EM Notes – Clinical Guidelines / Indicators

  1. Systematically developed statements to assist Dr and patient e.g. trauma calls, STEMI pathways, drug


  1. Use of effective treatment
  2. Consistent management esp. junior staff
  3. Patient information e.g. written sheets – head injury advice, paediatric info
  4. QA – monitoring outcomes, identifying problems


  1. Making the guidelines:
    1. May not be up to date, inadequately researched
    2. May not include consumer input
    3. May not include financial considerations or medico-legal considerations
    4. May not include departmental consideration eg access to tests
  2. Inflexibility of guidelines – cannot be tailored to individual care
    1. Can harm clinicians if they are used to unfairly judge quality of care
    2. Cannot use other management options
    3. Discourage research


  1. May be better used if locally adapted
  2. Increased utility if incorporated into computer programs

Design a protocol / Quality assurance / Purchase equipment

  • There’s never enough room for quality assurance –
Please Don’t Swing A Cat”
Plan Research, Benchmarks (find out what other people have done), Stake holders, Objectives, Timing (timeline, meetings)
Do Draft / Equipment trial
Study Input/feedback from stakeholders
Act Implement protocol / Purchase equipment
Cycle Follow up/review of protocol or purchase

Write a protocol (ICPDOC)

  1. Indications
  2. Contraindications
  3. Preparation (incl. level of supervision)
  4. Description
  5. Outcome
  6. Complications

Audit Cycle

Clinical Indicators

  1. A measure of clinical management (e.g. time to PTCA) or outcome of care (e.g. % access block)
  2. Measure – data available
  3. Clinically relevant
  4. Achievable
  5. Acceptable to staff

Hospital wide clinical indicators

  1. Trauma – acute subdural/ extradural <4 hours, missed cervical spine fracture
  2. Hospital – readmissions, acquired infection, through-put
  3. Post op – PE, return to OT

Common Emergency Department Indicators

  1. Triage – time seen, admission rates, % meeting wait time, admission to ICU
  2. Mortality
  3. Time to analgesia, antibiotics (meningitis, febrile neutropenic, compound fracture)
  4. Access block (e.g. target 20%, current Aust ave 27%)
  5. Chart audits
  6. STEMI – **door to needle (<60min)
  7. Trauma – missed c-spine, time to craniotomy (<4hrs)
  8. X-ray and pathology report follow up
  9. Staff retention
Triage Category Types Triage Waiting Times Targets
1 A, B (↑/↓), C (↓), D (GCS<9, current seizure),Ψ (agitated+risk) 2min 100%
2 Pain, time critical, Ψ (severe agitation), (ACS,CVS,PE,Ectopic,AAA,Sepsis,BSL<3,Eyes) 10min 80%
3 By system review, use word moderate, Ψ 30min 75%
4 By system review, use word mild/minor, Ψ60min 70%
5 Non-urgent. Admin, script, chronic, wound review not requiring repair, Ψ – requiring social assist 120min 70%