Emergency Department Pediatric Performance Measures Toolkit

Clinicians EMSC Stakeholders Hospital Prehospital Quality Improvement Research

Assessing the quality of medical care and identifying opportunities for improvement of care is an important responsibility of medical professionals, as well as all health care facilities. Though children account for 20% of emergency care visits nationally, few measures have been defined for assessing the emergency care of pediatric patients. This toolkit features the work of Evaline Alessandrini, MD, and her EMSC Targeted Issues project "Defining Quality Performance Measures for Pediatric Emergency Care." Her project seeks to improve pediatric emergency care through the consensus identification of pediatric emergency care performance measures and associated elements of documentation. Providing a framework for the measurement of pediatric emergency care will facilitate national benchmarking as well as an opportunity for development of risk adjustment processes to facilitate better pediatric emergency care research.

Background

“Defining Quality Performance Measures for Pediatric Emergency Care” is funded by a Targeted Issues Grant from the Emergency Medical Services for Children (EMSC) program and is in response to “Emergency Care for Children: Growing Pains,” the 2006 Institute of Medicine (IOM) report that recommends the development of national standards for emergency care performance measurement. To assist in achieving this goal, this project identified quality performance measures that comprehensively reflect pediatric emergency care. Measures were categorized by the six IOM quality domains, Donabedian’s structure/process/outcome framework, and pediatric emergency care disease frequency and severity.

The multiphase design included a literature and web review to identify candidate performance measures and the creation of four work groups composed of health care leaders in outcome and quality improvement. Nominal group techniques were employed to nominate an initial list of 335 potential measures. A Delphi method, with two rounds of voting across 4 distinct phases, was used to pare down this list to a final balanced set of 60 measures. An operational definition, including full numerator, denominator, and data element requirements for each of the 60 measures has been delineated. Lastly, each measure was assessed for 1) importance to emergency medical services for children, 2) scientific acceptability, 3) usability and 4) feasibility by a diverse stakeholder group that included pediatric emergency medicine physicians, general emergency medicine physicians practicing in academic or community settings, nurses, and parents. Using these ratings, we prioritized 15 measures for testing and improvement.

IOM Domains

The Six IOM Domains, First Outlined In The IOM Report "crossing The Healthcare Quality Chasm," Are: Effectiveness, Safety, Efficiency, patient-centeredness, timeliness, and equity. To learn more about each of the IOM Domains, refer to their website.

Donabedian Framework.

Measures were also classified by Donabedian’s structure/process/outcome framework. Structural elements provide indirect quality-of-care measures related to a physical setting and resources. Process indicators provide a measure of quality of care and services by evaluating the method or process by which care is delivered. Outcome elements describe valued results related to lengthening life, relieving pain, reducing disabilities and satisfying the consumer.

Emergency Department Pediatric Performance Measures

Subdivided in to the following 11 areas of interest, the 60 performance measures comprehensively reflect pediatric emergency care. As described below, during the performance measure development process, three important dimensions were considered: the IOM quality domains; the Donabedian Framework, a process and outcome framework for quality; and the Diagnosis Grouping System and Severity Classification System for pediatric emergency care disease frequency and severity.

Fifteen Priority Emergency Department Performance Measures

Each of the 60 measures were assessed for 1) importance to emergency medical services for children, 2) scientific acceptability, 3) usability, and 4) feasibility by a diverse stakeholder group that included pediatric emergency medicine physicians, general emergency medicine physicians practicing in academic or community settings, nurses, and parents. Using these ratings, the working group prioritized 15 measures for testing and improvement.

Mchcom.com Webinar: Using Performance Measures to Drive Improvement in Pediatric Emergency Care. (slides | transcript)

To address serious shortcomings related to pediatric emergency care (PEC), the "Emergency Care for Children: Growing Pains" component of the Institute of Medicine report recommends the development of national standards for emergency care performance measurement. This webinar addressed the following essential issues:

  • The importance and relevance of performance measurement in pediatric emergency care
  • Use of a consensus development process to define a balanced report card for pediatric emergency care
  • Integration of performance measurement into the electronic medical record
  • Examples of how measures have been used to improve pediatric emergency care
  • Pain assessment and management - the Children’s Hospital of Wisconsin
  • Effective treatment of pediatric asthma exacerbations - the Children’s Hospital of Philadelphia
  • Timely antibiotic administration for children with fever, neutropenia and central lines - Cincinnati Children’s Hospital Medical Center