Posted: May 9th, 2022

Quality of Healthcare in Emergency Departments

Quality of Healthcare in Emergency Departments

Emergency departments (EDs) are vital components of healthcare systems, providing accessible, timely and high-quality care to patients with acute and urgent needs. However, EDs face many challenges, such as increasing demand, crowding, resource constraints, patient safety issues and quality improvement needs. To measure and improve the quality of healthcare in EDs, various strategies have been proposed and implemented, such as developing quality indicators, implementing interventions to optimize ED processes and outcomes, and engaging patients in ED care. This blog post will review some of the evidence and best practices for these strategies, based on recent reviews and guidelines from the literature.

Quality indicators for EDs

Quality indicators are measurable aspects of healthcare that reflect the quality of care provided to patients. They can be used to monitor performance, identify gaps, benchmark against standards or peers, and evaluate the impact of interventions. Quality indicators for EDs can cover different domains, such as structure (e.g., staff, equipment, facilities), process (e.g., triage, diagnosis, treatment), outcome (e.g., mortality, morbidity, patient satisfaction) and efficiency (e.g., waiting time, length of stay, cost).

A review by Austin et al. (2020) identified 202 quality indicators for EDs from three previous reviews . The most common domains were process (44%), outcome (34%) and efficiency (14%). The most common topics were timeliness (18%), patient safety (13%) and clinical effectiveness (12%). The authors suggested that quality indicators for EDs should be pragmatic, measurable and prioritized according to the local context and improvement goals.

Another review by Hansen et al. (2020) proposed an updated framework for quality and safety in emergency medicine . The framework consisted of four components: core elements of emergency care (e.g., trained personnel, expert decisions, diagnostics), enablers of high-quality care (e.g., appropriate staff, access to care, coordinated care), impact of crowding on quality of care (e.g., increased morbidity, mortality and dissatisfaction), and quality improvement strategy (e.g., quality indicators, improvement interventions, monitoring outcomes).

Interventions to improve ED performance

Interventions to improve ED performance are actions or changes that aim to enhance the quality or efficiency of ED care. They can target different aspects of ED care, such as practice and process changes (e.g., triage, care transitions, technology), team composition changes (e.g., advanced nursing roles, scribes, pharmacy), or patient involvement (e.g., decision support, education).

A scoping review by Austin et al. (2020) reported 38 different interventions to improve ED performance from 74 reviews . The most common interventions were triage systems (13 reviews), fast-track or streaming systems (11 reviews), care transitions or discharge planning (10 reviews), advanced nursing roles (9 reviews), scribes (8 reviews) and technology interventions (8 reviews). The authors found that few interventions reported outcomes across all five outcome domains they identified: time, proportion, process, cost and clinical outcomes. They also noted that the evidence for the effectiveness of interventions was mixed and context-dependent.

A consensus framework by Hansen et al. (2020) recommended several interventions to improve quality and safety in emergency medicine . Some of these interventions were: implementing evidence-based guidelines and protocols; using clinical decision support systems; adopting lean management principles; applying human factors and ergonomics principles; conducting regular audits and feedback; engaging in multidisciplinary teamwork and communication; involving patients and families in care; fostering a culture of safety and learning; and collaborating with other healthcare providers.

The role of patients in improving ED performance

Patients are the main stakeholders of ED care and their perspectives and preferences are important for evaluating and improving the quality of healthcare in EDs. Patients can be involved in different ways in improving ED performance, such as providing feedback on their experiences and satisfaction; participating in shared decision making with clinicians; receiving education on their condition, treatment options and self-care; or engaging in self-management or follow-up care.

A review by Austin et al. (2020) found only two interventions that addressed the role of patients in improving ED performance . One intervention was a decision aid for patients with chest pain who were at low risk of acute coronary syndrome . The decision aid aimed to help patients understand their risk level, treatment options and preferences. The intervention reduced hospital admissions without increasing adverse events or decreasing patient satisfaction. Another intervention was an educational video for patients with low back pain who visited the ED . The video aimed to provide information on the causes, prognosis and management of low back pain. The intervention reduced opioid prescriptions without affecting pain scores or satisfaction.

A framework by Hansen et al. (2020) emphasized the importance of patient-centred care in emergency medicine . The framework suggested that patients should expect EDs to provide effective, safe, timely, equitable and respectful care. The framework also recommended that patients should be involved in their care, such as by expressing their needs and preferences, asking questions, providing feedback, and adhering to treatment plans.

Conclusion

Quality of healthcare in EDs is a complex and challenging issue that requires multiple strategies to measure and improve. Based on the literature, some of the strategies are: developing and using quality indicators that reflect the local context and improvement goals; implementing interventions that optimize ED processes and outcomes, based on evidence and best practices; and engaging patients in ED care, by providing information, education and decision support. These strategies can help EDs deliver the best care possible to patients with acute and urgent needs.

Bibliography

: Austin EE, Blakely B, Tufanaru C, Selwood A, Braithwaite J, Clay-Williams R. Strategies to measure and improve emergency department performance: a scoping review. Scand J Trauma Resusc Emerg Med. 2020;28(1):55. https://doi.org/10.1186/s13049-020-00749-2

: Hansen K, Boyle A, Holroyd B, Phillips G, Benger J, Chartier LB, et al. Updated framework on quality and safety in emergency medicine. Emerg Med J. 2020;37(7):437–442. https://doi.org/10.1136/emermed-2019-209290

: Hess EP, Hollander JE, Schaffer JT, Kline JA, Torres CA, Diercks DB, et al. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ. 2016;355:i6165. https://doi.org/10.1136/bmj.i6165

: Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572–1580. https://doi.org/10.1001/jama.2015.13043

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