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"Best practices" guidelines can facilitate quality of care improvements in the emergency department

Quality of care at hospital emergency departments (EDs) improves when their directors get feedback on how well their and similar EDs comply with process-of-care guidelines for medical problems typically seen in the ED, and they collaborate to design quality improvement interventions to improve compliance with these "best practices," finds a new study. The study was led by Helen R. Burstin, M.D., M.P.H., formerly of Brigham and Women's Hospital and now Director of the Agency for Healthcare Research and Quality's Center for Primary Care Research.

The study compared how well five Harvard-affiliated EDs complied with process-of-care guidelines for six chief complaints seen in the ED: abdominal pain, shortness of breath, chest pain, hand laceration, head trauma, or vaginal bleeding. The researchers analyzed patients' reports of care (via on-site questionnaires) during a 1-month period in 1993 and examined medical records for all patients with these complaints to determine each ED's guideline compliance. The researchers provided ED directors with feedback on each ED's baseline compliance, helped them to design quality improvement strategies to improve quality of care in their own EDs, and then analyzed guideline compliance 2 years later.

Results showed that compliance with process-of-care guidelines increased from 55.9 percent to 60.4 percent, and the rate of patient-reported problems with ED care decreased from 24 percent to 20 percent, both small but significant improvements. Following quality improvement changes, patients reported that they were less apt to have difficulty getting a message to family or friends, and no patients reported problems with translation services due to improved access to interpreters. Also, fewer patients reported that they did not understand how to take their medications or the possible side effects, and more patients filled their prescriptions. There were no significant improvements in patient ratings of satisfaction with care, which remained at 3.8 on a 1 (poor) to 5 (excellent) scale. The study was supported in part by an AHRQ-funded National Research Service Award fellowship (F32 HS00062).

More details are in "Benchmarking and quality improvement: The Harvard emergency department quality study," by Dr. Burstin, Alasdair Conn, M.D., Gary Setnik, M.D., and others, in the November 1999 American Journal of Medicine 107, pp. 437-449.

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