Introduction

The Emergency Department is designed for the care of outpatients at risk of immediate complications or death. Therefore, most of the care required in public hospitals is provided and funded, in whole or in part, by the State. However, for many years, this service has been characterized by a high user demand, which has affected the quality of care and, consequently, has led to the search for different management strategies. Such information shows the importance of a continuous analysis, given the persistence of deficiencies that are reflected in outpatient satisfaction ¹.

Regarding outpatients’ high demand for health care in the Emergency Department, several causes whose clinical situation is not necessarily a serious one have been identified. Regardless of the cause, most of its consequences refer to a longer waiting time and dissatisfaction. Several studies evaluate admission, flow or discharge strategies to distinguish which one is appropriate to counteract this problem. One flow strategy is the implementation of an office in the Emergency Department aimed at providing medical care to outpatients with minor emergencies or priority levels III, IV and V, according to the Emergency Severity Index (ESI) ².

A management strategy in search for the best quality of care must undergo a periodic evaluation that justifies, modifies or eliminates it, based on meeting the objectives of the health managers involved. At the international level, the implementation of an office for stable patients who highly demand medical care has been simulated in order to reduce the flow of outpatients ³. In addition, it has been pointed out that the creation of an office is one of the strategies to improve the quality of care in the emergency department of high-complexity health centers since it improved the waiting time and the flow of patients ⁴.

On the other hand, several studies show that there is a large gap between this problem in the quality of care and patient satisfaction ⁵. With the aim of optimizing medical care, in 2016, the Seguro Social de Salud del Perú (EsSalud, Social Health Insurance of Peru) implemented an immediate

care office in the emergency departments of its health care institutions ^6,7. However, public hospitals have not yet implemented this type of office, with the exception of Hospital María Auxiliadora since 2021, so no related studies have been conducted. For this reason, this research aims to determine the effectiveness of the implementation of the Immediate Care Office as a new quality management strategy in the Emergency Department of a public hospital in Lima, Peru.

Materials and methods

Results

Satisfaction of the Immediate Care Office outpatients

Out of the 169 outpatients administered the modified SERVQUAL questionnaire, 95 (56.21 %) were satisfied while 74 (43.79 %) were dissatisfied with the care received. The dimension with the highest satisfaction score was empathy, with 129 people (76.33 %), and the dimension with the lowest satisfaction score was reliability, with 82 people (48.52 %) (Figure 1).

Figure 1 Satisfaction of outpatients of the Immediate Care Office according to the dimensions of quality 

Source: self-elaboration based on the results of the modified SERVQUAL questionnaire administered to patients of the Immediate Care Office of Hospital María Auxiliadora. Waiting time and outpatient satisfaction

Spearman’s rho correlation coefficient showed a Sig. (2-tailed) value < 0.05 with 0.00, which indicates a relationship between both variables. In addition, a rho of -0.39 was identified, which adds an inverse relationship between them. In other words, the longer the waiting time for medical care, the lower the outpatient satisfaction (Table 4).

Table 4 Relationship between waiting time and outpatient satisfaction at the Immediate Care Office of Hospital María Auxiliadora 

			Waiting time	Outpatient satisfaction
		Correlation coefficient	1	-0.39**
Spearman’s rho	Waiting time	Sig. (2-tailed)		0
		N	169	169
		Correlation coefficient	-0.39**	1
	Outpatient satisfaction	Sig. (2-tailed)	0	.
		N	169	169

** Correlation is significant at the 0.01 level (2-tailed).

Source: self-elaboration based on the results of the modified SERVQUAL questionnaire administered to outpatients of the Immediate Care Office of Hospital María Auxiliadora.

Discussion

Two aspects that should be taken into account in the quality of care at the Emergency Department is waiting time and outpatient satisfaction, so their analysis is important for the choice of strategies. This agrees with a study on emergency and urgent care services, which points out that the improvement in the care of outpatients should be handled according to the problems identified in the health service ⁸.

The characteristics of the outpatients treated at the Emergency Department showed that the female sex prevailed. This result is similar to that of a study carried out in the emergency department of an EsSalud hospital, where females accounted for 51.61 % ⁹; a study conducted in Costa Rica on trends in the emergency department that revealed 54.91 % ¹⁰; a study focused on emergency department overcrowding, with 57.00 % ¹¹; and a study of the characteristics of non-critical care in an emergency department, with 65.83 % ¹².

The characteristic that disagrees with the results of some studies is the age range. The present study identified the 14-to-29-year age range as the predominant one; however, others, such as that of Rodríguez-Páez, in Colombia, found a predominance in the 15-to-44-year age range, with 57.00 % ¹³; Correa-Betancour, in Chile, in the 20-to-44-year age range, with 72.40 % ¹⁴; TaypeWaldo, in Peru, in those over 60 years, with 55.02 % ⁽¹⁵); and González-Peredo, in Spain, in the 31-to-50-year age range and those over 65 years ¹⁶.

On the other hand, priority level IV prevailed in this study. According to another research, such priority level is one of the most frequently found in emergency departments of high-complexity health centers ¹⁷ and patients with that priority level are frequently referred to the Internal Medicine area ¹⁸. This trend is consistent with other similar studies such as the one conducted in Chile, where less severe levels are also predominant ¹⁹; however, there is an opposite result in a study carried out in Colombia, where priority level II stands out ²⁰.

A study carried out in Ecuador on the analysis of quality management states that 60 % of outpatients disagree with the waiting time, so this should be taken into account for decision-making ²¹. Thus, the implementation of an adequate strategy improves waiting time ²² and outpatient satisfaction ²³. However, other studies, such as that of Suárez-Lima in Ecuador, indicate a high percentage of dissatisfaction despite a considerable waiting time ²⁴. On the other hand, Ayuzo-del Valle considers the choice of updated strategies as a necessary measure of health services management with emphasis on emergency department ²⁵.

Outpatient satisfaction is considered a measure of quality control ^26,27 and the questionnaire validated by MINSA and used in hospitals is the modified SERVQUAL questionnaire ²⁸. Out of the five dimensions evaluated in this study, empathy prevails; this result is similar to that of Piedra-Valoy ²⁹, where it accounts for 91.94 % of satisfaction, but opposite to that of Boada-Niño ³⁰, who states that reliability, with 84.75 %, is one of the dimensions with the highest satisfaction score. On the contrary, the present study identifies reliability as the dimension with the lowest satisfaction score, with 48.52 %.

One limitation of this research is that the modified SERVQUAL questionnaire was only administered to the group treated at the Emergency Department after the implementation of the Immediate Care Office due to issues with the granting of research permissions by the Hospital. Therefore, the results are limited to the satisfaction of a group of outpatients after the implementation of a quality management strategy and are not compared with the satisfaction of the group that did not underwent such implementation. It is recommended to conduct similar studies in other public hospitals considering these data before the implementation of a strategy such as this one in order to achieve a more complete analysis of its effectiveness.

In conclusion, the implementation of the Immediate Care Office as a new quality management strategy had better results in the waiting time. Consequently, it showed an association with outpatient satisfaction, as well as satisfaction in the five dimensions of quality of care. These results support the analysis of the implementation of strategies for improving medical care in the different highcomplexity health centers.