SCDAA Pre-Pilot Survey

We’re collecting this information about your past Emergency Department experience at the beginning of the pilot in order to establish a baseline to measure program effectiveness. You’ll need to complete this survey to be confirmed for participation.

Please answer the following questions with your last Emergency Department (ED) visit in mind. Note: throughout the survey we’ll refer to an Emergency Department as “ED.”

Your individual answers to this survey will be kept completely confidential. Only aggregated, non-identifiable data on the effectiveness of the pilot will be shared.

SCDAA Pre-Pilot Survey

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

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Phone *

Email *

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Name of Emergency Department *

City *

State *

Had you been seen at this Emergency Department prior to this last visit? *

Accompanied to ED

Did anyone accompany you to the ED? *

If yes, what is their relationship to you?

On a scale of 1-10, how would you rate your pain in the ED at the time of visit?

Selected Value: 0

With 1 = mild pain and 10 = your most severe pain

After seeing the doctor, how long did you wait before you received your first pain medication? *

Within 30 minutes
Within an hour
1-3 hours
3-5 hours
More than 5+ hours

How often was your pain re-assessed? *

Every 15 minutes
Every 30 minutes
Every hour
Every 2 hours
More than 2+ hours

Did you tell the ED staff the name of your regular doctor and/or hematologist? *

How responsive was ED staff to the provider information you gave them? *

1 - Very responsive
2 - Somewhat responsive
3 - Responsive
4 - Somewhat not responsive
5 - No response at all

Did you feel “heard” by the ED staff? *

1 - Yes, very much so
2 - Somewhat heard
3 - Doctor listened, but was not able to use information
4 - No, doctor would not take or use information I provided

Respect and concerns

Do you feel you were treated with respect? *

Were your pain/concerns adequately addressed? *

Do you have a doctor prescribed SCD pain plan? *

Yes
No, I didn’t provide a prescribed SCD pain plan

If yes, did the ED doctor follow your prescribed SCD pain plan? *

Patient Advocate Info

Were you offered the opportunity to speak to a patient advocate? *

Did you ask for a patient advocate? *

If yes, was a patient advocate provided?

Were you admitted to the hospital for further treatment? *

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If admitted, how long before you were provided a hospital room? *

Within 12 hours
Within 24 hours
1-2 days
2-3 days
4+ days

How many days did you spend in the hospital for this pain crisis? *

Was a pain plan discussed during your visit? *

How would you rate your overall ED experience with this visit? *

Best possible experience
Slightly better than previous
Same as previous visits
Slightly worse than previous
Worst possible experience

Explain your ED visit rating: *

Thank you! Once you’re enrolled in the program, you’ll report any ED visits you have during the pilot here: Post-ED Visit Survey.

If you have any questions about the pilot, please contact the program administrator at sicklecellpilot@medicalert.org.