The level of evidence for emergency department performance indicators: systematic review

The aim of this study was to perform a comprehensive systematic review of emergency department performance indicators in relation to evidence. A systematic search was performed through PUBMED, EMBASE, CINAHL and COCHRANE databases with (and including synonyms of) the search words: [emergency medicine OR emergency department] AND [quality indicator(s) OR performance indicator(s) OR performance measure(s)]. Articles were included according to the inclusion/exclusion criteria using the PRISMA protocol. The level of evidence was rated according to the evidence levels by the Oxford Centre for Evidence-Based Medicine. Performance indicators were extracted and organized into five categories; outcome, process, satisfaction, equity and structural/organizational measures. Six thousand four hundred and forty articles were initially identified; 127 provided evidence for/against a minimum of one performance indicator: these were included for further study. Of the 127 articles included, 113 (92%) were primary research studies and only nine (8%) were systematic reviews. Within the 127 articles, we found evidence for 202 individual indicators. Approximately half (n=104) of all this evidence (n=202) studied process-type indicators. Only seven articles (6%) qualified for high quality (level 1b). Sixty-six articles (51%) were good retrospective quality (level 2b or better), whereas the remaining articles were either intermediate quality (25% level 3a or 3b) or poor quality (17% level 4 or 5). We found limited evidence for most emergency department performance indicators, with the majority presenting a low level of evidence. Thus, a core group of evidence-based performance indicators cannot currently be recommended on the basis of this broad review of the literature.