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The level of evidence for emergency department performance indicators: systematic review

Madsen, Michaela; Kiuru, Sampsab,c; Castrèn, Maaretd; Kurland, Lisae,f

European Journal of Emergency Medicine: October 2015 - Volume 22 - Issue 5 - p 298–305
doi: 10.1097/MEJ.0000000000000279

The aim of this study was to perform a comprehensive systematic review of emergency department performance indicators in relation to evidence. A systematic search was performed through PUBMED, EMBASE, CINAHL and COCHRANE databases with (and including synonyms of) the search words: [emergency medicine OR emergency department] AND [quality indicator(s) OR performance indicator(s) OR performance measure(s)]. Articles were included according to the inclusion/exclusion criteria using the PRISMA protocol. The level of evidence was rated according to the evidence levels by the Oxford Centre for Evidence-Based Medicine. Performance indicators were extracted and organized into five categories; outcome, process, satisfaction, equity and structural/organizational measures. Six thousand four hundred and forty articles were initially identified; 127 provided evidence for/against a minimum of one performance indicator: these were included for further study. Of the 127 articles included, 113 (92%) were primary research studies and only nine (8%) were systematic reviews. Within the 127 articles, we found evidence for 202 individual indicators. Approximately half (n=104) of all this evidence (n=202) studied process-type indicators. Only seven articles (6%) qualified for high quality (level 1b). Sixty-six articles (51%) were good retrospective quality (level 2b or better), whereas the remaining articles were either intermediate quality (25% level 3a or 3b) or poor quality (17% level 4 or 5). We found limited evidence for most emergency department performance indicators, with the majority presenting a low level of evidence. Thus, a core group of evidence-based performance indicators cannot currently be recommended on the basis of this broad review of the literature.

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aSilkeborg Hospital and University of Copenhagen, Denmark

bAshburton Hospital, Canterbury DHB, New Zealand

cUniversity of Turku, Finland

dDepartment of Emergency Medicine and Services, Helsinki University Hospital and Helsinki University, Finland

eDepartment of Clinical Science and Education, Karolinska Institutet

fDepartment of Emergency Medicine, Södersjukhuset, Stockholm, Sweden

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Correspondence to Michael Madsen, MD, MSc, Viktoriagade 19B, 5.TH, Copenhagen V, DK-1655, Denmark Tel: +45 616 70402; fax: +45 7841 7203; e-mail:

Received December 22, 2014

Accepted April 9, 2015

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