Strategies to measure and improve emergency department performance: a scoping review

Elizabeth E Austin, Brette Blakely, Catalin Tufanaru, Amanda Selwood, Jeffrey Braithwaite, Robyn Clay-Williams, Elizabeth E Austin, Brette Blakely, Catalin Tufanaru, Amanda Selwood, Jeffrey Braithwaite, Robyn Clay-Williams

Abstract

Background: Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide. Crowding is a complex and challenging issue that affects EDs' capacity to provide safe, timely and quality care. This review aims to map the research evidence provided by reviews to improve ED performance.

Methods and findings: We performed a scoping review, searching Cochrane Database of Systematic Reviews, Scopus, EMBASE, CINAHL and PubMed (from inception to July 9, 2019; prospectively registered in Open Science Framework https://osf.io/gkq4t/). Eligibility criteria were: (1) review of primary research studies, published in English; (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on a hospital ED context in any country or healthcare system. Pairs of reviewers independently screened studies' titles, abstracts, and full-texts for inclusion according to pre-established criteria. Discrepancies were resolved via discussion. Independent reviewers extracted data using a tool specifically designed for the review. Pairs of independent reviewers explored the quality of included reviews using the Risk of Bias in Systematic Reviews tool. Narrative synthesis was performed on the 77 included reviews. Three reviews identified 202 individual indicators of ED performance. Seventy-four reviews reported 38 different interventions to improve ED performance: 27 interventions describing changes to practice and process (e.g., triage, care transitions, technology), and a further nine interventions describing changes to team composition (e.g., advanced nursing roles, scribes, pharmacy). Two reviews reported on two interventions addressing the role of patients in ED performance, supporting patients' decisions and providing education. The outcomes attributed to interventions used to improve ED performance were categorised into five key domains: time, proportion, process, cost, and clinical outcomes. Few interventions reported outcomes across all five outcome domains.

Conclusions: ED performance measurement is complex, involving automated information technology mechanisms and manual data collection, reflecting the multifaceted nature of ED care. Interventions to improve ED performance address a broad range of ED processes and disciplines.

Keywords: Length of stay; Observation units; Patient satisfaction; Point-of-care testing; Process re-design; Wait-time.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram for study selection
Fig. 2
Fig. 2
Distribution of published reviews over time
Fig. 3
Fig. 3
Distribution of published reviews by country affiliation of first author
Fig. 4
Fig. 4
Graphical presentation for ROBIS results across all included reviews. 1 study eligibility criteria prespecified and appropriate for the review question. 2 sensitivity of the search. 3 rigour of the data collection process. 4 appropriateness of the synthesis for the review question. 5 overall risk of bias. “Low”, “high”, or “unclear” represents the rated level of concern about bias associated with each domain [11]
Fig. 5
Fig. 5
Overview of the outcome measures used for ED interventions. The rich picture summarises the types of interventions identified by this review. The graphs for each intervention present the proportion of outcome measures reported for each domain for each intervention. Each proportion was calculated as the number of identified outcome measures in the domain divided by the total number of outcome measures for the intervention. CNS, clinical nurse specialist; CRNA, certified registered nurse anaesthetist; CIN, clinical initiatives nurse; RAZ/RAP, rapid assessment zone/ rapid assessment pod; MAU, medical assessment unit; ED, Emergency Department; QDU, quick diagnosis unit

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