Related Experiment Video
Updated: Jan 15, 2026
Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide
Published on: January 15, 2017
Audit and Feedback on Pediatric Emergency Department Performance Measures: A Stepped-Wedge Trial
James M Chamberlain1, Norma-Jean E Simon2, Lalit Bajaj3
1Departments of Pediatrics and Emergency Medicine, Division of Emergency Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
Insights
Monthly quality report cards in pediatric emergency departments showed mixed results. While some documentation improved, patient throughput metrics declined, indicating a need for intervention refinement.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Quality Improvement
- Health Informatics
Background:
- Audit and feedback mechanisms are known to drive clinician improvements.
- The impact of these strategies on pediatric emergency department (PED) systems remains under-explored.
- Assessing the feasibility and effectiveness of automated quality reports in PEDs is crucial.
Purpose of the Study:
- To evaluate the feasibility of a multisite, monthly automated quality performance report card system.
- To assess the impact of this intervention on quality metrics within and across PED sites.
- To analyze changes in performance measures and implementation slopes.
Main Methods:
- A stepped-wedge randomized trial was conducted across 7 PEDs (4 academic, 3 affiliated) within a research network.
- The intervention involved monthly site-level reports with benchmarks, visit counts, and 12-month trends from electronic health record (EHR) data.
- Key performance indicators included initial care documentation (weight, vital signs) and patient throughput metrics.
Main Results:
- Over 1.4 million encounters were analyzed.
- Significant improvements were observed in weight documentation (+0.2%), vital signs documentation (+10.1%), time to vital signs documentation (-12.0%), and time to radiology report (-3.5%).
- Conversely, throughput measures worsened, with increased time to clinician, length of stay, and left without being seen rates.
Conclusions:
- The study confirms the feasibility of delivering quality performance report cards to hospital leadership using EHR data.
- The intervention yielded mixed results regarding the effectiveness of improving site-level quality metrics.
- Further refinement of these quality improvement interventions is recommended before widespread dissemination.
Background:
Audit and feedback can prompt clinician improvements. The benefit of this approach in pediatric emergency department (PED) systems is unclear. We evaluated the feasibility of a multisite, monthly automated report card and its effect on quality performance within and across emergency department sites.
Methods:
We conducted a stepped-wedge randomized trial across 4 academic and 3 affiliated PEDs in the Pediatric Emergency Care Applied Research Network between January 2013 and April 2016. The intervention consisted of monthly site-level quality performance reports featuring bar charts with benchmarks, visit counts, and 12-month trends derived from electronic health record (EHR) data. Measures included initial care documentation (weight, vital signs) and throughput (time to clinician, time to imaging results, left without being seen rate, and length of stay). We evaluated the intervention's effect on performance measures and slope changes at implementation.
Results:
We included 1 426 109 encounters (864 940 during the preintervention period, 561 169 during the postintervention period). We observed improved performance for 4 measures: weight for all visits (+0.2%), documentation of all vitals (+10.1%), time to vitals documentation (-12.0%), and time to plain film radiology report (-3.5%). We observed a decline in performance measures related to throughput, with increases in time to clinician, mean length of stay, and the proportion of patients leaving without being seen.
Conclusions:
We demonstrate the feasibility of providing quality performance report cards to hospital leaders using EHR data. We found mixed results in terms of the effectiveness of improving site-level metrics. Future efforts may facilitate further refinement of these interventions prior to dissemination.
