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The development and evaluation of an evidence-based guideline programme to improve care in a paediatric emergency department
  1. Ayobami T Akenroye1,2,
  2. Anne M Stack1,2
  1. 1Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
  2. 2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Anne M Stack, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; anne.stack{at}


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.

  • emergency care systems
  • emergency care systems, efficiency
  • emergency department
  • paediatric emergency med
  • paramedics, guidelines

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