Effect of a strategy for improving quality of care based on systematic measurement of and feedback on quality indicators in 3 highly prevalent emergency department situations

Objectives: To assess the effect of ongoing measurement of quality indicators affecting 2

different clinical processes that are highly prevalent in emergency care (acute asthma

exacerbation and nephritic colic) and also on the use of major opiates; to determine the

effect of giving staff information about the results of measurements and providing

training on how to improve the quality indicators.

Methods: Systematic recording of measures relating to various aspects of care for

processes that are highly prevalent in the emergency department caseload. Records

were started in 2005. The quality-of-care indicators reflected consensus-based protocols.

When substantial deviations from recommendations were identified, sessions to provide

information and training were scheduled. The sessions included reviews of cases. The

results of these strategies were analyzed for 2006 through 2012. Statistics on the

following indicators were compiled retrospectively month by month. For asthma

exacerbations, we compiled data on the recording of respiratory frequency and peakflow

volume, the ordering of chest x-rays and arterial blood gas analysis, and admissions.

For nephritic colic, we examined the recording of pain assessment on a categorical

numerical pain scale, the ordering of abdominal x-rays and ultrasound imaging, urology

consultations, admissions to the observation area or hospital ward, and emergency

revisits within 72 hours. We also collected data on the use of major opiates.

Results: A total of 1767 asthma exacerbations, 6114 cases of nephritic colic, and 22 751

prescriptions for opiates were evaluated during the study period. All records were

included. Most quality indicators failed to meet recommended levels in 2006. The

training strategy led to small changes, only some of which reached statistical

significance. In the treatment of asthma exacerbation, the number of x-rays ordered

decreased (P<.05). The measurement of respiratory frequency tended to rise in frequency but the difference was not significant (P=.13), and the frequencies of orders for arterial blood gas analyses and rates of hospital admissions were similar (P=.66 in both cases). In the treatment of nephritic colic, admissions to the observation area increased (P<.001) and hospital admissions decreased (P=.01). Urology consultations and the number of x-rays also decreased (P<.05 and P<.01, respectively), while the number of ultrasound imaging studies tended to decrease (P=<.07). Revisits remained similar (P<.55). The use of opiates for pain control increased (P=.001). Targets had been reached for only 4 of 13 indicators at the end of the study period. Conclusions: The systematic monitoring of statistics on clinical processes as part of a strategy to improve quality-of-care indicators and feedback on results during training sessions has had some positive effects. However, the changes have been small and they became evident only over the medium to long term.