The measurement of time to first antibiotic dose for pneumonia in the emergency department: a white paper and position statement prepared for the American Academy of Emergency Medicine

Does Use of Electronic Alerts for Systemic Inflammatory Response Syndrome (SIRS) to Identify Patients With Sepsis Improve Mortality?

PURPOSE

The objective of this study was to assess whether earlier antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) and evidence of organ dysfunction identified through electronic alerts improves patient mortality.

METHODS

This is a retrospective observational cohort study of adult patients admitted across 5 acute-care hospitals. Mortality, Premier CareScience^TM Analytics Expected Mortality Score, and clinical and demographic variables were obtained through the electronic medical record and Premier (Premier Healthcare Solutions, Inc, Charlotte NC) reports. Patients with 2 SIRS criteria and organ dysfunction were identified through an automated alert. Univariate and multivariate logistic regression was performed.

RESULTS

Of those with SIRS and organ dysfunction, 8146 patients were identified through the electronic Best Practice Alert (BPA). Overall 30-day mortality rate was 8.7%. There was no significant association between time to antibiotic administration from BPA alert and mortality (P = 0.21) after adjusting for factors that could influence mortality, including age, heart rate, blood pressure, plasma lactate levels, creatinine, bilirubin levels, and the CareScience^TM Predicted Mortality Risk Score. Female gender (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.06-1.63) and facility were also independently associated with mortality.

CONCLUSION

The use of alerts in the electronic medical record may misclassify patients with SIRS as having sepsis. Time to antibiotic administration in patients meeting SIRS criteria and evidence of end-organ dysfunction through BPA alerts did not affect 30-day mortality rates across a health system. Patient severity of illness, gender, and facility also independently predicted mortality. There were higher rates of antibiotic use and Clostridioides difficile infection in patients with BPA alerts.

Community-acquired pneumonia requiring hospitalization: rational decision making and interpretation of guidelines

PURPOSE OF REVIEW

This review focuses on the evidence base for guideline recommendations on the diagnosis, the optimal choice, timing and duration of empirical antibiotic therapy, and the use of microbiological tests for patients hospitalized with community-acquired pneumonia (CAP): issues for which guidelines are frequently used as a quick reference. Furthermore, we will discuss possibilities for future research in these topics.

RECENT FINDINGS

Many national and international guideline recommendations, even on critical elements of CAP management, are based on low-to-moderate quality evidence.

SUMMARY

The diagnosis and management of CAP has hardly changed for decades. The recommendation to cover atypical pathogens in all hospitalized CAP patients is based on observational studies only and is challenged by two recent trials. The following years, improved diagnostic testing, radiologically by low-dose Computed Tomography or ultrasound and/or microbiologically by point-of-care multiplex PCR, has the potential to largely influence the choice and start of antibiotic therapy in hospitalized CAP patients. Rapid microbiological testing will hopefully improve antibiotic de-escalation or early pathogen-directed therapy, both potent ways of reducing broad-spectrum antibiotic use. Current guideline recommendations on the timing and duration of antibiotic therapy are based on limited evidence, but will be hard to improve.

Comparative quality measures of emergency care: an outcome cockpit proposal to survey clinical processes in real life

Background

Benchmarking of real-life quality of care may improve evaluation and comparability of emergency department (ED) care. We investigated process management variables for important medical diagnoses in a large, well-defined cohort of ED patients and studied predictors for low quality of care.

Methods

We prospectively included consecutive medical patients with main diagnoses of community-acquired pneumonia, urinary tract infection (UTI), myocardial infarction (MI), acute heart failure, deep vein thrombosis, and COPD exacerbation and followed them for 30 days. We studied predictors for alteration in ED care (treatment times, satisfaction with care, readmission rates, and mortality) by using multivariate regression analyses.

Results

Overall, 2986 patients (median age 72 years, 57% males) were included. The median time to start treatment was 72 minutes (95% CI: 23 to 150), with a median length of ED stay (ED LOS) of 256 minutes (95% CI: 166 to 351). We found delayed treatment times and longer ED LOS to be independently associated with main medical admission diagnosis and time of day on admission (shortest times for MI and longest times for UTI). Time to first physician contact (−0.01 hours, 95% CI: −0.03 to −0.02) and ED LOS (−0.01 hours, 95% CI: −0.02 to −0.04) were main predictors for patient satisfaction.

Conclusion

Within this large cohort of consecutive patients seeking ED care, we found time of day on admission to be an important predictor for ED timeliness, which again predicted satisfaction with hospital care. Older patients were waiting longer for specific treatment, whereas polymorbidity predicted an increased ED LOS.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases

Introduction

In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute.

Materials and methods

A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development.

Conclusion

The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Decision Analysis for Metric Selection on a Clinical Quality Scorecard

Clinical quality scorecards are used by health care institutions to monitor clinical performance and drive quality improvement. Because of the rapid proliferation of quality metrics in health care, BJC HealthCare found it increasingly difficult to select the most impactful scorecard metrics while still monitoring metrics for regulatory purposes. A 7-step measure selection process was implemented incorporating Kepner-Tregoe Decision Analysis, which is a systematic process that considers key criteria that must be satisfied in order to make the best decision. The decision analysis process evaluates what metrics will most appropriately fulfill these criteria, as well as identifies potential risks associated with a particular metric in order to identify threats to its implementation. Using this process, a list of 750 potential metrics was narrowed to 25 that were selected for scorecard inclusion. This decision analysis process created a more transparent, reproducible approach for selecting quality metrics for clinical quality scorecards.

Impact of Mandatory Public Reporting of Central Line-Associated Bloodstream Infections on Blood Culture and Antibiotic Utilization in Pediatric and Neonatal Intensive Care Units

BACKGROUND

As mandatory public reporting of healthcare-associated infections increases, there is concern that clinicians could attempt to decrease rates by avoiding the diagnosis of reportable infections.

OBJECTIVE

To determine whether blood culture and antibiotic utilization changed after mandatory public reporting of central line-associated bloodstream infection (CLABSI).

DESIGN

Interrupted time-series of blood culture and antibiotic rates before and after state-specific implementation of mandatory public reporting. We analyzed data from pediatric and neonatal intensive care units (ICUs) at 17 children's hospitals that contributed to the Pediatric Health Information System administrative database. We used multivariable regression with generalized linear mixed-effects models to determine adjusted rate ratios (ARRs) after implementation of mandatory public reporting. We conducted subgroup analysis on patients with central venous catheters. To assess temporal trends, we separately analyzed data from 4 pediatric hospitals in states without mandatory public reporting.

RESULTS

There was no significant effect of mandatory public reporting on rates of blood culture (pediatric ICU ARR, 1.03 [95% CI, 0.82-1.28]; neonatal ICU ARR, 1.06 [0.85-1.33]) or antibiotic utilization (pediatric ICU ARR, 0.86 [0.72-1.04]; neonatal ICU ARR, 1.09 [0.87-1.35]). Results were similar in the subgroup of patients with central venous catheter codes. Hospitals with and without mandatory public reporting experienced small decreases in blood culture and antibiotic use across the study period.

CONCLUSIONS

Mandatory public reporting of central line-associated bloodstream infection did not impact blood culture and antibiotic utilization, suggesting that clinicians have not shifted their practice in an attempt to detect fewer infections.

Antibiotic stewardship in the intensive care unit

The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.

Selection of hospital antimicrobial prescribing quality indicators: a consensus among German antibiotic stewardship (ABS) networkers

PURPOSE

Simple, valid, and evidence-based indicators to measure the quality of antimicrobial prescribing in acute-care hospitals are urgently needed and increasingly requested by policymakers. The aim of this study was to develop new consensus quality indicators (QIs) for hospital antibiotic stewardship (ABS) and infection management which will be further evaluated for internal quality management and external quality assessment in Germany.

METHODS

Based on an extensive literature review, the Austrian-German hospital ABS Guideline Committee and selected members of the German ABS Expert Network discussed and drafted a list of 99 potential indicators for hospitals that reflect structural prerequisites for ABS (35 items), ABS core activities (18 items), additional ABS measures (5 items), and process of care indicators (both generic and disease-specific-12 and 29 items, respectively). Questionnaires were mailed to German ABS experts and healthcare professionals with further education in ABS. Participants scored (on a nine-point Likert scale) relevance (clinical, ecological/resistance, economical/expenses) and presumed practicability (six categories: clarity of definition, effort to collect data, barrier to implementation, verifiability, suitability for external quality assessment, quality gap), taking into account their local work environment. The scores were processed according to the RAND/UCLA appropriateness method, and QIs were judged relevant if the median (clinical + ecological and/or economical) scores were >6. The indicators thus assessed to be potentially relevant were then filtered according to their practicability. Highly relevant QIs with borderline practicability scores and items with disagreements and overlapping areas were re-discussed in a final multidisciplinary panel consensus workshop convened in November 2012.

RESULTS

Of the 340 questionnaires that were mailed, 75 questionnaires were completed and returned. Of 99 initially proposed items, 32 were excluded due to insufficient scores. Of the remaining 67 items, 21 structural and 21 process of care QIs were finally selected, including four QIs with high clinical and ecological but limited economical relevance, and three QIs with high clinical and economical but limited ecological relevance. Among the selected QIs, efforts to collect data and implementation barriers were scored as suboptimal in many cases.

CONCLUSIONS

A catalog of consensus structural and process of care ABS-QIs was established. These should undergo further pilot and feasibility studies in the German hospital healthcare sector. The panelists were most critical regarding resource use/complexity issues and presumed implementation barriers. How this may limit applicability of QIs remains to be determined.

Time to first antibiotic dose for patients hospitalised with community-acquired pneumonia

Time to first antibiotic dose (TFAD) of 4h or 8h has been suggested as a quality measure for adult patients hospitalised with community-acquired pneumonia (CAP). Clinical evidence leading to implementation of this quality measure came from two large, retrospective studies. Following these studies, several prospective studies were conducted, with variable results. In a compilation of all observational studies to date, no significant benefit for short TFAD in terms of all-cause mortality was observed [unadjusted odds ratio (OR) = 1.01, 95% confidence interval (CI) 0.79-1.29, 13 studies; adjusted OR = 0.95, 95% CI 0.73-1.23, 14 studies]. Implementation of a requirement for short TFAD for CAP in the emergency department or other acute medical care setting may lead to unnecessary antibiotic treatment. We believe that attention should be shifted to early appropriate empirical antibiotic treatment for severe sepsis in hospital regardless of the source of infection, rather than focusing on CAP.

[Multidisciplinary guidelines for the management of community-acquired pneumonia]

Community-acquired pneumonia (CAP) is an infectious respiratory disease with an incidence that ranges from 3 to 8 cases per 1,000 inhabitants per year. This incidence increases with age and comorbidities. Forty per cent of CAP patients require hospitalization and around 10% of these patients are admitted in an Intensive Care Unit (ICU). Several studies have suggested that the implementation of clinical guidelines has a positive impact in the outcome of patients including mortality and length of stay. The more recent and used guidelines are those from Infectious Diseases Society of America/American Thoracic Society, published in 2007, the 2009 from the British Thoracic Society, and that from the European Respiratory Society/European Society of Clinical Microbiology and Infectious Diseases, published in 2010. In Spain, the most recently released guideline is the Sociedad Española de Neumología y Cirugía Torácica-2011 guideline. The present guidelines GNAC are designed to be used by the majority of health-care professionals that can participate in the care of CAP patients including diagnosis, decision of hospital and ICU admission, treatment and prevention. The Centro Cochrane Iberoamericano (CCIB) has participated in summarizing the previous guidelines and in the bibliography search. For each one of the following sections the panel of experts has developed a table with recommendations classified according to its evidence, strength and practical applicability using the Grading of Recommendations of Assessment Development and Evaluations (GRADE) system: 1. Epidemiology, microbiological etiology and antibiotic resistances.2. Clinical and microbiological diagnosis.3. Prognostic scales and decision of hospital admission.4. ICU admission criteria. 5. Empirical and definitive antibiotic treatment.6. Treatment failure. 7. Prevention.

[Early and late mortality of patients with community acquired pneumonia]

Community acquired pneumonia is the most frequent infective cause of severe sepsis and death. The risk of mortality in community acquired pneumonia is predictable by the "pneumonia severity index" and various biomarkers (e.g., procalcitonin, troponin-I). Quantitative testing of pneumococcal load (DNA) in blood has also become possible recently. Early death due to acute myocardial infarction is more frequent among patients with previous community acquired pneumonia. The 1-year and the 5-6 year survival is shorter among these patients. Pro-inflammatory cytokines synthesized during community acquired pneumonia accelerate chronic inflammation ongoing in atherosclerotic plaques. The pro-thrombotic condition present in atherosclerosis is also potentiated by community acquired pneumonia. These pathophysiological mechanisms may explain the epidemiologic fact that community acquired pneumonia is an independent risk factor of cardiovascular mortality.

Compliance with guidelines-recommended processes in pneumonia: impact of health status and initial signs

Initial care has been associated with improved survival of community-acquired pneumonia (CAP). We aimed to investigate patient comorbidities and health status measured by the Charlson index and clinical signs at diagnosis associated with adherence to recommended processes of care in CAP. We studied 3844 patients hospitalized with CAP. The evaluated recommendations were antibiotic adherence to Spanish guidelines, first antibiotic dose <6 hours and oxygen assessment. Antibiotic adherence was 72.6%, first dose <6 h was 73.4% and oxygen assessment was 90.2%. Antibiotic adherence was negatively associated with a high Charlson score (Odds ratio [OR], 0.91), confusion (OR, 0.66) and tachycardia ≥100 bpm (OR, 0.77). Delayed first dose was significantly lower in those with tachycardia (OR, 0.75). Initial oxygen assessment was negatively associated with fever (OR, 0.61), whereas tachypnea ≥30 (OR, 1.58), tachycardia (OR, 1.39), age >65 (OR, 1.51) and COPD (OR, 1.80) were protective factors. The combination of antibiotic adherence and timing <6 hours was negatively associated with confusion (OR, 0.69) and a high Charlson score (OR, 0.92) adjusting for severity and hospital effect, whereas age was not an independent factor. Deficient health status and confusion, rather than age, are associated with lower compliance with antibiotic therapy recommendations and timing, thus identifying a subpopulation more prone to receiving lower quality care.

Predictors for length of hospital stay in patients with community-acquired pneumonia: results from a Swiss multicenter study

Background

Length of hospital stay (LOS) in patients with community-acquired pneumonia (CAP) is variable and directly related to medical costs. Accurate estimation of LOS on admission and during follow-up may result in earlier and more efficient discharge strategies.

Methods

This is a prospective multicenter study including patients in emergency departments of 6 tertiary care hospitals in Switzerland between October 2006 and March 2008. Medical history, clinical data at presentation and health care insurance class were collected. We calculated univariate and multivariate cox regression models to assess the association of different characteristics with LOS. In a split sample analysis, we created two LOS prediction rules, first including only admission data, and second including also additional inpatient information.

Results

The mean LOS in the 875 included CAP patients was 9.8 days (95%CI 9.3-10.4). Older age, respiratory rate >20 pm, nursing home residence, chronic pulmonary disease, diabetes, multilobar CAP and the pneumonia severity index class were independently associated with longer LOS in the admission prediction model. When also considering follow-up information, low albumin levels, ICU transfer and development of CAP-associated complications were additional independent risk factors for prolonged LOS. Both weighted clinical prediction rules based on these factors showed a high separation of patients in Kaplan Meier Curves (p logrank <0.001 and <0.001) and a good calibration when comparing predicted and observed results.

Conclusions

Within this study we identified different baseline and follow-up characteristics to be strong and independent predictors for LOS. If validated in future studies, these factors may help to optimize discharge strategies and thus shorten LOS in CAP patients.

[Antibiotics and timing in infectious disease in the emergency department]

Infectious diseases, besides being a major cause of mortality in developing countries, are one of the main reasons for consultation in emergency medicine. In the last few years, there have been numerous published studies on the importance of starting antibiotic treatment at an early stage in the Emergency Department. However, this issue is of great controversy, owing to some contradictory studies as well as the implications this may have on the pressure of the patient care. This review is presents a summary of the scientific evidence published in this regard, and makes some recommendations based on this published evidence to improve the initial management of patients with an infection; a question of great importance as it can reduce mortality in some specific situations.

Guidelines for the management of adult lower respiratory tract infections--summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Do low-dose corticosteroids improve mortality or shock reversal in patients with septic shock? A systematic review and position statement prepared for the American Academy of Emergency Medicine

BACKGROUND

The management of septic shock has undergone a significant evolution in the past decade. A number of trials have been published to evaluate the efficacy of low-dose corticosteroid administration in patients with septic shock.

METHODS

The Sepsis Sub-committee of the American Academy of Emergency Medicine Clinical Practice Committee performed an extensive search of the contemporary literature and identified seven relevant trials.

RESULTS

Six of the seven trials reported a mortality outcome of patients in septic shock. Analysis of the data revealed that the relative risk (RR) of 28-day all-cause mortality in septic shock patients who received low-dose corticosteroids was 0.92 (95% confidence interval [CI] 0.79-1.07). All seven trials reported data concerning shock reversal or the withdrawal of vasopressors. Pooled results revealed that the RR of shock reversal is 1.17 (95% CI 1.07-1.28), which suggests that there may be significant improvement in shock reversal after corticosteroid administration. It is important to understand that two of the seven studies reviewed were disproportionately represented and accounted for 799 of 1005 patients (80%) considered for this recommendation.

CONCLUSIONS

The evidence suggests that low-dose corticosteroids may reverse shock faster; however, mortality is not improved for the overall population.

Timing of antibiotic administration and outcomes of hospitalized patients with community-acquired and healthcare-associated pneumonia

The effects of antibiotic timing on outcomes of patients with community-acquired pneumonia (CAP) are controversial. Moreover, no information is available regarding this issue in healthcare-associated pneumonia (HCAP). We aimed to determine the impact of antibiotic timing on 30-day mortality of patients with CAP and HCAP. Non-immunocompromised adults admitted to hospital through the emergency department (ED) with community-onset pneumonia were prospectively observed from 2001 to 2009. Patients who received prior antibiotics were excluded. Of 1593 patients with pneumonia who were analyzed, 1274 had CAP and 319 HCAP. The mean time from patient arrival at the ED until antibiotic administration was 5.8 h (standard deviation (SD) 3.5) in CAP and 6.1 h (SD 3.8) in HCAP (p 0.30). Mortality was higher in patients with HCAP (5.5% vs. 13.5%; p <0.001). After adjusting for confounding factors in a logistic regression analysis, the antibiotic administration ≤4 h was not associated with decreased 30-day mortality in patients with CAP (odds ratio (OR) 1.12, 95% confidence interval (CI) 0.57-2.21) and in patients with HCAP (OR 0.59, 95% CI 0.19-1.83). Similarly, antibiotic administration ≤8 h was not associated with decreased 30-day mortality in CAP (OR 1.58, 95% CI 0.64-3.88) and HCAP patients (OR 0.59, 95% CI 0.19-1.83). In conclusion, antibiotic administration within 4 or 8 h of arrival at the ED did not improve 30-day survival in hospitalized adults for CAP or HCAP.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Hospital-reported data on the pneumonia quality measure "Time to First Antibiotic Dose" are not associated with inpatient mortality: results of a nationwide cross-sectional analysis

OBJECTIVES

Significant controversy exists regarding the Centers for Medicare & Medicaid Services (CMS) "time to first antibiotics dose" (TFAD) quality measure. The objective of this study was to determine whether hospital performance on the TFAD measure for patients admitted from the emergency department (ED) for pneumonia is associated with decreased mortality.

METHODS

This was a cross-sectional analysis of 95,704 adult ED admissions with a principal diagnosis of pneumonia from 530 hospitals in the 2007 Nationwide Inpatient Sample. The sample was merged with 2007 CMS Hospital Compare data, and hospitals were categorized into TFAD performance quartiles. Univariate association of TFAD performance with inpatient mortality was evaluated by chi-square test. A population-averaged logistic regression model was created with an exchangeable working correlation matrix of inpatient mortality adjusted for age, sex, comorbid conditions, weekend admission, payer status, income level, hospital size, hospital location, teaching status, and TFAD performance.

RESULTS

Patients had a mean age of 69.3 years. In the adjusted analysis, increasing age was associated with increased mortality with odds ratios (ORs) of >2.3. Unadjusted inpatient mortality was 4.1% (95% confidence interval [CI] = 3.9% to 4.2%). Median time to death was 5 days (25th-75th interquartile range = 2-11). Mean TFAD quality performance was 77.7% across all hospitals (95% CI = 77.6% to 77.8%). The risk-adjusted OR of mortality was 0.89 (95% CI = 0.77 to 1.02) in the highest performing TFAD quartile, compared to the lowest performing TFAD quartile. The second highest performing quartile OR was 0.94 (95% CI = 0.82 to 1.08), and third highest performing quartile was 0.91 (95% CI = 0.79 to 1.05).

CONCLUSIONS

In this nationwide heterogeneous 2007 sample, there was no association between the publicly reported TFAD quality measure performance and pneumonia inpatient mortality.

The role of the Society for Academic Emergency Medicine in the development of guidelines and performance measures

Measurement of adherence to clinical standards has become increasingly important to the practice of emergency medicine (EM). In recent years, along with a proliferation of evidence-based practice guidelines and performance measures, there has been a movement to incorporate measurement into reimbursement strategies, many of which affect EM practice. On behalf of the Society for Academic Emergency Medicine (SAEM) Guidelines Committee 2009-2010, the purposes of this document are to: 1) differentiate the processes of guideline and performance measure development, 2) describe how performance measures are currently and will be used in pay-for-performance initiatives, and 3) discuss opportunities for SAEM to affect future guideline and performance measurement development for emergency care. Specific recommendations include that SAEM should: 1) develop programs to sponsor guideline and quality measurement research; 2) increase participation in the process of guideline and quality measure development, endorsement, and maintenance; 3) increase collaboration with other EM organizations to review performance measures proposed by organizations outside of EM that affect emergency medical care; and 4) answer calls for participation in the selection and implementation of performance measures through The Joint Commission and the Centers for Medicare and Medicaid Services (CMS).