Audit and Feedback in emergency: a systematic review and an Italian project to investigate and improve quality of care

Submitted: 22 June 2020
Accepted: 15 September 2020
Published: 23 December 2020
Abstract Views: 598
PDF: 318
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.


  • Sabrina Licata Istituto di Igiene ed Epidemiologia Clinica, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.
  • Annarita Tullio Istituto di Igiene ed Epidemiologia Clinica, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.
  • Francesca Valent Istituto di Igiene ed Epidemiologia Clinica, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy.

The Audit and Feedback process (AandF) is commonly accepted as a good way to improve quality in health care, also in Emergency Departments (ED), where health aspects and pathologies are very different, usually acute and highly complex. Within an Italian Ministry of Health research project called EASY-NET, we conducted a systematic review of literature on AandF in EDs from 2014 to December 2019 to evaluate the impact of this approach in a particular setting where time-dependent indicators are fundamental. We selected 24 articles: 9 about infective pathologies (i.e. antibiotic stewardship), 6 about cardiovascular acute emergencies (i.e. cardiac arrest), 2 about stroke, 3 about laboratory tests, and 4 about other fields (i.e. diabetic ketoacidosis or use of prothrombin complex). Most of articles proposed a multimodal approach: only 7 concerned AandF alone. Despite the wide range on interventions modality and the poor comparability of the considered studies, the results are encouraging and confirm the importance to implement AandF both in emergency and in other clinical settings.

Gude WT. Understanding and optimizing electronic audit and feedback to improve quality of care. PhD Thesis, University of Amsterdam, 2019

The Quality and Patient Safety Division A practical guide to clinical audit Aug 2013 QPSD-D-029-1 National quality improvement Team. Available at

Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;6:1–227. DOI:

Rogers RLG, Narvaez Y, Venkatesh AK, et al. Improving emergency physician performance using audit and feedback: a systematic review. Am J Emerg Med. 2015 Oct;33(10):1505-14. DOI:

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010;8:336–41. DOI:

Singh K, Devarajan R, Mohanan PP, et al. ACS QUIK Investigators. Implementation and acceptability of a heart attack quality improvement intervention in India: a mixed methods analysis of the ACS QUIK trial. Implement Sci. 2019 Feb 6;14(1):12. DOI:

Aldridge P, Horsley E, Rosettenstein K, et al. What the FLOQ? A quality improvement project to reduce unnecessary paediatric respiratory viral swabs in a peripheral metropolitan hospital. J Paediatr Child Health. 2018 Apr;54(4):416-419. DOI:

Bentley J, Henderson S, Thakore S, et al. Seeking Sepsis in the Emergency Department- Identifying Barriers to Delivery of the Sepsis 6. BMJ Qual Improv Rep. 2016 May 5;5(1). DOI:

Bordeleau S, Poitras J, Marceau D, et al. Use of prothrombin complex concentrate in warfarin anticoagulation reversal in the emergency department: a quality improvement study of administration delays. BMC Health Serv Res. 2015 Mar 15;15:106. DOI:

Murphy E, MacGlone S, McGroarty C. A novel approach to improving coagulation sample ordering in an emergency department. BMJ Qual Improv Rep. 2015 Feb 11;4(1). pii: u204785.w2857. DOI:

Kempegowda P, Coombs B, Nightingale P, et al. Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis . Clin Med (Lond). 2017 Oct;17(5):389-394. DOI:

Khanina A, Cairns KA, McGloughlin S, et al. Improving sepsis care for hospital inpatients using existing medical emergency response systems. Infect Dis Health. 2019 Nov 15. pii: S2468-0451(19)30099-9.

Hecker MT, Fox CJ, Son AH, et al. Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting. PLoS One. 2014 Feb 3;9(2):e87899. DOI:

Reznek MA, Barton BA. Improved incident reporting following the implementation of a standardized emergency department peer review process. Int J Qual Health Care. 2014 Jun;26(3):278-86. DOI:

Jauch EC, Huang DY, Gardner AJ, Blum JL. Strategies for improving outcomes in the acute management of ischemic stroke in rural emergency departments: a quality improvement initiative in the Stroke Belt. Open Access Emerg Med. 2018 May 16;10:53-59. DOI:

Jorgensen SCJ, Yeung SL, Zurayk M, et al. A. Leveraging Antimicrobial Stewardship in the Emergency Department to Improve the Quality of Urinary Tract Infection Management and Outcomes. Open Forum Infect Dis. 2018 May 2;5(6):ofy101. DOI:

Taylor KA, Durrheim DN, Merritt T, et al. Multidisciplinary analysis of invasive meningococcal disease as a framework for continuous quality and safety improvement in regional Australia. BMJ Open Qual. 2018 Feb 7;7(1):e000077. DOI:

Nazerian P, Vanni S, Fanelli A, et al. Appropriate use of laboratory test requests in the emergency department: a multilevel intervention. Eur J Emerg Med. 2019 Jun;26(3):205-211. DOI:

Scales DC, Golan E, Pinto R, et al. Strategies for Post-Arrest Resuscitation Care Network. Improving Appropriate Neurologic Prognostication after Cardiac Arrest. A Stepped Wedge Cluster Randomized Controlled Trial. Am J Respir Crit Care Med. 2016 Nov 1;194(9):1083-1091. DOI:

Hasan DA, Drennan J, Monger E, et al. Dispatcher assisted cardiopulmonary resuscitation implementation in Kuwait: A before and after study examining the impact on outcomes of out of hospital cardiac arrest victims. Medicine (Baltimore). 2019 Nov;98(44):e17752. DOI:

Bloos F, Rüddel H, Thomas-Rüddel D, et al. MEDUSA study group. Effect of a multifaceted educational intervention for anti-infectious measures on sepsis mortality: a cluster randomized trial. Intensive Care Med. 2017 Nov;43(11):1602-1612. DOI:

Spencer SP, Karsies T. Audit-and-Feedback and Workflow Changes Improve Emergency Department Care of Critically Ill Children. Pediatr Qual Saf. 2019 Jan 9;4(1):e128. DOI:

Stevens MB, Hastings SN, Powers J, et al. Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel Multicomponent Interdisciplinary Quality Improvement Initiative. J Am Geriatr Soc. 2015 May;63(5):1025-9. DOI:

Oostema JA, Chassee T, Baer W, et al. Brief Educational Intervention Improves Emergency Medical Services Stroke Recognition. Stroke. 2019 May;50(5):1193-1200. DOI:

Morrison LJ, Brooks SC, Dainty KN, et al. Strategies for Post-Arrest Care Network. Improving use of targeted temperature management after out-of-hospital cardiac arrest: a stepped wedge cluster randomized controlled trial. Crit Care Med. 2015 May;43(5):954-64. DOI:

Bobrow BJ, Spaite DW, Vadeboncoeur TF, et al. Implementation of a Regional Telephone Cardiopulmonary Resuscitation Program and Outcomes After Out-of-Hospital Cardiac Arrest. JAMA Cardiol. 2016 Jun 1;1(3):294-302. DOI:

Pellis T, Sanfilippo F, Roncarati A, et al. A 4-year implementation strategy of aggressive post-resuscitation care and temperature management after cardiac arrest.Resuscitation. 2014 Sep;85(9):1251-6. DOI:

Venkatesh AK, Hajdasz D, Rothenberg C, et al. Reducing Unnecessary Blood Chemistry Testing in the Emergency Department: Implementation of Choosing Wisely. Am J Med Qual. 2018 Jan/Feb;33(1):81-85. DOI:

Scott RA, Oman KS, Makic MB, et al. Reducing indwelling urinary catheter use in the emergency department: a successful quality-improvement initiative. J Emerg Nurs. 2014 May;40(3):237-44. DOI:

van de Ridder JM, Stokking KM, McGaghie WC, ten Cate OT. What is feedback in clinical education?. Med Educ. 2008;42(2):189-197. DOI:

Thomas JD, Arnold RM. Giving feedback. J Palliat Med. 2011;14(2):233-239. DOI:

Gude WT, Brown B, van der Veer SN, et al. Clinical performance comparators in audit and feedback: a review of theory and evidence.Implement Sci. 2019;14(1):39. Published 2019 Apr 24. DOI:

Ullman AJ, Ray-Barruel G, Rickard CM, Cooke M. Clinical audits to improve critical care: Part 1 Prepare and collect data. Aust Crit Care. 2018;31(2):101-105. DOI:

Ray-Barruel G, Ullman AJ, Rickard CM, Cooke M. Clinical audits to improve critical care: Part 2: Analyse, benchmark and feedback. Aust Crit Care. 2018;31(2):106-109. DOI:

Fone DL, Christie S, Lester N. Comparison of perceived and modelled geographical access to accident and emergency departments: a cross-sectional analysis from the Caerphilly Health and Social Needs Study Int J Health Geogr. 2006; 5: 16. DOI:

Decree by the President of the Italian Council of Ministers Definizione e aggiornamento dei livelli essenziali di assistenza, di cui all'articolo 1, comma 7, del decreto legislativo 30 dicembre 1992, n. 502 G.U. Serie Generale , n. 65 del 18 marzo 2017 available in Italian at,

Boling B, Hardin-Pierce M. The effect of high-fidelity simulation on knowledge and confidence in critical care training: An integrative review. Nurse Educ Pract. 2016;16(1):287-293. DOI:

Pulford BD, Colman AM, Buabang EK, Krockow EM. The persuasive power of knowledge: Testing the confidence heuristic. J Exp Psychol Gen. 2018;147(10):1431-1444. DOI:

Penfold RB, Zhang F. Use of Interrupted Time Series Analysis in Evaluating Health Care Quality Improvements. Acad Pediatr2013 Nov-Dec;13(6 Suppl):S38-44 DOI:

Bernal JL, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol. 2017;46(1):348-355.

Licata, S., Tullio, A., & Valent, F. (2020). Audit and Feedback in emergency: a systematic review and an Italian project to investigate and improve quality of care. Emergency Care Journal, 16(3).


Download data is not yet available.