Quality assurance in the emergency room.

Quality assurance programmes have become an accepted part of health care delivery in hospitals in a number of countries. In addition to their value as management and clerical systems designed to ensure that clinical care is of an acceptable standard,' they have also become popular among administrators who see the implementations of quality assurance programmes as a measure of the efficient and effective allocation axid use of resources.2 There are three general approaches to the development of quality assurance progammes3: (a) structural approaches-for example, addressing issues such as medical education, practitioner training and registration, equipment and facilities, (b) evaluation of the outcomes of health delivery, and (c) documenting and assessing the process of delivering health care. Most studies of quality assurance in clinical medicine have focused particularly on process and outcome as an index of the quality of care.4 For example many existing programmes study such parameters as the adequacy of medical records, patient satisfaction, laboratory utilisation, waiting times, and outcome variables such as mortality, postoperative infection or complication rates, duration and severity of symptoms, and so on.' There have been criticisms of both these approaches. Outcomes are not always easy to measure, and especially in the case of paediatric practice outcomes are not always attributable directly to the care provided6 7: for example children with viral upper respiratory infections are likely to get better irrespective of what type of care they receive. An evaluation of the process of care is usually a judgment rather than a precise objective measurement.8 Furthermore, interventions designed to improve the process of health care may not always be congruent with the priority outcome goal of improved health status. For example though it is desirable to decrease patient waiting times, admission rates, and the number of laboratory investigations performed, there comes a point when the pursuit of these process goals may be counterproductive in the context of improving health outcome. Reducing the waiting time should not be at the expense of an unhurried, thorough evaluation of each patient. Nevertheless, despite these shortcomings these approaches generally do provide a means of holding health care providers accountable for following procedures that are, to the best of current knowledge, appropriate and optimal. The maintenance of high standards of clinical care in paediatric emergency rooms poses particular challenges. These include: * The high patient attendances, so that doctors and nurses frequently work under considerable pressure to see patients quickly * The uneven nature of the workload * The tendency for the emergency room to be staffed by junior staff with relatively little experience * The rotation of doctors through the emergency room for limited periods of time, and the need for rosters covering the whole 24 hour period, thereby limiting their exposure to and reducing the potential effectiveness of educational activities * The life threatening nature of many of the presenting conditions. It is not surprising that quality of care questions are perceived as the least of the problems facing emergency room directors and administrators, and may explain the relative paucity of articles and studies focusing on quality assurance in this setting.7 114 However, one could argue that it is because of the difficulties outlined above that emergency quality assurance measures are especially important. In this paper we describe a programme of such measures developed for the emergency room of a large paediatric teaching hospital. We focus in particular on the structural and process areas of quality assurance and argue that while individually simple and inexpensive to introduce, together they provide a framework for facilitating the delivery of quality clinical care in a paediatric emergency setting.