Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol

Abstract

IntroductionRedirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion.ObjectivesOur primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians’ judgement as a criterion standard. Our tertiary objective is to examine how the ED physician’s perception of a virtual ED care alternative correlates with the EDAC.Methods and analysisA randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC.Ethics and disseminationThis study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

Validating the Emergency Department Avoidability Classification (EDAC): A cluster randomized single-blinded agreement study

“…ED physicians were recruited from an academic hospital in Hamilton, Canada. Retrospective ED visits were categorized based on the EDAC into a three-cluster design (avoidable, potentially avoidable and not avoidable) and randomly sampled using a predetermined randomization protocol [ 32 ]. Physicians were randomly assigned ED charts from each study cluster evenly and judged whether the ED visit could have been safely managed in a subacute primary care setting.…”

“…Physicians were blinded to the ED visits study cluster. We adhered to the study steps detailed in the study protocol [ 32 ].…”

“…The EDAC is a patient classification that identifies retrospective ED visits that could have been appropriately and safely managed in a subacute primary care clinical setting [ 32 ]. The EDAC’s inclusion criteria were constructed in a multi-stage, multicentred consensus process involving emergency and primary care physicians [ 30 , 33 ].…”

“…Each ED visit was rated by two ED physicians independently. We calculated a priori that 126 ED visits were needed to sufficiently power the study at an optimal 80% to detect statistical significance using a two tailed 0.05 alpha [ 32 ].…”

“…To determine if ED physicians could be established as a criterion standard, we calculated interrater reliability of physician agreement overall and for each EDAC class using a Cohen’s kappa coefficient with 95% confidence intervals (CIs). We predetermined a kappa coefficient equal to or greater than 0.6 would establish physician judgements as a criterion standard to identify avoidable ED visits [ 32 ]. This threshold was chosen as a 0.6 kappa indicated substantial agreement greater than chance [ 35 ].…”