Quality Assurance Programs for the Emergency Department

Jim Holliman, M.D., F.A.C.E.P.Professor of Military and Emergency MedicineUniformed Services UniversityClinical Professor of Emergency MedicineGeorge Washington UniversityBethesda, Maryland, U.S.A.

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 offeredAlso termed "Continuous Quality Improvement" (CQI) to emphasize the lack of "guarantee" in the process & need for ongoing avtivity

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

Specific Options for E.D. Q/A ProgramsDaily audit of a random sample of prior day's charts

Weekly or monthly audit of sampled chartsAudit 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

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

Important Structural Aspects of an E.D. Q/A ProgramInformation 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

Suggested Items for Daily E.D. Q/A Chart AuditsMissing documentationƒ Mode of arrivalƒ Vital signsƒ Allergiesƒ History componentsƒ Exam componentsƒ Lab resultsƒ X-ray findingsƒ Consultationsƒ Dispositionƒ 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

Chart Audit Items Which May Require Phone Notification of the Patient

Missed need for tetanus immunizationMissed fracture or dislocation on X-rayMissed pneumonia or tumor on X-rayMisinterpreted EKGAbnormal lab value not addressed in original visit

Positive blood or urine culture resultConsultant or referral physician wants to have earlier than originally scheduled follow-up

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. staffEvent requiring institutional "incident report"Complaint of major error by patient or familyComplaint of major error by consultant or referral physician

Potential life-threatening discrepancy noted on chart audit

Q/A Items to Review on a Weekly or Monthly BasisThese should be compared for each E.D physician and group of E.D. personnel :ƒ Complaints registered by patients or familiesƒ Patients leaving "against medical advice"ƒ Patients leaving prior to evaluationƒ Unscheduled rechecksƒ Wound complications (such as infections)ƒ Revisit for same problem within 7 daysƒ Mean time durations for evaluation, admission, or discharge

ƒ Caseloads per unit time

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 promptlyƒ 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

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