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Process quality indicators for musculoskeletal injuries in the emergency department
  1. Kirsten Strudwick1,2,
  2. Trevor Russell2,
  3. Anthony J Bell3,4,
  4. Mark Chatfield5,
  5. Melinda Martin-Khan5
  6. And The Research Collaboration for Quality Care for Musculoskeletal Injuries: Emergency Care Expert Panel
    1. 1 Emergency and Physiotherapy Departments, QEII Jubilee Hospital, Brisbane, Queensland, Australia
    2. 2 School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
    3. 3 The Wesley Hospital, Uniting Care Health, Brisbane, Queensland, Australia
    4. 4 Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
    5. 5 Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
    1. Correspondence to Kirsten Strudwick, Emergency Department, QEII Jubilee Hospital, Brisbane, QLD 4108, Australia; kirsten.strudwick{at}


    Objectives Measuring quality of care for musculoskeletal injuries presenting to the ED is important given their prevalence, variations in care, the associated morbidity and financial impacts and pressure to achieve time-based performance measures. Process quality indicators (QIs) provide a quantitative method to measure the actions taken during healthcare delivery. This study aimed to develop a set of process QIs to measure the quality of care for musculoskeletal injuries in the ED.

    Methods A multiphase mixed-methods study was undertaken from 2015 to 2018, commencing with a systematic review to identify existing musculoskeletal QIs. This review, along with current evidence regarding musculoskeletal injury management in the ED, informed an expert panel who developed a preliminary set of process QIs. The preliminary set was field tested at eight EDs in Queensland, Australia, to determine the validity, reliability, feasibility and usefulness of each QI. Prospective observational data collection and retrospective chart audits were used to score the process QIs. These results were presented to the expert panel who determined a final QI set.

    Results A total of 633 patients were recruited and 36 process QIs included in the final set. The QIs covered important domains of pain assessment and management, history taking and physical examination, appropriateness and timeliness of imaging, fracture management, mobility, patient information and discharge considerations including safety and referrals. The best performing QIs included the use of opioid sparing analgesics and avoiding prescription of ‘just in case’ opioids at discharge. The poorest performing QIs included the completion of spinal red flag questioning and referrals for fragility fractures.

    Conclusion An evidence and best practice-based set of QIs has been developed to allow EDs to assess and quantify the quality of care for musculoskeletal presentations. This will allow EDs to compare and benchmark, leading to the optimisation of care for patients.

    • audit
    • emergency department
    • musculo-skeletal
    • performance improvement
    • quality

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    • Collaborators Ellen Burkett, Joel Dunstan, Carolyn Jennifer Hullick, David Lawrence Kramer, Deborah Elaine-Ann Lenaghan, Kate Lockley, Paul Lockley, Catherine Jane McDougall, Jenni Clair Meehan, Lee Poole, Kevin Power, Deon Andries Strydom, Jane Wilson.

    • Contributors 1. Research project: A. Conception, B. Coordination, data collection, expert panel meetings, C. Data analysis and interpretation. 2. Manuscript: A. Writing of the first draft, B. Review, critique, final approval. KS: 1A, 1B, 1C, 2A, 2B. TR: 1A, 1B, 1C, 2B. AJB: 1A, 1B, 2B. MC: 1C, 2B. MM-K: 1A, 1B, 1C, 2B. The Research Collaboration for Quality Care for Musculoskeletal Injuries: Emergency Care Expert Panel: 1B, 2B.

    • Funding This project is funded by grants awarded through peer-reviewed processes by the Emergency Medicine Foundation (application number EMPJ-103R22-2014), and the Allied Health Professions’ Office of Queensland.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval Ethical clearance for this project was gained through the Metro South Human Research Ethics Committee (HREC/13/QPAH/276) and The University of Queensland Medical Research Ethics Committee (2013001155). Site-specific governance approval was obtained for QEII Jubilee Hospital (SSA/13/QPAH/283), Gold Coast University Hospital (SSA/16/QGC/133), The Royal Brisbane and Women’s Hospital (SSA/15/QRBW/441), Redcliffe Hospital (SSA/15/QNRC/32), Caloundra and Nambour General Hospitals (SSA/16/QNB/2), The Townsville Hospital (SSA/15/QTHS/125) and Cairns Hospital (SSA/16/QCH/40).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.