ED QA

01. Emergency Department (ED) QA Framework

A. Time-Based Clinical Indicators (Turnaround Times - TAT)

Efficiency is the primary quality measure in the ED.

1. Door-to-Triage Time:

   • Definition: Time from patient entry to completion of triage categorization (Red/Yellow/Green).

   • Benchmark: < 5 minutes.

2. Door-to-Doctor Time (Initial Assessment):

   • Definition: Time from registration/triage to being seen by a Casualty Medical Officer (CMO) or Resident.

   • Benchmark: Priority 1 (Red): Immediate; Priority 2 (Yellow): < 15 mins.

3. Door-to-ECG Time (for Chest Pain):

   • Definition: Time taken to capture an ECG for patients with non-traumatic chest pain.

   • Benchmark: < 10 minutes.

4. Door-to-Needle Time (Stroke Thrombolysis):

   • Definition: Arrival to start of fibrinolytic therapy for Ischemic Stroke.

   • Benchmark: < 60 minutes.

5. Door-to-Balloon Time (STEMI):

   • Definition: Arrival to Guidewire crossing in Cath Lab (if 24/7 Cathlab exists).

   • Benchmark: < 90 minutes.

6. Turnaround Time for Labs/Radiology in ED:

   • Definition: Time from sample collection/scan to report generation.

   • Benchmark: Urgent Labs < 45-60 mins; CT Scan/X-ray < 30 mins.

7. ED Length of Stay (ED-LOS):

   • Definition: Total time spent in ED (Arrival to Admission/Discharge/Transfer).

   • Benchmark: < 4 to 6 hours (to prevent overcrowding).

B. Patient Outcomes & Clinical Effectiveness

1. Return to Emergency Department (Re-visit Rate):

   • Indicator: Patients returning to ED with the same or related complaint within 72 hours of discharge.

   • Significance: Indicates missed diagnosis or poor discharge advice.

2. Death in Emergency (Mortality Rate):

   • Breakdown:

     • Brought Dead: Arrived with no signs of life.

     • Death < 24 Hours: Died within ED during stabilization.

     • Net Death Rate: Deaths occurring after stabilization efforts failed.

3. CPR Outcomes (Code Blue Survival):

   • Indicator: % of cardiac arrest patients in ED with "Return of Spontaneous Circulation" (ROSC) > 20 minutes.

4. Unplanned Transfer to ICU/OT:

   • Indicator: Patients initially triaged as "stable/ward admission" who deteriorated and required ICU/OT within 8 hours.

5. Pain Management Efficiency:

   • Indicator: Time from initial pain score assessment (VAS > 7/10) to administration of analgesia.

C. Patient Safety & Nursing Quality

1. Patient Identification Errors:

   • Indicator: Incidents of wrong patient tagging (especially for unconscious/John Doe patients).

2. Medication Errors:

   • Indicator: Prescribing, dispensing, or administration errors (e.g., wrong dose during rapid sequence intubation).

3. Fall Rate in ED:

   • Indicator: Number of patient falls within the ED premises (bathroom/stretcher).

4. Pressure Ulcer (Bed Sore) Incidence:

   • Indicator: Patients developing new pressure injuries (Stage 1) due to lying on hard ED trolleys for > 4 hours.

5. Phlebitis/Extravasation Rate:

   • Indicator: IV cannula site complications initiated in ED.

D. Medico-Legal & Documentation (Critical for Medical Colleges)

1. MLC (Medico-Legal Case) Documentation Compliance:

   • Audit: % of accident/assault cases where Police Intimation, Injury Report, and Weapon details are perfectly documented.

2. Initial Assessment Sheet Completeness:

   • Audit: Check for: History, Vitals (BP/Pulse/SpO2/Temp/GRBS), Provisional Diagnosis, and Plan of Care.

3. Consent Compliance:

   • Audit: % of invasive procedures (Central Line, Chest Tube, Thrombolysis) with valid informed consent.

4. LAMA (Left Against Medical Advice) Rate:

   • Indicator: % of patients leaving against advice. (High LAMA indicates poor communication or financial counseling).

E. Infection Control (HIC)

1. Hand Hygiene Compliance:

   • Audit: Adherence to WHO 5 Moments (Before touching patient, before clean procedure, after fluid exposure, etc.).

2. Needle Stick Injury (NSI) Rate:

   • Indicator: Number of staff (Residents/Nurses) injured by sharps in ED.

3. Biomedical Waste (BMW) Segregation:

   • Audit: % of waste found in the correct color-coded bins during random checks.

F. Medical College Specific (Academic QA)

1. Faculty Supervision Rate:

   • Audit: % of "Red" (Critical) cases where the Senior Resident or Assistant Professor physically reviewed the patient and countersigned the PGs notes within 1 hour.

2. Procedure Logbook Verification:

   • Audit: Are residents logging ED procedures (Intubation, Suturing, Foley's)?

3. Death Review Compliance:

   • Audit: % of ED deaths discussed in the departmental Mortality Meeting.

Implementation Checklist for ED Manager/HOD

• Daily Checks (Shift In-charge):

  • Crash Cart Check: Defibrillator test (discharge check), Laryngoscope light intensity, Emergency drug expiry.
    Narcotic Register: Physical stock count of Fentanyl/Morphine vs. Logbook.
    Triage Nurse Assigned: Is a trained staff member physically present at the entrance?
    Ambulance Check: Siren/Light functional? Oxygen cylinder full? Scoop stretcher available?

• Monthly Audits (Quality Team):

  • File Audit: Randomly pull 20 files (5 Death, 5 Discharge, 5 Transfer, 5 LAMA). Check for signatures, timestamps, and discharge summaries.
    Disaster Store Audit: Check availability of disaster kits (Triage tags, Hazmat suits - if applicable, extra IV fluids).

• Quarterly Review:

  • Staff Competency: ACLS/BLS validity status of all doctors and nurses.
    Equipment Calibration: Review due dates for Multipara monitors, ECG machines, Ventilators.