CJEM Articles: Brian H. Rowe

Background:

The evaluation of emergency department (ED) quality of care is hampered by the absence of consensus on appropriate measures. We sought to develop a consensus on a prioritized and parsimonious set of evidence-based quality of care indicators for EDs.

Methods:

The process was led by a nationally representative steering committee and expert panel (representatives from hospital administration, emergency medicine, health information, government, and provincial quality councils). A comprehensive review of the scientific literature was conducted to identify candidate indicators. The expert panel reviewed candidate indicators in a modified Delphi panel process using electronic surveys; final decisions on inclusion of indicators were made by the steering committee in a guided nominal group process with facilitated discussion. Indicators in the final set were ranked based on their priority for measurement. A gap analysis identified areas where future indicator development is needed. A feasibility study of measuring the final set of indicators using current Canadian administrative databases was conducted.

Results:

A total of 170 candidate indicators were generated from the literature; these were assessed based on scientific soundness and their relevance or importance. Using predefined scoring criteria in two rounds of surveys, indicators were coded as “retained” (53), “discarded” (78), or “borderline” (39). A final set of 48 retained indicators was selected and grouped in nine categories (patient satisfaction, ED operations, patient safety, pain management, pediatrics, cardiac conditions, respiratory conditions, stroke, and sepsis or infection). Gap analysis suggested the need for new indicators in patient satisfaction, a healthy workplace, mental health and addiction, elder care, and community-hospital integration. Feasibility analysis found that 13 of 48 indicators (27%) can be measured using existing national administrative databases.

Discussion:

A broadly representative modified Delphi panel process resulted in a consensus on a set of 48 evidence-based quality of care indicators for EDs. Future work is required to generate technical definitions to enable the uptake of these indicators to support benchmarking, quality improvement, and accountability efforts.

Objective: We describe the epidemiology of asthma presentations to emergency departments (EDs) for 3 main regions in the province of Alberta.

Methods: We used a comprehensive ED database to identify ED visits in Alberta from April 1999 to March 2005. We linked the visits to other provincial administrative databases to obtain all data on follow-up encounters for asthma during that period. Information extracted included demographics, regions of residence (Edmonton, Calgary or non–major urban [NMU]), timing of ED visits, and subsequent visits to non-ED settings. Data analysis included descriptive summaries and directly standardized visit rates.

Results: During the 6-year study period, 93 146 patients made 199 991 ED visits for asthma. Crude rates in 2004/05 were 7.9/1000, 6.5/1000 and 15.4/1000 in the Edmonton, Calgary and NMU regions, respectively. The Edmonton and Calgary re­gions had consistently lower visit rates than the NMU regions. The ED visits were followed by low rates of follow-up visits in a variety of non-ED settings, at different intervals.

Conclusion: Asthma is a relatively common presenting problem in Alberta EDs. This study identified relatively stable rates of presentation during the study period, and variation among regions in terms of age and sex. This study provides further understanding of the variation associated with ED presentation and indicates possible targets for specific interventions to reduce asthma-related ED visits.

Objective: Some low-acuity emergency department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study assessed the frequency and determinants of patients' efforts to access alternative care before ED presentation.

Methods: Patients aged 17 years and older were randomly selected from 2 urban ED sites in Edmonton. Survey data were collected on use and characteristics of alternative care before the ED visit. Information was also collected on patient demographics and factors influencing their perception of whether the ED was the best care option.

Results: Of the 1389 patients approached, 905 (65%) completed the survey and data from 894 participants were analyzed. Sixty-one percent reported that they sought alternative care before visiting the ED. Eighty-nine of the patients who attempted alternative access before the ED visit felt that the ED was their best care option. Results of the multivariate logistic regression analysis showed that injury presentation, living arrangements, smoking status and whether or not patients had a family practitioner were predictors for seeking alternative care before visiting the ED.

Conclusion: Most ambulatory patients attempt to look for other sources of care before presenting to the ED. Despite this attempted access to alternative care, while patients wait for ED care, they perceive that the ED is their best care option at that point in time.

Introduction: Despite the frequency of acute asthma in the emergency department (ED) and the availability of guidelines, significant practice variation exists. Asthma care maps (ACMs) may standardize treatment. This study examined the use of an ACM to determine its effects on patient management in a regional hospital.

Methods: Patients aged 2 to 65 years who presented to the ED with a primary diagnosis of acute asthma were enrolled in a prospective study that took place 5 months before (pre) and 5 months after (post) ACM implementation. Research assistants using a standardized questionnaire abstracted data through direct patient interviews and then followed up at 2 weeks with a standardized telephone interview.

Results: Overall, 71 pre patients and 70 post patients were enrolled. Characteristics in both groups were similar. The care map was used in 100% of the cases during the post period. The mean length of stay in the ED for the pre, compared with the post period, was similar (2 h 14 min v. 2 h 25 min; p = 0.60), as were admission rates (11% v. 9%; p = 0.59). Systemic corticosteroid use was similar (62% v. 57%; p = 0.56); however, the total number of β-agonists (2 v. 4 treatments; p = 0.002) and anticholinergics (1 v. 2 treatments; p < 0.001) administered in the ED was higher during the post period. Prescriptions for oral (73% v. 60%; p = 0.15) and inhaled (78% v. 78%; p = 0.98) corticosteroids at discharge remained the same. Relapse rates at follow-up were unchanged (29% v. 34%; p = 0.52).

Conclusion: This study provides evidence that implementation of an ACM increased acute bronchodilator use; however, prescribing preventive medications did not increase. Further research is required to evaluate other strategies to improve asthma care by emergency physicians.