Development of Clinical Quality of Care Indicators for Acute Coronary Syndrome in Emergency Department and Current Performance Analysis in Two Northern Hospitals

Background: The issue of quality of health care has been discussed widely and is a topic of current concern. However, the past indicators for performance measure connected with evidence-base medicine rarely. Current direction of developing quality indicators turns to disease-oriented, evidence-based, and concerning about both process and outcome. Early diagnosis and timely treatment of patients of acute coronary syndrome (ACS) always are the challenges in emergency department (ED). Currently, there are not indicators of quality of care for ACS in ED in Taiwan.
Objective: In this pilot study, we hoped to develop the clinical quality of care indicators for ACS in ED and analyzed the current performance in two northern hospitals.
Method: In the first stage, we developed summaries for each of the potential quality indicators modified from evidence-based clinical guidelines for ACS, and a multidisciplinary expert panel rated the potential indicators by used of two rounds of Delphi technique for 5 dimensions of quality, including validity of evidence, feasibility, impact on outcomes, room for improvement, and controllability. In the secondary stage, we retrospectively measured the performances of indicators for ACS in ED in two northern Taiwan hospitals, including one medical center and one district teaching hospital, from 1st Oct., 2004 to 31st Mar., 2005 by chart abstraction.
Results: Seven indicators , 2 evaluating indicators and 5 therapeutic indicators, met the all 5 dimensions finally, and those were rate of Complete electrocardiogram within 10 minutes of presentation, Cardiac markers follow-up more than 6 hours when ED stay, Clopidogrel use if allergy to Aspirin, β-blocker at arrival, Clopidogrel on non-ST elevation myocardial infarction (NSTEMI) patients, Glycoptotein IIb/IIIa inhibitor on NSTEMI patients with percutaneous coronary intervention (PCI), and PCI within 90 minutes of arrival. The performances of these indicators in the two objective hospitals were 45.51%/44.34%, 72.34%/56.76%, 100%/0%, 3.91%/5.61%, 60.78%/32.08%, 28.75%/0%, and 20.83%/38.89% respectively.
Conclusions: Comparing with previous studies or quality indicator sets, designed for entire hospital admission, only rate of electrocardiogram within 10 minutes of presentation was mentioned before in the category of evaluating indicator. Almost all studies or indicator sets emphasized the early administration of Aspirin and β-blocker and timely PCI after arrival. Clopidogrel and Glycoprotein IIb/IIIa inhibitor administration rate were the new developed indicators in our study. Both of study hospitals should improve the performances of evaluating indicators and β-blocker administration rate. The performance of timely PCI after arrival was ideal in one of the study hospitals.