title: Emergency department quality and safety indicators in resource-limited settings: an environmental survey.
abstract: BACKGROUND
  As global emergency care grows, practical and effective performance measures are needed to ensure high quality care. Our objective was to systematically catalog and classify metrics that have been used to measure the quality of emergency care in resource-limited settings.
  
  
  METHODS
  We searched MEDLINE, Embase, CINAHL, and the gray literature using standardized terms. The references of included articles were also reviewed. Two researchers screened titles and abstracts for relevance; full text was then reviewed by three researchers. A structured data extraction tool was used to identify and classify metrics into one of six Institute of Medicine (IOM) quality domains (safe, timely, efficient, effective, equitable, patient-centered) and one of three of Donabedian's structure/process/outcome categories. A fourth expert reviewer blinded to the initial classifications re-classified all indicators, with a weighted kappa of 0.89.
  
  
  RESULTS
  A total of 1705 articles were screened, 95 received full text review, and 34 met inclusion criteria. One hundred eighty unique metrics were identified, predominantly process (57 %) and structure measures (27 %); 16 % of metrics were related to outcomes. Most metrics evaluated the effectiveness (52 %) and timeliness (28 %) of care, with few addressing the patient centeredness (11 %), safety (4 %), resource-efficiency (3 %), or equitability (1 %) of care.
  
  
  CONCLUSIONS
  The published quality metrics in emergency care in resource-limited settings primarily focus on the effectiveness and timeliness of care. As global emergency care is built and strengthened, outcome-based measures and those focused on the safety, efficiency, and equitability of care need to be developed and studied to improve quality of care and resource utilization.
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. eaaronson@partners.org.|Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital/Massachusetts General Hospital, Boston, MA, USA. eaaronson@partners.org.|Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA. eaaronson@partners.org.|Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA. eaaronson@partners.org.
authors.forename: Emily L
authors.initials: EL
authors.lastname: Aaronson
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. rmarsh@partners.org.|Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA. rmarsh@partners.org.
authors.forename: Regan H
authors.initials: RH
authors.lastname: Marsh
authors.affiliation: Center for Clinical Excellence, Brigham and Women's Hospital, Boston, MA, USA. mguha@partners.org.
authors.forename: Moytrayee
authors.initials: M
authors.lastname: Guha
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. jschuur@partners.org.|Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA. jschuur@partners.org.
authors.forename: Jeremiah D
authors.initials: JD
authors.lastname: Schuur
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. srouhani@partners.org.|Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA. srouhani@partners.org.
authors.forename: Shada A
authors.initials: SA
authors.lastname: Rouhani