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QUALITY INDICATORS FOR EMERGENCY MEDICINE Dr Peter Jones MSc EBHC (Oxon) FACEM With thanks to Dr Alana Harper FACEM and Dr James LeFevre FACEM.

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Presentation on theme: "QUALITY INDICATORS FOR EMERGENCY MEDICINE Dr Peter Jones MSc EBHC (Oxon) FACEM With thanks to Dr Alana Harper FACEM and Dr James LeFevre FACEM."— Presentation transcript:

1 QUALITY INDICATORS FOR EMERGENCY MEDICINE Dr Peter Jones MSc EBHC (Oxon) FACEM With thanks to Dr Alana Harper FACEM and Dr James LeFevre FACEM

2 Aim of this presentation Choosing Wisely Doing it Smart

3 Why Bother? Each ED could just decide what to measure and how to measure it Problems Time Resources Skills Duplication Accuracy Comparisons Imposed from outside Maximise the return for effort in a resource constrained environment

4 Whose Problem is it? PATIENTED HOSPITAL GOVERNMENT QUALITY ED Overcrowding

5 NZ ED LOS Target Improvement Source: Ministry of Health, NZ 80% <6hr in 2009, 93% <6hr in 2013 No Extra Funding

6 Cost of Target Improvement $52.2million Opportunity Cost?

7 Doing it Smart Balance Process AND Outcome Does improvement on the process indicator result in better outcomes?

8 CHOOSING QUALITY INDICATORS for EM The Shorter Stays in ED National Research Project

9 SSED What Effect on Clinical Markers of Care? Clinical Quality Markers Selection Literature review / Evidence Search Reference Group Meeting December 2010

10 SSED NRP Stream 2 Quality Method: Clinical Markers Eight conditions identified Represent whole system Sample Size Calculations Not all outcomes could be measured at all sites 10000 sets of notes = not feasible

11 Critical Appraisal of Quality Indicators (QICA) Rationalise choice of indicators

12 Using the QICA Tool Checklist 2 Authors independently appraised indicators Outcome brought to whole team Different views  Compromise Desire to measure >1 outcome and reflect whole system

13 EM Clinical Quality Indicators for the SSED Project Severe Asthma (30 min difference time to steroid) Common / relevant / important / evidence good All ages / Māori / Pacific Data available / accessible / sample size manageable all sites Sepsis (60 min difference time to antibiotic) Evidence moderate / important / relevant / all ages / Māori / Pacific Sample size issues + difficult data collection STEMI (15 min difference time to lysis) Evidence strong but practice changed over time

14 Doing it Smart Balance Process AND Outcome Time to treatment AND Appropriate treatment

15 SSED NRP Asthma Results: Time to Treatment To Steroid (60 min) To Salbutamol (Immediate) To Ipratropium (90 min) BABABA H1 59 (25-125) 63 (31-122) 29 (13-52) 25 (11-63) 30 (12-92) 57 (14-120) H2 70 (28-165) 44 (20-106) 21 (11-35) 23 (11-61) 61 (16-136) 43 (17-151) H3 64.5 (30-139) 47 (19-116) 22 (10.5-70) 22 (9-45) 51 (15.5-125) 31 (14.5-62) H4 72 (32-133) 67 (39-144) 30 (13-67) 42 (19-107) 67 (23-149) 60 (29-156) All 65 (29-141) 59 (23-122) 25 (12-57) 25 (12-63) 51 (16-131) 44 (18-123)

16 SSED NRP Asthma Results: ED Treatment Steroid (%)Salbutamol (%)Ipratropium (%) BABABA H189.894.798.3 54.169 H294.5 98.398.45856.6 H39295.195.699.153.663.8 H488.696.394.497.176.960.8 All91.495.196.798.260.562.5 More steroids ED: OR 2.1 (1.2-4.3) P=0.02

17 Doing it Smart Implementation of 4hr rule v SSED Within NZ between hospital variation How you do it counts!

18 Do Access Targets Improve Quality of Care? UK Mortality: No Change WA/QLD Mortality: Improved? UK Mortality: No Change NZ Mortality: TBA Victoria Mortality: No Change

19 Doing it Smart Should Quality be Incentivised? Pay for performance / league tables Unintended consequences are under your control! Don’t forget the Patients…

20 Quality in Emergency Medicine Questions?

21 Quality Indicators in the ED Abstract Healthcare quality indicators may seem to be chosen arbitrarily with the emphasis on ease of measurement rather than measuring what really counts. When choosing indicators key questions to consider are: Whose problem are you trying to solve and what are the benefits and costs for measuring this indicator? Beyond choosing the indicator the key to success lies in how you implement and act on the results you get. This presentation will use real world examples to inform the quality indicator selection and implementation process for ED and the health system.

22 Time to Treatment (min or hr*) Appropriate Treatment** (%) Mortality (%) BA p BA p BA p STEMI 28 (19-50) 31 (21-52) 0.14 91 (75-96) 88 (76-96) 0.53 6 (1-18) 12 (6-37) 0.57 Appx 14* (11-22) 20* (9-28) 0.23 76 (65-84) 66 (54-76) 0.26 0 (0-6) 1.4 (0-8) 0.98 Sepsis 135 (56-199) 113 (49-203) 0.93 92 (84-97) 88 (80-94) 0.54 39 (29-50) 37 (28-47) 0.86 #NOF 37* (22-56) 28* (20-51) 0.24 32 (26-39) 42 (35-51) 0.06 16 (11-22) 16 (11-22) 0.95 SSED NRP Stream 2 Other Indicators: Outcomes **Appropriate Treatment: AMI criteria for thrombolysis; Appropriate antibiotic for sepsis; Appendix not perforated at operation; Theatre <24hr for #NOF

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