-Physician Index represents a positive informed consent process. Among the participants, 65.2% indicated that they understood all parts of the consent form. Of all patients, 92.8% reported that information about the specific surgical procedure was provided by physicians. However, 47.5% of the patients reported that they did not feel comfortable with their surgeons. The mean score of the Delivered Information Index was 5.63 (2.38). The mean patient-physician relationship score was 14.38 (3.31). There was a moderate positive correlation between the delivered information index and the patient-physician relationship (r=0.50; p<0.001). In addition, there was a moderate positive correlation between the delivered information index and the time spent on the informed consent process, as well as between the patient-physician relationship and the time spent on the informed consent process (r=0.52; r=0.40, respectively). The study emphasized the lack of communication between patients and physicians, the limitation of information on treatment risks, adverse effects, and alternative treatment options.

Experience Framework

This article is associated with the Policy & Measurement lens of The Beryl Institute Experience Framework (https://theberylinstitute.org/experience-framework/).

• Access other PXJ articles related to …

The Role Of Patient-Centered Communication Scale In Patients’ Satisfaction Of Healthcare Providers Before And During The Covid-19 Pandemic, Mohammad A. Tabatabai, Patricia Matthews-Juarez, Nader Bahri, Robert Cooper, Donald Alcendor, Aramandla Ramesh, Derek Wilus, Karan Singh, Paul Juarez

Patient Experience Journal

Assess the effect of patient-centered communication (PCC) scale on the patient satisfaction of healthcare providers (HCPs). The 2020 Health Information National Trends Survey (HINTS) was used to analyze the patient’s satisfaction of HCPs. This survey includes 2466 patients’ responses and were analyzed using the multivariable binary Hyperbolastic regression model of type II. The study examines the effects of PCC scale on patients’ satisfaction of HCPs while controlling for pandemic status, employment, education, marital status, race, political views, waiting time status, sex, income, and age. PCC scale was the most significant predictor of patients’ satisfaction of their HCPs (P-value < 0.001) followed by waiting time status (P-value < 0.001), and age (P-value = 0.016). The odds of patient satisfaction with the healthcare provider services were approximately 20% higher prior to the pandemic than during the pandemic (P-value = 0.415). The odds of satisfaction for patients earning $100k+ was approximately three times more than those making less than $35,000 (P-value = 0.003). PCC scale is a powerful measure that may be used as a metric for patients’ satisfaction of HCPs. Taking steps to improve communication between HCPs and patients is a key factor in patient satisfaction. Concentrating on the seven domains of PCC will result in higher patient satisfaction of HCPs. The improvement in PCC will encourage each patient to disclose vital information about his or her health. This may increase the accuracy of diagnosis, quality of care, and health outcomes.

Experience Framework …

Doctor Behaviors That Impact Patient Satisfaction, Bryan Lilly, Michael J. Tippins, Katharine Tippins, Julia Lilly

Patient Experience Journal

Patient satisfaction with their doctor is an essential component of healthcare that impacts both patient health outcomes and fiscal success of healthcare organizations. This study identifies doctor behaviors that act as drivers of patient satisfaction when doctor expertise is set aside and determines the importance of these behaviors between different age groups. Survey data were gathered from two samples, one comprising younger adults at a mid-size Midwestern university (n=100) and one comprising older adults from a national market research survey panel provider (n=187). Subjects were asked to rate their satisfaction with their doctors from 0‑100 and rate the importance of …

Psychometric Properties Of The Impact Index In Patients With Chronic Conditions, Kd Valentine, Suzanne Brodney, Carol Cosenza, J. Lee Hargraves, Karen Sepucha, Susan Edgman-Levitan, Michael Barry

Patient Experience Journal

The purpose of this paper was to extend the generalizability of the patient-reported Impact Index by assessing convergent validity in patients with common chronic conditions. We conducted a cross-sectional survey of 1,000 English-speaking patients aged 21 and older who visited their provider in the past 6 months and were included in one or more of a hospital’s chronic condition registries. Patients completed a survey that included the Impact Index (4-item measure of how impacted a patient is by their health condition: range 0-12, higher score indicating greater negative impact on quality of life), overall health, and self-report of diagnosis of …

How Are The Vibes? Patient And Family Experiences Of Rapport During Telehealth Calls In Palliative Care, Wendy English, Jackie Robinson, Merryn Gott

Patient Experience Journal

Interactions with rapport are considered essential to palliative care and beneficial to patient outcomes. With the current interest in telehealth, more knowledge is needed about rapport during telehealth encounters in palliative care from the patient and family viewpoint. The objective of this study was to explore patient and family experiences of rapport with health professionals during telehealth interactions in the community palliative care setting. This was a qualitative Interpretive Description study, with 18 patients and 11 family member participants recruited from four hospice locations in Aotearoa, New Zealand. Semi-structured interviews were conducted, and audio recorded between November 2020 and May …

The Initial Psychometric Evaluation Of A New Emergency Department Patient-Reported Experience Measure (Ed Prem), Claudia Bull, Julia Crilly, Sharon Latimer, Emma Hall, Brigid M. Gillespie

Patient Experience Journal

Patient-reported experience measures (PREMs) are critical to evaluating the person-centeredness, safety, and quality of healthcare services internationally. The aim of this study was to describe the initial psychometric evaluation of a new Emergency Department (ED) PREM. Adult patients presenting to the ED of a tertiary hospital in southeast Queensland, Australia during January 2022 were recruited in-person. Participants selected their preferred ED PREM mode of administration from online, telephone, or postal, and had 14 days from recruitment to complete the survey. Item reduction, structural validity, discriminant validity, and internal consistency reliability were assessed. A sample of 349 (68.4%) was achieved. Item …

Patient-Centered Care Frameworks, Models And Approaches: An Environmental Scan, Aghna Wasim, Maria Sajan, Umair Majid

Patient Experience Journal

Although the definition of patient-centered care (PCC) remains unclear, researchers and healthcare professionals describe the concept as treating the patient as a unique human being with consideration for their physical and psychosocial needs and emphasize the importance of shared-decision making between patients and healthcare professionals. However, discussion around the connection and overlap between PCC and patient and family engagement (PE) has been limited. Some authors describe PE as an operationalization of PCC, while others consider PE a type of PCC. An enhanced understanding of PCC might allow for improvements in implementing PE across healthcare systems. Insight into the operationalization of …

Digital Patient Engagement At A Perioperative Surgical Home Implemented Community Hospital, Srinivasan Sridhar, Amy Mount Hunter, Bernadette Mccrory

Patient Experience Journal

Patients in rural areas typically require more perioperative ‘optimization’ for surgery. The rural healthcare systems often overwhelmed with coordinating perioperative services and deliver less than optimal surgical outcomes. This is due to limited supporting microsystems and ability to effectively engage and track patients over the 120-day perioperative period to limit post-surgical complications. The study assessed longitudinal patient engagement within a newly established Perioperative Surgical Home (PSH) at a rural community hospital serving 10+ surrounding counties to identify barriers and best practices for engagement. A digital patient engagement platform was implemented and used to assess longitudinal patient outcomes and engagement from …

Living With Covid-19 In The Community During The First Wave Of The Pandemic: Lessons From Patients For Healthcare Providers And Policy Makers, Linda Rozmovits, Michelle Marcinow, Ilja Ormel, Terence Tang, Elizabeth Mansfield, Kerry Kuluski, Seema Marwaha, Susan Law Dr

Patient Experience Journal

This qualitative descriptive study explores patients’ experiences of living with COVID-19, in the community, during the early stages of the pandemic. Between October 2020 and April 2021, fifteen semi-structured, video-recorded interviews were conducted, via Zoom, with participants in five Canadian provinces. Participants self-identified as having had a confirmed or suspected case of COVID-19. The constant comparative method was used to produce a thematic analysis of findings. Key findings include 1) PCR tests were not widely available in Canada, during the first wave, so many participants lacked a confirmed diagnosis and, subsequently, encountered challenges accessing specialist medical care; 2) Rapidly changing …

Patient Experience In An Interprofessional Collaborative Practice For Underserved Patients With Heart Failure, Connie White-Williams, Maria R. Shirey, Reid Eagleson, Wei Su, Terri Poe, Brittany Fitts, Vera Bittner

Patient Experience Journal

Heart failure is a complex chronic condition that results in multiple patient visits throughout the care continuum. Patient experience has associations with clinical outcomes. The purpose of this study was to examine patient experience among the underserved in a specialized interprofessional collaborative practice heart failure clinic. This prospective study utilized both qualitative and quantitative data to describe the patient experience within an interprofessional collaborative practice. Data were collected from patient experience surveys in 1128 patients seen in the Heart Failure Transitional Care Services for Adults (HRTSA) clinic between January 1, 2018, and December 31, 2021. Interprofessional collaborative practice surveys were …

Listening As Medicine: A Thematic Analysis, Rachel Kishton M.D., Heta Patel, Divya Saini, Jeffrey Millstein M.D., Aaron Levy Ph.D.

Patient Experience Journal

Realizations of the importance of “the art of medicine” in trust-building and patient satisfaction have resulted in the incorporation of narrative medicine programs into training curricula. By learning how to respond to patient stories as well as communicate their own, healthcare providers can ensure that their patients feel heard and respected. This study seeks to define what constitutes empathetic listening through a qualitative analysis of personal narratives collected from patients, caregivers, and providers across an urban academic healthcare system. Stories (n=41) underwent thematic analysis to note common experiences related to listening during a health system encounter. Eighteen grounded codes were …

A Concept Analysis Of The Patient Experience, Tanja Avlijas Rn, Mscn, Janet E. Squires Rn, Phd, Michelle Lalonde Rn, Phd, Chantal Backman Rn, Phd

Patient Experience Journal

Patient experience, an essential indicator of quality patient care, is of increasing importance to hospitals that want to improve and maintain strong patient experience metrics to remain competitive in the business of healthcare. The aim of this study was to clarify the concept of the patient experience by identifying its existing definitions, methods of measurement, and underlying themes and attributes, to differentiate it from similar concepts and propose an operational and theoretical definition to guide valid and reliable development of future assessment tools. Walker and Avant’s eight-step methodology served as the framework for this concept analysis. A literature search, using …

Enhancing Patient-Centered Care For Limited English Proficiency Patients Through Tell Me More®: A Student-Driven Initiative To Explore The Patient As A Person And Develop Students’ Communication Skills, Angela Liu, Alicia W. Leong, Alice Fornari, Taranjeet Kalra Ahuja

Patient Experience Journal

Tell Me More® (TMM) is a medical student-driven initiative to build rapport between patients, students, and the healthcare team through patient interviews and collaboratively created posters. Patients with limited English proficiency (LEP) often experience impaired communication with providers. TMM has the potential to address the loss of patient-centered dialogue in interpreter-mediated communications. In this exploratory pilot study, we aimed to include LEP patients in TMM by using medical interpreter phones (MIPs) at Long Island Jewish Medical Center, Northwell Health. Our objectives were to: (1) evaluate the feasibility of this approach, (2) compare TMM engagement between LEP and English-speaking (ES) patients, …

Non-Covid-19 Hospitalizations: Patients’ Experiences During The Covid-19 Pandemic, Julia Patrick

Patient Experience Journal

The purpose of this Qualitative Descriptive study was to describe the experience of hospitalized adults during the pandemic who did not have COVID-19. Semi-structured interviews were conducted with 20 English-speaking adults who were hospitalized on a medical or surgical floor after April 1, 2020 and were negative for COVID-19 throughout their entire hospital stay. The interview questions focused on the overall hospital experience, the nurse’s role in their experience, comfort needs, and the experience of having comfort needs met during the hospitalization. Conventional content analysis of the transcribed transcripts revealed five main themes related to the hospital experience: I don’t …

Developing A Patient Satisfaction Measure For Imaging-Based Patient Information During Clinical Consultations, Hindrik J.J. Pinkster, Anne M.L. Meesters, Frank F.A. Ijpma, Erik Taal, Joep Kraeima, Peter M. Ten Klooster

Patient Experience Journal

Different types of medical imaging are increasingly being used to explain specific aspects of injuries to patients during consultations. However, there are no validated questionnaires available yet that specifically measure patients’ satisfaction with the use of such images. The objective of this study was to develop and evaluate a patient-centred measure of satisfaction with the use of medical imaging modalities in clinical treatment. A preliminary 22-item version of the Questionnaire for Patient Satisfaction with Imaging (QPSI) was developed based on extant literature and interviews with trauma patients. Final item selection and psychometric evaluations were conducted amongst a sample of 106 …

Patients’ Perceptions And Knowledge Of Source Isolation For Multi-Resistant Organisms In An Australian Metropolitan Hospital: A Bedside Interview With Questionnaire Study, Alison Smith, Gillian Ray-Barruel

Patient Experience Journal

The aim of this study was to explore perceptions and knowledge of source isolation among hospitalised patients colonised or infected with multi-resistant organisms, to identify if information provided and delivery method are helpful and appropriate, and to identify areas for practice improvements. Purposive sampling was conducted. Between November 2019 and January 2020, bedside interviews with structured questionnaires (combining multiple-choice and free-text questions) were conducted with adult in-patients requiring isolation for multi-resistant organisms in a 180-bed metropolitan hospital in Brisbane, Australia. Data analysis included quantifying multiple-choice responses and thematic analysis of free-text responses. Thirty participants completed the interview questionnaire. Lack of …

Going From An Academic Medical Center To A Community Hospital: Patient Experiences With Transfers, Alexander Kazberouk, Nicole Boyd, Sandra Oreper, Michael Chang, James D. Harrison, Priya A. Prasad, Ari Hoffman

Patient Experience Journal

Academic medical centers (AMCs) often operate at or near full capacity, which leads to delays in care while smaller community hospitals may have excess capacity. To address this issue and to match patient needs to care acuity, patients may be transferred from an AMC emergency department for direct admission to a community hospital. We aimed to explore the experiences and perspectives of patients who were transferred. We randomly selected patients transferred between February 2019 and February 2020. We conducted structured thirty-minute interviews containing fixed response and open-ended questions focusing on the transfer rationale and experience, care quality, and patient financial …

Determinants Of Ambulatory Patients’ Satisfaction With Encounter At Core Service Stations In A Tertiary Hospital Of A Developing Country, Ndubuisi Emuka Opurum, Ogaji Samuel Daprim, Felix Emeka Anyiam

Patient Experience Journal

Patients may have different and complex convictions of what their idea of satisfaction is, which may not be addressed regarding what they perceive as satisfaction. Therefore, using the patients’ demographic and clinical characteristics could tailor the individual needs of these patients, hence, providing feedback and recommendations on improvement in services provided. This study examined the determinants of patients’ satisfaction with general outpatient department (GOPD) services of a tertiary hospital in Rivers State, Nigeria. A descriptive cross-sectional study was carried out among new and repeat patients attending the GOPD of the University of Port-Harcourt Teaching Hospital, Rivers State, Nigeria. A structured …

Outpatient Visit Modality And Parallel Patient Satisfaction: A Multi-Site Cohort Analysis Of Telemedicine And In-Person Visits During The Covid-19 Pandemic, Nicole J. Ploog, Jordan Coffey, Laurie Wilshusen, Bart Demaerschalk

Patient Experience Journal

Telemedicine approaches provide many benefits to patients across both primary and specialty care. Patient acceptance is imperative to successful telemedicine implementation. As telemedicine utilization continues to surge, it is imperative that healthcare organizations have a method for evaluating the patient experience with these types of visits. Previous studies on experience with telemedicine have focused on smaller patient populations with narrow inclusion criteria and limited geographical reach. This research described how patients’ satisfaction with video telemedicine-based visits varied based on patient characteristics and how they compare with in-person visits. We obtained and analyzed results from standardized patient experience surveys to compare …

Improving The Accuracy Of Interactive Voice Response (Ivr) Technology For Pediatric Experience Scores, Elizabeth Spaargaren Ms, Mph, Cpxp, Abigail Kozak Mba, Cpxp, Cara Herbener Cpxp, Barbara Lawlor Burke Ma, Cpxp

Patient Experience Journal

The increased use of interactive voice response (IVR) in assessing patient and family experience should be paired with evidence-based practices on how to obtain the most accurate information via this survey mode. We added a brief clarification sentence of the survey scale at the start of the IVR call to improve our experience data both qualitatively and quantitatively. Our setting was an urban pediatric hospital. We gathered lived experiences from our patients, families, and providers to understand and design a change to the IVR survey mode that would reduce survey inaccuracies. Outcome measures were assessed by baseline measurement and post-intervention …

The Impact Of Follow-Up Calls After A Pediatric Emergency Department Visit, Joseph R. Mijares Iii, Sephora Morrison

Patient Experience Journal

Pediatric emergency department (ED) visits can be a stressful time for patients and their caregivers. This high stress environment can lead to questions and needed clarifications post-discharge. We implemented a post-discharge callback system to resolve these concerns for a focused subset of patients who historically have provided the most negative comment feedback on ED patient experience surveys. We hypothesized that comment types would shift to more positive than negative and the themes of the comments received would change. We developed a discharge callback process that focused on patients who were triaged as ESI level 4 during their emergency department visit. …