Quality Assurance Programs for the Emergency Department

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.
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 :
Identification of errors or deficiencies in patient
ƒ Training E.D. staff to avoid errors and correct
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
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. :
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
Daily audit of a random sample of prior day's
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
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 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
Formal wriiten records of audits must be
maintained in case future additional review
is needed
Suggested Items for Daily
E.D. Q/A Chart Audits
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
Followup not listed for
newly diagnosed
Abnormal exam, lab,
EKG, or X-ray results not
Verification of attending
supervision of resident
and student cases
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
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
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 :
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
ƒ Caseloads per unit time
Important Q/A System
Components for the E.D.
Followup for positive cultures reported by the
hospital microbiology lab :
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
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 &
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