Emergency Medicine—Quality Indicators: the United Kingdom Perspective

The College of Emergency Medicine, London, England, UK.
Academic Emergency Medicine (Impact Factor: 2.01). 12/2011; 18(12):1239-41. DOI: 10.1111/j.1553-2712.2011.01223.x
Source: PubMed


ACADEMIC EMERGENCY MEDICINE 2011; 18:1239–1241 © 2011 by the Society for Academic Emergency Medicine
During the 1990s, relentlessly increasing emergency department (ED) attendances in the United Kingdom led to major dysfunction and ED overcrowding. The situation was exacerbated by outdated ED design, inadequate ED capacity, traditional ED processes, a predominantly junior doctor–based workforce, and insufficient in-hospital beds for patients requiring admission.
The crisis led to high-profile lobbying by the U.K. emergency medicine body (British Association for Emergency Medicine) and in the populist media. This led to the Reforming Emergency Care initiative and the 4-hour target.
This article describes the benefits and disadvantages associated with a single time-related measure of ED performance. The article also describes the subsequent development of a raft of quality indicators designed to provide a greater breadth of ED measurement, reflecting timeliness, quality, and safety. The intention is for these indicators to act as levers for change and to generate a program of continuing improvement in emergency care.
The indicators were introduced in England in April 2011, and currently there is a period of bedding-in and collective learning. The quality indicators will be reviewed and refined as required, with any amendments introduced in April 2012.

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    • "Excessive total time in the ED has been linked to poor outcome, and has been suggested as an important quality indicator [20]. Time to physician, as well, has been described as an indicator of quality and safety in the ED, since seeing a decision-maker is a necessity in order to get a prompt assessment and, subsequently, adequate treatment [20]. Hence, our results indicate that teamwork may have a positive impact on these important quality indicators in the ED. "
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    ABSTRACT: Long waiting times for emergency care are claimed to be caused by overcrowded emergency departments and non-effective working routines. Teamwork has been suggested as a promising solution to these issues. The aim of the present study was to investigate the effects of teamwork in a Swedish emergency department on lead times and patient flow. The study was set in an emergency department of a university hospital where teamwork, a multi-professional team responsible for the whole care process for a group of patients, was introduced. The study has a longitudinal non-randomized intervention study design. Data were collected for five two-week periods during a period of 1.5 years. The first part of the data collection used an ABAB design whereby standard procedure (A) was altered weekly with teamwork (B). Then, three follow-ups were conducted. At last follow-up, teamwork was permanently implemented. The outcome measures were: number of patients handled within teamwork time, time to physician, total visit time and number of patients handled within the 4-hour target. A total of 1,838 patient visits were studied. The effect on lead times was only evident at the last follow-up. Findings showed that the number of patients handled within teamwork time was almost equal between the different study periods. At the last follow-up, the median time to physician was significantly decreased by 11 minutes (p = 0.0005) compared to the control phase and the total visit time was significantly shorter at last follow-up compared to control phase (p = <0.0001; 39 minutes shorter on average). Finally, the 4-hour target was met in 71 % in the last follow-up compared to 59 % in the control phase (p = 0.0005). Teamwork seems to contribute to the quality improvement of emergency care in terms of small but significant decreases in lead times. However, although efficient work processes such as teamwork are necessary to ensure safe patient care, it is likely not sufficient for bringing about larger decreases in lead times or for meeting the 4-hour target in the emergency department.
    Full-text · Article · Nov 2013 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
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    • "Two review papers report on interviews or audits [32-34]. A single article refers to a British governmental report [35]. Two articles elaborate on the IOM guidelines [8,15] and a single article includes performance measurement tracking by the application of statistical process control (SPC) [36]. "
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    ABSTRACT: Evaluation of emergency department (ED) performance remains a difficult task due to the lack of consensus on performance measures that reflects high quality, efficiency, and sustainability. To describe, map, and critically evaluate which performance measures that the published literature regard as being most relevant in assessing overall ED performance. Following the PRISMA guidelines, a systematic literature review of review articles reporting accentuated ED performance measures was conducted in the databases of PubMed, Cochrane Library, and Web of Science. Study eligibility criteria includes: 1) the main purpose was to discuss, analyse, or promote performance measures best reflecting ED performance, 2) the article was a review article, and 3) the article reported macro-level performance measures, thus reflecting an overall departmental performance level. A number of articles addresses this study's objective (n = 14 of 46 unique hits). Time intervals and patient-related measures were dominant in the identified performance measures in review articles from US, UK, Sweden and Canada. Length of stay (LOS), time between patient arrival to initial clinical assessment, and time between patient arrivals to admission were highlighted by the majority of articles. Concurrently, "patients left without being seen" (LWBS), unplanned re-attendance within a maximum of 72 hours, mortality/morbidity, and number of unintended incidents were the most highlighted performance measures that related directly to the patient. Performance measures related to employees were only stated in two of the 14 included articles. A total of 55 ED performance measures were identified. ED time intervals were the most recommended performance measures followed by patient centeredness and safety performance measures. ED employee related performance measures were rarely mentioned in the investigated literature. The study's results allow for advancement towards improved performance measurement and standardised assessment across EDs.
    Full-text · Article · Aug 2013 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
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    ABSTRACT: ACADEMIC EMERGENCY MEDICINE 2011; 18:1229–1233 © 2011 by the Society for Academic Emergency Medicine Emergency department (ED) crowding is a major public health problem in the United States, with increasing numbers of ED visits, longer lengths of stay in the ED, and the common practice of ED boarding. In the next several years, several measures of ED crowding will be assessed and reported on government websites. In addition, with the implementation of the Affordable Care Act (ACA), millions more Americans will have health care insurance, many of whom will choose the ED for their care. In June 2011, a consensus conference was conducted in Boston, Massachusetts, by the journal Academic Emergency Medicine entitled “Interventions to Assure Quality in the Crowded Emergency Department.” The overall goal of the conference was to develop a series of research agendas to identify promising interventions to safeguard the quality of emergency care during crowded periods and to reduce ED crowding altogether through systemwide solutions. This was achieved through three objectives: 1) a review of interventions that have been implemented to reduce crowding and summarize the evidence of their effectiveness on the delivery of emergency care; 2) to identify strategies within or outside of the health care setting (i.e., policy, engineering, operations management, system design) that may help reduce crowding or improve the quality of emergency care provided during episodes of ED crowding; and 3) to identify the most appropriate design and analytic techniques for rigorously evaluating ED interventions designed to reduce crowding or improve the quality of emergency care provided during episodes of ED crowding. This article describes the background and rationale for the conference and highlights some of the discussions that occurred on the day of the conference. A series of manuscripts on the details of the conference is presented in this issue of Academic Emergency Medicine.
    Full-text · Article · Dec 2011 · Academic Emergency Medicine
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