Discussion
Twenty-eight measures that capture five common clinical presentations and two cross-cutting processes of care were developed by the NPRQI with the participation of a diverse panel of experts and national organisations. These measures encompass the four phases of care in the ED: assessment, diagnostics, intervention and disposition. This approach allows for a prospective, feasible and patient-centred focus to paediatric-specific QI efforts. Low-volume EDs may never have sufficient patient encounters to focus on final diagnoses for timely QI efforts. By targeting critical cross-cutting processes and common clinical presentations, EDs can assess quality of care among a larger undifferentiated paediatric population.18 The patient experience model, as highlighted within the Institute for Healthcare Improvement’s Triple Aim, is based on the care provided in response to a clinical presentation, not a specific diagnosis.22 The measures within each clinical domain were derived from evidence-based research that links early and appropriate assessment, targeted diagnostics, timely interventions and disposition to improved outcomes.
The NPRQI represents a new framework for the inclusion of quality measures for all categories of paediatric care divided across four phases of care: assessment, diagnostics, interventions and disposition. Assessment serves as the foundation for paediatric patient safety. For example, early recognition of altered mental status is essential to timely management of head trauma.23–25 Early recognition of tachycardia and hypotension are core components of sepsis recognition.26 In turn, early recognition of the critically ill or injured child leads to timely administration of evidence-based interventions linked to improved outcomes. For example, early administration of steroids are associated with decreased hospitalisation among children with moderate and severe asthma and, among children with seizures, treatment delays can result in prolonged seizure activity.27 28 In addition to improved outcomes, timeliness of interventions improves patient experience.29 Diagnostic testing should be undertaken judiciously and in conjunction with family-centred care. Unnecessary exposure to radiation in the paediatric patient is both costly and associated with potential harm.30 31 Invasive procedures and unnecessary testing, too, can adversely impact patient experience and cost.32 Adherence to standardised, site-specific transfer criteria and processes promotes timely access to necessary resources and may minimise unnecessary cost to patients and families.33 A first step to adhering to evidence-based guidelines in specific populations is optimising care processes across all phases of ED care.
The past decade has fostered significant growth in the development of evidence-based guidelines as research in paediatric emergency care has shifted from single-centre data to multicentre studies enabling researchers to address low frequency, high-risk conditions in a more systematic manner. Multicentre research has also allowed for creation of evidence-based guidelines and validated decision rules for common paediatric reports. This approach is exemplified by the Emergency Medical Services for Children-funded Paediatric Emergency Care Applied Research Network (PECARN), which has published over 150 articles on a diverse range of paediatric emergency medicine topics.17 While much of the research from multicentre trials focuses on high risk, low-frequency events such as sepsis, some of the most prominent guidelines generated from PECARN relate to common clinical conditions encountered at virtually every ED in the USA: management of closed head injury in children, bronchiolitis management, pain management, suicidality and paediatric patient safety considerations.17 31 34–36
The NPRQI measures individually may overlap with the development of paediatric measures by others.12–14 What differs is the context in which they are implemented which focuses on clinical presentation rather than a specific diagnosis, and that they are imbedded in a set of measures that capture all ED phases of care for managing the patient, not the diagnosis. This approach can be applied across low-volume EDs where specific diagnoses are infrequent, but the phases of ED care are universal. The large proportion of NPRQI measures (28.6%) that fall within cross-cutting care processes further supports engagement by very-low volume EDs (fewer than five paediatric patients per day). These measures set the foundation for measuring the quality of ED care provided for most children in the USA. In the absence of pay-for-performance incentives, the adoption of paediatric-specific quality measures in low-volume EDs (where most children seek care) will depend on the ease of data collection, relevance to a large proportion of the paediatric population and linkage to patient-centred outcomes. These measures strive to be feasible at the local level and actionable for the ED care team.
Families rely on EDs of close proximity to meet the needs of critically ill and injured children, most of which see fewer than 15 children per day.1 37 The potential impact of quality measures on care delivery is dependent on relevance to the population served, and uptake by those who can implement change. Engagement of frontline practitioners in QI efforts is essential to ensuring the success of improvement strategies. The measures proposed herein are a first step to recognising variability in care within a single ED as the focus is optimisation of processes of care that are central to the delivery of high-quality care for all paediatric patients. The potential impact of the 28 NPRQI quality measures is that any ED can immediately improve processes of care that are linked to improved health outcomes in children.
The NPRQI measures provide a foundation for any ED care team to measure adoption of evidence-based guidelines for paediatric care using a patient-centred, provider-driven approach to QI. Unlike many quality measures that rely on administrative data or a diagnosis-based retrospective review, the NPRQI measures were designed for any ED to assess performance and improve delivery of care to the undifferentiated paediatric patient. The NPRQI paediatric quality measures may be biased from using a consensus model. It was critical to engage a diverse group to participate in the modified Delphi process as well as create an environment for sharing differing perspectives. The subset of research panellists engaged in measures proposal and final review were chosen for their clinical, research and implementation expertise to ensure feasibility. The consensus panel was composed of multidisciplinary organisational representatives that intersect with low-volume EDs. With significant input from consensus panellists and national organisations, the NPRQI measures are relevant, feasible and linked to improved outcomes for paediatric patients with common clinical presentations.
