Prioritizing performance measurement for emergency department care: consensus on evidence-based quality of care indicators

Neutrophil-to-lymphocyte ratio as a predictor for outcomes in patients with short-term emergency department revisits

BACKGROUND

Analysis of short-term emergency department (ED) revisits is a common emergency care quality assurance practice. Previous studies have explored various risk factors of ED revisits; however, laboratory data were usually omitted. This study aimed to evaluate the prognostic significance of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte (PLR), and systemic immune-inflammation index (SII) in predicting outcomes of patients revisiting the ED.

METHODS

This retrospective observational cohort study investigated short-term ED revisit patients. The primary outcome measure was high-risk ED revisit, a composite of in-hospital mortality or intensive care unit (ICU) admission after 72-hour ED revisit. The NLR, PLR, and SII were investigated as potential prognostic predictors of ED revisit outcomes.

RESULTS

A total of 1916 encounters with short-term ED revisit patients were included in the study; among these, 132 (6.9%) encounters, comprising 57 in-hospital mortalities and 95 ICU admissions, were high-risk revisits. High-risk revisit patients had significantly higher NLR, PLR, and SII (11.6 vs 6.6, p < 0.001; 26.2 vs 18.9, p = 0.004; 2209 vs 1486, p = 0.002, respectively). Multiple regression analysis revealed revisit-NLR as an independent factor for predicting poor outcomes post-ED revisits (odds ratio: 1.031, 95% CI: 1.017-1.045, p < 0.001); an optimal cut-off value of 7.9 was proven for predicting high-risk ED revisit.

CONCLUSION

The intensity of the inflammatory response expressed by NLR was an independent predictor for poor outcomes of ED revisits and should be considered when ED revisits occur. Future prediction models for ED revisit outcomes can include revisit-NLR as a potential predictor to reflect the progressive conditions in ED patients.

Canadian nurse initiated analgesia protocol to reduce delays in the emergency department: A quality improvement study

BACKGROUND

Australian literature supports nurse-initiated opioid analgesia protocols may be effective, but this practice is not yet widely adopted in Canada.

LOCAL PROBLEM

Previous quality audits of Emergency Departments (EDs) in Victoria (Canada) indicate long delays to administration of analgesia.

METHODS

Two tertiary care hospitals in a Canadian city of approximately 400,000 people were chosen for a quality improvement initiative. A manual retrospective chart review was conducted on a total of 122 patients which was compared to data from 125 patients from a previous audit in 2019.

INTERVENTIONS

ED nursing staff both hospitals were provided education and daily reminders to document pain score at triage, and to flag an acute analgesia opioid order set on the charts of patients with moderate or severe pain (greater than 4 out of 10 in the Numerical Rating Scale (NRS) or by triage nurse's clinical judgment). At Victoria General Hospital (VGH), nurses had the option of finding an emergency physician (EP) to sign the acute analgesia opioid order set, or independently administer IV opioids from a presigned order set without consulting an EP. At Royal Jubilee Hospital (RJH), nursing staff could only administer IV opioids from the order set after an EP was consulted. Median time to opioid analgesia after the intervention was compared to 2019 data for each hospital.

RESULTS

Each hospital significantly reduced median time to administration of opioids: VGH achieved 45.6 % reduction (1 h 8 min improvement, p = 0.001) and RJH achieved a 62.5 % reduction (2 h 11 min improvement, p < 0.001). Secondary outcomes indicated patients may receive analgesia faster when the opioid protocol was nurse initiated (median 43 minutes) vs physician initiated (median 1 h 1 min) at VGH. Pain score documentation at triage improved from <10 % in 2019 to >50 % in 2020 at both sites. Approximately 95 % of EP and nursing staff thought nurse-initiated opioids are safe, effective, and should be supported by regulatory boards.

CONCLUSION

Implementing a new triage protocol to expedite initiation of an analgesic protocol was associated with significantly reduced time to analgesia for patients with moderate to severe pain. Time reductions may be greater with nurse-initiated analgesia before physician assessment.

Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission

BACKGROUND

Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.

METHODS

The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.

RESULTS

The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.

CONCLUSION

The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.

Quality indicators in respiratory therapy

Quality indicators in healthcare refer to measurable and quantifiable parameters used to assess and monitor the performance, effectiveness, and safety of healthcare services. These indicators provide a systematic way to evaluate the quality of care offered, and thereby to identify areas for improvement and to ensure that patient care meets established standards and best practices. Respiratory therapists play a vital role in areas of clinical administration such as infection control practices and quality improvement initiatives. Quality indicators serve as essential metrics for respiratory therapy departments to assess and enhance the overall quality of care. By systematically tracking and analyzing indicators related to infection control, treatment effectiveness, and adherence to protocols, respiratory care practitioners can identify areas to improve and implement evidence-based changes. This article reviewed how to identify, implement, and monitor quality indicators specific to the respiratory therapy departments to set benchmarks and enhance patient outcomes.

Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study

BACKGROUND

Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients.

METHODS

A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round.

RESULTS

Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management.

CONCLUSION

Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Strategies to Measure and Improve Emergency Department Performance: A Review

Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.

Protocol for developing a set of performance measures to monitor and evaluate delirium care quality for older adults in the emergency department using a modified e-Delphi process

INTRODUCTION

Older adults are at high risk of developing delirium in the emergency department (ED). Delirium associated with an ED visit is independently linked to poorer outcomes such as increased length of hospital stay and mortality. Performance measures (PMs) are needed to identify variations in the quality of delirium care to help focus improvement efforts where they are most needed. A preliminary list of 11 quality statements and 24 PMs was developed based on a synthesis of high-quality clinical practice guidelines. The purpose of this study is to gain consensus on a subset of PMs that can be used to evaluate delirium care quality for older ED patients.

METHODS AND ANALYSIS

This protocol for a modified e-Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies. Clinical experts from across Canada and internationally will be recruited through peer referral, professional organisations and social media calls for expressions of interest. A minimum of 17 participants will be recruited. The primary survey for each round will consist of closed-ended questions with the opportunity to provide comments to justify decisions and clarify understanding. Using 9-point Likert scales, participants will rate each quality statement according to the concepts of importance and actionability, then its associated PMs according to the concept of necessity. Results will be fed back to participants in subsequent rounds. A priori stopping criteria have been defined in terms of consensus and stability. A minimum of three rounds will be undertaken to allow participants to have feedback, revise previous responses, then stabilise responses.

ETHICS AND DISSEMINATION

Ethical approval was provided at the University of Manitoba Health Research Ethics Board (ID HS25728 (H2022:340)). Informed consent will be obtained electronically using the Research Electronic Data Capture secure online platform. Knowledge translation and dissemination will be done through traditional (eg, conference presentations, peer-reviewed publications) and non-traditional (eg, ED Grand Rounds) strategies.

Healthcare-associated adverse events and readmission to the emergency departments within seven days after a first consultation

Introduction

The use of emergency hospital service has become increasingly frequent with a rise of approximately 3.6%. in annual emergency department visits. The objective of this study was to describe the reasons for reconsultations to emergency departments and to identify the risk and protective factors of reconsultations linked to healthcare-associated adverse events.

Materials and methods

A retrospective, descriptive, multicenter study was performed in the emergency department of Troyes Hospital and the Sainte Anne Army Training Hospital in Toulon, France from January 1 to December 31, 2019. Patients over 18 years of age who returned to the emergency department for a reconsultation within 7 days were included. Healthcare-associated adverse events in the univariate analysis (p < 0.10) were introduced into a multivariate logistic regression model. Model performance was examined using the Hosmer-Lemeshow test and calculated with c-statistic.

Results

Weekend visits and performing radiology examinations were risk factors linked to healthcare associated adverse events. Biological examinations and the opinion of a specialist were protective factors.

Discussion

Numerous studies have reported that a first consultation occurring on a weekend is a reconsultation risk factor for healthcare-associated adverse events, however, performing radiology examinations were subjected to confusion bias. Patients having radiology examinations due to trauma-related pathologies were more apt for a reconsultation.

Conclusion

Our study supports the need for better emergency departments access to biological examinations and specialist second medical opinions. An appropriate patient to doctor ratio in hospital emergency departments may be necessary at all times.

Acute abdominal pain at referral emergency departments: an analysis of performance of three time-dependent quality indicators

BACKGROUND

Abdominal pain is one of the most frequent causes for emergency department (ED) visits. The quality of care and outcomes are determined by time-dependent interventions with barriers to implementation at crowded EDs.

OBJECTIVES

The study aimed to analyze three prominent quality indicators (QI) including pain assessment (QI1), analgesia in patients reporting severe pain (QI2), and ED length of stay (LOS) (QI3) in adult patients requiring immediate or urgent care due to acute abdominal pain. We aimed to characterize current practice regarding pain management, and we hypothesized that extended ED LOS (≥ 360 min) is associated with poor outcomes in this cohort of ED referrals.

METHODS

This is a retrospective cohort study enrolling all patients with acute abdominal pain as the main cause of ED presentation, triage category red, orange, or yellow, and age ≥ 30 years during two months period. Univariate and multivariable analyses were deployed to determine independent risk factors for QIs performance. For QI1 and QI2, compliance with the QIs were analyzed, while 30-day mortality was set as primary outcome for QI3.

RESULTS

Overall, 965 patients were analyzed including 501 (52%) males with a mean age of 61.8 years. Seventeen percent (167/965) of the patients had immediate or very urgent triage category. Age ≥ 65 years, and red and orange triage categories were risk factors for non-compliance with pain assessment. Seventy four per cent of patients with severe pain (numeric rating scale ≥ 7) received analgesia during the ED visit, in median within 64 min (IQR 35-105 min). Age ≥ 65 years and need for surgical consultation were risk factors for prolonged ED stay. After adjustment to age, gender and triage category, ED LOS ≥ 360 min proved to be independent risk factor for 30-day mortality (HR 1.89, 95% CI 1.71-3.40, p = 0.034).

CONCLUSION

Our investigation identified that non-compliance with pain assessment, analgesia and ED length of stay among patients presenting with abdominal pain to ED results in poor quality of care and detrimental outcomes. Our data support enhanced quality-assessment initiatives for this subset of ED patients.

Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department

The emergency department (ED) is a care setting with a high risk for medical error. In collaboration with our nursing colleagues, we identified a new trigger, under-triage, and demonstrated how its implementation could detect and reduce medical errors in the ED.

Length of stay as quality indicator in emergency departments: analysis of determinants in the German Emergency Department Data Registry (AKTIN registry)

Several indicators reflect the quality of care within emergency departments (ED). The length of stay (LOS) of emergency patients represents one of the most important performance measures. Determinants of LOS have not yet been evaluated in large cohorts in Germany. This study analyzed the fixed and influenceable determinants of LOS by evaluating data from the German Emergency Department Data Registry (AKTIN registry). We performed a retrospective evaluation of all adult (age ≥ 18 years) ED patients enrolled in the AKTIN registry for the year 2019. Primary outcome was LOS for the whole cohort; secondary outcomes included LOS stratified by (1) patient-related, (2) organizational-related and (3) structure-related factors. Overall, 304,606 patients from 12 EDs were included. Average LOS for all patients was 3 h 28 min (95% CI 3 h 27 min-3 h 29 min). Regardless of other variables, patients admitted to hospital stayed 64 min longer than non-admitted patients. LOS increased with patients' age, was shorter for walk-in patients compared to medical referral, and longer for non-trauma presenting complaints. Relevant differences were also found for acuity level, day of the week, and emergency care levels. We identified different factors influencing the duration of LOS in the ED. Total LOS was dependent on patient-related factors (age), disease-related factors (presentation complaint and triage level), and organizational factors (weekday and admitted/non-admitted status). These findings are important for the development of management strategies to optimize patient flow through the ED and thus to prevent overcrowding.

Identifying indicators influencing emergency department performance during a medical surge: A consensus-based modified fuzzy Delphi approach

During a medical surge, resource scarcity and other factors influence the performance of the healthcare systems. To enhance their performance, hospitals need to identify the critical indicators that affect their operations for better decision-making. This study aims to model a pertinent set of indicators for improving emergency departments' (ED) performance during a medical surge. The framework comprises a three-stage process to survey, evaluate, and rank such indicators in a systematic approach. The first stage consists of a survey based on the literature and interviews to extract quality indicators that impact the EDs' performance. The second stage consists of forming a panel of medical professionals to complete the survey questionnaire and applying our proposed consensus-based modified fuzzy Delphi method, which integrates text mining to address the fuzziness and obtain the sentiment scores in expert responses. The final stage ranks the indicators based on their stability and convergence. Here, twenty-nine potential indicators are extracted in the first stage, categorized into five healthcare performance factors, are reduced to twenty consentaneous indicators monitoring ED's efficacy. The Mann-Whitney test confirmed the stability of the group opinions (p < 0.05). The agreement percentage indicates that ED beds (77.8%), nurse staffing per patient seen (77.3%), and length of stay (75.0%) are among the most significant indicators affecting the ED's performance when responding to a surge. This research proposes a framework that helps hospital administrators determine essential indicators to monitor, manage, and improve the performance of EDs systematically during a surge event.

Selecting Performance Indicators and Targets in Health Care: An International Scoping Review and Standardized Process Framework

Objective

Health care organizations monitor hundreds of performance indicators. It is unclear what processes and criteria organizations use to identify the indicators they use, who is involved in these processes, how performance targets are set, and what the impacts of these processes are. The purpose of this study is to synthesize international approaches to indicator selection and develop a standardized process framework.

Methods

Using the PubMed and Web of Science search engines, a scoping review of peer reviewed and grey literature following PRISMA-ScR guidelines was conducted to identify documents describing indicator selection processes used by health systems. English-language papers from 11 countries published from 2010 to 2020 were included. Papers were thematically analyzed to develop a standardized process framework.

Results

The review included 33 peer-reviewed papers and 11 grey-literature documents. While there are common practices used in health care to select indicators, no single standardized process framework for indicator selection exists. Arbitrary or incomplete indicator selection processes risk over-measurement, lack of alignment with strategic and operational goals, lack of support by end-users, and paralyzed decision-making ability. By consolidating international practices, we developed the 5-P indicator selection process framework to mitigate process risks and support high-quality indicator selection processes.

Conclusion

The 5-P indicator selection process framework consists of five domains and 17 elements, and offers health care agencies a practical structure they can use to design indicator selection processes. The framework also provides researchers with a basis by which the implementation of these processes may be evaluated.

A comparative evaluation of the strengths of association between different emergency department crowding metrics and repeat visits within 72 hours

OBJECTIVE

We sought to compare strengths of association among multiple emergency department (ED) input, throughput and output metrics and the outcome of 72-h ED re-visits.

METHODS

This database analysis used healthcare administrative data from three urban, university-affiliated EDs in Calgary, Canada, calendar years 2010-2014. We used data from all patients presenting to participating EDs during the study period, and the primary analysis was performed on patients discharged from the ED. Regression models quantified the association between input, throughput and output metrics and the risk of return ED visit within 72 h of discharge from the index ED encounter. Strength of association between the crowding metrics and 72-h ED re-visits was compared using Akaike's Information Criterion.

RESULTS

The findings of this study are based on data from 845,588 patient encounters ending in discharge. The input metric with the strongest association with 72-h re-visits was median ED waiting time. The throughput metric with the strongest association with 72-h re-visits was the ED occupancy. The output metric with the strongest association with 72-h re-visits was the median inpatient boarding time.

CONCLUSION

Input, throughput and output metrics are all associated with 72-h re-visits. Delays in any of these operational phases have detrimental effects on patient outcomes. ED waiting time, ED occupancy, and boarding times are the most meaningful input, throughput and output metrics. These should be the preferred metrics for quantifying ED crowding in research and quality improvement efforts, and for clinicians to monitor ED crowding in real time.

Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes

BACKGROUND

While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED.

METHODS

We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major.

RESULTS

Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n = 442, 95.7%); lower acuity (Emergency Severity Index ≥3, n = 426, 92.2%); due to persistence/progression of illness (n = 403; 87.2%) with viral illness being the common diagnosis (n = 159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these.

CONCLUSIONS

APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.

Health Policies Based on Patient Satisfaction: A Bibliometric Study

Healthcare decision-makers increasingly face a changing and ever-evolving landscape, forcing them to formulate public policies based on the results from different scientific investigations. This article evaluates the field of research on patient satisfaction as a basis for health policies. The analysis was carried out with a sample of 621 articles published between 2000 and 2020 in the Scopus database. The world's largest producer and research co-operator on patient satisfaction and health policy was the United States. However, the most prolific authors, institutions, and journals are of British origin. Regarding the themes, we find that, in economic and management matters, scientific production is scarce. To study the evolution of keywords, we divided the study period into two periods of an equal number of years. In both sub-periods, the keyword "Human" stands out. In the second sub-period, the word "Perception" stands out, which indicates the current attention paid to the patient's opinion.

Cancer-related Emergency Department Visits: Comparing Characteristics and Outcomes

Introduction

There is increasing appreciation of the challenges of providing safe and appropriate care to cancer patients in the emergency department (ED). Our goal here was to assess which patient characteristics are associated with more frequent ED revisits.

Methods

This was a retrospective cohort study of all ED visits in California during the 2016 calendar year using data from the California Office of Statewide Health Planning and Development. We defined revisits as a return visit to an ED within seven days of the index visit. For both index and return visits, we assessed various patient characteristics, including age, cancer type, medical comorbidities, and ED disposition.

Results

Among 12.9 million ED visits, we identified 73,465 adult cancer patients comprising 103,523 visits that met our inclusion criteria. Cancer patients had a 7-day revisit rate of 17.9% vs 13.2% for non-cancer patients. Cancer patients had a higher rate of admission upon 7-day revisit (36.7% vs 15.6%). Patients with cancers of the small intestine, stomach, and pancreas had the highest rate of 7-day revisits (22–24%). Cancer patients younger than 65 had a higher 7-day revisit rate than the elderly (20.0% vs 16.2%).

Conclusion

In a review of all cancer-related ED visits in the state of California, we found a variety of characteristics associated with a higher rate of 7-day ED revisits. Our goal in this study was to inform future research to identify interventions on the index visit that may improve patient outcomes.

Quality of care, resource use and patient outcome by use of emergency response team compared with standard care for critically ill medical patients in the emergency department: a retrospective single-centre cohort study from Norway

OBJECTIVE

The study aimed to investigate quality of care, resource use and patient outcome in management by an emergency response team versus standard care for critically ill medical patients in the emergency department (ED). The emergency response team was multidisciplinary and had eight members, with a registrar in internal medicine as team leader.

DESIGN

Register-based retrospective cohort study.

SETTING

Tertiary hospital in Norway.

PARTICIPANTS

The study included 1120 patients with National Early Warning Score 2 (NEWS2) 5-10 points from 2015 and 2016. Patients missing ≥3 NEWS2 part scores, <18 years and with orders 'Not for ICU' or 'Not for resuscitation' were excluded.

OUTCOME MEASURES

Quality of care: pain assessment documented, analgesics given within 20 min, complete set of vital signs documented and antibiotics within 60 min if sepsis. Resource use: >3 diagnostic interventions, critical care in the ED and ED length of stay (LOS) <180 min. Patient outcome: intensive care unit (ICU) admission, ICU LOS <66 hours, hospital LOS <194 hours and mortality.

RESULTS

The median age was 66 years, 53.5% were male, 44.3% were admitted to the ICU and the mortality rate was 10.6%. Altogether 691 patients received team management and 429 standard care. Team management had a positive association with 'complete set of vital signs documented' (OR 1.720, CI 1.254 to 2.360), 'analgesics given within 20 minutes' (OR 3.268, CI 1.375 to 7.767) and 'antibiotics within 60 minutes if sepsis' (OR 7.880, CI 3.322 to 18.691), but a negative association with ' pain assessment documented' (OR 0.068, CI 0.037 to 0.128). Team management was also associated with 'critical care in the ED' (OR 9.900, CI 7.127 to 13.751), 'ED LOS <180 min' (OR 2.944, CI 2.070 to 4.187), 'ICU admission' (OR 2.763, CI 1.962 to 3.891) and 'mortality' (OR 1.882, CI 1.142 to 3.102).

CONCLUSIONS

Team management showed positive results for quality of care and resource use. The results for later outcomes such as mortality, ICU LOS and hospital LOS were more ambiguous.

Quality Indicators for Older Persons' Transitions in Care: A Systematic Review and Delphi Process

We identified quality indicators (QIs) for care during transitions of older persons (≥ 65 years of age). Through systematic literature review, we catalogued QIs related to older persons' transitions in care among continuing care settings and between continuing care and acute care settings and back. Through two Delphi survey rounds, experts ranked relevance, feasibility, and scientific soundness of QIs. A steering committee reviewed QIs for their feasible capture in Canadian administrative databases. Our search yielded 326 QIs from 53 sources. A final set of 38 feasible indicators to measure in current practice was included. The highest proportions of indicators were for the emergency department (47%) and the Institute of Medicine (IOM) quality domain of effectiveness (39.5%). Most feasible indicators were outcome indicators. Our work highlights a lack of standardized transition QI development in practice, and the limitations of current free-text documentation systems in capturing relevant and consistent data.

Patient-Reported Outcome Measurements (PROMs) After Discharge From the Emergency Department: A Cross-Sectional Study

BACKGROUND

The purpose of a patient-reported outcome (PRO) is to elicit the perspectives of patients and translate them into a reliable measurement questionnaire.

OBJECTIVES

The objective of this cross-sectional study was to detect a set of PROs and PRO measurements (PROMs) about patients with isolated trauma of the limbs receiving emergency department (ED) care.

METHODS

A survey was performed in the ED using a questionnaire among the enrolled patients to identify which proposed outcomes were perceived as important by the patients according to their expectations.

RESULTS

Ninety-six consecutive patients were conveniently enrolled. For each item of the questionnaire, the percentage of patients who agreed to perceive it important were calculated. Three items were perceived important by almost 85% of the patients: getting an x-ray (91%; 95% CI: 88%-98%), obtaining a written therapy (94%; 95% CI: 87%-97%), and feeling the physicians' and nurses' empathy (97%; 95% CI: 91%-99%). The ED system was able to satisfy 2 of the 3 agreed PROs in at least 85% of the cases: getting an x-ray (97%; 95% CI: 91%-99%) and obtaining a written therapy (97%; 95% CI: 91%-99%). Moreover, in 30/96 patients (31%; 95% CI: 22%-41%), all the PROs were satisfied, and in 75/96 patients (78%; 95% CI: 69%-85%), all agreed PROs were satisfied.

CONCLUSIONS

Our study shows an example of core of PROs proposed by the ED physicians and agreed by the patients. Moreover, we presented a set of PROMs which could be used to measure the quality of an ED.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study

BACKGROUND

In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal.

OBJECTIVE

The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease.

METHODS

A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness.

RESULTS

Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025.

CONCLUSIONS

The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/25619.

Pediatric Emergency Department Return Visits: An Innovative and Systematic Approach to Promote Quality Improvement and Patient Safety

OBJECTIVES

Emergency department (ED) return visits (RVs) leading to hospital admission are a quality measure that can potentially signal gaps in patient care. Systematic capture and investigation of RVs at a case level can provide an understanding of patient- and visit-level factors associated with RVs, and thus inform system-level quality improvement (QI) opportunities. Our objective is to describe the development of a database that enables tracking and analyzing of all pediatric ED RVs, to understand recurring themes and inform QI initiatives.

METHODS

A single-center retrospective cohort study was conducted at a quaternary care children's hospital during a 3-year period (December 2013 to November 2016). All 72-hour RVs were audited for patient- and visit-level variables and clinicians completed root-cause analyses of their RVs. Using descriptive statistics, variables associated with RVs and system-level quality themes were identified.

RESULTS

Of 214,047 ED patient visits, 1546 (0.7%) patients returned within 72 hours and were admitted. The RV patients had higher acuity scores on both visits compared with all ED visits, and the RV group had a higher proportion of children younger than 12 months than the overall ED visit group (25.0% vs 16.2%). The underlying cause for the majority of RVs was determined to be natural disease progression (63%), whereas 9% were callbacks for positive blood cultures or discrepant radiology results, and 6% were categorized as misdiagnoses. Several successful QI initiatives were completed as a result of the program.

CONCLUSIONS

Systematic monitoring and investigation of all ED RVs provides an innovative and effective approach to seeking provider- and system-level improvement opportunities.

Improving Quality of Care Through a Mandatory Provincial Audit Program: Ontario's Emergency Department Return Visit Quality Program

The Emergency Department Return Visit Quality Program was launched in Ontario, Canada, to promote a culture of quality. It mandates the province's largest-volume emergency departments (EDs) to audit charts of patients who had a return visit leading to hospital admission, including some of their 72-hour all-cause return visits with admission and all of their 7-day ones with sentinel diagnoses (ie, acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis), and submit their findings to a governmental agency. This provides an opportunity to identify possible adverse events and quality issues, which hospitals can then address through quality improvement initiatives. A group of emergency physicians with quality improvement expertise analyzed the submitted audits and accompanying narrative templates, using a general inductive approach to develop a novel classification of recurrent quality themes. Since the Return Visit Quality Program launched in 2016, 125,698 return visits with admission have been identified, representing 0.93% of the 86 participating EDs' 13,559,664 visits. Overall, participating hospitals have conducted 12,852 detailed chart audits, uncovering 3,010 (23.4%) adverse events/quality issues and undertaking hundreds of quality improvement provincewide projects as a result. The inductive analysis revealed 11 recurrent themes, classified into 3 groupings: patient characteristics (ie, patient risk profile and elder care), ED team actions or processes (ie, physician cognitive lapses, documentation, handover/communication between providers, radiology, vital signs, and high-risk medications or medication interactions), and health care system issues (ie, discharge planning/community follow-up, left against medical advice/left without being seen, and imaging/testing availability). The Return Visit Quality Program is the largest mandatory audit program for EDs and provides a novel approach to identify local adverse events/quality issues to target for improved patient safety and quality of care. It provides a blueprint for health system leaders to enable clinicians to develop an approach to organizational quality, as well as for teams to construct an audit system that yields defined issues amenable to improvement.

Strategies to measure and improve emergency department performance: a scoping review

Background

Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide. Crowding is a complex and challenging issue that affects EDs’ capacity to provide safe, timely and quality care. This review aims to map the research evidence provided by reviews to improve ED performance.

Methods and findings

We performed a scoping review, searching Cochrane Database of Systematic Reviews, Scopus, EMBASE, CINAHL and PubMed (from inception to July 9, 2019; prospectively registered in Open Science Framework https://osf.io/gkq4t/). Eligibility criteria were: (1) review of primary research studies, published in English; (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on a hospital ED context in any country or healthcare system. Pairs of reviewers independently screened studies’ titles, abstracts, and full-texts for inclusion according to pre-established criteria. Discrepancies were resolved via discussion. Independent reviewers extracted data using a tool specifically designed for the review. Pairs of independent reviewers explored the quality of included reviews using the Risk of Bias in Systematic Reviews tool. Narrative synthesis was performed on the 77 included reviews. Three reviews identified 202 individual indicators of ED performance. Seventy-four reviews reported 38 different interventions to improve ED performance: 27 interventions describing changes to practice and process (e.g., triage, care transitions, technology), and a further nine interventions describing changes to team composition (e.g., advanced nursing roles, scribes, pharmacy). Two reviews reported on two interventions addressing the role of patients in ED performance, supporting patients’ decisions and providing education. The outcomes attributed to interventions used to improve ED performance were categorised into five key domains: time, proportion, process, cost, and clinical outcomes. Few interventions reported outcomes across all five outcome domains.

Conclusions

ED performance measurement is complex, involving automated information technology mechanisms and manual data collection, reflecting the multifaceted nature of ED care. Interventions to improve ED performance address a broad range of ED processes and disciplines.

Canadian in-hospital mortality for patients with emergency-sensitive conditions: a retrospective cohort study

Background

The emergency department (ED) sensitive hospital standardized mortality ratio (ED-HSMR) measures risk-adjusted mortality for patients admitted to hospital with conditions for which ED care may improve health outcomes. This study aimed to describe in-hospital mortality across Canadian provinces using the ED-HSMR.

Methods

Hospital discharge data were analyzed from April 2009 to March 2012. The ED-HSMR was calculated as the ratio of observed deaths among patients with emergency-sensitive conditions in a hospital during a year (2010–11 or 2011–12) to the expected deaths for the same patients during the reference year (2009–10), multiplied by 100. The expected deaths were estimated using predictive models fitted from the reference year. Aggregated provincial ED-HSMR values were calculated. A HSMR value above or below 100 respectively means that more or fewer deaths than expected occurred within a province.

Results

During the study period, 1,335,379 patients were admitted to hospital in Canada with an emergency-sensitive condition as the most responsible diagnosis. More in-hospital deaths (95% confidence interval) than expected were respectively observed for the years 2010–11 and 2011–12 in Newfoundland [124.3 (116.3–132.6); & 117.6 (110.1–125.5)] and Nova Scotia [116.4 (110.7–122.5) & 108.7 (103.0–114.5)], while mortality was as expected in Prince Edward Island [99.9 (86.5–114.8) & 100.7 (87.5–115.3)] and Manitoba [99.2 (94.5–104.1) & 98.3 (93.5–103.3)], and less than expected in all other provinces and territories.

Conclusions

Our study revealed important variation in risk-adjusted mortality for patients admitted to hospital with emergency-sensitive conditions among Canadian provinces. The ED-HSMR may be a useful outcome indicator to complement existing process indicators in measuring ED performance.

Trial registration

N/A – Retrospective cohort study.

Predicting Emergency Department "Bouncebacks": A Retrospective Cohort Analysis

INTRODUCTION

The short-term return visit rate among patients discharged from emergency departments (ED) is a quality metric and target for interventions. The ability to accurately identify which patients are more likely to revisit the ED could allow EDs and health systems to develop more focused interventions, but efforts to reduce revisits have not yet found success. Whether patients with a high number of ED visits are at increased risk of a return visit remains underexplored.

METHODS

This was a population-based, retrospective, cohort study using administrative data from a large physician partnership. We included patients discharged from EDs from 80 hospitals in seven states from July 2014 - June 2016. We performed multivariable logistic regression of short-term return visits on patient, visit, hospital, and community characteristics. The primary outcome was the proportion of patients who had a return visit within 14 days of an index ED visit.

RESULTS

Among 6,699,717 index visits, the overall risk of 14-day revisit was 12.6%. Frequent visitors accounted for 18.7% of all visits and 40.2% of all 14-day revisits. Frequent visitor status was associated with the highest odds of a revisit (odds ratio [OR] 3.06; 95% confidence interval [CI], 3.041 - 3.073). Other predictors of revisits were cellulitis (OR 2.131; 95% CI, 2.106 - 2.156), alcohol-related disorders (OR 1.579; 95%CI, 1.548 - 1.610), congestive heart failure (OR 1.175; 95% CI, 1.126 - 1.226), and public insurance (Medicaid OR 1.514; 95% CI, 1.501 - 1.528; Medicare OR 1.601; 95% CI, 1.583 - 1.620).

CONCLUSION

Previous ED use - even a single previous visit - was a stronger predictor of a return visit than any other patient, hospital, or community characteristic. Clinicians should consider previous ED use when considering treatment decisions and risk of return visit, as should stakeholders targeting patients at risk of a return visit.

Establishment of a Unified Quality Indicators System to Increase the Effectiveness of Emergency Departments

The overall quality of an emergency department (ED) can be measured by its ability to provide fast, efficient yet high-quality medical treatments to its patients. The objective of the present study was to derive a common set of key indicators that could be used to assess the quality of the performance of EDs. A modified Delphi process was employed to achieve this. This consisted of a detailed literature review followed by a three-round expert panel interaction, which was used to reduce and refine the list of indicators. The members of the panel comprised ED physicians, ED nurses and hospital and ED administrators drawn from six EDs. This process yielded 47 essential performance indicators and 12 recommended indicators. The performance indicators were classified into 7 main groups according to their characteristics. The chosen indicators comprise a core set that will be used in an ongoing study on a representative sample of EDs.

Risk Factors for Emergency Department Unscheduled Return Visits

Background and Objectives: This study aims to identify reasons for unscheduled return visits (URVs), and risk factors for diagnostic errors leading to URVs, with comparisons to data from a similar study conducted in the same institution 9 years ago. Materials and Methods: This retrospective study included adult patients who attended the emergency department (ED) of a tertiary hospital in Singapore between January 2014 and June 2014, with re-attendance within 72 h for the same or similar complaint. The primary outcome was wrong or delayed diagnoses. Secondary outcomes include admission to the ED observation unit or ward on return visit. Findings were compared with the previous study performed in 2005 to identify trends. Results: Of 67,422 attendances, there were 1298 (1.93%) URVs from 1207 patients (median age 34, interquartile range 24 to 52 years; 59.7% male). The most common presenting complaint was abdominal pain (22.2%). One hundred ninety-one (15.8%) patients received an initial wrong or delayed diagnosis. Factors (adjusted odds ratio; 95% CI) associated with this were: presenting complaints of abdominal pain (2.99; 2.12–4.23), fever (1.60; 1.1–2.33), neurological deficit (4.26; 1.94–9.35), and discharge without follow-up (1.61; 1.1–2.26). Among re-attendances, 459 (38.0%) required admission. Factors (adjusted odds ratio; 95% CI) associated with admission were: male gender (1.88; 1.42 to 2.48); comorbidities of diabetes mellitus (2.07; 1.29–3.31), asthma (5.23; 1.59–17.26), and renal disease (7.48; 2.00–28.05); presenting complaints of abdominal pain (1.83; 1.32–2.55), fever (3.05; 2.10–4.44), and giddiness or vertigo (2.17; 1.26–3.73). There was a reduction in URV rate compared to the previous study in 2005 (1.93% versus 2.19%). Abdominal pain at the index visit remains a significant cause of URVs (22.2% versus 25.1%). Conclusions: Presenting complaints of neurological deficits, abdominal pain, fever, and discharge without follow-up were associated with wrong or delayed diagnoses among URVs.

Validation of a tool to assess patient satisfaction, waiting times, healthcare utilization, and cost

AIM

Patients' experience of the quality of care received throughout their continuum of care can be used to direct quality improvement efforts in areas where they are most needed. This study aims to establish validity and reliability of the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) - a tool that collects patients' experience that quantifies aspect of care used to make judgments about quality from the perspective of the Alberta Quality Matrix for Health (AQMH).

BACKGROUND

The AQMH is a framework that can be used to assess and compare the quality of care in different healthcare settings. The AQMH provides a common language, understanding, and approach to assessing quality. The HAPSQ is one tool that is able to assess quality of care according to five of six AQMH's dimensions.

METHODS

This was a prospective methodologic study. Between March and October 2015, a convenience sample of patients presenting with chronic full-thickness rotator cuff tears was recruited prospectively from the University of Calgary Sport Medicine Centre in Calgary, Alberta, Canada. Reliability of the HAPSQ was assessed using test-retest reliability [interclass correlation coefficient (ICC)>0.70]. Validity was assessed through content validity (patient interviews, floor and ceiling effects), criterion validity (percent agreement >70%), and construct validity (hypothesis testing).

FINDINGS

Reliability testing was completed on 70 patients; validity testing occurred on 96 patients. The mean duration of symptoms was three years (SD: 5.0, range: 0.1-29). Only out-of-pocket utilization possessed an ICC<0.70. Patients reported that items were relevant and appropriate to measuring quality of care. No floor or ceiling effects were present. Criterion validity was reached for all items assessed. A priori hypotheses were confirmed. The HAPSQ represents an inexpensive, reliable, and valid approach toward collecting clinical information across a patient's continuum of care.

Relevance of using length of stay as a key indicator to monitor emergency department performance: Case study from a rural hospital in Thailand

OBJECTIVE

The present study explores factors related to length of stay (LOS) in a rural public hospital in Thailand and assesses the feasibility of using LOS as an ED key performance indicator.

METHODS

Using a mixed-methods approach, qualitative methods (in-depth interviews, patients' chart review and participatory observations) were used to guide and elaborate findings from quantitative analysis of 555 electronic ED records.

RESULTS

Multivariate analysis revealed that age, Emergency Severity Index score and number of laboratory tests were significantly associated with LOS. The qualitative approach provided contradicting evidence on the linkage between LOS and patient outcomes. On the one hand, considering the 4 h rule, a child with asthma was referred to a tertiary care hospital because of deterioration after 4 h of ED care. On the other hand, a woman with sepsis was hospitalised with improved condition despite 7 h of ED care. Interviews revealed the waiting time to see doctors was probably the top priority issue for patients.

CONCLUSIONS

Factors related to LOS in a rural hospital in Thailand are similar and in contrast to those of a previous study in a medical school setting. Reasons for the discrepancy of findings and implications for improving ED services were discussed. Our data support the notion of controversy in using LOS as a key indicator of ED performance in this rural hospital setting. Thus, it is imperative to not rely on any single throughput or process indicators to monitor ED performance, but to take into account a set of indicators including patient outcomes.

Diagnostic Decision-Making in the Emergency Department

Emergency medicine requires diagnosing unfamiliar patients with undifferentiated acute presentations. This requires hypothesis generation and questioning, examination, and testing. Balancing patient load, care across the severity spectrum, and frequent interruptions create time pressures that predispose humans to fast thinking or cognitive shortcuts, including cognitive biases. Diagnostic error is the failure to establish an accurate and timely explanation of the problem or communicate that to the patient, often contributing to physical, emotional, or financial harm. Methods for monitoring diagnostic error in the emergency department are needed to establish frequency and serve as a foundation for future interventions.

Consensus-based cross-European recommendations for the identification, measurement and valuation of costs in health economic evaluations: a European Delphi study

OBJECTIVES

Differences between country-specific guidelines for economic evaluations complicate the execution of international economic evaluations. The aim of this study was to develop cross-European recommendations for the identification, measurement and valuation of resource use and lost productivity in economic evaluations using a Delphi procedure.

METHODS

A comprehensive literature search was conducted to identify European guidelines on the execution of economic evaluations or costing studies as part of economic evaluations. Guideline recommendations were extracted by two independent reviewers and formed the basis for the first round of the Delphi study, which was conducted among European health economic experts. During three written rounds, consensus (agreement of 67% or higher) was sought on items concerning the identification, measurement and valuation of costs.

RESULTS

Recommendations from 18 guidelines were extracted. Consensus among 26 panellists from 17 European countries was reached on 61 of 68 items. The recommendations from the Delphi study are to adopt a societal perspective, to use patient report for measuring resource use and lost productivity, to value both constructs with use of country-specific standardized/unit costs and to use country-specific discounting rates.

CONCLUSION

This study provides consensus-based cross-European recommendations on how to measure and value resource use and lost productivity in economic evaluations. These recommendations are expected to support researchers, healthcare professionals, and policymakers in executing and appraising economic evaluations performed in international contexts.

Using a modified nominal group technique to develop general practice

Background

There are few areas of health care where sufficient research-based evidence exists and primary health care is no exception. In the absence of such evidence, the development of assisted support must be based on the opinions and experience of professionals with knowledge of the relevant field. The purpose of this research project is to explore how the nominal group technique can be used to establish consensus by analysing how it supported the development of structured, knowledge-based, electronic health records for preventive child health examinations in Danish general practice.

Methods

We convened an expert panel of five general practitioners with a special interest in the preventive child health examinations. We introduced the panel to the nominal group technique, a well-established, structured, multistep, facilitated, group meeting technique used to generate consensus. The panel used the technique to agree on the key clinical and socioeconomic themes to include in new electronic records for the seven preventive child health examinations in Denmark. The panel met three times over a four-month period between 2013 and 2014 and their meetings lasted between two-and-a-half and five hours.

Results

1) The structured and stepwise process of the nominal group technique supported our expert panel’s focus as well as their equal opportunities to speak. 2) The method’s flexibility enabled participants to work as a group and in pairs to discuss and refine thematic classifications. 3) Serial meetings supported continual evaluation, critical reflection, and knowledge searches, enabling our panel to produce a template that could be adapted for all seven preventive child health examinations.

Conclusion

The nominal group technique proved to be a useful method for reaching consensus by identifying key quality markers for use in daily clinical practice. Our study focused on the development of content and a layout for systematic, knowledge-based, electronic health records. We recommend the method as a suitable working tool for dealing with complex questions in general practice or similar settings, and we present and discuss modifications to the original model.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children

OBJECTIVE

The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit.

METHODS

This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission).

RESULTS

Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission.

CONCLUSIONS

Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.

Implementation of an emergency department atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation, reduces length of stay and thirty-day revisit rates for congestive heart failure

Objectives

An evidence-based emergency department (ED) atrial fibrillation and flutter (AFF) pathway was developed to improve care. The primary objective was to measure rates of new anticoagulation (AC) on ED discharge for AFF patients who were not AC correctly upon presentation.

Methods

This is a pre-post evaluation from April to December 2013 measuring the impact of our pathway on rates of new AC and other performance measures in patients with uncomplicated AFF solely managed by emergency physicians. A standardized chart review identified demographics, comorbidities, and ED treatments. The primary outcome was the rate of new AC. Secondary outcomes were ED length of stay (LOS), referrals to AFF clinic, ED revisit rates, and 30-day rates of return visits for congestive heart failure (CHF), stroke, major bleeding, and death.

Results

ED AFF patients totalling 301 (129 pre-pathway [PRE]; 172 post-pathway [POST]) were included; baseline demographics were similar between groups. The rates of AC at ED presentation were 18.6% (PRE) and 19.7% (POST). The rates of new AC on ED discharge were 48.6 % PRE (95% confidence interval [CI] 42.1%-55.1%) and 70.2% POST (62.1%-78.3%) (20.6% [p<0.01; 15.1-26.3]). Median ED LOS decreased from 262 to 218 minutes (44 minutes [p<0.03; 36.2-51.8]). Thirty-day rates of ED revisits for CHF decreased from 13.2% to 2.3% (10.9%; p<0.01; 8.1%-13.7%), and rates of other measures were similar.

Conclusions

The evidence-based pathway led to an improvement in the rate of patients with new AC upon discharge, a reduction in ED LOS, and decreased revisit rates for CHF.

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.

The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review

BACKGROUND

The prevalence of chronic illness and multimorbidity rises with population aging, thereby increasing the acuity of care. Consequently, the demand for emergency and critical care services has increased. However, the forecasted requirements for physicians have shown a continued shortage. Among efforts underway to search for innovations to strengthen the workforce, there is a heightened interest to have nurses in advanced practice participate in patient care at a great extent. Therefore, it is of interest to evaluate the impact of increasing the autonomy of nurses assuming advanced practice roles in emergency and critical care settings on patient outcomes.

OBJECTIVES

The objectives of this study are to present, critically appraise, and synthesize the best available evidence on the impact of advanced practice nursing on quality of care, clinical outcomes, patient satisfaction, and cost in emergency and critical care settings.

REVIEW METHODS

A comprehensive and systematic search of nine electronic databases and a hand-search of two key journals from 2006 to 2016 were conducted to identify studies evaluating the impact of advanced practice nursing in the emergency and critical care settings. Two authors were involved selecting the studies based on the inclusion criteria. Out of the original search yield of 12,061 studies, 15 studies were chosen for appraisal of methodological quality by two independent authors and subsequently included for analysis. Data was extracted using standardized tools.

RESULTS

Narrative synthesis was undertaken to summarize and report the findings. This review demonstrates that the involvement of nurses in advanced practice in emergency and critical care improves the length of stay, time to consultation/treatment, mortality, patient satisfaction, and cost savings.

CONCLUSIONS

Capitalizing on nurses in advanced practice to increase patients' access to emergency and critical care is appealing. This review suggests that the implementation of advanced practice nursing roles in the emergency and critical care settings improves patient outcomes. The transformation of healthcare delivery through effective utilization of the workforce may alleviate the impending rise in demand for health services. Nevertheless, it is necessary to first prepare a receptive context to effect sustainable change.

Patients' Perspectives on Outcomes of Care After Discharge From the Emergency Department: A Qualitative Study

STUDY OBJECTIVE

Much effort has been expended to understand what care experiences patients value in the emergency department (ED), yet little is known about which outcomes patients value after ED care. Our goal is to define outcomes of ED care that are valued by patients discharged from the ED, with the goal of informing the development of a patient-reported outcome measure for ED care.

METHODS

We conducted qualitative semistructured interviews with patients recruited during their care at 1 of 2 EDs and interviewed in either English or French 1 to 9 days after their visit. Patients who were hospitalized were excluded. Interviews focused on perceived outcomes of care since the ED visit and expectations of care before the ED visit. We identified themes with standard descriptive content analysis techniques and a modified version of the constant comparative method, drawing on grounded theory methods.

RESULTS

We interviewed 46 patients in English (n=38) or French (n=8). Participants with diverse reasons for seeking care appeared to value common outcomes from ED care that centered around 4 themes: understanding the cause and expected trajectory of their symptoms; reassurance; symptom relief; and having a plan to manage their symptoms, resolve their issue, or pursue further medical care. These themes were also reflected in the expectations participants recalled having when they decided to seek care in the ED.

CONCLUSION

The 4 outcomes defined constitute areas for improvement and will inform the development of an ED patient-reported outcome questionnaire. Consideration should be given to measuring patient-reported outcomes separately from patient experience.

Variables associated with administration of analgesia, nurse-initiated analgesia and early analgesia in the emergency department

OBJECTIVE

To determine the patient and clinical variables associated with administration of any analgesia, nurse-initiated analgesia (NIA, prescribed and administered by a nurse) and early analgesia (within 30 min of presentation).

METHODS

We undertook a retrospective cohort study of patients who presented to a metropolitan ED in Melbourne, Australia, during July and August, 2013. The ED has an established NIA programme. Patients were included if they were aged 18 years or more and presented with a painful complaint. The study sample was randomly selected from a list of all eligible patients. Data were extracted electronically from the ED records and by explicit extraction from the medical record. Logistic regression models were constructed to assess associations with the three binary study end points.

RESULTS

1289 patients were enrolled. Patients were less likely to receive any analgesia if they presented 08:00-15:59 hours (OR 0.67, 95% CI 0.46 to 0.98) or 16:00-24:00 hours (OR 0.55, 95% CI 0.37 to 0.80) were triage category 5 (OR 0.20, 95% CI 0.08 to 0.49) or required an interpreter (OR 0.34, 95% CI 0.14 to 0.86). Patients were less likely to receive NIA or early analgesia if they were aged 56 years or more (OR 0.70 and 0.63; OR 0.57 and 0.21, respectively) or if they had received ambulance analgesia (OR 0.59, 95% CI 0.36 to 0.95; OR 0.38, 95% CI 0.20 to 0.74, respectively).

CONCLUSIONS

Patients who present during the daytime, have a triage category of 5 or require an interpreter are less likely to receive analgesia. Older patients and those who received ambulance analgesia are less likely to receive NIA or early analgesia.

An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider

BACKGROUND

Scientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a provider (ie, a paradoxical visit, PV).

METHODS

Using a retrospective cohort design, administrative data from Winnipeg, Manitoba were interrogated to identify all ED patients 17+ years old as having zero, single or multiple PVs in 2012/2013. Analyses compare the sociodemographic, physical (eg, arthritis), mental (eg, substance abuse) and concurrent healthcare use profile of non-PV, single and multiple PV patients.

RESULTS

The study cohort consisted of 122 639 patients with 250 754 ED visits. Across all ED sites, 2.3% of patients (N=2815) made 3387 PVs, comprising 1.4% of all ED visits. Descriptively, more single versus non-PV patients lived in urban core and lowest-income areas, were frequent ED users generally, were substance abusers and had seven plus primary care physician visits. Multiple PV patients had a similar but more extreme profile versus their single PV counterparts (eg, 54.7% of multiple vs 27.4% of single PV patients had substance abuse challenges). From multivariate statistics, single versus non-PV patients are defined uniquely by their frequent ED use, by their substance abuse, as living in a core and low income area, and as having multiple visits with primary care physicians.

CONCLUSIONS

PV patients have needs that do not align with the acute model of ED care. These patients may benefit from a more integrated care approach likely involving allied health professionals.

Factors Affecting Quality of Emergency Service in Iran's Military Hospitals: A Qualitative Study

INTRODUCTION

Quality is a key factor for the success of any organization. Moreover, accessing quality in the emergency department is highly significant due to the sensitive and complex role of this department in hospitals as well as the healthcare and medical treatment system. This study aimed to identify, from the perspective of medical experts and nurses serving in the military health and medical treatment system, the factors that affect the quality of emergency service provided in selected military hospitals in Iran.

METHODS

This qualitative research was performed in Valiaser Hospital of Tehran (Iran) in 2015, using the framework analysis method. The purposive sampling technique was used for data collection. A total of 14 participants included two emergency medicine specialists, four general physicians, two senior nurses (holding M.Sc. degrees), and six nurses (holding B.Sc. degree). Data were collected through semistructured interviews. Sampling continued until data saturation occurred. The Atlas/Ti software was employed for data analysis.

RESULTS

Four basic themes emerged as the effective factors on the quality of emergency services, namely, structural themes, process/performance themes, outcome themes, and environmental/contextual themes. Moreover, through a framework analysis, 47 subthemes were specified and summarized as indicators of the different aspects of the main themes.

CONCLUSION

The factors affecting the quality of emergency services in Iran's selected military hospitals are especially complicated due to the diversity of the missions involved; thus, different factors can influence this quality. Therefore, an effort should be made to tackle the existing obstacles, facilitate the identification of these effective factors, and promotion of the quality of healthcare services.

The challenges of measuring quality-of-care indicators in rural emergency departments: a cross-sectional descriptive study

BACKGROUND

Evidence-based indicators of quality of care have been developed to improve care and performance in Canadian emergency departments. The feasibility of measuring these indicators has been assessed mainly in urban and academic emergency departments. We sought to assess the feasibility of measuring quality-of-care indicators in rural emergency departments in Quebec.

METHODS

We previously identified rural emergency departments in Quebec that offered medical coverage with hospital beds 24 hours a day, 7 days a week and were located in rural areas or small towns as defined by Statistics Canada. A standardized protocol was sent to each emergency department to collect data on 27 validated quality-of-care indicators in 8 categories: duration of stay, patient safety, pain management, pediatrics, cardiology, respiratory care, stroke and sepsis/infection. Data were collected by local professional medical archivists between June and December 2013.

RESULTS

Fifteen (58%) of the 26 emergency departments invited to participate completed data collection. The ability to measure the 27 quality-of-care indicators with the use of databases varied across departments. Centres 2, 5, 6 and 13 used databases for at least 21 of the indicators (78%-92%), whereas centres 3, 8, 9, 11, 12 and 15 used databases for 5 (18%) or fewer of the indicators. On average, the centres were able to measure only 41% of the indicators using heterogeneous databases and manual extraction. The 15 centres collected data from 15 different databases or combinations of databases. The average data collection time for each quality-of-care indicator varied from 5 to 88.5 minutes. The median data collection time was 15 minutes or less for most indicators.

INTERPRETATION

Quality-of-care indicators were not easily captured with the use of existing databases in rural emergency departments in Quebec. Further work is warranted to improve standardized measurement of these indicators in rural emergency departments in the province and to generalize the information gathered in this study to other health care environments.

[Potential for the survey of quality indicators based on a national emergency department registry : A systematic literature search]

BACKGROUND

Emergency department processes are often key for successful treatment. Therefore, collection of quality indicators is demanded. A basis for the collection is systematic, electronic documentation. The development of paper-based documentation into an electronic and interoperable national emergency registry is-besides the establishment of quality management for emergency departments-a target of the AKTIN project. The objective of this research is identification of internationally applied quality indicators.

METHODS

For the investigation of the current status of quality management in emergency departments based on quality indicators, a systematic literature search of the database PubMed, the Cochrane Library and the internet was performed.

RESULTS

Of the 170 internationally applied quality indicators, 25 with at least two references are identified. A total of 10 quality indicators are ascertainable by the data set. An enlargement of the data set will enable the collection of seven further quality indicators. The implementation of data of care behind the emergency processes will provide eight additional quality indicators.

CONCLUSION

This work was able to show that the potential of a national emergency registry for the establishment of quality indicators corresponds with the international systems taken into consideration and could provide a comparable collection of quality indicators.