title: The development and evaluation of an evidence-based guideline programme to improve care in a paediatric emergency department.
abstract: BACKGROUND
  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.
authors.affiliation: Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Ayobami T
authors.initials: AT
authors.lastname: Akenroye
authors.affiliation: Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Stack
mesh_terms: D001900:Boston; D004636:Emergency Service, Hospital / Q000592:standards*; D019317:Evidence-Based Medicine; D019983:Guideline Adherence; D006786:Hospitals, Urban; D006801:Humans; D015279:Organizational Culture; D010372:Pediatrics / Q000592:standards*; D017410:Practice Guidelines as Topic; D016730:Program Development; D015397:Program Evaluation; D058996:Quality Improvement; D011795:Surveys and Questionnaires
keywords: emergency care systems; emergency care systems, efficiency; emergency department; paediatric emergency med; paramedics, guidelines