Dr. Welch is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing.
The National Quality Forum (NQF) was bolder than anyone had expected. To the surprise of many who worked on this project, the forum endorsed five ED clinical measures and five operational ones after vetting information from numerous quality organizations and technical expert panels.
The NQF measures include evidence-based clinical actions considered critical in evaluating chief complaints. These are measured as compliance percentages or ratios. There also are operational benchmarks for performance, which typically are time measures and indicative of service quality. The definitions are:
1. Median Time from ED Arrival to ED Departure for Admitted ED Patients: Median time from ED arrival to time of departure from the ED for patients admitted to the facility from the ED.
2. Median Time from ED Arrival to ED Departure for Discharged ED Patients: Median time from ED arrival to time of departure from the emergency department for patients discharged from the ED.
3. Admit Decision Time to ED Departure Time for Admitted Patients: Median time from admit decision time to time of departure from the ED for emergency department patients admitted as inpatients.
4. Door-to-Provider Time: Time of first contact in the ED to the time when a patient sees the physician (provider) for the first time.
5. Left Without Being Seen: Percentage of patients leaving without being seen by a physician.
6. Severe Sepsis and Septic Shock Management Bundle: Initial steps in managing patients presenting with infection (severe sepsis or septic shock).
7. Confirmation of Endotracheal Tube Placement: Some method should be attempted to confirm ETT placement any time an endotracheal tube is placed into an airway in the ED, an endotraceal tube is placed by an outside provider and that patient arrives already intubated (EMS or hospital transfer), or when an airway is placed after patients arrive to the ED.
8. Pregnancy Test for Female Abdominal Pain Patients: Percentage of women 14 to 50 who present to the ED with a chief complaint of abdominal pain who have a pregnancy test (urine or serum) ordered in the ED.
9. Anticoagulation for Acute Pulmonary Embolus Patients: Percentage of patients newly diagnosed with a pulmonary embolus in the ED or referred to the ED with a new diagnosis of pulmonary embolus who has orders for anticoagulation (heparin or low molecular weight heparin) for pulmonary embolus while in the ED.
10. Pediatric Weight in Kilograms: Percent of ED patients under 13 with a current weight in kilograms documented in the ED record.
In a news release from NQF, the forum said the intent of the 10 measures is to reduce crowding, decrease patient waits, and improve quality. “The measures aim to improve efficiency and care coordination in emergency departments where high demand and capacity issues have increased patient wait time and decreased physician productivity,” the statement said.
These are worthwhile goals for emergency medicine, and these measures and the ideology behind them should be supported. The regrettable part is that emergency medicine did not develop these measures. Rather, we had to be pulled into this work by payers, quality organizations, regulatory bodies, and the public.