SYSTEMATIC REVIEW

Quality Indicators for Musculoskeletal Injury Management in the Emergency Department: a Systematic Review Kirsten Strudwick, Mark Nelson, Melinda Martin-Khan, PhD, GCSc (Stats), MHthSc, Michael Bourke, PhD, Anthony Bell, MBBS, FACEM, MBA, MPH, FRACMA, and Trevor Russell, PhD

Abstract Objectives: There is increasing importance placed on quality of health care for musculoskeletal injuries in emergency departments (EDs). This systematic review aimed to identify existing musculoskeletal quality indicators (QIs) developed for ED use and to critically evaluate their methodological quality. Methods: MEDLINE, EMBASE, CINAHL, and the gray literature, including relevant organizational websites, were searched in 2013. English-language articles were included that described the development of at least one QI related to the ED care of musculoskeletal injuries. Data extraction of each included article was conducted. A quality assessment was then performed by rating each relevant QI against the Appraisal of Indicators through Research and Evaluation (AIRE) Instrument. QIs with similar definitions were grouped together and categorized according to the health care quality frameworks of Donabedian and the Institute of Medicine. Results: The search revealed 1,805 potentially relevant articles, of which 15 were finally included in the review. The number of relevant QIs per article ranged from one to 11, resulting in a total of 71 QIs overall. Pain (n = 17) and fracture management (n = 13) QIs were predominant. Ten QIs scored at least 50% across all AIRE Instrument domains, and these related to pain management and appropriate imaging of the spine. Conclusions: Methodological quality of the development of most QIs is poor. Recommendations for a core set of QIs that address the complete spectrum of musculoskeletal injury management in emergency medicine is not possible, and more work is needed. Currently, QIs with highest methodological quality are in the areas of pain management and medical imaging. ACADEMIC EMERGENCY MEDICINE 2015;22:127–141 © 2015 by the Society for Academic Emergency Medicine

E

mergency departments (EDs) are structured to treat medical emergencies that are life-threatening or may cause serious permanent disability. However, there is an increasing trend for patients with low-acuity complaints1 and musculoskeletal injuries to use EDs as their primary mode of access to health care.2,3 Musculoskeletal conditions are a leading cause of disease burden in the United States4 and are second only to cancer in Australasia.5 U.S. data from 2006 and 2007 show that 30% of the 61.2 million musculoskeletal injuries treated that year were seen in EDs.6 Further to

this, there is a significant financial effect; U.S. data in 2004 estimated the annual cost for health care of musculoskeletal injuries to be U.S. $127.4 billion, of which 31% was expended in ED or inpatient care.4 Given the rising burden of musculoskeletal disease, improved quality of care for musculoskeletal injuries has become increasingly important to patients, clinicians, organizations, policy-makers, and purchasers of care. Emergency medicine (EM) health care models and priorities vary around the world. For example, the focus of quality in U.S. health care is on develop-

From the Physiotherapy Department (KS, MN, MB), the Emergency Department (KS, AB), QEII Jubilee Hospital, Metro South Health, Queensland; the Division of Physiotherapy, School of Health and Rehabilitation Sciences (KS, MN, MB, TR), the Centre for Research in Geriatric Medicine (MM), the Centre for Online Health (MM), and the School of Medicine (AB), The University of Queensland, Queensland, Australia. Received July 28, 2014; revision received September 17, 2014; accepted September 18, 2014. The authors have no relevant financial information or potential conflicts to disclose Supervising Editor: Shahriar Zehtabchi, MD. Address for correspondence and reprints: Kirsten Strudwick; e-mail: [email protected].

© 2015 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12591

ISSN 1069-6563 PII ISSN 1069-6563583

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ing payment and delivery models that incentivize and support the provision of high-quality, cost-efficient care.7 Alternatively, the United Kingdom and Australasia focus on quantifying health care using time-based performance measures that address patient outcomes associated with overcrowding and long waiting times in the ED.8–10 Despite the popularity of time-based performance measures, meeting time targets for completion of ED care has not been universally associated with better outcomes for patients.11 In fact, focusing on a single time-related measure does not necessarily correspond to high levels of quality, and other important performance areas, such as return visits and resource allocation to nonemergency activities, can be overlooked.12 The principle of value-based health care delivery centers on quality improvement, where quality is assessed as health outcomes.13 Quality indicators (QIs) provide a measurement for quantitative assessment of the clinical management of patients, which in turn influences these health outcomes.13 It is recognized that health care delivery should be individualized and organized around medical conditions, rather than patients being broadly grouped together.13 It follows that QIs should be focused on specific clinical conditions to make them more meaningful for quality improvement.14,15 This is particularly significant given that there are now a number of different clinical personnel, models of care, and assessment and treatment options for patients who present to EDs with musculoskeletal injuries. There are documented differences in the management and follow-up of musculoskeletal injuries between different ED personnel.16,17 These differences can ultimately affect patient experiences and outcomes both within the ED and during their recovery.18–22 The use of musculoskeletal-specific QIs are an evidence-based way of benchmarking these different types of models and management options, which can ultimately guide improvements in efficiency, costeffectiveness, and the quality of EM performance. The need for indicators specifically measuring musculoskeletal injuries is supported by The National Quality Forum, which launched a Musculoskeletal Measure project in 2013, stating that “because of the burden of musculoskeletal disease, there is a critical need for nationally recognized musculoskeletal care measures.”23 A set of widely used and accepted set of musculoskeletal-specific QIs for use in the ED does not currently exist. The aims of this systematic review were to identify existing musculoskeletal QIs that are designed for use in the ED and to critically evaluate their methodological quality. METHODS Study Design This was a systematic review that used PRISMA guidelines and followed a protocol registered with PROSPERO (International Prospective Register of Systematic Reviews; registration number CRD42014008977).

Database Details Database searches were conducted of MEDLINE, EMBASE, and CINAHL, combining keywords and MeSH terms for emergency, quality of care, and musculoskeletal injuries (Data Supplement S1, available as supporting information in the online version of this paper). There were no limitations to year of publication. The gray literature was also searched, including websites mentioned in previous studies of ED pediatric24 and trauma QIs25,26 and those of specific musculoskeletal-related, EM, or quality improvement organizations, to increase the yield of the search (Data Supplement S2, available as supporting information in the online version of this paper). Duplicates and non–English-language articles were removed. Relevant reference lists of full-text articles were hand searched. The search was completed in 2013. Study Selection English articles were considered that met the following inclusion criteria: explicit definition of at least one QI, explicitly related to the ED care of musculoskeletal injuries or the associated symptoms of such injuries, the QI was specifically developed for ED use, and method of QI development was documented. Musculoskeletal injury was defined as: 1) any extremity or vertebral column musculoskeletal injury classified in the World Health Organization International Classification of Diseases (ICD-10 version 2) under the appropriate subcategories of Diseases of the Nervous System, Diseases of the Musculoskeletal System and Connective Tissue, and Injury, Poisoning, and Certain Other Consequences of External Causes;27 2) an Injury Severity Score28 of ≤9, Abbreviated Injury Score29 of ≤2, or Australasian Triage Scale Category 3 (urgent), Category 4 (semiurgent), or Category 5 (nonurgent)30; or 3) the result of acute lowvelocity trauma. Reviews, conference proceedings and abstracts, commentaries, letters to the editor, and narrative reports were excluded due to lack of detailed information. References from relevant reviews were hand-searched. Studies describing QIs to assess the whole of ED, such as average length of stay and wait times, were also excluded as they did not meet the inclusion criteria of having been specifically designed for musculoskeletal injuries. Data Collection and Extraction Two authors (KS, MN) independently screened all titles, abstracts, and full-text articles, eliminating articles at each stage by applying the inclusion and exclusion criteria. Disagreement was resolved by the two authors reaching consensus at the conclusion of each stage of article elimination. A third person (MM) was consulted if agreement could not be reached at any stage of article elimination. The PRISMA checklist31 guided the structure and reporting of the systematic review. One author (KS) extracted data from each included article using a standardized form. Core data elements included study design, study setting, description of the QIs, data specifications, and results of any QI testing. QIs were classified independently by two authors (KS, MM), combining two frameworks for health care quality: the Donabedian framework32 and the Institute of Medicine

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30. Australasian College for Emergency Medicine. Guidelines on the Implementation of Australasian Triage Scale in Emergency Department. Melbourne, Australia: Australasian College for Emergency Medicine, 2013. 31. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–9. 32. Donabedian A. The quality of care. JAMA 1988;260:1743–8. 33. Institute of Medicine. Crossing the quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001. 34. Agency for Healthcare Research and Quality. Part IV. Selecting Quality and Resource Use Measures. Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/ perfmeasguide/perfmeaspt4.html. Accessed Nov 15, 2014. 35. de Koning J, Burgers J, Klazinga N. Appraisal of Indicators through Research and Evaluation (AIRE): Department of Social Medicine, Academic Medical Center, University of Amsterdam [in Dutch]. Available at: http://old.cbo.nl/Downloads/407/AIRE% 20Instrument%20(VERSIE%202.0).pdf. Accessed Nov 19, 2014. 36. Pasman HR, Brandt HE, Deliens L, Francke AL. Quality indicators for palliative care: a systematic review. J Pain Sympt Manag 2009;38:145–56. 37. Center for Health Policy/Center for Primary Care and Outcomes Research & Battelle Memorial Institute. Quality Indicator Measure Development, Implementation, Maintenance, and Retirement. Rockville, MD: Agency for Healthcare Research and Quality, 2011. 38. Centers for Medicare & Medicaid Services. Hospital Outpatient Quality Reporting Program. Available at: http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html. Accessed Nov 15, 2014. 39. Australian Council on Healthcare Standards. Australasian Clinical Indicator Report 2005–2012: Emergency Medicine, Version 5. Available at: http:// www.achs.org.au/media/76221/emergency_medicine_gc.pdf. Accessed Nov 15, 2014. 40. Banerjee J, Benger J, Treml J, et al. The National Falls and Bone Health Audit: implications for UK emergency care. Emerg Med J 2012;29:830–2. 41. Jones P, Harper A, Wells S, et al. Selection and validation of quality indicators for the Shorter Stays in Emergency Departments National Research Project. Emerg Med Australas 2012;24:303–12. 42. Tsai CL, Sullivan AF, Gordon JA, et al. Quality of care for joint dislocation in 47 US EDs. Am J Emerg Med 2012;30:1105–13. 43. National Health and Medical Research Council. National Emergency Care Pain Management Initiative Final Report. Melbourne, Australia: National Health and Medical Research Council, 2011.

44. Partners HealthCare and University of Washington. Emergency Department Imaging Efficiency Measures. Available at: http://www.brighamand womens.org/Departments_and_Services/emergencymedicine/QualityImprovement/Approp%20CSpine% 20Radiography%20UW-PHS%20harmonized%20me asure%205-19-10.pdf. Accessed Nov 19, 2014. 45. Herd DW, Babl FE, Gilhotra Y, Huckson S. PREDICT group. Pain management practices in paediatric emergency departments in Australia and New Zealand: a clinical and organizational audit by National Health and Medical Research Council’s National Institute of Clinical Studies and Paediatric Research in Emergency Departments International Collaborative. Emerg Med Australas 2009;21:210–21. 46. Terrell KM, Hustey FM, Hwang U, Gerson LW, Wenger NS, Miller DK. Quality indicators for geriatric emergency care. Acad Emerg Med 2009;16:441–9. 47. Swing SR, Schneider S, Bizovi K, et al. Using patient care quality measures to assess educational outcomes. Acad Emerg Med 2007;14:463–73. 48. Guttmann A, Razzaq A, Lindsay P, Zagorski B, Anderson GM. Development of measures of the quality of emergency department care for children using a structured panel process. Pediatrics 2006;118:114–23. 49. Beattie E, Mackway-Jones K. A Delphi study to identify performance indicators for emergency medicine. Emerg Med J 2004;21:47–50. 50. Chadbunchachai W, Saranrittichai S, Sriwiwat S, Chumsri J, Kulleab S, Jaikwang P. Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai 2003;86:1–7. 51. Lindsay P, Schull M, Bronskill S, Anderson G. The development of indicators to measure the quality of clinical care in emergency departments following a modified-Delphi approach. Acad Emerg Med 2002;9:1131–9. 52. American College of Emergency Physicians. Trauma care systems quality improvement guidelines. Ann Emerg Med 1992;21:736–9. 53. Centers for Medicare & Medicaid Services. Handbook for the CMS Measures Management System Blueprint, version 10. Phoenix, AZ: Health Services Advisory Group, 2013. 54. Centers for Medicare & Medicaid Services. Hospital Outpatient Department Quality Reporting Specifications Manual v6.0b. Available at: http:// www.qualitynet.org/dcs/ContentServer?c=Page&page name=QnetPublic%2FPage%2FSpecsManualTemplat e&cid=1228772438492. Accessed Nov 15, 2014. 55. Australian Council on Healthcare Standards. Australasian Clinical Indicator Report: 2005–2012. Sydney, Australia: Australian Council on Healthcare Standards, 2013. 56. Australian Council on Healthcare Standards. Australasian Clinical Indicator Report 2005–2012: Statistical Methods. Sydney: Australia, 2013. 57. Australian Council on Healthcare Standards. Clinical Indicator User Manual: Emergency Medicine, version 5. Sydney, Australia: Australian Council on Healthcare Standards, 2013.

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Identification

Records identified through database search (n = 1,585) 1,142 MEDLINE 290 CINAHL 153 EMBASE

Additional records identified through gray literature (including websites) (n = 493)

Screening

Records screened for duplicates and non-English language (n = 2,078) Duplicates and non-English language articles removed (n = 273) Records screened on title and abstract (n = 1,805)

Eligibility

Records excluded on: (Title n = 1,420) (Abstract n = 199) Full-text articles assessed for eligibility (n = 186) Records identified from review of reference lists (n = 37)

Included

Records excluded after full-text articles reviewed (n = 208) Studies included in review (n = 15)

Figure 1. PRISMA flow diagram.

procedures on pain management for femur fractures. The remaining 10 QIs were measures of outcomes of care. Only one of the 45 overlapping QIs (“neurovascular status documented for extremity injury”) was not represented in more than one IOM domain. Top Rating QIs References marked with an asterisk in Table 2 are those considered to be of high methodological quality by scoring 50% or greater across all AIRE domains and are presented in Table 3 in further detail. Of the 71 QIs, 10 were considered to be of high quality. As displayed in Table 2, this equates to only five overlapping QIs, demonstrating that similar aspects of care exist among high-quality QIs. These aspects were pain management (n = 8) and appropriate imaging of the spine (n = 2). DISCUSSION This systematic review summarizes existing ED musculoskeletal QIs in the literature and the existing evidence to support their use. The 15 articles reviewed demonstrated 71 QIs that measure quality of care for musculoskeletal injuries in the ED setting. Despite the large number of existing QIs, there is a paucity of methodological quality and evidence supporting the development of most QIs.

Top Rating QIs The best available evidence demonstrated 10 QIs with high methodological quality that are suitable and ready for use. However, the scope of these is narrow, covering only two aspects of management of musculoskeletal injuries: pain management and appropriate medical imaging of the spine. The two QIs developed by the Centers for Medicare & Medicaid Studies (CMS) scored higher than all others, which reflects the rigorous development process required for use by CMS and subsequent endorsement of the QI by The National Quality Forum. Types of Musculoskeletal QIs A core group of QIs encompassing musculoskeletal injury assessment and management cannot be recommended, given the lack of methodological quality of all remaining QIs. Some QIs were represented in multiple articles, which perhaps reflects the attention these areas of quality health care receive in daily practice, research, and ED policies. For example, pain assessments and time to analgesia were popular QIs among the included articles. This reflects the prevalence of acute pain presentations to the ED in both adults and children and may be due to the fact that poor management of pain is known to be associated with ED overcrowding and workloads.60,61 Timely analgesia is often the focus of ED

10 EDs (seven pediatric, three mixed) in Australia and NZ Target EDs not specified

Target EDs not specified

2009

2007

Guttmann et al.,48 Canada

2006

174 EDs in Ontario

Target EDs not specified

2010

2009

45 EDs in Australia

2011

National Health and Medical Research Council,43§ Australia Partners Healthcare,44 USA Herd et al.,45 Australia & NZ

Society for Academic Emergency Medicine (Terrell et al.),46 USA Swing et al.,47 USA

47 EDs in USA

2012

Tsai et al.,42 USA

EDs in NZ

Healthcare Trusts in UK

2012

2012

Public and private sectors, metropolitan and nonmetropolitan EDs in Australia and NZ

2013

Australian Council on Healthcare Standards,39‡ Australia & New Zealand Banerjee et al.,40 UK

Jones et al.,41 NZ

EDs in USA

Study Setting

2013

Year

Center for Medicare & Medicaid Services,38* USA

Source, Reference, Country

Table 1 Article Characteristics

Expert panel discussion Consensus method Literature review Field testing

Expert panel discussion Consensus method Literature review

Literature review Expert panel discussion (thematic analysis) Literature review Consensus method Audit Literature review Expert panel discussion Audit Literature review Expert panel discussion Expert panel discussion Field testing Audit Systematic review Expert panel discussion Consensus method

Expert panel discussion Audit

Literature review Expert panel discussion Field testing Audit Expert panel discussion Literature review Field testing Audit

Study Design

Pediatrics (aged 5–19 yr)

Not specified

Elderly (aged 65 yr or older)

Pediatrics (mean age = 5.6 yr)

Adults (aged 16–65 yr)

Not specified

Aged 14–89 yr

Not specified

Elderly (aged 65 yr and older)

Long-bone fractures: Aged 2 yr or older Low back pain: Age not specified Adults (aged 15 yr and older) and pediatrics (aged under 15 yr)

Study Population (Age)

Low back pain C-spine injury Ankle injury Knee injury Extremity injury Patient requiring analgesia Patient requiring medical imaging Ankle injury

Patients requiring analgesia

Femur fractures

Traumatic neck pain

Joint dislocations of shoulder, elbow, hip, knee, ankle Patients requiring analgesia

Fragility fractures (wrist, humeral, pelvic, or vertebral) Patients requiring analgesia

Limb pain Fractures

Long-bone fractures Low back pain

Type of Injury

3

9

6

11

1

3

5

1

8

4

2

Number of Relevant QIs

(Continued)

42%–46%

32%–41%

64%†

45%–47%

83%†

72%†

52%†

44%†

63%†

90%†

97%†

Quality Score Range (Lowest– Highest)

ACADEMIC EMERGENCY MEDICINE • February 2015, Vol. 22, No. 2 • www.aemj.org 131

EDs in Ontario

Trauma care systems

2002

1992

Study Design

Literature review Consensus method Expert panel discussion Field testing Expert panel discussion

Expert panel discussion Audit

Consensus method

Study Population (Age)

Not specified

Aged 0–85 yr

Not specified

Not specified

Type of Injury

Acute traumatic event: ICD-9-CM diagnoses of 800.00–959.9

Ankle injury

Fractures Patients requiring analgesia Patients requiring imaging or investigations Minor injury All trauma

*Additional resources on the Center for Medicare & Medicaid Services website were used to perform this evaluation.53,54 †All QIs within this article have the same quality score. ‡Additional Australian Council on Healthcare Standards resources were used in order to perform this evaluation.55–58 §An additional National Health and Medical Research Council resource was used in order to perform this evaluation.59

American College of Emergency Physicians,52 USA

Regional hospital in Thailand

2003

Study Setting

EDs in the UK

Chadbunchachai et al.,50 Thailand Lindsay et al.,51 Canada

Year

2004

Beattie and Mackway-Jones,49 UK

Source, Reference, Country

Table 1 (Continued)

4

2

4

8

Number of Relevant QIs

29%–30%

66%–72%

28%–33%

34%–40%

Quality Score Range (Lowest– Highest)

132 Strudwick et al. • MUSCULOSKELETAL QIs IN THE ED: A SYSTEMATIC REVIEW

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133

Figure 2. Disease-specific and general musculoskeletal quality indicators.

quality improvement processes because of the inherent difficulties in achieving this in a busy or overcrowded environment. Setting pain management QIs focuses people’s attention on initial management of pain early in the presentation. Additionally, use of medical imaging against evidence-based clinical guidelines were popular QIs; however, only two QIs demonstrated high methodological quality. Medical imaging in the ED is a common and frequently performed component of health care delivery to aid in diagnosis, establish prognosis, and guide therapy. Although clinical guidelines exist to guide decision-making and ensure quality and safety of medical imaging services, few standards exist to address the variations in the delivery of services or to define the quality of outpatient imaging care.38 Availability of advanced imaging modalities such as magnetic resonance imaging (MRI), and the use of these in a fee-forservice model, creates the need for QIs to ensure appropriate use and that the relevance of these QIs in different systems may be deprioritized depending on availability of such modalities. While this review revealed evidence to support the use of QIs to measure appropriate use of MRI in low back pain, and radiography or computed tomography imaging for neck trauma, the remaining QIs measuring imaging quality of care did not demonstrate a high methodological rigor. These include appropriateness of ankle and knee radiographs and misinterpreted medical imaging. Further development and validation are therefore required for these QIs. Of the disease-specific QIs found in this review, knee injuries and low back pain had the least number of QIs (Figure 2). This is surprising given that both injuries are common presentations to the ED. An estimated 2.5 million sports-related injuries present to EDs annually in the United States,62 and low back pain accounts for over 3% of all emergency visits.63 While epidemiology studies show that knee injuries are the most commonly

injured joint by adolescent athletes, there is an increasing trend in the incidence of knee injuries among adult and senior patients.62 As acute knee injury is a common cause of disability and decreased functioning, the initial management of these injuries in the ED is important to ensure accurate diagnosis and investigations, effective management, and appropriate streaming for followup.64 Meanwhile, back pain can be difficult to assess and manage in the ED, as patients often have high expectations of pain relief and investigations.65 There are large variations in care and poor compliance with guidelines for the management of patients with low back pain, particularly in regard to referrals for imaging, provision of advice, and simple analgesics.66 The importance of excluding high-risk illnesses in patients presenting with pain in the lower back is only achieved through a thorough history and physical examination. Consequently, further QIs should be developed supporting this high-risk area of EM assessment and to support recent developments and research in the area of management of acute nonspecific musculoskeletal low back pain.67 Methodological Quality All 71 QIs demonstrated good or very good scores for evidence of a “purpose, relevance, and organizational context,” as outlined in the AIRE Instrument. These clinically relevant domains (Table 2) include pain management guidelines and policies, conformance with medical imaging protocols, joint dislocation management (including vital signs, neurovascular assessment, confirmed successful reduction), fracture management (including specialized management of fragility fractures), and adverse events. Available evidence presented in these articles can be used to identify important and promising QIs appropriate for further development and evaluation. Despite all articles developing their QI sets via consensus methods or expert panel discussions, the study

Analgesia/pain management Pain assessment/score documented (ACHS,39 NHMRC,43 Terrell,46 Tsai,42 Herd,45 Beattie49)* Time to analgesia (CMS,38 ACHS39 NHMRC,43 Herd,45 Jones,41 Beattie,49 Swing47)* Administration of analgesia (Tsai,42 Herd,45 Beattie49) Pain reassessment documented (ACHS, 39 NHMRC,43 Terrell,46 Beattie49)* Full vital signs documented after IV/IM sedatives (Tsai42) % of EDs with pain management policies/guidelines (Herd45) % of EDs with analgesic-specific policies or guidelines (Herd63) % of EDs with pain management education and quality improvement processes (Herd45) Ability of triage nurse to prescribe analgesia (Beattie49) If older adult receives analgesic medication while in ED, then meperidine should be avoided (Terrell46) IF an older adult receives an opioid analgesia prescription upon discharge from the ED, then a bowel regimen should also be provided (Terrell46) Medical imaging/investigation % of patients with an ankle/foot injury who receive a radiograph (Lindsay, 51 Guttmann48) % of negative ankle radiographs (Lindsay,51 Guttmann48) Time from triage to ankle radiograph (Guttmann48) Blunt injury above clavicle; no C-spine X-ray (Chadbunchachai50) Appropriate cervical spine radiography and CT imaging in trauma (Partners Healthcare,44 Swing47)* Conformance with Ottawa ankle rules (Swing47) Conformance with knee rules (Swing47)

Overlapping QIs (References Indicate All Articles That Include This QI)

92 80 77 77 77

57 92

92

87

87

ACHS39

Tsai42

Herd45

Herd45

Herd45

Beattie49

Terrell46

Terrell46

Lindsay51

Lindsay51

Swing

72

72

Swing47 39

39

83

97

Partners Healthcare44

47

8

33

44

44

39

39

67

42

42

42

36

97

39

89

97

Stakeholder Involvement (%)

62

Chadbunchachai

Guttmann 72

80

Tsai42

50

100

CMS38

48

92

Purpose, Relevance and Organizational Context (%)

ACHS39

Highest Scoring Article

31

31

67

8

33

81

81

81

81

3

17

17

17

31

86

31

100

86

Scientific Evidence (%)

24

24

84

36

29

51

75

44

44

8

45

45

45

60

86

59

100

86

Additional Evidence, Formulation and Usage (%)

41

41

83

29

42

66

72

64

64

34

45

45

45

52

90

52

97

90

Total (Average of Four Domains) (%)

AIRE Instrument Methodological Quality Score–Standardized Total

Process

Process

Process

Process

Process

Outcome

Process

Process

Process

Structure

Structure

Structure

Structure

Process

Process

Process

Process

Process

Donabedian Framework Equity

U

U

U

U

U

U

U

U

U

U U

U

U U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

Safety

U

Efficiency U

U

Timeliness

U

Effectiveness

Institute of Medicine Domain

Table 2 Quality Indicators Relevant to Musculoskeletal Injuries in Emergency Medicine: Measure Descriptions, AIRE Instrument Scores, and Quality Domains

(Continued)

U

U

U

U

U

PatientCenteredness

134 Strudwick et al. • MUSCULOSKELETAL QIs IN THE ED: A SYSTEMATIC REVIEW

57 58

80 73

80 63

78 78 77

62

Beattie49

Swing47

Tsai42

Swing47

Tsai42 Chadbunchachai50

Herd45

Herd45

Herd45

Chadbunchachai50

90

Banerjee40

90

90

90

Banerjee40

Banerjee40

Banerjee40

Banerjee

40

90

90

Banerjee

40

Banerjee 90

100

CMS40

% of MRI lumbar spine for low back pain (CMS40)* Availability of image linking to neurosurgical center (Beattie49) % of patients with misinterpreted X-rays (Swing47) Neurological and vascular status Neurovascular status documented for extremity injury (Tsai,42 Swing47) Neurological exam documented (Swing47) Joint reductions Successful reduction (Tsai42) Treatment > 4 hours (Chadbunchachai50) Fracture management Nonpharmacological treatment documented (Herd45) Pain-reducing devices documented (Herd45) % of EDs with disease/injury specific policies or guidelines for “fractured limb,” “femoral shaft fracture,” and “other” (Herd45) Blunt injury above clavicle; no collar (Chadbunchachai50) % of EDs with fracture liaison nurse or similar (Banerjee40) % of EDs with fracture liaison nurse who performs a falls and osteoporosis assessment on older people with a fragility fracture (Banerjee40) % of evidence of medication review in fragility fractures (Banerjee40) % of cardiovascular examination performed in fragility fractures (Banerjee40) % of patients that have an assessment for visual impairment in fragility fractures (Banerjee40) % of evidence of gait, balance and mobility assessment in fragility fractures (Banerjee40) % of patients that attended any form of exercise in fragility fractures (Banerjee40) 40

Purpose, Relevance and Organizational Context (%)

Highest Scoring Article

56

56

56

56

56

56

56

8

42

42

42

39 8

39

39

39

67

89

Stakeholder Involvement (%)

44

44

44

44

44

44

44

8

17

17

17

31 22

11

31

11

3

100

Scientific Evidence (%)

60

60

60

60

60

60

60

36

45

50

50

60 36

33

60

33

27

100

Additional Evidence, Formulation and Usage (%)

63

63

63

63

63

63

63

29

45

47

47

52 33

39

52

35

38

97

Total (Average of Four Domains) (%)

AIRE Instrument Methodological Quality Score–Standardized Total

Overlapping QIs (References Indicate All Articles That Include This QI)

Table 2 (Continued)

Process

Process

Process

Process

Process

Process

Structure

Process

Structure

Process

Process

Outcome Process

Process

Process

Outcome

Structure

Outcome

Donabedian Framework

U

U U U

U U

U

U

U

U U U

U U

U

U

U

U

U

U

(Continued)

U

U

PatientCenteredness

U

U

U

U

Equity

U

U

U U

U U

U

U

U

U

U

U

Safety

U

U

U

U

Efficiency U

Timeliness

U

Effectiveness

Institute of Medicine Domain

ACADEMIC EMERGENCY MEDICINE • February 2015, Vol. 22, No. 2 • www.aemj.org 135

Herd45

60

60

65

65

ACEP52

Beattie49

Beattie49

60

60

ACEP52

ACEP

52

ACEP52

65

77

Banerjee40

Beattie

90

Highest Scoring Article

49

Purpose, Relevance and Organizational Context (%)

67

67

11

11

11

11

67

42

56

Stakeholder Involvement (%)

3

3

28

28

28

28

3

11

44

Scientific Evidence (%)

21

27

19

19

19

22

27

49

60

Additional Evidence, Formulation and Usage (%)

39

40

29

29

29

30

40

45

63

Total (Average of Four Domains) (%)

AIRE Instrument Methodological Quality Score–Standardized Total

Process

Process

Outcome

Outcome

Outcome

Outcome

Outcome

Process

Process

Donabedian Framework

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

U

Safety

U

Efficiency

U

Timeliness

U

Effectiveness

Institute of Medicine Domain

U

Equity

U

U

U

PatientCenteredness

ACEP = American College of Emergency Physicians; ACHS = Australian Council on Healthcare Standards; CMS = Centers for Medicare & Medicaid Studies; NHMRC = National Health and Medical Research Council; QI = quality indicator. *mark quality indicators that are of high methodological quality, and are included in Table 3 for further evaluation

% of patients prescribed a bisphosphonate or other appropriate treatment for osteoporosis in fragility fractures (Banerjee40) % of consultations/referrals (Herd45) Adverse events Missed injury–patients readmitted or treatment changed (Beattie,49 Swing,47 Chadbunchahai50) Hospital transfers Patient transferred between trauma hospitals (ACEP52) Patient transferred from a nondesignated facility to a trauma hospital (ACEP52) Patient transferred from a nondesignated facility to another nondesignated facility (ACEP52) Patient not transferred from a nondesignated facility to a trauma hospital (ACEP52) Other Patients with wounds who have tetanus status ascertains and receive appropriate antitetanus treatment (Beattie49) Total time spent in ED by patients with minor injuries (Beattie49)

Overlapping QIs (References Indicate All Articles That Include This QI)

Table 2 (Continued)

136 Strudwick et al. • MUSCULOSKELETAL QIs IN THE ED: A SYSTEMATIC REVIEW

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Table 3 Quality Indicators With High Methodological Quality (Score ≥ 50% Across All Four AIRE Instrument Quality Domains) AIRE Instrument–Standardized Scores (%)

Quality Indicator

Indicator Target*

Purpose, Relevance, and Organizational Context

Pain assessment/score documented High† 92 Documented initial pain assessment score for adult limb pain (ACHS39) Patients presenting to the 80% 80 ED in pain have a documented pain score within 30 minutes of admission to the ED (NHMRC43) Pain reassessment documented High† 92 Documented pain reassessment score for 39 adult limb pain (ACHS ) 80% 80 Patients with severe pain (7 or greater) who decrease their pain score by 3 or more points within 1 hour (NHMRC43) Time to analgesia High† 92 Analgesic therapy within 30 minutes for adult limb 39 pain (ACHS ) Analgesic therapy within High† 92 30 minutes for pediatric limb fracture (ACHS39) High† 80 Median time to analgesia of 30 minutes from triage (NHMRC43) Median time from arrival A decrease in 100 to time of initial oral or the median parenteral pain medication value administration for ED patients with long bone fracture (CMS38) % of MRI lumbar spine for low back pain Low† 100 % MRI of lumbar spine with a diagnosis of low back pain for which the patient did not have prior evidence of claims-based antecedent conservative therapy (CMS38) Appropriate cervical spine radiography and CT imaging in trauma % of patients undergoing High† 97 cervical spine radiography or CT imaging for trauma who have a documented evidence-based indication prior to imaging (Canadian C-Spine Rule or NEXUS Low-Risk Criteria) (Partners Healthcare44)

Stakeholder Involvement

Scientific Evidence

Additional Evidence, Formulation and Usage

97

86

86

64

94

50

97

86

86

64

94

50

97

86

86

97

86

86

64

94

50

89

89

100

89

100

94

83

67

84

ACHS = Australian Council on Healthcare Standards; CMS = Centers for Medicare & Medicaid Studies; MRI = magnetic resonance imaging; NHMRC = National Health and Medical Research Council. *The indicator target is the organization’s goal for that particular QI. For some of these QIs it is a moving target, while for others it is a constant target. †The listed QIs aim for “high” targets of concordance; therefore, the ED is considered to perform better if they score high against that particular QI. This does not include “% of MRI lumbar spine for low back pain,” which aims for “low” concordance, where a lower score is considered as the desired performance level.

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designs for most articles were deficient in supporting evidence in the form of literature reviews or in basing the QIs on evidence-based guidelines or studies. Additionally, most QIs scored poorly across items that assessed the formulation and usage of the QIs. These included a lack of evidence of risk adjustment, reliability, feasibility, and instructions for presentation and interpretation of data. Similar systematic reviews of QIs measuring quality of care for major trauma in EDs show the same tendencies.25,26 As such, this review concurs with the conclusions of Stelfox et al.26 that reliance on QIs is often based on shared perceptions of what represents good-quality care and is not necessarily consistent or supported by evidence-based research. Stelfox et al. recommended that a “paradigm shift from expert opinion-based quality assurance to evidence-based quality measures is needed.” Health Care Quality Domains Most existing QIs were process measures, which focus on the way care is delivered. Only a small proportion of existing QIs identified were in the Donabedian framework categories of structure and outcome (Table 2). The predominance of process QIs is often because these indicators are easily measurable. They are also often more sensitive measures of quality, require less risk adjustment, and are amenable to change by providers in ED.68 This in turn drives quality improvement efforts by directing attention to specific and correctable processes that need improvement.68–70 However, valid process measures should be linked to improving outcomes. There are documented strong links between compliance with process indicators and outcomes.71,72 Valid measures of structure and outcome are important as they provide a direct means for programs to evaluate themselves. Further investigation is needed to examine the relationships between structures and outcomes and process and outcomes specifically for patients with musculoskeletal injuries who present to EDs. Most of the identified QIs predominantly fall into the IOM framework domains of effectiveness and safety (Table 2). With recent focus on enhancing the value of health care, the role of the consumer, and eliminating disparities in care delivery, it is perhaps surprising that the IOM domains of efficiency, equity, and patient-centeredness are represented in less than half of the 45 overlapping QIs. No existing QIs addressed consumer satisfaction, despite competitive health care systems relying on patient and family satisfaction as a key marker of value.73 The paucity of QIs addressing timeliness may be a result of the search strategy inclusion criteria, whereby systemwide ED QIs were excluded, because it is well known that time-based measures predominate in the literature surrounding ED overcrowding and patient flow.74 For indicators to drive change at a clinical level, they must be evidence-based and feasible to routinely collect and should undergo a validation process.75 The results of this review show that few of the QIs used in EDs relevant to the management of musculoskeletal injuries have been developed in this way. Develop-

ment of QIs addressing the complete spectrum of musculoskeletal injury assessment and management in EM is required, given the rising burden of musculoskeletal disease and the variations in clinical care of musculoskeletal injuries that can affect patient experiences and outcomes. These QIs should incorporate both general musculoskeletal and specific injury QIs, which may be prioritized according to clinical and economic effects. These QIs should be standardized and include details of definitions, indicator measurements, and data specifications, as well as determinations of the indicator reliability and validity to evaluate the quality of care. This would result in an evidence-based strategy that serves to codify and benchmark different types of ED models and treatments and would have the potential to guide improvements in efficiency, cost-effectiveness, and the quality of EM performance. LIMITATIONS A number of limitations present in this review must be acknowledged. First, strict inclusion criteria dictated that the methodology of QI development had to be described for articles to be included. This may have excluded publications where a QI was trialed in a field study or audit, without a formal QI selection or development process. Further, only articles in English were included as there were no available resources or funding to have non–English-language articles translated. Second, the gray literature search of organizational websites required an endpoint. It is recognized that this search could have proceeded further into institutional websites (i.e., websites of individual health centers or hospitals). Third, the methodological appraisal of the QIs was based only on the information extracted from the included publications, and no authors were contacted for further details. Methodology was not always described in detail, which may have led to weaker methodological quality scores on the AIRE Instrument. Additionally, scoring was based on original publications, where some QI projects may have since followed-up with field work or achieved endorsement of the QI. These limitations may have affected the scoring of some articles, as the AIRE Instrument items mainly concern elements of the development process and subsequent usage of the QIs. CONCLUSIONS The best available evidence demonstrated 10 quality indicators with high methodological quality that are suitable and ready for use. The scope of these is narrow, covering only two aspects of management of musculoskeletal injuries in ED: pain management and appropriate medical imaging of the spine. Methodological quality for the majority of existing quality indicators is poor, and recommendations for a core set of quality indicators that address the complete spectrum of musculoskeletal injury management in emergency medicine are not possible.

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