Assignment: Diagnostic Accuracy
Because unwanted variation can exist anywhere in the continuum, a gap in quality can have the net effect of less than optimal outcomes for the child. Aligning care with clinical standards supported by systematic approaches to guideline development will improve the probability that patient populations will receive care based on the most current professional knowledge. Clinical guidelines serve to synthesize available evidence and bridge the gap between science and clinical practice; not through rigid protocol adherence but by a framework for care delivery, thus contributing to efficiency, cost containment, and improved patient outcomes.11 Clinical standards may refer to pathways, protocols, evidence-based summaries, or full guidelines, and ideally are developed in a patient-/family- centric manner in order to address care across the continuum.Health care has become increasingly complex, and variation in care delivery has contributed to that complexity and potential gaps in quality. The understanding that unwanted variation is the enemy of quality has been attributed to W. Edwards Deming, statistician, professor, and expert in quality management,6 and can be applied to any type of care delivery, including that within the EMSC continuum of care. Unwanted variation in health care can contribute to waste, inefficiency and ineffectiveness in providing diagnostic accuracy and therapeutic reliability. Several studies across the pediatric emergency care continuum have described wide variations in practice. In prehospital care, Shah and colleagues described the prehospital transport of 250 actively seizing children to 10 urban EDs in which a wide variation in delivery of medication routes for midazolam were noted with approximately half resulting in dosing errors.7 Similar variation also has been noted in utilization patterns for trauma specialty care for children with moderate and severe injuries.8 Although variation in care delivery for children treated in EDs has been well described,4 the association between this variation with cost and quality is becoming increasingly highlighted. Data from the Pediatric Health Information System, a comparative pediatric database housed in the Children’s Hospital Association, was used to assess the management of 3 pediatric conditions treated in 21 hospital EDs (ie, gastroenteritis, asthma, and simple febrile seizures). While wide variation in care was noted, higher costs were not associated with better quality.9 ED based care also has implications on the quality of care delivered in inpatient settings. One study of children treated on inpatient units for bronchiolitis noted variations in diagnostic testing and management among 16 US hospitals that was unrelated to patient demographics or severity of illness.10
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