1. Quality Assurance Programs for the Emergency Department Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

2. What is Emergency Department "Quality Assurance" ? (Q/A)  Refers to mechanisms or programs designed to review patient care in the emergency department (E.D.) for : ƒ Identification of errors or deficiencies in patient care ƒ Training E.D. staff to avoid errors and correct deficiencies ƒ Overall improvement of quality of care offered  Also termed "Continuous Quality Improvement" (CQI) to emphasize the lack of "guarantee" in the process & need for ongoing avtivity

3. What Are the Options for an E.D. Q/A Program ?  One or more of these may be useful and applicable for any E.D. : ƒ Daily review of some or all of the prior day's E.D. patient care records (charts) ƒ Review and reports on specific "directed" types of cases or subjects ƒ Review and reports on all types of "major" events (such as deaths in the E.D.) ƒ Mechanisms for presentation of Q/A reports to E.D. staff for education ƒ Mechanisms to contact patients and families regarding potential problems or complaints

4. Specific Options for E.D. Q/A Programs  Daily audit of a random sample of prior day's charts  Weekly or monthly audit of sampled charts  Audit of all charts for a specified type of case for a defined period of time  Audit of all charts for specified individual members of the E.D. staff  Weekly or monthly meetings of staff designated as Q/A leaders or committee  Regular verbal & written reports for education of E.D. staff

5. Important Philosophical Aspects of an E.D. Q/A Program  Must have input from all the E.D. staff  "Due process" must be assured (for protection of the staff's rights)  It must be emphasized that the major goal of the Q/A system is improving patient care and educating the staff (not penalizing or criticizing the staff)  Should be an "open" process even though confidentiality of patient's medical information must be assured

6. Important Structural Aspects of an E.D. Q/A Program  Information from chart audits must be sent to E.D. leaders and administrators  Information from chart audits regarding deficiencies must be communicated directly back to the E.D. staff  Followup audits of identified deficiencies must be done to demonstrate correction or improvement  Formal wriiten records of audits must be maintained in case future additional review is needed

7. Suggested Items for Daily E.D. Q/A Chart Audits  Missing documentation ƒ Mode of arrival ƒ Vital signs ƒ Allergies ƒ History components ƒ Exam components ƒ Lab results ƒ X-ray findings ƒ Consultations ƒ Disposition ƒ Follow-up instructions  Missed tetanus immunizations  Followup not listed for newly diagnosed hypertension  Abnormal exam, lab, EKG, or X-ray results not addressed  Verification of attending supervision of resident and student cases

8. Chart Audit Items Which May Require Phone Notification of the Patient  Missed need for tetanus immunization  Missed fracture or dislocation on X-ray  Missed pneumonia or tumor on X-ray  Misinterpreted EKG  Abnormal lab value not addressed in original visit  Positive blood or urine culture result  Consultant or referral physician wants to have earlier than originally scheduled follow-up

9. Situations Requiring "Automatic" Q/A Review and Report  Death of patient in the E.D.  Major injury to patient occuring in the E.D.  Assault or major injury to E.D. staff  Event requiring institutional "incident report"  Complaint of major error by patient or family  Complaint of major error by consultant or referral physician  Potential life-threatening discrepancy noted on chart audit

10. Q/A Items to Review on a Weekly or Monthly Basis  These should be compared for each E.D physician and group of E.D. personnel : ƒ Complaints registered by patients or families ƒ Patients leaving "against medical advice" ƒ Patients leaving prior to evaluation ƒ Unscheduled rechecks ƒ Wound complications (such as infections) ƒ Revisit for same problem within 7 days ƒ Mean time durations for evaluation, admission, or discharge ƒ Caseloads per unit time

11. Important Q/A System Components for the E.D.  Followup for positive cultures reported by the hospital microbiology lab : ƒ Need to notify referral physician promptly ƒ May also need to notify patient directly  If E.D. EKG "overreading" is done by cardiology, need to notify patient directly to come back to E.D. if ischemia was missed  If major X-ray finding missed, need to notify patient directly or assure that referral physician notified and will follow up

12. Who Should Perform E.D. Q/A ?  Best if daily chart Q/A audits are done by physician not assigned that day to clinical duty  Probably best if specific staff designated as Q/A reviewers for better consistency  Department leaders and administrators need to be directly involved  Each type of department personnel must have input and specific Q/A system duties  Data may be accumulated by non-clinical personnel, but only personnel with clinical experience should be responsible for review & interpretation