MEDICINE

ORIGINAL ARTICLE

Numerical Parameters and Quality Indicators in a Medical Emergency Department

Harald Dormann, Katharina Diesch, Thomas Ganslandt, Eckhardt G. Hahn

SUMMARY
Background: Despite calls for improved quality and efficiency in medical emergency departments, there exist hardly any quality indicators, and no methods of calculating efficiency have been published to date. The present study illustrates a means of presenting numerical parameters of a medical emergency department and of identifying potential quality indicators. Methods: Over a period of 12 months, all patient contacts of the medical emergency department in the University hospital of Erlangen were analyzed with respect to patient flow, diagnoses, and treatment units. The diagnostic agreement (DA) parameter was calculated from a systematic comparison of admitting and discharge diagnoses, and diagnostic efficiency (DE) was defined and calculated as the quotient of DA x100 divided by the length of stay in the emergency department. Results: Among the 6683 patients treated, 64.6% underwent further in-hospital care. The diagnostic spectrum of the outpatients differed markedly from that of the inpatients. Patients with diseases of the heart, gastrointestinal tract, and lungs were usually admitted to the hospital for further treatment. Patient contacts had a characteristic circadian and weekly rhythmic pattern. For the overall patient collective, the DA was 71%. The mean length of stay in the emergency department was 116 minutes, and the DE was therefore 0.61/min. The DA was highest (92%) among patients with atrial flutter or fibrillation, while the DE was highest (0.85/min) among patients with acute myocardial infarction. 14% of the patients required further treatment in intensive care. Conclusion: Numerical parameters and quality indicators for a hospital emergency department can be presented in transparent fashion. DA and DE can be used as parameters for diagnosis-related and intradepartmental quality assessment.

Cite this as: Dtsch Arztebl Int 2010; 107(15): 26167 DOI: 10.3238/arztebl.2010.0261
Klinikum Frth, Zentrale Notaufnahme, Lehrkrankenhaus der Universitt Erlangen Nrnberg: PD Dr. med. Dormann Lehrstuhl fr medizinische Informatik der Friedrich Alexander Universitt Erlangen Nrnberg: Diesch, Dr. med. Ganslandt Prof. emeritus, Medizinische Klinik 1 der Friedrich Alexander Universitt Erlangen Nrnberg: Prof. Dr. med. Hahn

ncreasingly, patients are admitted to hospital as emergency cases beyond the remit of outpatient emergency care. The university medical center in Erlangen has registered annual increases of up to 10%. Thanks to the continuous availability of medical services, a large proportion of patients even present to hospitals independently (1, 2). The organizational structures of emergency departments vary widely, partlybut not entirelyowing to the links with rescue services and the general environment of the hospital. Different organizational approaches range from outpatient admission units with triage systems to special emergency outpatient clinics (chest pain unit) or admission units for emergencies where possible referrals/transfers to specialist wards or units are decided only after a time delayfor example, the next morning (1, 36). Although triage instruments have become the quality standard in emergency departments, and time intervalsfor example, from the patients arrival to initial contact with a doctor/nursing staffcan be measured in a replicable fashion, this does not allow any conclusions about the qualityin the sense of correctness/ appropriateness of measuresor about the time it takes to reach a diagnosis. Ultimately, quality indicators are lacking in the heterogeneous area between outpatient care delivered by general practitioners and inpatient care (4, 7). The main requirements for an emergency department are, however, homogenous. They consist of recognizing the acutely life threatening condition of the patient, providing appropriate treatment, or referring the patient for such treatment. This process comprises primary diagnostics and risk stratification on the basis of lead symptoms, initial care, and organization of further specialist diagnostic tests and treatment (1, 2, 6, 8). The present study aims to investigate whether on the basis of data from the hospital information systemdata whose documentation is mandatory and that are available in an electronic formatobjectifiable numerical parameters of an emergency department can be calculated and used as potential quality indicators.

Method
In a retrospective design, we included in the study all patient contacts at the medical emergency admissions

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Formula for calculating the diagnostic efficiency (DE)

FIGURE 1

analyzed according to diagnostic groups (one-digit ICD code) or by individual diagnoses (three-digit ICD code).
Diagnosis related length of hospital stay The length of hospital stay describes a time interval counted in minutes and is calculated from the interval between the time a patient is registered by the administrators to the time that patient is transferred into another organizational unit from the emergency ward, as documented in the clinical information system. For the purposes of this study, the length of a patients hospital stayrelated to their diagnosis at admissionwill be referred to as the diagnosis related length of stay. Diagnostic agreement and diagnostic efficiency Diagnosis at admission is based on a patients medical history, clinical examination by the admitting doctor in the medical emergency department, emergency investigations (for example, laboratory testing, radiology, and electrocardiography), and further diagnostic measuresrecorded in the clinical information management system as a diagnostic code. The discharge diagnosisalso coded in the information systemis based on the total information and data gathered during the patients inpatient stay, and on the diagnosis at admission. For the purposes of this article, this serves as the reference diagnosis to calculating the diagnostic efficiency (DE). Assuming that an admission diagnosis (ICD) made in the emergency department is confirmed as the discharge diagnosis, the diagnostic agreement (DA) can be calculated within a group as the relative frequency of agreement between the diagnosis made in the emergency department and the main diagnosis made in the hospital. On the basis of the DA and the respective ICD based length of stay in the emergency ward (shortest, longest, and mean length of stay in minutes), then the ICD based DE can be calculated for the shortest stay (DEshort), for the longest stay (DE-long), and for the mean stay (DE-mean) according to the formula shown in Figure 1. Statistics The collected data were tabled and evaluated by using the statistical package SPSS version 13. The descriptive results of continuous variables were reported as Minimum Maximum Mean Median Standard deviation (SD) Skewness Standard error of skewness (SE).

department at the university medical center in Erlangen over a period of 12 months. Patients movementsin a daily or weekly rhythm patterndischarge diagnoses, and the respective treatment times in the emergency department were analyzed. The medical emergency department at the university medical center is responsible for surgical and neurological admissions of patients from the Erlangen area, with a population of more than 100 000, and from the surrounding areas. Further, the university medical center is of supraregional importance; patients from other regions are admitted to hospital through this emergency department. The university medical center comprises 23 hospitals with about 1400 beds. As a rule, patients are delivered by emergency services or emergency physicians to one of the emergency wards. Primary examination of the patient then takes place in the medical emergency department, followed by diagnostic tests and treatment on the basis of the main symptoms, and in adherence to internal standards. The emergency department is staffed by an at least third year resident with a qualification in emergency medicine or rescue services, and a minimum of 1 years experience in intensive care medicine; the staff work in shift patterns. Continuous backup is provided by on-call medical specialists. Altogether, 8 monitoring stations are available as acute treatment units. Short term inpatient care is not available in the emergency department. Further interventionsfor example, emergency endoscopiesare conducted in the endoscopy ward or the intensive care unit.
Data management We obtained our data from the university medical centers centralized data warehouse, where data from central information systems as well as from different departmental systems are collected and made available for integrated evaluations. The evaluations took place by using a direct SQL database query as well as an integrated user interface with graphical tools for analyzing the data (9). The entire cohort of medical emergency admissions was identified on the basis of organizational units, changes in types of cases, and main diagnoses according to the ICD-10, and the resultant dataset was analyzed under several clinical aspects. Types of diagnoses Admission and discharge diagnoses and main hospital diagnoses correspond to the definition of the German coding guidelines and were taken from the hospitals clinical information system. The diagnoses were

Results
During the study period, 6683 patients were treated in the emergency department. 4321 patients (64.6%) received further care as hospital inpatients. The mean age of the patients was 67.4 years (minimum 18, maximum 104); 52.4% of patients were female. Of those admitted
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as inpatients, 270 (6.2%) died during further treatment. 2362 patients (mean age 49.2 years; minimum 18, maximum 96; 45.7% female) were discharged directly by the emergency department after diagnosis and treatment.
Patient contact in the daily and weekly profile The daily profile showed the largest increase in patientsindependently of what day of the week it was between 8 am and 11 am, with peaks occurring at 11 am, 2 pm, and 7 pm (Figure 2). The number of inpatient admissions developed in parallel to the number of patient contacts and independently of the time of day. Of the patients admitted to hospital, 5% were admitted to wards not specializing in internal medicine. 14% of patients were admitted to intensive care units. Range of outpatient and inpatient diagnoses The treating physicians documented 8626 admission diagnoses (ICD one-digit to three-digit codes). At the time of admission, 4973 of these diagnoses were in 4321 inpatients and 3653 were in 2362 outpatients. Table 1 shows the three most common admission diagnoses, subcategorized by specialty. Quality indicators We present data on admission and discharge diagnoses from the clinical information system, as well as the diagnosis related length of stay in the emergency departmentsome of them subcategorized by specialtyas numerical parameters and the resulting agreement and efficiency as potential quality indicators. Diagnoses at admission and discharge Of a total of 4973 admission diagnoses, 71% were confirmed as discharge diagnoses. In 29% of patients, an additional 2160 treatment diagnoses were also coded. The frequency spread of these diagnoses was wide. The most common were gastrointestinal hemorrhage (K92.2), dehydration, and syncope and collapse (R55), dyspnea (R06.0), unstable angina (I20.0), left ventricular failure (I50.1), urinary tract infection (N39.0), acute posthemorrhagic anemia (D62), and acute subendocardial myocardial infarction (I21.4). Diagnosis related length of stay The mean length of stay in the emergency department was 116 minutes (minimum 1 minute, maximum 952 minutes, SD 77 minutes, skewness 2, SE 0.038). For the specialty specific length of stay, the following treatment times applied: Gastroenterology/hepatologyIn this group, patients with gastrointestinal hemorrhage (K92) were transferred after receiving treatment for 80 minutes, those with acute pancreatitis (K85) after 88 minutes, other diseases of biliary tract (K83) after 98 minutes, alcoholic liver disease (K70) after 90 minutes, noninfectious gastroenteritis or colitis (K52) after 114 minutes, and calculus of bile duct with cholangitis/ cholelithiasis (K80) after 130 minutes.
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FIGURE 2

Patient flow statisticsDaily and weekly rhythm of patient contact with the emergency department (6683 patients)

For the most common individual diagnoses, it was striking that, for example, patients with acute bleeding gastric ulcers or duodenal ulcers (K25.0, K26.0) were transferred after 55 minutes and 47 minutes, but patients with chronic duodenal ulcers with hemorrhage (K26.4) were transferred only after 138 minutes. PneumologyIn this group, patients with pneumonitis due to solids and liquids (J69) were transferred after 88 minutes treatment, those with acute respiratory failure (J96) after 102 minutes, with chronic obstructive pulmonary disease (J44) after 108 minutes, and with pneumonias (J18, J15) after 112 minutes. Patients with pulmonary embolism and signs of right ventricular failure (I26.0) were treated in the emergency department for 98 minutes, and those without signs of right ventricular failure (I26.9) for 156 minutes. CardiologyExamination of the most common diagnostic codes led to the conclusion that for cardiovascular disorders (I) with atrial fibrillation and flutter (I48), the mean length of stay was 109 minutes, and for congestive heart failure (I50) it was 123 minutes. Among the individual diagnostic codes, the picture is more differentiated. For acute transmural myocardial infarction of the anterior wall (I21.0) and acute transmural myocardial infarction of the inferior wall (I21.1), the length of stay was 26 and 20 minutes.
Diagnostic agreement and diagnostic efficiency Among the 4321 patients receiving inpatient treatment, the DA between admission and discharge diagnosis was 0.71. Table 2 provides an overview of the DA of the three most common admission diagnoses. The DA was highest for patients with atrial fibrillation and flutter (I48), at 0.92, followed by a DA of 0.89 for patients with acute coronary syndrome (I20/21), and a DA of 0.89 for patients with chronic obstructive pulmonary disease with acute lower respiratory infection (J44). The mean diagnostic efficiency (DE) was highest for patients with acute coronary syndrome, at 0.85/min;

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TABLE 1 Range of diagnoses by specialty, subdivided into inpatient and outpatient diagnoses (only the 3 most common diagnoses were included) Cardiological/ thromboembolism ICD I20/ I21 Description Acute unstable angina/ acute myocardial infarction Congestive heart failure Atrial fibrillation or flutter % 13.2 Gastroenterological/ hepatological ICD K92 Description Signs of gastrointestinal hemorrhage % 3.4 Pneumological Nephrological Endocrinological/ metabolic % 2.0 ICD E86 Description Volume depletion % 1.6

No of inpatient diagnoses: n=4973 ICD J15/ 18 Description Pneumonia % 4.9 ICD N39 Description Urinary tract infection, site not specified, or proteinuria Acute renal failure Acute tubulointerstitial nephritis

I50

4.2

K85

Acute pancreatitis Diseases of the biliary duct

1.9

J44

COPD

2.9

N17

1.0

E11

Complications of type 2 diabetes

1.1

I48

3.8

K83

1.2

J96

Respiratory failure

1.3

N10

0.2

E87

Other dis1.0 orders of fluid, electrolyte and acid-base balance Volume depletion 1.0

No of outpatient diagnoses: n=3653 I10 Essential (primary) hypertension Phlebitis and thrombophlebitis Atrial fibrillation or flutter 4.3 K29 Gastritis, duodenitis 0.8 J18 Pneumonia, organism unspecified Asthma 0.7 N39 Urinary tract infection, site not specified, or proteinuria Chronic renal failure 0.9 E86

I80

1.5

K52

Other noninfective gastroenteritis and colitis Paralytic ileus and intestinal obstruction without hernia

0.7

J45

0.6

N18

0.4

E11

Complications of type 2 diabetes

0.8

I48

1.3

K56

0.3

J44

COPD

0.5

N00

Acute nephritic syndrome

0.2

E87

0.6 Other disorders of fluid, electrolyte and acidbase balance

and similarly high for patients with acute pancreatitis, at 0.84/min; followed by 0.81/min for patients with atrial fibrillation or flutter. The lowest values of 0.16/min, 0.19/min, and 0.37/min applied to patients with an admission diagnosis of acute respiratory failure (J96), volume depletion (E86), or other disorders of fluid, electrolyte and acidbase balance (E87). Relative to the total departmental cohort, the DE was 0.61%/min (DE-short 71.00/min, DE-long 0.07/min).

Discussion
One of the challenges that an emergency department is faced with is to decide whether inpatient admission is indicated. Findings or symptoms are assigned to an admission diagnosis by the admitting emergency physician; this diagnosis justifies inpatient admission and has to stand up to inspection by, for example, the Medical Services of Statutory Health Insurance Bodies in Germany (Medizinischer Dienst der Krankenversicherung, MDK). Primary misadmissions have to be recorded, as do discharges for financial reasons (1, 2, 3, 6, 10, 11). The indication for admission in this study was independent

of the time of day and developed in parallel with the total number of patient contacts per time unit. The number of patients (Figure 2) follows a circadian rhythm that is typical for emergency departments and is not influenced by the severity of the illness (1, 4, 10, 12, 13). Patients receiving outpatient treatment have a wide range of diagnoses, and symptoms including a raised temperature, nausea/vomiting, cough, or unspecific pain in the upper abdomenthese patients account for 44%. Patients receiving inpatient care have clearly defined specialist diagnoses in 59% of cases. Symptoms and abnormal laboratory findings are in fourth position among inpatient diagnoses, whereby syncope and collapse take pole position. A lead symptom oriented approach in primary diagnostics therefore seems a useful standard in the emergency setting (1, 6, 8, 13). A correct diagnosis is a quality indicator of an emergency department (14). In the present study, this was estimated retrospectively by means of the DA. Our study found that specific diagnosessuch as cardiac arrhythmia, acute coronary syndrome, chronic obstructive pulmonary disease, or acute pancreatitiswere correctly diagnosed in the emergency
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TABLE 2 Diagnostic agreement (DA) and diagnostic efficiency (DE) depending on the shortest, mean, and longest length of stay for the 3 most common diagnoses in the emergency department Cardiological/ thromboembolism ICD I20/ I21 I50 I48 DA 0.89 0.80 0.92 DE (DE-short, DE-long) 0,.85 (88.970.11) 0.61 (80.190.19) 0.81 (91.980.26) Gastroenterological/ hepatological ICD K92 K85 K83 DA 0.60 0.86 0.56 DE (DE-short, DE-long) 0.52 (47.950.12) 0.84 (86.020.20) 0.59 (56.450.23) Pneumological Nephrological Endocrinological/ metabolic DE (DE-short, DE-long) 0.56 (75.260.12) 0.39 (24.000.18) 0.60 (83.330.22) ICD E86 E11 E87 DA 0.27 0.76 0.38 DE (DE-short, DE-long) 0.19 (13.290.04) 0.68 (75.930.28) 0.37 (37.500.12)

No of inpatient diagnoses: n=4973 ICD J15/ 18 J44 J96 DA 0.86 0.89 0.19 DE (DE-short, DE-long) 0.70 (85.830.14) 0.72 (88.730.21) 0.16 (18.920.06) ICD N39 N17 N10 DA 0.75 0.48 0.83

department to a higher than average extent. By contrast, unspecific transfer diagnosessuch as disturbances to the electrolyte balance or respiratory failurewere mostly not confirmed. Since in clinical emergency medicine, time is an essential factor for the prognosis, we used the diagnosis related length of stay in addition to the DA as a further index (1518). Diagnosis related length of stay as the only quality indicator, however, entails the risk of misjudgement when assessing the efficiency of an emergency department (19, 20). For example, the much cited golden hour or door to balloon time prioritize the time aspect only for patients with a confirmed diagnosis (17, 18). From the perspective of a departmental cohort, however, falsely negatively diagnosed cases are not captured, and a mean length of stay can therefore not be determined (19, 20). By contrast, it has to be borne in mind that this does not do any justice to the acrobatics performed by emergency departmentsnamely, the correct diagnosis per unit of time. By using the DE as a new, combined criterion, both indices are included in the quality assessment. Theoretically, values between 0 and 100 for DE can be measured (if the length of treatment >1 min). Since the diagnostic process requires steps that take a minimum amount of time even in the best-case scenario (for example, deep vein thrombosis in the leg: physical examination, D-dimer tests, ultrasonography), the maximum value of 100 cannot be achieved in practice. The optimum treatment case in each diagnostic group is calculated by means of the DEshort and the case with the longest stay by means of the DE-long. Optimization of the diagnostic process becomes possible only by means of systematically identifying such special cases. In the present study, the DA was 0.71 and the DE 0.61/min for the entire cohort. The highest diagnosis related DE0.85/min (DEshort=88.97, DE-long=0.11) was calculated for patients with acute coronary syndrome. The lowest
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DE0.16/min (DE-short=18.92, DE-long=0.06)applied to patients with unspecific diagnoses, such as respiratory failure, which are often indicative of an unclear diagnosis at the time the patient is transferred. A bed ward assigned to the emergency department would probably contribute to increasing the DA, and possibly the DE, for this treatment area (21, 22). However, dependence from local conditions should have a subordinate role because, as mentioned earlier, for the treatment of certain diagnoses, time allowances (door to needle time) exist that have to be supported in different hospitals by organizational and technical measures (for example, standby service for heart catheterization) (15, 23, 24). A limitation of our study is the fact that the data were taken retrospectively from the documentation of the clinical information system. Prospective studies are needed to find out whether prospective data capture for the purpose of quality documentation would result in significant deviations from the patterns we identified. Further, the correctness (reliability and correct allocation/assignation) of the diagnostic codes is subject to the coding quality. As is known from postmortem studies, the clinical and diagnostic correctness in making diagnoses is subject to a certain error ratio, which in this studyas in most other clinical studies (19, 20)was not taken into consideration. A further limitation of the study lies in the fact that we did not measure the length of time from the patients admission to their transfer but the length of time from administrative instruction to transfer. We did not include in the analysis the type of admission (for example, admission by emergency physician), the time of admission (day, night), or the doctors level of medical qualification and experience, and how all these affect the DE. For the less than 5% of pathologies that were not related to internal medicine, no DE was calculated. How quality indicators affect important primary outcome measuresfor example, the length of time until the patient responds to treatment, the duration of the hospital stay, the recovery success, or mortalitywas not investigated. In order to

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establish the newly developed quality indicators that were presented in this study, validation is therefore required. However, the numerical parameters came from the clinical information system and can be electronically generated; they characterize how emergency admissions work and are available for all emergency departments. We intentionally chose clearly defined parameterssuch as time intervals and coded diagnoseswhich would stand up to external assessment.
Conflict of interest statement The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors. Manuscript received on 6 November 2008, revised version accepted on 14 September 2009. Translated from the original German by Dr Birte Twisselmann.

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KEY MESSAGES

Electronic data available from hospitals clinical

information systems can be used to calculate numerical parameters and to develop quality indicators for emergency admissions.

The diagnostic agreement (DA) of the diagnoses made

at admission and discharge, and diagnosis related mean length of stay, are simple parameters of emergency admissions and can be interpreted clearly.

The diagnostic efficiency (DE) is a new numerical parameter that can be used to identify efficient or inefficient treatment cases within a diagnostic group in a department.

In order to find out whether the DE can be used interdepartmentally as a quality marker, further validation is required.

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Corresponding author Priv.-Doz. Dr. med. Harald Dormann Klinikum Frth Jakob Henle Str. 1 90766 Frth, Germany harald.dormann@klinikum-fuerth.de

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