Our survey’s response rate was 67%. EPs worked significantly more often in larger EDs. We found that in EDs with EPs, physicians attended significantly more courses and implemented more clinical activities than EDs without EPs. These differences remained significant in the regression analyses for both the number of courses and implemented clinical activities.
The lowest number of patient visits per year in our study, representing 69 EDs, was 7,818. The study of Ikkersheim, conducted in the same period and representing 27 Dutch EDs, found a minimum of 3,466 patient visits per year . This could be due to the different percentage of rural hospitals in the overall study, being 21.5% in our study compared to 63% in Ikkersheim’s. They also found a 100% score in having a triage system compared to our 85% in EDs without EPs (100% in EDs with EPs). This could simply be explained by the overall numbers of EDs studied.
Our data also shows that EPs work in small and large hospitals as well as in academic settings in all regions of The Netherlands. EPs however work significantly more often in EDs with larger patient visits per year. This is probably because EPs initially started working in larger EDs with EM training programs and over time expanded to academic hospitals and rural areas. In emergency departments with EPs, physicians had attended more courses both individually and as composite numbers compared to emergency departments without EPs. After controlling for a training program, the number of courses attended remained significant.
We also found that in emergency departments with EPs, more clinical audit activities were undertaken. This association remained significant after controlling for the size of the department. It is likely that the significant difference in the radiology meeting could be the underlying cause for the significant composite numbers of clinical audits in EDs with EPs. A large liability insurance company for hospitals instigated the radiology meeting together with EPs from The Netherlands Society of Emergency Medicine (NVSHA) . The significant difference in the number of hospitals with EPs that have a radiology meeting, suggests the influence of EPs on implementing clinical audit activities. Although the financial capacity for larger EDs might be influential in attending more courses or implementing clinical audits, our data does not support this hypothesis. Very little has been reported on training courses and quality-improving activities in Dutch emergency departments. Van Geloven found a very low percentage of physicians in the ED having followed courses like ATLS (27%) or ECGs (6%). That study however, was done in 1999 before the introduction of the emergency medicine training program . This could explain the higher numbers we found. Our study suggests that EPs have a positive influence on physicians attending ABCDE courses and in implementing clinical audit activities, but it is likely that ED leadership or hospital management is influential as well. Although this was one of the first nationwide inventories of its kind in The Netherlands, and other factors were mentioned as well, the positive influence of EPs suggests that their presence could improve the quality of care and therefore patient safety.
At the moment there are not enough EPs to staff all the EDs in The Netherlands and the length of their training program, 3 years, is not meeting the criteria of the ‘Doctors’ Directive of the European Union, which states it should be 5 years (EU Directive 2006/100/EC) . Dutch EPs need the longer training program and simultaneously the recognition as a Medical Specialist to run the ED as a closed format. Undoubtedly, EPs have improved the quality of patient care on an individual patient level, but until the above-mentioned criteria are met, it will be difficult for EPs to implement overall clinical audits for all ED patients.
This study might also suggest that increasing the size of EDs in The Netherlands could potentially improve quality registrations and meetings. Although audit and feedback were found to have a moderately positive effect in the most recent Cochrane review, this study cannot identify causal effects . Consequently, this would then lead to a reduction in the numbers of EDs. We already see a similar occurrence in GP practices where larger practices seem to have more safety features present [21, 22].
Some limitations of this study should be mentioned. We cannot rule out a possible selection bias, as the response rate was 67%. However, our sample included a variety of EDs from every region in the country, suggesting reasonable representativeness.
Respondents had different backgrounds and positions, which may have influenced their answers and could have resulted in information and recall bias. This response rate is however high compared to many surveys among healthcare providers. Furthermore, the relation between non-response and selection bias is not so obvious.
This study documented the presence of EPs in the ED, not taking into account the total numbers of EPs and whether or not they were present 24/7. Therefore we cannot say that it is the influence of the EPs alone that leads to a higher percentage of courses attended . It could well be that it is in fact the hospital that wants to improve the quality of care and therefore employs EPs and lets other physicians, working in the ED, attend necessary courses. However, finding a significant difference in having a radiology meeting in EDs with EPs, an initiative strongly supported by emergency physicians may suggest a positive influence of EPs.
Our study focused on general features, continuing professional education and clinical audit activities, which do not necessarily reflect the quality of patient care. However, after the timeframe of the data collection of this study, the Dutch inspectorate of health issued a document stating that all physicians working in the ED are obligated to attend an ABCDE course before treating ED patients. This might suggest that training and quality activities may benefit the quality of patient care. Given the cross-sectional design, however, this study cannot identify causal effects.