Quality management and benchmarking in emergency medicine

Use of checklists improves the quality and safety of prehospital emergency care

OBJECTIVES

High-level emergency medical care requires transfer of evidence-based knowledge into practice. Our study is the first to investigate the feasibility of checklists in improving prehospital emergency care.

MATERIALS AND METHODS

Three checklists based on standard operating procedures were introduced: General principles of prehospital care, acute coronary syndrome and acute asthma/acutely exacerbated chronic obstructive pulmonary disease. Subsequent to prehospital care and immediately before transport, information on medical history, diagnostic and therapeutic procedures was obtained. Data of 740 emergency missions were recorded prospectively before (control group) and after implementation of checklists and compared using the χ-test (significance level P<0.05).

RESULTS

Documentation on patients' history (pre-existing diseases: 69.1 vs. 74.3%; medication: 55.8 vs. 68.0%; allergies: 6.2 vs. 27.7%) and diagnostic measures (oxygen saturation: 93.2 vs. 98.1%; auscultation: 11.1 vs. 19.9%) as well as basic treatment procedures (application of oxygen: 73.2 vs. 85.3%; intravenous access: 84.6 vs. 92.2%) increased significantly. Subanalysis of acute coronary syndrome cases showed a significant increase of 12-lead ECG use (74.3 vs. 92.4%), administration of oxygen (84.2 vs. 98.6%), ASA (71.7 vs. 81.9%), heparin (71.1 vs. 84.0%), β blockers (39.5 vs. 57.1%) and morphine (26.8 vs. 44.6%). In the chronic obstructive pulmonary disease subgroup, oxygen supply (78.8 vs. 98.5%) and application of inhalative and intravenous β2-mimetics (42.4 vs. 66.7% and 12.1 vs. 37.9%) increased significantly.

CONCLUSION

Introduction of checklists for prehospital emergency care may help to improve adherence to treatment guidelines. Additional efforts (e.g. team trainings) have to be made to increase quality of care.

The Role of Patients' Stories in Emergency Medicine Triage

Emergency medicine is a communicative activity, and characteristics such as incomplete information, time pressure, and the potentially serious consequences of errors complicate effective communication and decision making. The present study examined the triage process as an interpretive activity driven in part by the patient's story. Of four identified communication processes in the emergency department (ED), the "handoff" of patients between shifts has been identified as especially problematic since missing contextual details from patients' stories increased the probability of errors. The problematic nature of patient handoffs led to our interest in triage, the initial site of interpretation and decision making. Triage distinguishes patients with emergent medical conditions requiring immediate care from those who can more safely wait for medical attention. We report results from 110 hours of observing the triage process and semistructured interviews with 16 triage nurses in a Level I Trauma Center in an urban teaching hospital in the southeastern United States. Field notes and interview transcripts were analyzed and coded to explore decision rules and information sources used in triage decision making. Triage nurses generally discounted patients' stories in favor of information from visual cues and vital signs. Patients' stories tended to influence the triage process only in certain cases when the story contained information that was not readily apparent, such as a recent organ transplant. Triage nurses' reliance on "gut feeling," however, might be a kind of narrative sense-making that combines observable and measurable clinical facts with the narrative competence to utilize intuition and past experience.

[National data set "emergency department": development, structure and approval by the Deutsche Interdisziplinäre Vereinigung für Intensivmedizin und Notfallmedizin]

BACKGROUND

The Deutsche Interdisziplinäre Vereinigung für Intensivmedizin und Notfallmedizin (DIVI) is divided into sections one of which is the "Sektion Notaufnahmeprotokoll" (emergency department protocol section) founded in 2007. The main task was to create a national data set for the documentation of patients in emergency departments (ED).

MATERIAL AND METHODS

In order to create such a data set a careful look was taken at the current state of documentation in many different hospitals throughout Germany. In addition, existing registries and international requirements were also taken into consideration. The content of the dataset "ED documentation" was developed in interdisciplinary and interprofessional expert rounds.

RESULTS

The dataset "ED documentation" forms the first basis for documentation in German EDs. The modular data set contains 676 fields and covers all relevant information of the whole clinical process in the ED. Legal issues as well as several aspects for internal and external quality management are also included. For this reason the data of several German quality registries (e.g. TraumaRegister DGU® of the German Society of Trauma Surgery) are part of the data set. Furthermore, the data set forms the basis for several financial and billing aspects. A set of six forms was created in accordance with the developed modular data set. In 2010 the data set was approved by the executive committee of the DIVI. Several German medical associations (e.g. German Association for Emergency Medicine/Deutsche Gesellschaft Interdisziplinäre Notfall- und Akutmedizin, DGINA) recommend its use. Currently 80 hospitals are using the data set.

CONCLUSION

Beside the ability to exchange information the presented data set is the basis for internal and external quality assessment in the ED even if most of the available scoring and benchmarking tools are not validated for the German medical system. Implementing an ED register in Germany which is planned in the future, could close this gap.

Methodology for developing quality indicators for the care of older people in the Emergency Department

Background

Compared with younger people, older people have a higher risk of adverse health outcomes when presenting to emergency departments. As the population ages, older people will make up an increasing proportion of the emergency department population. Therefore it is timely that consideration be given to the quality of care received by older persons in emergency departments, and to consideration of those older people with special needs. Particular attention will be focused on important groups of older people, such as patients with cognitive impairment, residents of long term care and patients with palliative care needs. This project will develop a suite of quality indicators focused on the care of older persons in the emergency department.

Methods/design

Following input from an expert panel, an initial set of structural, process, and outcome indicators will be developed based on thorough systematic search in the scientific literature. All initial indicators will be tested in eight emergency departments for their validity and feasibility. Results of the data from the field studies will be presented to the expert panel at a second meeting. A suite of Quality Indicators for the older emergency department population will be finalised following a formal voting process.

Discussion

The predicted burgeoning in the number of older persons presenting to emergency departments combined with the recognised quality deficiencies in emergency department care delivery to this population, highlight the need for a quality framework for the care of older persons in emergency departments. Additionally, high quality of care is associated with improved survival & health outcomes of elderly patients. The development of well-selected, validated and economical quality indicators will allow appropriate targeting of resources (financial, education or quality management) to improve quality in areas with maximum potential for improvement.

Less is more? The impact of trauma volume on the positive rate of head computed tomography scans in head trauma patients

Objective. Few studies have assessed the impact of trauma volume on the operational efficiency of emergency departments. Herein, we evaluate the association between trauma volume with the positive rate of head computed tomography scans in head trauma patients in a tertiary care hospital. Methods. This is a retrospective cohort review involving all head trauma patients presenting to a tertiary care hospital. Trauma census, head trauma patient volume, the number of emergent head CT scans, and the number of positive head CT scans were collected on a monthly basis. Comparison was primarily made between the trauma patient volume and the positive rate of head CT scans. Results. 25,549 trauma patients were reviewed. Of these, 5,168 (20.2%) sustained head trauma and 3,336 head CT scans were performed with mean 29.1% positive rate of substantial head injuries. The monthly data were analyzed and a statistically significant correlation between monthly trauma volume and decrease in positive rate of head CT scan was identified (Pearson r = −0.51, P = 0.02). With introducing different cut-point values of trauma volume, we identified the threshold of trauma census as approximately 4.9 and 8.8% higher than mean monthly trauma volume in discriminating significant decrease of positive rate of head CT scans.

Adherence to Guideline-Based Standard Operating Procedures in Pre-Hospital Emergency Patients with Chronic Obstructive Pulmonary Disease

This study investigated improvements in pre-hospital care for patients with acute exacerbated chronic obstructive pulmonary disease (aeCOPD) achieved by using a standard operating procedure (SOP). An SOP for pre-hospital treatment of patients with aeCOPD was designed based on valid national guidelines. A total of 1000 Emergency Medical Service patient care reports were analysed prospectively: 500 before and 500 after introduction of the SOP. Overall guideline adherence was 34.6% before and 53.8% after introduction of the SOP; this increase was not statistically significant. After SOP introduction, the administration of β2-mimetics by inhalative, intravenous and subcutaneous routes increased significantly. The level of knowledge of the national guidelines was rated at 67% by emergency physicians during self-assessment, but was only 33% when physicians were asked specific questions during interview. Introducing the SOP for patients with aeCOPD did not significantly improve adherence to valid national guidelines, but did help to improve specific elements of therapy.