Posted by: Tony Shannon | May 11, 2012

Emergency Medicine: doing the right thing/the right thing to do?

(This post is adapted from an earlier article here
and is being posted in parallel on the Emergency Physicians International social network
in advance of ICEM 2012 meeting)


Aside from tackling patient care on an individual patient by patient basis, many of us are members of healthcare teams and departments making efforts to improve the organisation of the healthcare they provide.

As will be explored during the ICEM 2012 meeting in Dublin, there is an acknowledged gap between evidence based medicine and current practice, i.e. a real gap between “what we know and what we practice”.

Doing the Right Thing: Clinical Audit

One of the key approaches to tackling this gap can be termed “clinical audit”.

Clinical audit has grown in importance over the last few decades in the medical field. The common approach to clinical audit may be explained with the help of a cycle, the audit cycle. Within some healthcare systems the PDSA or PDCA cycle is the cornerstone of audit. PDSA meanings Plan, Do, Study, Act or PDCA meaning Plan, Do, Check, Act.

Lets examine these important elements in a little more detail.

What does the PDSA or PDCA stand for?

P is for Plan.. i.e. the clinician decides what they want or need to explore. For instance in the field of Emergency Medicine it may be the  management of asthma care in the Emergency Department (ED).

It may begin with an interest to explore this aspect of care in the department and compare this with the gold standard that may be recommended nationally or internationally.
With an eye on the “gold standard” knowledge base a number of parameters from a number of patient records need to be explored, i.e. in asthma care, perhaps the % of patients who had their Peak Flow Rate (PFR) measured on arrival to the department and/or the time within which they received their first treatment.
An analysis of a selection of patient records is needed, gathering the relevant patient related information in order to be able to compare current practice against the gold standard that the best evidence knowledge bases recommend.

That analysis usually highlights some common problems (e.g. the PFRs are not being routinely done).Then related solutions need to be formulated, such as standardise the process of initial assessment of asthma, perhaps with a proforma which mandates the recording of PFRs. This trial solution forms the basis of  the “Plan”

D is to Do..

The second step in this particular cycle is called Do. That simply means implement the changes recommended in the plan, at a small scale at first…

S -Study (or C for Check) is to then measure the effect of the changes that were developed in the Plan. It is hoped that improvements will have been seen as the cycle unfolds, but disimprovements are equally important to measure and inform further improvements and actions.

Act.. is in theory, the final phase acting on the further actions recommended in the Study phase.

It should be evident that as explained this is not a single cycle of change but at least two. One can also note that the formality of  the PDCA cycle is simply as a variant on the human problem solving cycle….albeit focussed on exploring the clinical issue in question.
One interesting thing to note is this clinical audit/process improvement cycle is one of many improvement activities that are to be cyclical in nature (i.e. you complete a loop and then reloop some time later). Most of the various methodologies behind quality and risk management are also cyclical in nature.  As are other approaches to quality management. Life is full of cycles..

Trawling through the notes.. Recurring audit theme: improve clinical documentation

Needless to say that much of the current activity of clinical audit involves trawling through patient records to see if things have been done well or not. Interestingly many of the key findings of clinical audit commonly highlight the poor information available and poor clinical documentation is very often an issues that is uncovered.
Without available, complete or legible clinical notes, much of the conclusion drawn in a typical audit are thereby limited by these constraints. Furthermore one of the most common conclusions from a clinical audit that I regularly see is to improve clinical documentation. ( e.g. suggest a template/proforma for specific documentation purposes)…

Ultimately the important and growing need for clinical audit as an integral part of medical practice clearly highlights that we need to get much slicker at information management in healthcare.
Indeed the clinical audit process ultimately needs to be made available as a by-product of routine care to enable real-time feedback of clinical care and continuous improvement. As this is challenging but important, currently audit has become a common driver to develop information systems around “secondary use” drivers such as audit, without serving the frontline particularly well, which has limited success.

So there is a related need for greater effort towards interoperability of health information systems, to ensure that benefits to primary users of clinical systems can also facilitate secondary use processes such as clinical audit.


The Right Thing to Do? Research

If clinical audit is aimed at ensuring clinicians are “doing things right” then healthcare research aims at searching for the “right thing to do”.

Academic Medicine has always been highly regarded within the medical profession and been instrumental in changing the lives of many many people. You may recall the story behind the research into the cholera outbreaks across districts of London by Dr John Snow in 1854. The secret of that breakthrough was by uncovering the right information that provided the “evidence” that there was a very strong link with a local water pump. This evidence helped break the cycle of cholera at the time and began the science of epidemiology.

Internationally, healthcare has of course developed at significant speed over the last decades. The rate of medical discovery is already outstripping our ability to keep up and provide Evidence Based Medicine at the point of care. In modern times, after much progress in medical research there now exists an important disconnect between medical research and information management at the frontline. This gap from “Bench to Bedside” is the target of Translational Medicine and Knowledge Translation attempts to “Bridge the Chasm”.
There also remains many unanswered healthcare questions that need to be tackled, particularly as we get into discussions about value for money in public services such as healthcare… we need to be increasingly certain that we are guiding clinicians based on the best available evidence, which will always raise related research questions

At the frontline, clinical care is paramount of course, it requires the support of Evidence Based Medicine in real time and given the right information and knowledge management systems, there could/should be increasing support for  important clinical research as a by-product of routine clinical care. Yet healthcare research is hard to do at the frontline, esp. in the midst of the complexity of an environment such as busy Emergency Departments.

The burden of parallel efforts = difficulty with research recruitment?

We have talked about clinical audit, which often begins with a retrospective look at clinical practice aiming to improve. The challenge of tackling prospective clinical research questions at the clinical coalface is an order of magnitude more complex again.. From my experience,  one of the key current challenges of supporting and participating in a clinical trial in an acute clinical setting comes down to the current paper based approach to both clinical documentation and research, usually in parallel rather than joined up. So when you are in the midst of a busy clinical shift in an ED, under pressure for time, you may find recruitment into a clinical research trials to be just a bit challenging.

So to better align the pressurised clinical frontline delivery agenda with the academic research agenda, we must forge a much better union between clinical frontline and the academic research information and knowledge systems. Indeed if healthcare information systems could better support clinicians at the frontline and harvest the information needed for a clinical trial as a by-product of that process, that would revolutionise the research burden.

In that way, I should be able to manage my patients care as needed and interwoven within the clinical encounter and with the patients consent, I may ask some additional research related questions, order an additional research related investigation without interrupting the clinical cycle of care the patient requires. In that way, in avoiding the current duplicative effort that is currently required (i.e. documenting clinical care of the patient in their record, then re-recording many of the same details in a parallel research proforma) we could align these efforts in a win-win for all

Integration between clinical frontline/audit/research systems required

So again the key conclusion from this look at Emergency Department systems and the Audit & Research agenda is that these are increasingly interdependent, so therefore require the greater integration and interoperability between Emergency Medicine frontline, audit and research information and knowledge management systems.



Further reading

This article is based on a series of related articles on healthcare improvement at;


PS. For those of you who already have /think you may have an early interest in EM Informatics, please consider joining the EM Informatics Chapter here at Emergency Physicians International).


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