Design
This cross-sectional study was conducted online using Google Forms (Alphabet Inc., California, USA) from August to november 2022, involving five hospitals in indonesia and six in malaysia. These hospitals were selected through existing research networks. The names and locations of the hospitals are presented in supplemental Fig. 1. Ethical approval was waived by the central ethics committee of txp medical. co. ltd, while local ethical approval were obtained at each site. All experimental protocols were approved from the respective local ethics committee. The study adheres to the consensus-based checklist for reporting of survey studies (cross) guidelines for survey research. [9]
Box plots of survey results for emergency care issues in Indonesia. The lines inside each boxplot represent the median value and the circles inside each boxplot represent the mean value. The top three highest mean values in each boxplot are labeled 1, 2, and 3 above the corresponding boxes. a Issues identified in the quality of prehospital care. Scale: 1 = Strongly Disagree, 10 = Strongly Agree. b Issues identified in the quality of emergency care in the ED. Scale: for the first question, 1 = Strongly Disagree, 10 = Strongly Agree; for the second question, 1 = Least crowded, 10 = Most crowded; for the last two questions, 1 = Very easy, 10 = Time-consuming. c Missing clinical information from prehospital care to the ED. Scale: 1 = Strongly Disagree, 10 = Strongly Agree. d Issues identified in the length of patient stay at the ED. Scale: 1 = Very short, 10 = Very long. ED, emergency department
The url of the online questionnaire was distributed to all ed staff, including doctors, nurses, and medical workers, by each site’s chief investigator. Throughout the study period, staff were prohibited from discussing the survey content. The survey’s purpose and respondent rights were detailed on the first page of the questionnaires (see supplementary material). Invited ED staff who agreed with the survey policy and provided informed consent were directed to the questionnaire webpage. Participation was anonymous, voluntary, and uncompensated.
Survey settings
The survey collected diverse perspectives from ED staff in each country. A total of 11 hospitals, five from Indonesia and six from Malaysia, participated in the study. Details on the number of employees, hospital type, capacities, and patient volumes in Indonesia and Malaysia are listed in Supplemental Table 1.
Contents of the online survey and measurements
The survey consists of two main sections: (1) Respondent Demographic Characteristics, which collected participant data, and (2) Survey on the Emergency Department, which aimed to investigate the issues associated with ED management and identify issues recognized by the participants. The questions were initially produced in English with the help of a native English speaker, then translated into the lingua franca in each country: Bahasa Indonesia for Indonesia and Bahasa Malaysia for Malaysia. We performed translation and back translation, and the consistency was confirmed by two emergency physicians (TG and LK). The questionnaire was formulated through more than 10 meetings, primarily based on the clinical experiences and expertise of our research team, aiming to encompass a wide array of issues commonly encountered in emergency care settings.
We collected the following information: (1) respondent characteristics (five questions), (2) issues identified in the quality of prehospital care (six questions), (3) issues identified in the quality of emergency care in the ED (eight questions), (4) missing clinical information from prehospital care or ambulance team to the ED (11 questions), and (5) issues identified in the length of patient stay at the ED (six questions). The questionnaire consisted of 47 questions, estimated to take approximately 10 min (see Supplementary material).
To prevent duplicated responses, an initial question asked if respondents had previously participated, with a prompt to continue or exit based on their answer. Furthermore, to ensure unique identification and prevent multiple entries, respondents were requested to provide the first five characters of their email addresses. These measures aimed to maintain the integrity and validity of the survey data by minimizing duplicate responses. All questions were configured as mandatory in the Google Form used for data collection, ensuring that respondents completed each item before proceeding. This methodology resulted in no missing responses.
Statistical analysis
The characteristics were reported as medians and interquartile ranges (IQRs) for continuous variables and as numbers and percentages (%) for categorical variables, respectively. Issues identified in prehospital and emergency care, which were collected using a 10-point Likert scale, were analyzed as medians with IQRs and means, along with standard deviations [10, 11]. The Likert scale is simple to use and quantifies subjective opinions, allowing for nuanced responses and statistical analysis. Its consistency and flexibility make it a versatile tool in research. The mean values were used to identify the top three issues identified in prehospital and emergency care, because the respective median values of four or more items tied for the top ranking, making it challenging to discern the top three factors. Results are presented first for Indonesia, then Malaysia, ending with the common top issues in both countries. All analyses were performed using R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria).
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