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New insights have recently changed the therapeutical approach to bronchospastic attack (BA). In this paper we present the results of a quality assurance study devised to: (1) verify the extent to which these new insights are put into practice in our Emergency Medicine Department (EMD); (2) evaluate changes in EMD medical staff behaviour faced with BA after discussion and distribution of medical practice guidelines on the treatment of BA (a document produced by a group of experts in pulmonary medicine working in the EMD on the basis of current literature and personal experiences); (3) assess the impact of such guidelines on quality care. A retrospective analysis demonstrated an incorrect treatment of BA in the EMD. After the introduction of the guidelines we observed: (1) an improvement in physician behaviour that completely agreed with guidelines in 56% of instances after discussion and distribution of the document, in 8% before; (2) an improvement in the outcome of patients treated for BA in the EMD (13 versus 36% relapses for patients treated in the EMD and discharged).

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At the Emergency Department of Udine General Hospital (Italy) a programme to reduce admissions to the Internal Medicine Department was introduced in 1991. The majority of these admissions come from the Emergency Department, where many people, often without acute conditions, claim medical care. The programme consisted in organizational, professional and economic changes. At the end of 1991, the overall number of admissions to Udine General Hospital, as compared to 1990, decreased by 7.1%, but admissions to the Internal Medicine Department showed an 11.2% reduction. Finally, examinations for internal medical complaints in the emergency ward, not followed by hospitalization, increased by 15.5%. These results showed a reduction in admissions to the Internal Medicine Department greater than previously planned, with an increase in the number of outpatient examinations in the emergency room not followed by admission. Further targets were planned for 1992 to increase the quality of the service.

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An assessment was made on emergency laboratory test ordering at Udine General Hospital (Italy) to investigate the reasons for the excessive number of requested tests. All the orders for emergency laboratory tests during one week in June 1990 were studied. For each test the time of the order was recorded for every day of the week. The most important aspect of our investigation is the distribution of the orders during the day: in fact, test orders reached two peaks, the upper between 7 and 11 a.m., and the lower between 3 and 6 p.m. The analysis of the record cards showed that 42% of the orders were inappropriate. These preliminary findings were very useful in making the consensus on a Quality Assurance program easier, to improve the use of the Emergency Laboratory by doctors and nurses. Some preliminary results in the Emergency Medicine Department confirmed the validity of this program.

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A program for automatic reading of medical prescriptions has been introduced in Friuli Venezia Giulia (Italy), to control the quality of medical care and the physicians' prescribing methods in office-based medical practice. Data on the prescribing practice of general practitioners, drug consumption and costs are collected, and then general practitioners are confidentially informed, through patient-specific medication profiles, on the number and costs of their prescriptions. The first data often showed inappropriate prescription practice on the part of doctors. Through this program an approach based on quality assurance principles is made possible to improve prescribing practice. Being "peer review" activities, bereft of fiscal or punitive ends, they are more readily acceptable by physicians who feel directly involved in improving the use of drugs, with positive connotations for containing costs.

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In the course of a quality assurance (QA) activity on the use of antimicrobics the authors set out to assess the management of urinary tract infection (UTI) in 76 patients. From culture data they noted an excellent or correct use in 78% of the patients, but a misuse in 22%. A committee was organized, with representatives of all departments, which set out criteria for the correct treatment of UTI. Using these criteria, the medical records were retrospectively assessed and the results are described. The protocol will be communicated to all involved, and then a reassessment will be made, to evaluate change in behaviour.

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