The effectiveness of physiologically based early warning or track and trigger systems after triage in adult patients presenting to emergency departments: a systematic review.

BACKGROUND: Changes to physiological parameters precede deterioration of ill patients. Early warning and track and trigger systems (TTS) use routine physiological measurements with pre-specified thresholds to identify deteriorating patients and trigger appropriate and timely escalation of care. Patients presenting to the emergency department (ED) are undiagnosed, undifferentiated and of varying acuity, yet the effectiveness and cost-effectiveness of using early warning systems and TTS in this setting is unclear. We aimed to systematically review the evidence on the use, development/validation, clinical effectiveness and cost-effectiveness of physiologically based early warning systems and TTS for the detection of deterioration in adult patients presenting to EDs. METHODS: We searched for any study design in scientific databases and grey literature resources up to March 2016. Two reviewers independently screened results and conducted quality assessment. One reviewer extracted data with independent verification of 50% by a second reviewer. Only information available in English was included. Due to the heterogeneity of reporting across studies, results were synthesised narratively and in evidence tables. RESULTS: We identified 6397 citations of which 47 studies and 1 clinical trial registration were included. Although early warning systems are increasingly used in EDs, compliance varies. One non-randomised controlled trial found that using an early warning system in the ED may lead to a change in patient management but may not reduce adverse events; however, this is uncertain, considering the very low quality of evidence. Twenty-eight different early warning systems were developed/validated in 36 studies. There is relatively good evidence on the predictive ability of certain early warning systems on mortality and ICU/hospital admission. No health economic data were identified. CONCLUSIONS: Early warning systems seem to predict adverse outcomes in adult patients of varying acuity presenting to the ED but there is a lack of high quality comparative studies to examine the effect of using early warning systems on patient outcomes. Such studies should include health economics assessments.

Development of key performance indicators for emergency departments in Ireland using an electronic modified-Delphi consensus approach.

OBJECTIVE: The objective of this study was to develop a consensus among emergency medicine (EM) specialists working in Ireland for emergency department (ED) key performance indicators (KPIs). METHODS: The method employed was a three-round electronic modified-Delphi process. An online questionnaire with 54 potential KPIs was set up for round 1 of the Delphi process. The Delphi panel consisted of all registered EM specialists in Ireland. Each indicator on the questionnaire was rated using a five-point Likert-type rating scale. Agreement was defined as at least 70% of the responders rating an indicator as 'agree' or 'strongly agree' on the rating scale. Data were analysed using standard descriptive statistics. Data were also analysed as the mean of the Likert rating with 95% confidence intervals (95% CIs). Sensitivity of the ratings was examined for robustness by bootstrapping the original sample. Statistical analyses were carried out using SPSS version 16.0. RESULTS: The response rates in rounds 1, 2 and 3 were 86, 88 and 88%, respectively. Ninety-seven potential indicators reached agreement after the three rounds. In the context of the Donabedian structure-process-outcome framework of performance indicators, 41 (42%) of the agreed indicators were structure indicators, 52 (54%) were process indicators and four (4%) were outcome indicators. Overall, the top-three highest rated indicators were: presence of a dedicated ED clinical information system (4.7; 95% CI 4.6-4.9), ED compliance with minimum design standards (4.7; 95% CI 4.5-4.8) and time from ED arrival to first ECG in suspected cardiac chest pain (4.7; 95% CI 4.5-4.9). The top-three highest rated indicators specific to clinical care of children in EDs were: time to administration of antibiotics in children with suspected bacterial meningitis (4.6; 95% CI 4.5-4.8), separate area available within EDs (seeing both adults and children) to assess children (4.4; 95% CI 4.2-4.6) and time to administration of analgesia in children with forearm fractures (4.4; 95% CI 4.2-4.7). CONCLUSION: Employing a Delphi consensus process, it was possible to reach a consensus among EM specialists in Ireland on a suite of 97 KPIs for EDs.