Abstract

The research revolves around the culture of emergency department. Hospital emergency departments make a distinctive subculture inside the healthcare, in an atmosphere of social interaction and variation. Every organization can create its own values. Hospitals or other primary care centers having emergency departments usually. Initially, the emergency room was planned as a treatment room for emergency cases such as road accident cases or other acute conditions in which life is on risk. This department later specialized in the treatment of emergency cases which were presented with no consultation, by an emergency vehicle or any transport available at that time. It was taken place in the Emergency department of Tehsil Headquarter Hospital Pind Dadan Khan. The patients were interviewed regarding their experience, their time of arrival, the medical personnel who received them and their satisfaction level with the provided treatment and care. The other method which was used is participant as observer. The most consistently observed finding associated with higher levels of satisfaction, was the patient-oriented care provided by doctors, nurses and paramedic staff. Doctors and nurses who spent more time with the patient, had better communication skills, showed more empathy and treated the patients within 5 minutes of arrival in the emergency resulted in more patient satisfaction. On the basis of these characteristics, the calculated number of satisfied patients turned was more than the patients who were not satisfied. However, major emergency patients responded that they would not prefer emergency departments of public sector hospitals of Tehsil Pind Dadan Khan for future because major emergency services were not available.

Key Words

Emergency Department, Health Care, Patient Satisfaction, Social Interaction

Introduction

Introduction

The research about the culture of emergency department. Worrying conditions, patient centered care, social gaps in a department, stress to perform, teamwork and keeping the work life balance is observed to contribute in the current works on medical anthropology. Hospitals or other primary care centers having emergency departments usually. Initially, the emergency room was planned as a treatment room for emergency cases such as road accident cases or other acute conditions in which life is on risk. This department later specialized in the treatment of emergency cases which were presented with no consultation, by an emergency vehicle or any transport available at that time. 

The emergency room is a zone of a medical clinic particularly arranged and staffed for emergency or trauma care administration, prevalently called emergency or crisis room. A crisis is expressed as a circumstance that represents an impending danger to human life, property, or condition. Crisis Division (ED) the primary known utilization of crisis room was in 1886 and crisis room is characterized as an emergency clinic room or territory staffed and prepared for the gathering and treatment of people requiring prompt medicinal consideration. ‘There is little uncertainty that medicinal services suppliers have adverse mentalities toward patients, and that such frames of mind have harming complications for treatment, a few specialists and attendants do not give careful attention toward genuine cases of emergency that is the reason individuals have bad understanding and negative impact’ (Torrens & Yedvab, 1970). 

Hospital emergency departments play a growing role in the Pakistan health care system, accounting for a rising proportion of hospital admissions and serving increasingly as an advanced diagnostic centre for primary care physicians. Significance of study main purpose was to hear about the condition of small level hospital and their emergency department culture. That study reveals the hurdles of Tehsil Headquarter Hospital Pind Dadan khan. Mostly this study helps to overcome the problems of public who were badly injured and do not come up with their life and failed the battle of their life due to no trauma centre there. The problems of the rural area reach to the government. Things in the future can be improved. During the research many things also improved in emergency department. By studying culture of emergency department better understand the problems of the people of Pind Dadan Khan. 

In latest years, health education professionals looked for methods to expand human behaviours, social psychological assessment with methods that concentrate in human behaviour’s cultural and social context. Examples from the Caribbean and South Africa explored the value of the thick description approach borrowed from anthropology. It showed that an anthropological method has much to give to understand human behaviour as a foundation for noise measures. However, while an anthropological approach offers valuable baselines for measures its wide scope goes beyond traditional health educational goals (changing health beliefs, health counselling). Interventions are not intended to inform individuals but to improve cultures. The conceivable connection between how very much educated the patients are on present in the ED and their general satisfaction with consideration is of significance in emergency drug. Good relation with the doctor plays very important role. Past examinations have assessed this relationship reflectively, and there seems, by all accounts, to be a positive connection (Trout, Magnusson, & Hedges, 2000). 

In emergency department around 33% of the visits were observed to be non-emergency.Most people in the medicine and public health sectors do not know the prospective part that anthropology can perform in public health policy growth. The purpose of that article was to give the audience knowledge of the unique view that medical anthropology can help inform public health policy decisions.Over the previous half-century socio-cultural anthropology has experienced major conceptual and pragmatic modifications. Anthropology was mocked as a discipline for its position in colonial warfare. Anthropologists often followed colonial farmers and soldiers during colonial times in attempt to promote their job this is often related to the context of anthropology as the handmaiden age.

It is said that anthropologists acquired the confidence of natives in this position by using their linguistic skills and social consciousness to help the colonial state in implementing measures that eventually contributed to further oppression and disempowerment.“Health professionals need social understanding and cross-cultural communication skills because education facilities are more efficient when they respond to cultural requirements” (Winkelman, 2008).Wounds are in charge of roughly 10% of the worldwide weight of infection. Universally, the main sources of death from wounds are street traffic wounds, falls, suffocating, and poisoning cases. In 2013, about 1.4 million individuals kicked the bucket due to RTIs, and 88% of these fatalities happened in low-and center salary nations. Another a large portion of a million kicked the bucket from fall wounds around the same time, likewise over whelming (Rahwan, Ramchurn, Jennings, & Giovannucci, 2009).

Review of Literature

The medical clinic emergency room is essential consideration division which is in charge of early consideration the executives of patient with broad range of wounds and ailment. An understudy was to watch the environment and casual activities which was happen in emergency division. According to Alanazi (2012), the primary thing which was seen in the emergency clinic is rushing about wherever in the medical clinic. A large portion of the wounds which was found in the crisis office go from a little paper cut, hit a run mishap, fire unfortunate casualties, youngster misuse, viciousness, obliteration and suicide. Some specialist or staff part organize test for individuals who is casualty of wounds. Specialist, medical caretakers, doctor, specialist and supporter checking persistent with the assistance of stethoscope heart rhythm and respiratory framework checked.

Beland, Lemay, Philiber, Maheux, & Gravel (1991), said that when you lean toward your way of life, you just addition the huge increment in patient and center fulfillment, yet in addition measure the quality and execution of the whole board. The positive effect of the developing fulfillment of the specialist cooperation can't keep the expense of transformation of an important provider. An acceptable provider has a mind overwhelming impact that addresses the most essential part of the disaster area, from open mindfulness and cerebrum involvement in patient consideration and general support guidelines. In that paper, we center around the essential components required to build up a solid emergency division culture. Regardless of whether you know about it or not, your crisis division as of now includes a one-of-a-kind subculture inside your association. It might be certain and agreeable, or it might have some broken. Your crisis office's way of life is the entirety of its authority, basic beliefs, mentalities, and practices, and it is impacted by the condition your group works in every day, the manner in which they speak with every individual they interface with, and how drawn in and by and by put they are in the achievement of the crisis office and emergency clinic.

Methodology

Researchers design their methodologies to extract data. The purpose behind clear research was the expose of the happenings as existing at present. Descriptive methodology is used by researcher to explain the details about locale, significance of the locale. According to shuttle worth methodology is basically descriptive and it is defined as the method through which behavior of subject and observation is described according to scientific method without manipulating it (Shuttleworth, 2008). Generally descriptive methodology is to define the problem in simple words or to identify it. Participant observation and interview is involved in descriptive research. It is not based on statistics because it’s mainly focusses on the qualitative data and less quantitative data. The main theme of descriptive research is to explain the hypothesis and objective of research and to qualify the hypothesis and objectives. Interview schedule was used to gather data and information. The data was collected on field diaries and notes which was after noted down on the Microsoft word and analyzed in SPSS Statistical Package for Social Sciences.

In methodology, the researcher decides the tools according to procedures and technique. For collecting the data tools are designed. In this case participant as observer, questionnaire, interview guide and case study check list designed for gaining information. Methods clearly defined the accurate description of the study. Methods describe the materials which were used in the study (Kallet, 2004). The methods define the all methods which were used in the research. The Study Designis descriptive in public hospital. It was taken place in the Emergency department of Tehsil Headquarter Hospital Pind Dadan Khan. Duration of study was carried out within time period of 90 days.

The Sample SizeIn this research depends upon the population of Tehsil Headquarter Hospital Pind Dadan Khan. And sample was overall emergency department and their wards which were specific for emergency patients. Purposive sampling technique was used. Some while convenience sampling was used. According to Black (2010), Purposive sampling is a non-probability sampling method and it occurs when components choose for the samples are picked by the judgment of the researcher. Scientists regularly trust that they can acquire an agent test by utilizing a sound judgment, which will bring about sparing time and cash. A real sample was the total population of emergency who visited in the timing of field work.Data was collected from the emergency department of THQ Hospital Pind Dadan Khan, Jhelum. Data was collected from patients and doctors. Medication information was taken from pharmacist of hospital and there uses info from doctors. 

The data of this study is collected from 42 emergency patients by using interview schedule covering different dimensions of satisfaction the patients visiting the ED in tehsil headquarter hospital were interviewed regarding their experience, their time of arrival, the medical personnel who received them and their satisfaction level with the provided treatment and care. Second method which was used is participant as observer. Patient overall level of satisfaction is treated as dependent variable, while dimensions of satisfaction are each treated as independent variables.

Patients from both genders were enrolled who gave consent to participate in the studies with female count of 36 and male of 6. In a single day almost 10-15 patients were followed in the department of emergency. That patients were observed. and those patients who were able to give interview then interview were taken from them. When they admitted into the wards of emergency department.  They were interviewed in the form of interview schedule that were close ended prepared with the help of supervisor.

Results

Emergency department culture was the single most influential factor on emergency department performance. Culture impacts any number of emergency department challenges, ranging from nursing-physician staff conflict and dysfunctional team dynamics to high turnover, poor patient experience, operational inefficiency, and negative community reputation. By developing medical director to embrace positive, service-driven core values, attitudes, and behaviors, and engaging your clinical team in embracing this philosophy as well, it can lay the foundation for transformative, performance-impacting change in emergency department.




Monthly Participant Observation (Diagnosis Observations)

1439 total patients of the month in the emergency department in case of emergency given below:

• 54 patients of (ARI) Acute respiratory infection Acute respiratory tract infection includes upper respiratory infection and lower tract infection that is related to airways (Jamison DT, 2006).

• 06 patients of Asthma (Asthma is a disease in which airways narrow and swell)

• 347 patients of (APD) Acid peptic disease

• 02 patients of (OAD) Obstructive airways disease

• 02 patients of (IHD) Ischemic heart disease

• 24 patients of (PUO) Pyrexia unknown origin

• 150 patients of (HTN) Hypertension

• 28 patients of (DM) Diabetes mellitus

• 204 patients of (RTA) Roadside traffic accident

• 01 patient of Burn case

• 27 patients of Dog bite

• 01 patient of Snake bite

• 47 patients of (GE) Gastrointeritis

• 32 patients Refer to Tertiary care hospital

• 86 patients of ECG Electrocardiogram

• 01 patient of (PMR) Post mortum report

• 22 patients of (MLR) Medico legal report

• 25 (TB) Tuberclosis




Medical Specialist

Medical specialists are backbone of hospital. They play very important role in the hospital. When a medical officer did not handle the case then medical specialist can handle it with their efficiency of work. Medical specialists were specialist in their one field due to advanced studies and handled situation very wisely. Medical specialist was experienced and already known about the situation which brought to the hospital. Their presences make hospital more efficient and advanced. Most of the patients who are in critical condition can be better overcome from disease and critical situation of their health. In tehsil head quarter hospital Pind Dadan khan there was no medical specialists who were there to serve emergency department and patients who are in critical condition.




Surgical Specialist

Surgical specialist are those doctors who done their higher studies in the surgery and can handled operations very well. They play very important role in hospital organization. Surgical specialists are of many types such as orthopedic surgeon who was in bone binding specialist. Cardiologists who were specialized heart surgeon. Cardiologist helps patient to treat the diseases of heart. There is no surgical specialist in tehsil headquarter hospital Pind Dadan Khan for surgical procedure or any small surgical procedures.




Gynecologist or Obstetrician

Gynecologists are those who helped female patient to check their reproductive health. There is Gynecologist type which called obstetrician. Obstetrician who was specialized in pregnant women health and birth of child. There was no gynecologist in tehsil headquarter hospital Pind Dadan Khan for labor cases only simple spontaneous vaginal delivery was available there. Major cases of labor are referred to District headquarter of Jhelum, Sargodha or Rawalpindi.




Anesthesiologist

Anesthesiologist specialized in anesthesia before operation of any kind. Anesthesiologist play very important role because they know about the veins and arteries pattern in the human body.  There was no anesthetist in tehsil headquarter hospital Pind Dadan Khan who had for serving patients before surgery or any minor major injury.




Child Specialist

There was no child specialist found in tehsil headquarter Pind Dadan Khan. There was a diploma holder in child health (DCH) who was considered as child specialist in tehsil Pind Dadan Khan. But according to standard it was not considered as child specialist by any definition.




Operation Theater (OT)

In tehsil headquarter an operation theater (OT) was found but mostly it was closed and locked. From more than 7 months OT was closed and gynecologist left the hospital due to OT was not working and lack of facilities there. No C-section for labor due to lack of gynecologist.




Blood Bank and Pathology Lab

There was no blood bank in THQ hospital pind dadan khan. A pathology lab was present there but its condition was as pathetic as you can imagine it to be. A severely lack of blood patient (Anemia) test results have 13 Hb in that pathology lab. That was the worst condition of hospital and their lab. Overall lab facility was only available in morning shift. Otherwise, no facility was available there.




X-ray Facility

There was no facility of x-ray in morning shift though it was available after 2pm which was also on call basis.

There was ultrasound facility available but mostly of the machines out of order due to lack of maintenance.




Intensive Care Unit

There was one ICU room available there. Intensive care unit was completely closed due to lack of facilities and lack of staff also. In Tehsil headquarter hospital Pind Dadan Khan medical emergency management was poor.




Emergency Medicine or Lifesaving Drugs

Streptokinase medicine which was used in myocardial infraction and heart attack to breakdown clots of blood. That medicine was not available there. Mostly myocardial infraction patients are referred after taking ECG and giving angisid, loprin and lowplast.




Distance for Referred Patients

From tehsil Pind Dadan Khan, district headquarter Jhelum is 150 to 180 minutes away. Secondly district headquarter (DHQ) Sargodha is 2 to 2.5 hour away and thirdly Rawalpindi which is 3 hours away. Few or none of myocardial infraction patient survive while mostly fail the battle of life on their way to district headquarter. In hospital if streptokinase was available then due to lack of staff to run ICU and manage myocardial infraction. For emergency patients other than myocardial infraction such as head injuries and road side traffic accident there was no specific facilities available.




Labor Room

In labor room only SVD (Spontaneous vaginal delivery) and DNC dilation and curettage were available. DNC in which a tissue was removed from uterus to treat heavy bleeding. Other than that, condition all patients of labor referred to DHQ. There was no surgical emergency available there.




Lack of Staff

In tehsil headquarter hospital Pind Dadan Khan because of central induction policy now a day many medical officers are accessible in emergency department but lack of staff nurses, dispenser and other staff members for hospital.

In THQ Hospital Pind Dadan Khan had only 4 dispenser and 8 to 10 number of nurse’s staff for overall THQ hospital. Only one nurse was available for evening shift which served 3 wards (male, female and children) which was usually consist of 55 beds at a time. Due to shortage of staff senior ward servant serve emergency department as a dispenser. In emergency department there was only one doctor, one dispenser and one ward servant were only there in their duty timings.

Due to lack of staff in tehsil headquarter hospital Pind Dadan Khan taking a one-day leave was tough due to no replacement of other staff member. There was no security guard in the hospital even a single man was not there to protect all the hospital. Mostly doctors did not stay here for long due to abuse and threats to doctors and staff in daily routine. In Pakistan mostly frustration and anger over lack of quality healthcare and steady work is released on the doctors who was on duty work. All doctors were worked there without any security guard. Many staff such as nurses who joined THQ, they serve for 2-3 months after that they left for the reason that THQ hospital does not facilitate them. 




Alternate Use of Medicine

Major essential medicine was not available in pharmacy of THQ hospital Pind Dadan Khan Tab cefixime and injection ceftriaxone was used there to treat all type of infection there except the whole world.







Employs Facilities

In THQ Hospital Pind Dadan Khan hospital housing was for the doctors. Others staff members was severe issue that is why nobody was willing to serve the hospital for long time. Houses which were for doctors and nurses was built in 1970s and never renovated and their condition is not good to live there. Elite class employee refuse to live in that houses because of their bad condition. There were no incentives that attract a doctor or other staff member to serve at THQ hospital Pind Dadan Khan after leaving big city. A consultant who was studied for ten years why they join THQ in that pitiable condition.




Ambulance Facility

Ambulance facility was available from rescue who has only two ambulance for emergency referral. Those two

ambulances were for whole 3 -4 lakh population of Pind Dadan khan. Mostly people of Pind Dadan Khan lived

below the poverty line.




Table 1. Gender Distribution of Emergency Patients

Gender	Frequency	Percent
Male	11	26.2
Female	31	73.8
Total	42	100.0

 

According to overall data of respondent from emergency department male patients was twenty six percent and female patient was seventy three percent. The percentage of female was more due to mostly admitted patient were female. Male patients were mostly referred due to road side traffic accidents.

 

Table 2. Age Distribution According to Generalized Emergency or Disease

Respondent	Frequency	Percent
0 to 15 years	6	14.3
16 to 30 years	18	42.9
31 to 45 years	6	14.3
46 to 60 years	9	21.4
Other	3	7.1
Total	42	100.0

 

The age of respondent in emergency department vary from one another. Forty three percent of respondent were belonging from age of 16-30 years. The percentage of that age group large than all groups due to cases of diarrhea patients in those days due to less cleanliness and outside food. The second reason which was behind that age group is mostly road side traffic accident of peak age group due to over speeding or recklessness. In this age group two cases of road side traffic accident which had minor injuries. Severe injured patient of road side traffic accidents was referred after giving them basic protocol which was available there.

Three patients of typhoid in that age group they were in very serious condition. They were admitted in outdoor patient department wards. There were proper cares for them in wards. Two patients of hypertension in which one case was due to tension and other one related to intake of high sodium chloride diet. Two patients were of severe body allergic reaction. In which their body was fully swelled and they did not able to move due to swelling in body and feet’s. One allergic patient did not improve by the medicine of allergic reaction. Then that case was referred after two days of admission. Two cases were of diarrhea in that age group.

In which patients badly suffer from vomiting and loose motion. Due to that situation their body dehydrated and blood pressure down. They were admitted in emergency ward. One patient was of acute teeth pain doctor dealt with it. One patient was of ear bleeding due to some medicine reaction and that cause high blood pressure and damaged her ear drum which can cause bleeding. After checkup and situation patient situation can overcome due to presence of ENT specialist there. One patient was of urinary tract infection which was also easily dealt by the medical officer in gynecologist ward.

One patient of myocardial infraction in which its basic protocols fulfilled then that case was referred to Rawalpindi. Last case of that age group was poisoning case in which medico legal report action should be taken but it was resolved by family members. Poisoning case was handled by emergency duty doctor they fulfill the protocols of medication such as bottle which include fluids that helps to wash stomach. If poisoning case was not reported within two hours then it also causes death. Twenty one percent respondent were belonging from 46-60 years. In that age group respondent were belong to different cases. One patient was of severe knee and joint pain. Then doctor recommended him to test uric acid from outside lab then their treatment was done in hospital after test report. Test facility was not available inside the hospital. The facility of test which was available there, were also not working there.

Two patients of hepatitis C were in emergency department. One patient was near the recovery of hepatitis C due to care and proper treatment. The other patient of Hepatitis C was in very serious condition their health was very sick and did not eat properly. Due to age of higher group, they slowly recover because of weakness. Both patients were admitted in emergency ward after 2 hours they shifted in outdoor patient department wards. One patient of stomach pain and her body swelled. The patient of stomach issue was referred to gastroenteritis specialist in OPD then that patient was treated under the custody of specialist. That patient was also admitted in ward.

One patient of paralysis attack in which her lower jaw free. Mouth did not close due to lower jaw free. Firstly, when patient came into emergency then their jaw was closed by doctors with dressing and after prescription, she was admitted in emergency ward under observation. She did not able to eat anything then bottle include some injections given to her. One patient of road side traffic accident which had minor injuries but due to that age group they recover slowly. That case was easily handled by doctors. One patient was of typhoid fever.  In which they were given prescription of medicine and admitted to OPD ward. One patient of medico legal report due to their serious condition referred to Rawalpindi. First, he was checked after that situation not handled. One case was of hypertension in which the patient brought dead to the emergency department.

Fourteen percent respondents were belonging from 31-45 years. One patient was of acidity. She had stomach pain and burning sensation in heart. One patient was of heavy bleeding in periods. One patient was of severe kidney pain. One patient was of anemia. One patient was of joint pain. One patient was of acid peptic disease and lastly one patient was of hypertension.

Fourteen percent respondents were belonging from 1-15 years. In that scenario 3 cases were off diarrhea. They eat something from outside that can cause bacterial infection. Due to diarrhea, they were dehydrated due to vomiting and loose motion. Weakness can cause health issue and dehydration was fulfilled by giving proper medicine. Diarrhea patients admitted in OPD wards. One patient was off respiratory tract infection in which their breathing process disturb. He felt difficulty in breathing. When breathing stop then the symptom was related to death due to that reason patient became more distress. One patient was of dog bite. He was passing from fields and a dog can bite him. After that he came to emergency department with his big brother on the bike then he checked up from emergency room. Then doctor give him prescription and paramedical staff given him injection. One patient was of acid peptic disease.

Only seven percent of respondent were belonging to age group 61 plus. One patient was of typhoid in which he was suffering from cold, flu and full body pains. One patient was off bone fracture she was suffering from back pain and she had vertebral disc issue. One patient was off hypertension. In which his blood pressure shoots and ECG was not normal.

 

	Frequency	Percent
By Car	2	4.8
By taxi	1	2.4
OnPublic transport	13	31.0
Other	21	50.0
In an ambulance	5	11.9
Total	42	100.0

Table 3. Mode of Transportation Emergency Department

 

According to emergency respondent’s fifty percent emergency patients traveled to emergency department by the means of motorcycle and rhiksaw. That was due to shortage of ambulance and due to poor people in that area who has no major resources. Mostly people lived there under the poverty line. One reason was also that lack of awareness there. Only two ambulances were available for too much large population of tehsil Pind Dadan Khan and nearby villages which include sixteen union councils. Thirty percent of emergency patients travel to emergency by the means of public transport. Twelve percent of emergency patients traveled to emergency by means of ambulance of rescue 1122. They approach to ambulance by calling on its number. Ambulance reaches to them in 5 minutes. 5 percent of emergency patients reach there by car. Those categories include elite class. Three percent of patients who used taxi or any other car to reached in emergency.

 

Table 4. Waiting Time for Emergency Patients

	Frequency	Percent%
0-15 Minutes	28	66.7
16-30 minutes	8	19.0
More than 30 minutes	6	14.3
Total	42	100

Anova

Analysis of variance was used to find the means of the all groups are equal. Equal variance between groups can be checked by using homogeneity of variance. The hypothesis can be checked by homogeneity of variance.

H0: is equals to there are no differences among two or more variance

H1: is equals to there are differences among two or more variance

When level of significance is less than 0.050 then H0 disallowed or rejected while H1 is approved or supported. While when we conducting ANOVA equal variance is supposed, consequently if homogeneity is destroyed then welch t test is used while I used one-way anova in which means of different compared. The purpose of the study was to study the satisfaction level of patients among doctors. Descriptive study allowed to determining the mean of the independent variable such as patient level of satisfaction and the dependent variable doctor checked the patient. After testing one-way ANOVA to analyze the data according to satisfaction level. The results of my findings on data were significant, results were strong, allowing to rejecting the null hypothesis. After results I indicate that there are statistically significant results on the satisfaction of patients on doctors who were treated in the hospital. Mean of the yes indicates larger value than the means of no and yes to some extent options.

 

Descriptive Statistics

Table 5. Descriptive Statistics on Satisfaction Level of Emergency Patients

Descriptive	N	Mean	Std. Deviation	Std. Error	Minimum	Maximum
Satisfaction level of patients
Yes	25	19.9600	10.44222	2.08844	4.00	42.00
No	26	9.8077	10.37697	2.03509	.00	35.00
Yes, to some extent	26	10.4231	8.54715	1.67623	.00	28.00
Total	77	13.3117	10.74619	1.22464	.00	42.00

 

Table 6. Significance of Satisfaction Level

	Sum of Squares	df	Mean Square	F	Sig.
Between Groups	1641.175	2	820.587	8.510	.000
Within Groups	7135.345	74	96.424
Total	8776.519	76

 

The probability is less than 0.05 proved that null hypothesis was rejected and alternative hypothesis is accepted. There were numerous motivations to think about patient satisfaction as an essential objective in the Emergency Department. Fulfilled(satisfied) patients were bound to agreement with treatment, in this manner, their affluence improved. Fulfilled patients are additionally less inclined to guarantee risk (Younesian, Shirvani, & Tabatabaey, 2018). Variables influencing patient satisfaction were of various types. Such as time given to the patient. Attention given to the patient made them more satisfied. A portion of these components indeed, even contradict what parental statistics see as best clinical practice. The relatives which were with the patient of emergency department were more satisfied than the patient own self. Subsequently, one must admit that patients were not the best assessors of clinical quality or treatment which was done with them during the visit of emergency department.

 

Table 7. Represent the Overall Care Received in Emergency Department

Care received	Frequency	Percent
Excellent	8	19.0
Good	22	52.4
Fair	10	23.8
Don’t know	2	4.8
Total	42	100.0

Discussion

The specialist understanding with the patient’s relationship was a key driver of clinical results both in advancing wanted outcomes and in prevention unfriendly results. A viable specialist quiet relationship includes the two gatherings in co-making a working relationship that is dependable, compelling, and tough. The specialist persistent relationship in the general emergency clinic has a few one-of-a-kind highlights, including restricted security, the exchange of restorative and mental sickness, and the interaction of connections among the therapist, the patient, and the therapeutic or careful group. 

The relationship advances great results by making an enabled, drew in, and dynamic organization with patients who feel heard and precisely comprehended by their doctors. Fruitful connections expect doctors to rehearse an inviting position, participatory basic leadership, and care about both the patient's and the doctor's inward lives. Particularly in psychiatry, the doctor must comprehend and identify with the patient all in all individual, which requires both exact finding and detailing, mixing organic, social, mental, and otherworldly points of view. Struggle is an inescapable part of terrifically significant connections and, appropriately oversaw, can develop and reinforce them. In the specialist understanding relationship, strife can emerge from numerous sources and can either crash the relationship or give a chance to improve correspondence, collusion, and responsibility.

Patient fulfillment is viewed as one of the significant quality indicators at the emergency department. Estimation of persistent fulfillment stands ready to play an undeniably significant job in the developing push toward responsibility among social insurance suppliers. The crisis division (ED) has turned into the clinic’s front entryway, presently representing the greater part of all confirmations in the United States. This has set significant strain on numerous offices, with the expanding interest for administration quite a bit of it improper to the site of consideration prompting long holding up times, swarmed conditions, loading up patients in hallways, increased emergency vehicle redirections, and exceedingly factor care and results. But Pakistan is not as like United States that’s why the standard was not as per requirement.

Because of the way that the emergency department is a remarkable division among other therapeutic consideration administrations, intellectual capacity of the components influencing understanding satisfaction of patient is basic everywhere. Our discoveries likewise shown that there is an affiliation among fulfillment and being the patients relative, instructive level, time of affirmation (arrival at the emergency department) and occupant region (village or city). Not with standing, further examination uncovers that aside from the interviewees themselves (patients or their relatives) and their instructive foundations as two components, there was no important relationship between other variables and fulfillment. Patients relatives were progressively happy with the emergency department visit for patient than the patients themselves were, and the patient fulfillment level was lower in those with higher instructive levels. Time of confirmation, sexual orientation distinction and spot of living arrangement had no significant connection with fulfillment level. Patients who visited the crisis division between 2:00 p.m. furthermore, 8:00 p.m. they had given more time due to less severity of patients crowding. Then the patients of afternoon visit were more satisfied than morning patients. Detailed higher fulfillment than the individuals who visited in the first part of the day or medium-term hours, there was no important factual contrast among various occasions of the day.

Staff designs, tolerant volume and seriousness of the patient conditions may play a huge part in these distinctions in satisfaction of the patients. In the night hours, holding up times might be on the ascent as patient volumes have expanded during the day. Factors such as, age and sexual orientation do not profoundly affect fulfillment level. It additionally demonstrates that an affiliation exists between patient’s fulfillment and the regard they get from doctors and medical caretakers during stay in emergency department. Reliable with other research, the outcomes showed that patient sex does not substantially impact. Emergency department quiet meet the fulfillment level. The discoveries of that research uncovered that the normal time a patient held on to be seen by a specialist or an inhabitant in crisis medication was less than fifteen minutes. There was a relationship with fulfillment level; the individuals who paused longer were less fulfilled.

In spite of the fact that the ability of medicinal services suppliers and their cordiality and politeness are significant factors in persistent fulfillment, exertion should concentrate on shortening the holding up times just as improving patients' recognitions about holding up in the emergency department. While longer pausing times expanded patient disappointment, it was not known regardless of whether contrasts in holding up time reflected real contrasts in clinical quality. Tolerant impression of crisis office care quality was likewise much lower than view of consideration quality at other walking care suppliers, notwithstanding for patients with comparative holding up times (Soleimanpour, et al., 2011). Our investigation demonstrates that acute infected patients were happier with give most astounding need to the sentiment of being welcome, staff politeness regard, and the conceivability of data. Holding up time was bound to be viewed as satisfactory when consistent data is gotten, while composed data had low need. Patients who were associated with their treatment were bound to feel certain that the fitting treatment is given. Certainty at release increments with the length of affirmation, and was related with inclination all around educated about further plans, significant indications and contact people. Certainty was likewise upgraded by satisfactory data and staff cordiality what more, regard (Norgaard, Matzen, Groot, Nielsen, & Mollerup, 2013). 

Conclusion and Recommendations

People of Pind Dadan khan are in very worst condition due to lack of emergency facilities. Mostly referred patient died due to no emergency major facilities were not there. Specialist doctors were not there. There is too much political interference in the hospital. Lack of security in the hospital. Pakistan is developing nation which have increased risk of diseases that needs emergency system to be improved especially on tehsil level. Mostly death of patients was related to road traffic accidents. To overcome this problem, public knowledge needs to be increase. Traffic laws obey by the people strictly. 

From the above discussion it is clear that the public hospital of tehsil Pind Dadan khan is in good condition according to structure and building while facilities not fulfilled. The public hospital of Tehsil Pind Dadan khan has emergency department while emergency services are available in minor quantities. Major emergency services not available such as trauma center, blood bank, Intensive care unit has to be properly furnished. New staff hired to fulfill the vacant seats and to run basic health care unit. Pathology labs should be improved.

Main issue is that the emergency management staff increased and introduce trauma center. New machinery is provided to hospital such as monitoring machines, blood test facilities should be improved. Appoint specialist doctors to save life of people. Security and privacy should maintain for doctors and patients also. For hospital staff accommodation should improve as soon as possible. Lack of life saving drugs. drugs should be given to them on time. If they need to improve our hospital then housing for staff can be improved and renovated. Make new accommodations for hospital staff. That was the most severe issue. 

Accommodation was necessary because in the Tehsil Pind Dadan Khan there was no good accommodations was available for rent. Radiology services and pathology laboratory was renovated as in district head quarter. There was also arrangement of security guards for staff who serve hospital and take actions on the misbehave with doctors. In the hospital political leaders and social worker visit hospital and they came with their protocols. But they not focus on to improve health services in the city. The people of Pind Dadan khan are deprived of most basic medical services. Behavior of paramedical staff should be improved which serve in wards. Ambulances no. increased from 2 to 6. 

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