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Abstract
The emergency department (ED), sometimes termed the emergency room (ER), emergency ward (EW), accident & emergency (A&E) department or casualty department, is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and requiring immediate attention.(1,2) The ED is very often the first impression of a hospital for patients and their carers, and most people will experience it at some point in their life.(3) Hospital emergency care takes place in a high-volume, highly complex environment that is prone to errors and quality concerns. Patients often arrive at the ED in large numbers with problems ranging from heart attacks and HIV complications to burns, gunshot wounds, and domestic violence. They must be quickly triaged for surgery, hospital admission, or other types of care. ED clinicians often must make rapid, life-altering clinical decisions with little knowledge of the patient.(4)
The EDs comprise distinct physical facilities and organizational structures established in hospitals to deliver emergency medical care to the acutely ill and injured. EDs are similar to other hospital clinical units. The organization of work in the ED must bring together the elements of physical facility, clinical equipment, other technology and human resources to create an effective and efficient care process involving reception, triage, initial assessment and resuscitation, detailed assessment and investigation, transitional evaluation and monitoring, and disposition. Since patient flow begins at triage, patient assessment should be rapid and accurate to provide efficient emergency care.(2,5-7) Twenty four hours a day, seven days a week, the hospital ED plays an essential role in the health care delivery system, treating patients with a wide array of health problems, ranging from stomach and chest pain to gun shot wounds and traffic accidents.(8)
Over the last several decades, the role of hospital-based emergency and trauma care has evolved. EDs continue to focus on their traditional mission of providing urgent and lifesaving care, but have taken on additional responsibilities to meet the needs of communities, providers and patients. Today, their complex role also provides care for uninsured patients, public health surveillance, disaster preparedness, and serving as an adjunct to community physician practices. In some rural communities, the hospital ED may be the main source of health care for a widely dispersed population. Balancing these roles in the face of increasing patient volume and limited resources has become increasingly challenging. The situation is creating a widening gap between the quality of emergency care expected and the quality actually received. Today emergency care systems face an epidemic of crowded EDs. Overcrowding induces stress in providers and patients, and can lead to errors and impaired overall quality of care.(9,10)
Overcrowding in the ED is a complex problem. It was found that utilization of the ED by patients with non-urgent medical problems may contribute to overcrowding and impair access for patients with true emergencies in a severely crowded ED.(10-12) Concerns about ED utilization and overcrowding in communities were well publicized in the late 90’s and early 2000’s. Several projects have been implemented to reduce ED crowding by improving access to primary care and other providers. Yet all problems in ED utilization will not be solved by improving access to other providers for non-emergent care. There will still be access barriers for uninsured and underinsured. Patients may go to the ED because they perceive the quality of care there to be superior to the local clinic, or because of cultural reasons (such as being accustomed to walk-in care rather than appointments).(7) Many turn to the emergency system when in medical need, often for conditions that have worsened because of a lack of regular primary care. The ED often serves as primary care provider, a role for which it is not optimally designed. Rather, the ED is designed for rapid, high-intensity responses to acute injuries and illnesses.(9-11) Because non-emergency patients are usually low triage priorities, they often experience extremely long wait times as they are passed over for more urgent cases.(9,10) Inappropriate ED utilization is a “symptom” of access barriers to primary and specialty care, urgent care, mental health services, social services, transportation, housing, etc. It may also indicate a breakdown in chronic illness management at the primary and specialty care levels.(7)
Quality of care is defined as the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.(13) Quality is defined as meeting or exceeding a customer’s expectations. In the ED, the customer is any person who is affected by a process. Customers include patients, physicians, nurses, technical staff, and other hospital personnel. Quality may be represented by shorter waiting times, quicker delivery of specimens to the lab, or fewer delays in operative procedures while searching for missing paperwork.(14) The measurement of time intervals in the ED and the tracking of patients who leave before they are seen have become de facto markers for quality and efficiency in the literature.(15)
To measure the quality of care offered in the ED, indicators by which the provided care is measured should be defined. Performance indicators (PI) are defined as “quantitative measures that can be used to monitor and evaluate the quality of a condition or the performance of an organization that affect patient outcomes”. Indicators, to be of value, should be valid, reliable, timely, comparable and responsive to change. However, they are not direct measures of quality in themselves; they are tools that can support quality improvement and as with any tool, they can be used inappropriately.(16-18) PI for healthcare organizations represent a strategy for accountability worldwide. A universal approach to either the design for indicators or their applicability to local needs remains a work in progress. (18,19)