Presented by Dr Ahmed Kamal at the Egyptian Critical Care Summit 2015, the leading medical event for Critical care & Emergency Medicine in Egypt

1. My
Quality Indicators in EM
Ahmed Kamal
Consultant in Emergency Medicine
South Wales -UK
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

2. What is wrong in this photo
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

3. Here are some
• No O2
• No C Spine Protection
• No apparent analgesia
• Lack of apparent equipment
• Lack of privacy
• No Communication
• No identification Badge
• No apparent charts/ guidelines
• Not in a children’s room
• No Nurse to be seen.
• No Universal precautions
Egyptian Critical Care Summit 12-15
January 2015 - Cairo
I don’t want
to be here
I want to
be there

4. Why Quality Indicators
• 1. Unbiased objective analysis of performance.
• 2. Evidence of performance against difficulties.
• 3. An Indication of the performance of:
– Whole Hospital
– Organisation
– Health Care System
• 4. For Bench marking
Egyptian Critical Care Summit 12-15
January 2015 - Cairo
Influence
Change

5. Good Emergency care
• 1. Available 24 hours / 7 days a week in an
appropriate environment.
• 2. Easy to access & Convenient.
• 3. Is Patient – Focused.
• 4. Timely and consistent.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

6. Good Emergency care
• 5. Right first time.
• 6. Delivers Excellent clinical outcomes including:
– Recovery
– Survival
– Lack of adverse events
• 7. Delivers a good Pt Experience.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

7. Quality Indicators for Emergency Medicine
Waiting
Times
Pain Control in ED
M&M review
Staff and Trainees satisfaction
Complaints
Left
without
being
seen
Service ExperienceEBM
Best Medicine Practice
Unplanned
re-attenders
Senior signing off
Egyptian Critical Care Summit 12-15 January 2015 -
Cairo

8. Waiting
Times
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1. Waiting Times
Egyptian Critical Care Summit 12-15 January 2015 - Cairo

9. Total Time in the ED
• Definition
• 95% of patients < 4 hours.
• For an efficient well funded ED the critical
door is : The discharge door.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

10. Egyptian Critical Care Summit 12-15
January 2015 - Cairo

11. Total Time in the ED : How to get it correct?
• Recognition that the ED is the hub of delivery of
Emergency care:
– Appropriate work force funding.
– Early access to senior clinical decision makers.
– Prompt access to diagnostic including pathology and
imaging.
– Functional Bed Management team.
– Adequate IT provision
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

12. Waiting Times
Egyptian Critical Care Summit 12-15
January 2015 - Cairo
60.00%
65.00%
70.00%
75.00%
80.00%
85.00%
90.00%
95.00%
100.00%
08/12/14
09/12/14
10/12/14
11/12/14
12/12/14
13/12/14
14/12/14
15/12/14
16/12/14
17/12/14
18/12/14
19/12/14
20/12/14
21/12/14
22/12/14
%PerformanceAchieved
Day
RGH 4 Hour Waits
4Hr % Achieved
4 Hour Target

13. Total Time in the ED
Failure to achieve the target should trigger an
intervention.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

14. • Staffing
• Bed
• Inter – departmental
• Organizational protocols
Local
• Diversion Policy
• Funding
Regional
• Funding
• Re shaping of service and
planning
National
Intervention
Egyptian Critical Care Summit 12-15 January 2015 - Cairo

15. Total Time in the ED : Challenges
• Under resourced departments will struggle.
• The Exodus of patients at 3.50 hours must be
avoided.
• To the organisation :
– ED is a fundamental component of the Health
Service.
– Director of Emergency care’s role
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

16. Other relevant Times
• Time to initial assessment
• Time to Treatment
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

17. TEXT 1
Pain
Control
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2. Pain Control in ED
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

18. CEM Guidelines
Algorithm for treatment of undifferentiated acute pain in the Emergency
Department
MODERATE PAIN (4-6)
As for mild pain
plus oral
NSAID (if not already given)
or
SEVERE PAIN (7-10)
IV Opiate
Or
Rectal NSAID
Supplemented by oral
MILD PAIN (1-3)
Oral Paracetamol
Or
Oral NSAID e.g. ibuprofen
ASSESS PAIN SEVERITY
Use splints / Slings / Dressings etc.
Consider other causes of distress*
Consider regional blocks
No Pain
Pain score: 0
Mild Pain
1 - 3
Moderate Pain
4 - 6
Severe Pain
7 - 10
Suggested
route & type of
analgesia
No action Oral analgesia Oral analgesia IV Opiates
or
PR NSAID
Initial
Assessment
Within 20 mins of
arrival
Within 20 mins of
arrival
Within 20 mins of
arrival
Within 20 mins of
arrival
Re-evaluation Within 60mins of
initial assessment
Within 60mins of
analgesia
Within 60mins of
analgesia
Within 30 mins of
analgesia
Egyptian Critical Care Summit 12-15
January 2015 - Cairo
Algorithm for treatment of undifferentiated acute pain in the Emergency
Department
*Other causes of distress include: fear of the unfamiliar environment, needle phobia, fear of injury severity etc.
MODERATE PAIN (4-6)
As for mild pain
plus oral
NSAID (if not already given)
or
Codeine Phosphate
A
s
f
o
SEVERE PAIN (7-10)
IV Opiate
Or
Rectal NSAID
Supplemented by oral
analgesics
MILD PAIN (1-3)
Oral Paracetamol
Or
Oral NSAID e.g. ibuprofen
ASSESS PAIN SEVERITY
Use splints / Slings / Dressings etc.
Consider other causes of distress*
Consider regional blocks
No Pain
Pain score: 0
Mild Pain
1 - 3
Moderate Pain
4 - 6
Severe Pain
7 - 10
Suggested
route & type of
analgesia
No action Oral analgesia Oral analgesia IV Opiates
or
PR NSAID
Initial
Assessment
Within 20 mins of
arrival
Within 20 mins of
arrival
Within 20 mins of
arrival
Within 20 mins of
arrival
Re-evaluation Within 60mins of
initial assessment
Within 60mins of
analgesia
Within 60mins of
analgesia
Within 30 mins of
analgesia

19. 2. Pain Control in ED
• Triage
• Audits
• Teaching
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

20. Patient Group Directions
• PGDs provide a legal framework that allows some
registered health professionals to supply and/or
administer a specified medicine(s) to a pre defined
group of patients, without them having to see a
doctor (or dentist).
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

21. Methods for pain relief.
• Oral.
• I.V./I.M.
• Topical.
• Intra-nasal.
• Regional.
• Inhalation.
• Commuications
• Splint &
Immobilzation

22. TEXT 1
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Complaints
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3. Complaints
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

23. 3. Complaints in one word
• Communications:
• With pts
• With relatives
• Other Health teams
members
• With Colleagues
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

24. 3.Complaints
• Number and Nature
• System for :
– Receive
– Address
– Respond to
• Act on findings.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo
}Within a specific time frame

25. TEXT 1
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Service Experience
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4. Service Experience
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

26. Service Experience ( SE)
• Is not : A patient satisfactory indicator
• Asks specific questions:
– Cleanliness
– Communication
• Reflects the 24 hours of overall (SE).
• May also include carers and staff perception of
service
• Requires data collection and analysis regularly
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

27. Service Experience
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

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Unplanned
re-attenders
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5. Unplanned Re attenders
Egyptian Critical Care Summit 12-15 January 2015 - Cairo

29. 5. Unplanned re-attender
• Definition
• Relevance?
• Range of 1-5%
• % should not be 0% - Reason?
• Above 5% is an indication of poor quality of care.
• Guideline or protocol
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

30. 5. Unplanned re-attender
• System to Collect Data
• 2 Cohort of patients
– Single re-attenders
– Multiple re-attenders ( complex issues such as
Mental health or primary care)
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

31. 5. Unplanned re- attender
• Reasons – Multi factorial
– Misdiagnosis
– Getting worse
– Unrelated second condition
• Strategies to Manage the above two groups
on different ways
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

32. TEXT 1
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Left
without
being
seen
6. Left without being seen
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

33. 6. Left without being seen
• Registered patients
• IT coding
• Multifactorial
• Relevance : Safety issues
• Should be < 5% of total annual attendance
number.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

34. 6. Left without being seen
• Achieve <5% with:
– Prompt process
– Good pt Flow
– Good Pt communication
– Adequate staffing
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

35. Did not wait Pt Management strategy
Dublin
O’Keefe EMJ July 2012
• 1 year study 2008
• 2872 (6.3 %) of total attendance - DNW
• Senior review of triage notes:
• 107 Pts (3.7 %) recall of Pts who DNW.
• Of those : 9.4% required Acute admission
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

36. TEXT 1
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EBM
Practice
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7. Evidence Based Practice Medicine
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

37. 7. Evidence Base Medicine
practice
• Adherence to guidelines and protocols
– BTS Guidelines for Asthma
– ACS guidelines
– NICE guidelines for HI.
– NICE Guidelines to stroke
– Ottawa ankle and Knee rules.
• Audit
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

38. TEXT 1
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M&M Review
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8. M&M review
Egyptian Critical Care Summit 12-
15 January 2015 - Cairo

39. M& M review
• Quarterly Clinical governance meeting.
• No blame culture.
• The Coroner’s power
• Measures to Minimise incidents:
– Audit presentations
– Teaching
– Bench marking
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

40. TEXT 1
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Staff & Trainees
Satisfaction
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9. Staff and Trainees satisfaction
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

41. 9 A. Trainees satisfaction
• Job Satisfaction Survey.
• Anonymous.
• Independently Assessed.
• Teaching ( Shop floor & protected teaching time).
• Clear and fair Career structure.
• Study leave.
• Salary.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

42. 9 A. Trainees Satisfaction
• Quality of Training and
supervision.
• E Portfolio : Supervised Learning
Events
– Team assessment of behaviour
(TAB)
– Mini-clinical evaluation
exercise for learning (mini-
CEX)
– Case-based Discussion (CBD)
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

43. 9 B. Staff satisfaction
• Service experience
• Bullying at work
• Reasonable working conditions
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

44. TEXT 1
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Senior Sign
Off
TEXT 6
10. Senior Signing Off
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

45. 10. Senior ( ST4 or above)
sign -off
• Non Traumatic Chest pain.
• Febrile Illness < 1 year old
• Unscheduled return 9 with the same
complaint) with 72 hours.
• Head and spinal Injuries.
• Abdominal presentations.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

46. Horses for courses
• Juniors : Represent The Head of ED
• Head of ED: Answerable to CEO and to
Her Majesty's Coroner.
• CEO : Department of Health
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

47. Requirement for success
• Realistic Funding
• Experienced EM
leadership
• Efficient and Dynamic
IT system
• Record Keeping system.
• Appropriate Coding &
Audit
• Guidelines and
Protocols endorsed by
the CEO
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

48. & Finally
• QI should be used to support and not to
punish the ED
• Quality Indicators are useful tools only if
used to achieve a useful change.
Egyptian Critical Care Summit 12-15
January 2015 - Cairo

49. Thank You
• Dr Raza Qureshi MBBS, FRCS, FCEM
• Dr Paul Kennedy MBBS, MRCS, FCEM
Egyptian Critical Care Summit 12-15
January 2015 - Cairo