The development and evaluation of an evidence-based guideline programme to improve care in a paediatric emergency department

Emerg Med J. 2016 Feb;33(2):109-17. doi: 10.1136/emermed-2014-204363. Epub 2015 Jul 6.


Introduction: Care guidelines can improve the quality of care by making current evidence available in a concise format. Emergency departments (EDs) are an ideal site for guidelines given the wide variety of presenting conditions and treating providers, and the need for timely decision making. We designed a programme for guideline development and implementation and evaluated its impact in an ED.

Methods: The setting was an urban paediatric ED with an annual volume of 60 000. Common and/or high-risk conditions were identified for guideline development. Following implementation of the guidelines, their impact on effectiveness of care, patient outcomes, efficiency and equitability of care was assessed using a web-based provider survey and performance on identified metrics. Variation in clinical care between providers was assessed using funnel plots.

Results: Eleven (11) guidelines were developed and implemented. 3 years after the initiation of the programme, self-reported adherence to recommendations was high (95% for physicians and 89% for nurses). 97% of physicians and 92% of nurses stated that the programme improved the quality of care in the ED. For some guidelines, provider-to-provider care practice variation was reduced significantly. We found reduced disparity in imaging when assessing one guideline. There were also reductions in utilisation of diagnostic tests or therapies. As a balancing measure, the percentage of patients with any of the guideline conditions who returned to the ED within 72 h of discharge did not change from before to after guideline initiation. Overall, 80% of physician and 56% of nurse respondents rated the guideline programme at the highest value.

Conclusions: A programme for guideline development and implementation helped to improve efficiency, and standardise and eliminate disparities in emergency care without jeopardising patient outcomes.

Keywords: emergency care systems; emergency care systems, efficiency; emergency department; paediatric emergency med; paramedics, guidelines.

MeSH terms

  • Boston
  • Emergency Service, Hospital / standards*
  • Evidence-Based Medicine
  • Guideline Adherence
  • Hospitals, Urban
  • Humans
  • Organizational Culture
  • Pediatrics / standards*
  • Practice Guidelines as Topic*
  • Program Development
  • Program Evaluation
  • Quality Improvement*
  • Surveys and Questionnaires