Using data to support 247 care - measuring good emergency department care

The starting point when measuring the quality of care in emergency departments is to acknowledge that it is not just about the numbers and waiting times. Feedback from patients and their families and carers is key to pinpointing areas for improvement.

The best trusts are triangulating this feedback with good data and there is a number of standard indicators that are measured to gauge performance. However, this relies on trusts’ ability to collect and monitor the data.

The current indicators take into account ambulatory care, unplanned readmission, the total time spent in the emergency department, how many people leave without being seen, time to initial assessment, service experience (patient and family/carer), time to treatment and consultant sign-off.

These indicators are all vital in building up a picture of how a department is performing. The best trusts have in place adequate IT systems that are able to track the patient pathway seamlessly to collect and monitor data. Indicators they use cover ambulatory care because the ambulatory care process is vital to success. Patients with certain high-volume, low-risk conditions should be treated in a way that avoids admission unless absolutely necessary.

This helps to provide consistency of practice for other conditions. Another indicator used is unplanned readmission within seven days of original attendance. The data suggest there are two different cohorts being monitored: those who reattend frequently and single reattendance.

Nearly 50 per cent of patients who are readmitted, do so within seven days of discharge, potentially costing trusts £300m in lost annual income. Readmission within a short time frame can be indicative of issues related to hospital care or shortcomings in the process of discharging patients to the appropriate level of care.

Total time spent in the emergency department reflects the benefits that have accrued from the four-hour emergency care standard while minimising the consequences of a single time-related measure of care.

Experience during the past 10 years has established a body of evidence indicating that in a properly staffed department, supported by prompt access to diagnostics and well-managed flow into inpatient beds, more than 95 per cent of patients will complete their care within four hours. If the department is under-resourced or in-hospital bed capacity is inadequate, then compliance with the target becomes difficult.

CHKS has been working with the RCEM to analyse emergency department treatment times in English hospitals. This analysis has focused on variation in treatment times within the four-hour target and beyond. It was carried out using hospital episode statistics data from all English acute hospital trusts for the 12 months to July 2015.

When CHKS researchers looked at the number of patients treated within two hours, they found a significant variation. The best trust treated 71 per cent of its patients within two hours, whereas at the worst only 12 per cent of patients were treated within this time. The analysis also looked at treatment times across all acute trusts according to the number of minutes patients spent in the emergency department. The results showed a significant spike at 240 minutes, which coincides with the four-hour target. This suggests the four-hour target, rather than need, may be determining many treatment times.

Service experience
This is not simply a patient satisfaction indicator, but an indicator of overall service experience reflecting the 24-hour nature of emergency and urgent care. It requires data on service experience to be gathered and analysed on a regular basis; the minimum requirement is for quarterly review. The indicator also requires clear evidence of action taken in response to the findings of the review.

This service experience indicator is not restricted to patients, but may also include carers, staff or others’ perceptions of the service. Its aim is not to derive satisfaction ratings but to explore more broadly how the service is experienced and therefore how it might be improved. Unlike the other indicators, there is no comparison between sites. It is intended to support local quality improvement.

The indicator is used because it is essential to understand how a service is experienced if it is to be responsive to the needs of users. Emergency and urgent care services address a wide range of human need beyond the purely clinical, including compassionate care for the bereaved, comfort for the dying and alleviation of anxiety for all. Overall experience of emergency and urgent care services is therefore as important as clinical outcomes.

Time to initial assessment
This quality indicator records the time from arrival in the emergency department to full initial assessment, for patients arriving by ambulance. Initial assessment includes a pain score and physiological early warning score for all these patients. By monitoring this indicator, trusts aim to reduce the time the patient spends without assessment by staff. Serious untoward events have been noted where there have been significant delays in formal assessment.

Time to treatment
This quality indicator records the time between arrival and the time when the patient is seen by a decision-making clinician; in practical terms such a clinician is somebody able to discharge the patient from the emergency department, such as a suitably experienced doctor or emergency nurse practitioner. Arrival time is well defined and is measured in two ways: either the time of initial assessment/triage or initial registration, whichever is sooner, or by ambulance handover time or 15 minutes after ambulance arrival, whichever is sooner. The time that the patient is seen by a decision-making clinician is already routinely recorded and reported in many emergency departments.

Consultant sign off
This quality indicator is adapted from the recently released RCEM standard for consultant sign-off. It identifies three high-risk presentations that should be reviewed by a consultant prior to discharge: non-traumatic chest pain in adults (over 17 years of age); febrile illness in children (less than one year old); and unscheduled reattendances (with the same complaint) within 72 hours. If a consultant is not immediately available then review may be undertaken by an experienced trainee in emergency medicine (ST4 or above) or a staff grade or similar substantively appointed doctor who has been designated to undertake this role by the emergency medicine consultant staff.

What other indicators can be used?
These indicators all track the patient experience from arrival at the front door of the emergency department, how long they have to wait until they are seen and who they see during their time there. However, many trusts use additional measures to provide greater insight and lead to greater improvement. Using trolley waits as an indicator can also provide a better picture of patient experience than just the four-hour wait. Trolley waits can be distressing for the patient and their family and can also contribute to crowding.

This indicator can highlight challenges with patient flow across the hospital. Monitoring when crowding occurs, handover delays and also ambulance diverts can all help build a clearer picture of a trust’s performance and help to pinpoint where changes can be made and burdens eased. Common causes of crowding include non-urgent visits, inadequate staffing and bed shortages; effects of crowding include patient mortality, transport and treatment delays, ambulance diversion, patients walking out untreated and increased costs.

This blog is taken from the CHKS Best Practice in 24/7 Care report which you can download here.
The starting point when measuring the quality of care in emergency departments is to acknowledge that it is not just about the numbers and waiting times. Feedback from patients and their families and carers is key to pinpointing areas for improvement.