Creating a System to Facilitate Translation of Evidence Into Standardized Clinical Practice: A Preliminary Report

Article Outline

• Abstract
• Introduction
  • System Overview
  • The Committee for Procedural Quality and Evidence-Based Practice Process
  • Preliminary Results
  • Cultural Change: Acceptance of Guidelines
  • Feedback: Physician Scorecards
  • Electronic Support (http://www.CPQE.com): A Quality Initiative Web Site
  • Expansion and Longevity
  • Summary
• Appendix
• References
• Copyright

Study objective

The Institute of Medicine, through its landmark report concerning errors in medicine, suggests that standardization of practice through systematic development and implementation of evidence-based clinical pathways is an effective way of reducing errors in emergency systems. The specialty of emergency medicine is well positioned to develop a complete system of innovative quality improvement, incorporating best practice guidelines with performance measures and practitioner feedback mechanisms to reduce errors and therefore improve quality of care. This article reviews the construction, ongoing development, and initial impact of such a system at a large, urban, university teaching hospital and at 2 affiliated community hospitals.

Methods

The Committee for Procedural Quality and Evidence-Based Practice was formed within the Department of Emergency Medicine to establish evidence-based guidelines for nursing and provider care. The committee measures the effect of such guidelines, along with other quality measures, through pre- and postguideline patient care medical record audits. These measures are fed back to the providers in a provider-specific, peer-matched “scorecard.”

Results

The Committee for Procedural Quality and Evidence-Based Practice affects practice and performance within our department. Multiple physician and nursing guidelines have been developed and put into use. Using asthma as an example, time to first nebulizer treatment and time to disposition from the emergency department decreased. Initial therapeutic agent changed and documentation improved.

Conclusion

A comprehensive, guideline-driven, evidence-based approach to clinical practice is feasible within the structure of a department of emergency medicine. High-level departmental support with dedicated personnel is necessary for the success of such a system. Internet site development (available at http://www.CPQE.com) for product storage has proven valuable. Patient care has been improved in several ways; however, consistent and complete change in provider behavior remains elusive. Physician scorecards may play a role in altering these phenomena. Emergency medicine can play a leadership role in the development of quality improvement, error reduction, and pay-for-performance systems.

SEE EDITORIAL, P. 78.

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Introduction 

In 1999, the Institute of Medicine published To Err is Human: Building a Safer Health Care System.¹ This groundbreaking report estimated that up to 100,000 hospitalized patients each year die of medical errors and poor-quality medical care. Although the number of deaths has been disputed, the report galvanized health care stakeholders to action.² The White House, Congress, industry, hospitals, and medical professionals were compelled to respond to the indictment, and many actions have been taken to address medical errors. This focus on errors has led to a consideration of the overall quality of care. In 2002, the Joint Commission on Accreditation of Healthcare Organizations, the lead organization responsible for hospital oversight, made major changes in its accreditation process and implemented core measures as quality markers of health care delivery for acute myocardial infarction, congestive heart failure, community-acquired pneumonia, surgical infection prevention, and pregnancy-related conditions. These measures assess timeliness of care, therapeutic intervention, education, and mortality; they are now used as benchmarks for practice.³ Further, health care payers are beginning to demand similar-quality data in exchange for reimbursement through programs labeled “pay for performance.”⁴

In May 2000, the Society for Academic Emergency Medicine sponsored a conference on errors in emergency medicine.⁵, ⁶ The attendees agreed that there were few organized approaches addressing the problem of errors in the emergency department (ED) and there was little research and investigative structure to support specific corrective actions.⁶ Despite the numerous and daunting barriers, the conference report states, “It is imperative to begin.” A minimum of 14 areas of concern and potential improvement were identified, and one of the achievable goals identified for EDs was “simplification and standardization of processes.” In support of standardization is a study of 6,712 patients treated for 30 acute and chronic conditions, which found that only 53.5% received the current recommended or “best care” for acute conditions.⁷ One solution for standardizing care and ensuring that recommended diagnostics and treatments are delivered in the ED may be the implementation of evidence-based protocols and guidelines; it is likely that reduced variation in care decreases the likelihood of medical errors, particularly those of omission, and improves patient outcomes. Thus, in 2005, our department initiated a systematic approach to increase standardization of emergency procedures and clinical care through evidence-based medicine.

System Overview 

Our quality initiative is led by the Committee for Procedural Quality and Evidence-Based Practice. Our Department of Emergency Medicine, in July 2003, formed the Committee for Procedural Quality and Evidence-Based Practice to meet the challenge of improving the quality of care provided in 1 large academic hospital’s ED and 2 community hospital EDs. Previous attempts to standardize care within our complex system have been fragmented and lacked longevity; therefore, this novel centralized committee has been well resourced by the department chairperson to accomplish its goals. This high level of support is necessary for changes to be made to any complicated health care system.⁸ The committee is directed by a dedicated faculty member and is codirected by a senior faculty member with experience in administration and quality improvement. A dedicated registered nurse with advanced computer skills constitutes the common thread through all meetings and functions of the committee and is vital to its overall success. She is responsible for coordination and publication of protocols, formatting and revision of all of the committee’s products, data collection through medical record review, and data entry and is also the primary link from the Committee for Procedural Quality and Evidence-Based Practice to the hospital data systems. A biostatistician designs and builds data gathering instruments for monitoring and evaluating committee initiatives. A parallel meeting group of nurses and nursing management pursues the evidence-based practice of nursing care. Approval and institution of all committee initiatives rests within the committee’s leadership, which makes the process manageable and responsive to end users’ needs.

Overall, the Committee for Procedural Quality and Evidence-Based Practice seeks to positively influence the patient care plan throughout a typical patient care visit to the ED. Figure 1 represents a patient’s care path and the areas of that path on which the committee is active. Activities include the creation of guidelines, order sets, evaluation forms, discharge instructions, and observation medicine protocols. Compliance with guidelines and protocols is then measured through structured audits, with feedback of these data and other quality measures given to the committee and then to providers in the form of physician scorecards. A core philosophy adopted by the Committee for Procedural Quality and Evidence-Based Practice is that physicians need not be required to use the practical tools offered but must be held accountable to the care standards outlined in guidelines and protocols. Thus, audits are not focused on use of the tools but on all documentation of care provided to patients, as described in detail below.

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• Figure 1. 

  Impact and feedback. This diagram represents the Committee for Procedural Quality and Evidence-Based Practice process, beginning with an identified need and progressing to a product that may affect many aspects of a patient’s treatment experience. The impact of these products on the originally identified need is then measured and fed back to stakeholders. CPQE, Committee for Procedural Quality and Evidence-Based Practice; JCAHO, Joint Commission on Accreditation of Health Organizations.

The ultimate goal of this process is to obtain complete compliance with standardized care, exceptional circumstances notwithstanding. The audit process is primarily designed to evaluate existing care against the objective criteria defined within the guidelines and protocols. This process then assesses the changes in care brought about by the implementation of and education about the guidelines. Failure to achieve complete care standardization is considered a means of identifying practice patterns that must be addressed with further educational intervention. In addition, the audit process provides a positive feedback mechanism by which providers are informed of their performance and how care standardization affects patient outcomes and ED resource use. For each guideline or protocol, those elements of patient outcome and resource use that are directly measurable within the context of the Committee for Procedural Quality and Evidence-Based Practice, such as time to treatment, admission rates, recidivism, and lengths of stay, are predetermined components of the audit process. Future reports will focus on the results of the audit process and determination of measurable, guideline-affected patient outcomes as objective measures of the effectiveness of the Committee for Procedural Quality and Evidence-Based Practice program.

The Committee for Procedural Quality and Evidence-Based Practice Process 

Guidelines, also known as algorithms,⁹ and pathways have become common tools during the past 15 years in all branches of medicine to improve quality and efficiency of care.¹⁰ The Committee for Procedural Quality and Evidence-Based Practice, facing a broad goal to influence quality across our entire department, has developed a reproducible, sustainable process of guideline development and a medical record audit system to measure the benefits of our system. The process is an inclusive design encompassing the entire department. Figure 2 illustrates the flow of information from physicians and nurses into the committee and back out into practice. Development of a guideline, implementation, and the audit process is best illustrated with an example.

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• Figure 2. 

  Continuous flow of information from physicians, nurses, and electronic sources into the Committee for Procedural Quality and Evidence-Based Practice, with resulting guideline development and feedback into each stakeholder group.

Asthma was the first disease process addressed because it has been well studied, resulting in published and generalizable treatment algorithms.¹¹ Such guidelines have been found to be an effective means for treating asthma patients and have reduced resource use while improving patient outcomes.¹², ¹³ To explore existing guidelines, update them with new knowledge, and adapt them to our system, a literature review was undertaken by an emergency medicine resident, with the express goal of producing a 1- to 2-page guideline for the treatment of asthma within our 3-hospital system. The patient population is predominantly nonpediatric as a result of the nearby presence of a large children’s hospital; therefore, the guidelines are adult specific. The resident was instructed to use MEDLINE and to access sources of existing guidelines. Particular emphasis was placed on review articles and meta-analyses, such as those conducted by the Cochrane Group; although scientific inquiry frequently discounts such articles, they are fundamental to the condensation of extensive information into practical, evidence-based guidelines. As the guideline was developed, the needs of all involved in the care of the patient were considered. In this example of asthma, pulmonologists from all 3 clinical sites were consulted to incorporate their needs in the finalization of the guidelines. Institutional variations in formulary and staffing responsibilities were accommodated through these interactions. The guidelines and a summary of the literature review were then presented during a monthly evidence-based conference to the emergency medicine faculty, residents, and nurses for open discussion, comment, corrections, and modification. The committee then finalized the guidelines, developed a flowchart design, and published them for use. An order set and discharge sheets were also created to facilitate incorporation of the guidelines into individual practice patterns. To avoid complexity in the system, a single asthma order sheet was made to encompass the greatest number of patients. Blank order lines are available to add specific medications for atypical patients.

The guidelines developed for providers are diagnosis based. To encapsulate the entire practice of emergency medicine within the Committee for Procedural Quality and Evidence-Based Practice process, the nursing guideline development group develops chief complaint-based guidelines complementary to the condition guideline and order sets. The nursing guidelines, which are initiated at triage by standing orders, become the clinical starting point for the committee process. If asthma becomes the likely diagnosis according to the nursing guidelines for shortness of breath, for example, the asthma guideline and order set are initiated by the treating physician. All Committee for Procedural Quality and Evidence-Based Practice products are developed simultaneously to ensure seamless progression from the complaint-based nursing guideline to the diagnosis-based order set.

In addition to developing guidelines, the Committee for Procedural Quality and Evidence-Based Practice process allows for evaluation of impact of the guidelines. Evaluation is important for 2 distinct purposes: to identify needed guideline revisions in response to unanticipated systems barriers and to measure guideline compliance, changes in resource use, and patient outcomes. This evaluation serves as evidence to providers that the process has an effect and offers evidence on the return on investment in the committee process. To accomplish evaluation, a rigorous comparison of patient care between the pre- and postguideline periods is conducted. The committee nurse uses a standardized medical record review form, designed to capture all components of guideline-driven care and predetermined patient outcomes and resources expected to be affected by the guidelines, to abstract either a consecutive or a random sample of patients. For asthma, this evaluation process abstracted data on the evaluation, treatment, time to treatment, disposition, and recidivism. The data are entered into a customized database built to support all committee data needs, and they are then analyzed by the biostatistician to estimate change in practice and change in outcomes.

Preliminary Results 

Appendix E1 (available online at http://www.annemergmed.com) shows the guidelines, flowchart, order sets, and chart abstraction forms for asthma. Results were analyzed from the quality-improvement data gathered through the chart audit process. Patient groups were similar in the pre- and postcommittee guideline period (Table 1). Length of stay was decreased while not affecting the number of patients readmitted at 72 hours (Table 1). Initial bronchodilator therapy was altered between the groups (Table 2). Time to first treatment was faster in postguidelines group (Table 3), and documentation of therapy improved (Table 4).

Table 1. Characteristics of a baseline sample of 140 patients presenting to the ED between December 30, 2004, and June 30, 2005, and the postguideline sample of 142 patients presenting to the ED between April 1, 2006, and May 31, 2006. Data are given as frequencies and percentages except as otherwise indicated. Groups were demographically similar; length of stay declined without affecting 72-hour readmittance rate.

Demographic	Preguideline, N=140	Postguideline, N=142
Age, y (mean, SD)	39.7(13.9)	38.7(15.1)
Race
Black	104(74.3)	111(78.2)
Caucasian	30(21.4)	26(18.3)
Other/mixed race	6(4.3)	5(3.5)
Sex
Male	52(37.1)	55(38.7)
Female	88(62.9)	87(61.3)
Insurer
Private	20(14.3)	20(14.1)
Medicare	22(15.7)	28(19.7)
Medicaid/other federal source	34(24.3)	40(28.2)
Uninsured	64(45.7)	54(38.0)
Length of stay, h (mean, SD)	5.1(3.5)	4.3(2.4)
Readmitted within 72 h	6(4.3)	6(4.2)

Table 2. Types of bronchodilator therapy. Choice of initial therapy moved away from MDI and toward albuterol/ipratropium HHN after guideline initiation.

Initial Therapy	Preguideline, Patients, No. (%)	Postguideline, Patients, No. (%)
Albuterol MDI with spacer	28(21.1)	8(6.0)
Albuterol HHN	14(10.5)	10(7.5)
Albuterol/ipratropium HHN	90(67.7)	113(84.3)
Continuous nebulization: Albuterol up to 10 mg/1 h	0(0.0)	2(1.5)
Ipratropium 1 mg by nebulization/1 h, added to albuterol	1(0.8)	1(0.7)

MDI, Metered-dose inhaler; HHN, Handheld nebulizer.

Table 3. Time to first treatment (mean, SD) for each acuity level in hours. Time to first treatment declined for all triage levels after initiation of guidelines.

ESI, Emergency Severity Index (ref. AHRQ Publication No. 05-0046-DVD).¹⁹

Table 4. The number and proportion of discharged patients who satisfied discharge goals or who had undocumented discharge goals. Documentation of several factors involving nursing care improved, whereas provider documentation of improved pulmonary examination result or repeat assessment changed little.

Cultural Change: Acceptance of Guidelines 

A major challenge to the Committee for Procedural Quality and Evidence-Based Practice process was to obtain buy-in from the users of the system. Our nursing staff has embraced this new focus on quality care and the use of guidelines, yet physicians, despite forming and applauding the process, have proven difficult to influence consistently. The paradigm shift from reliance on memory to using written guidelines is a considerable one for most practitioners. Research has shown that multiple, separate interventions are needed to overcome barriers to acceptance and to initiate changes in provider behavior.¹⁴, ¹⁵, ¹⁶, ¹⁷ This use of multiple methods to influence adult learners has been shown to be more effective than a single intervention alone.¹⁴, ¹⁵, ¹⁶, ¹⁷ The guideline development uses local expert consensus in conjunction with published evidence. Product ease of use has been a pillar of development since the committee’s inception. Guidelines have been introduced using multiple, short (5-minute), educational events during weekly conference time and conducted in conjunction with a new guidelines publication, supplemented with periodic e-mail reminders.

Feedback: Physician Scorecards 

The final step in changing physicians’ behavior may be through the use of performance feedback to providers. The Committee for Procedural Quality and Evidence-Based Practice provides the results of the patient-care audits as they occur, and more comprehensive feedback is provided using quarterly scorecards. These scorecards primarily include Joint Commission on Accreditation of Healthcare Organizations core measures and the Committee for Procedural Quality and Evidence-Based Practice guidelines compliance. The scorecards are provider specific and allow each provider to compare their compliance rates against those of the entire group. The scorecards also include practitioner-specific procedure complication rates and patients treated per hour. We believe the Committee for Procedural Quality and Evidence-Based Practice scorecards with peer comparison are critical to complete the feedback loops to the practitioners of the system and will lead to the persistent changes in provider behavior that have been elusive.

Electronic Support (http://www.CPQE.com): A Quality Initiative Web Site 

The Committee for Procedural Quality and Evidence-Based Practice process takes advantage of the expanding role of bioinformatics in health care. To overcome the lack of an electronic medical record at our institutions, paper-based guidelines, order sets, and a manual audit process are used. However, the committee recognized the need for an electronic repository for its products early in the process because paper format quickly proved difficult to store and led to limited use of the committee’s products. The guidelines, order sets, and other documents are stored electronically and accessed and printed for use through the Internet. The Web site http://www.CPQE.com was built with the educational publishing software Lectora (Trivantis Corporation, Cincinnati, OH) to catalogue end-user information. The goal is for www.CPQE.com to be the one place health care providers can access all of the informational tools necessary to care for a patient within our system.

As a result of the popularity of the electronic storage system developed for the committee, paper storage systems are being phased out of the ED, additionally reinforcing provider desire to use and become familiar with the electronic repository. We hypothesize that this will increase access to and awareness of disease-specific guidelines by directing the provider to a comprehensive library, and it will smooth the inevitable transition to electronic data systems by providing familiarity with computer-based systems and by phasing in the underlying data structure that will ultimately be involved in implementing those systems.

Expansion and Longevity 

The sheer diversity of diagnoses and chief complaints presenting to EDs could easily overwhelm a newly minted system such as ours. Therefore, a measured approach to guideline development has allowed us to focus on conditions that we believe have maximal systems and patient-care impact. The need for additional guideline development, expansion of evaluation measures to include patient and system outcomes, and continuous quality monitoring of guidelines already in place, however, calls for an ever-expanding role for initiatives such as the Committee for Procedural Quality and Evidence-Based Practice. An appropriate balance between resources and benefits must be achieved to avoid long-term failure of the initiative. We contend that recognition of the ED as a compressed model of the entire health care delivery system¹⁸ has allowed the Committee for Procedural Quality and Evidence-Based Practice to engage resources available within our health system but outside the ED. These resources, such as decision support and quality assurance, have aided the implementation and testing of our quality initiative. The ED, with its “health system in a box” organization, makes the ideal microcosm to develop practice initiatives that can be scaled to meet the needs of an entire health care system.

Summary 

This article describes a structure and method for initiation of a quality process and demonstrates that it is feasible to implement evidence-based quality initiatives in the ED. Our process encompasses a busy, urban ED and 2 community EDs. The Committee for Procedural Quality and Evidence-Based Practice is a process designed to promote patient care that is evidence based, efficient, and reproducible from triage through disposition and encompasses physician and nursing care. The Committee for Procedural Quality and Evidence-Based Practice has shown that modification of systems to incorporate evidence-based care into practice through education, guideline development, work-saving tools, and feedback can influence patient care positively. However, provider behavior change has not been uniform or to the extent expected. The Committee for Procedural Quality and Evidence-Based Practice has led the Department of Emergency Medicine to become a leader in quality initiatives within our health system. The committee director, codirector, and department chairman have been asked to present this initiative at multiple levels of administration and to consult internally in response to this effort. However, long-term success of this endeavor relies on acceptance and use by all stakeholders, including providers; therefore, further development and study of the Committee for Procedural Quality and Evidence-Based Practice are necessary. Provider-specific, peer-comparison scorecards hold promise to influence practitioners to accept guidelines and evidence-based care.

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Appendix 

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• Appendix E1. 

  CPQE products developed for asthma.

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References 

1. Kohn L. To err is human: an interview with the institute of medicine’s Linda Kohn. Jt Comm J Qual Improv. 2000;26:227–234
   • View In Article
   • MEDLINE
2. Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. Crit Care Med. 2006;34:S1–S6
   • View In Article
   • MEDLINE
   • CrossRef
3. Getting started with core measures. Jt Comm Perspect. 2002;22:7–8
   • View In Article
   • MEDLINE
4. Integrated Healthcare Association. History of IHA’s pay for performance initiative. Available at: Accessed http://www.iha.org/payfprfd.htm
   • View In Article
5. Biros MH, Adams JG, Wears RL. Errors in emergency medicine: a call to action. Acad Emerg Med. 2000;7:1173–1174
   • View In Article
   • MEDLINE
   • CrossRef
6. Vincent C, Simon R, Sutcliffe K, et al. Errors conference: executive summary. Acad Emerg Med. 2000;7:1180–1182
   • View In Article
   • MEDLINE
   • CrossRef
7. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–2645
   • View In Article
   • CrossRef
8. Handler JA, Feied CF, Coonan K, et al. Computerized physician order entry and online decision support. Acad Emerg Med. 2004;11:1135–1141
   • View In Article
   • MEDLINE
   • CrossRef
9. Schriefer J. The synergy of pathways and algorithms: two tools work better than one. Jt Comm J Qual Improv. 1994;20:485–499
   • View In Article
   • MEDLINE
10. Grimshaw J, Freemantle N, Wallace S, et al. Developing and implementing clinical practice guidelines. Qual Health Care. 1995;4:55–64
    • View In Article
    • MEDLINE
11. Velez LI, Benitez F, Todd CW, et al. An update on the emergency department management of asthma. Emerg Med Rep. 2006;27:38–45
    • View In Article
12. Emond SD, Woodruff PG, Lee EY, et al. Effect of an emergency department asthma program on acute asthma care. Ann Emerg Med. 1999;34:321–325
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (62 KB)
    • CrossRef
13. Goldberg R, Chan L, Haley P, et al. Critical pathway for the emergency department management of acute asthma: effect on resource utilization. Ann Emerg Med. 1998;31:562–567
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (73 KB)
    • CrossRef
14. Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings (The Cochrane Effective Practice and Organization of Care Review Group). BMJ. 1998;317:465–468
    • View In Article
15. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? (a framework for improvement). JAMA. 1999;282:1458–1465
    • View In Article
    • MEDLINE
    • CrossRef
16. Davis DA, Thomson MA, Oxman AD, et al. Changing physician performance (A systematic review of the effect of continuing medical education strategies). JAMA. 1995;274:700–705
    • View In Article
    • MEDLINE
17. Wensing M, Grol R. Single and combined strategies for implementing changes in primary care: a literature review. Int J Qual Health Care. 1994;6:115–132
    • View In Article
    • MEDLINE
18. Feied CF, Smith MS, Handler JA, et al. Emergency medicine can play a leadership role in enterprise-wide clinical information systems. Ann Emerg Med. 2000;35:162–167
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (50 KB)
    • CrossRef
19. Gilboy N, Tanabe P, Travers DA, et al. Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No. 05-0046-2 Rockville, MD: Agency for Healthcare Research and Quality; 2005;May
    • View In Article