• Audit
• cardiac care
• care systems
• effectiveness
• emergency ambulance systems

There is increasing concern that medical care is of variable quality, with variable outcomes, safety, costs and experience for patients.1 Despite substantial efforts to improve patient safety, some studies suggest little evidence of reductions in adverse events.2 Furthermore, there is limited agreement about what outcomes are expected and whether increased expenditure results in a real improvement in outcome or experience. In emergency medicine, many countries have developed specific indicators to help drive improvements in patient care.3–5 Most of these are time based and there is a lack of consensus regarding which indicators are high priority and what an appropriate framework for measuring quality should look like.

Emergency medicine is different to many specialties in that presentations are symptom based, a confirmed diagnosis may not be made during the clinical encounter, and clinical follow-up in the emergency department (ED) is uncommon, making the benchmarking of processes and outcomes related to specific diagnoses difficult. Hard clinical outcomes such as risk-adjusted mortality are usually remote from the specific interventions in the ED. In addition, the spectrum of illnesses and injuries presenting to ED is vast, potentially necessitating a large number of indicators to measure quality across a representative range of presentations. Although indicators for emergency care should focus on the part of the healthcare system that emergency clinicians can influence, it is important that indicators relate to the final outcome of a patient encounter with the health sector, and that they promote integration along the emergency care pathway. For example, a patient with an acute myocardial infarction (AMI) arriving at hospital and getting swiftly to the angiography suite within 30 min is not optimal if the system is not set up to manage the next step, of a trained cardiologist performing an angioplasty immediately. All steps being aligned in the clinical …