The Swedish National Emergency Registry (SVAR), a modern emergency care registry

‘You need to measure to improve’, said by the late John Eisenberg, an advocate for research in healthcare services and quality of care; an appeal that is still highly relevant [1]. However, despite the development to convert medical records from paper to electronic health records (eHR) in many countries, there is a paucity of comprehensive national emergency care registries and, in principle, a complete absence in low- and middle-income countries [2]. Consequentially, fundamental questions, for example, the number of annual ED visits or ambulance missions, can often not be answered accurately on a national level. If the emergency medicine community is not able to answer questions such as these, how then can we provide accurate data to use as the basis for unbiased discussions with policy makers, health care professionals, and most importantly – the public, that is, our patients? In the current letter, we aim to describe the Swedish National Emergency Registry (SVAR), a registry based on automated data capture [3] and designed to address these issues.

Common terminology and consensus on definitions of operation metrics are prerequisites for a comprehensive emergency care registry. However, there is no global consensus on terminology and definitions of variables to include in such a registry, despite the efforts of the Emergency Department Benchmarking Alliance [4–6]. Attempts to create a consensus of measures of quality and value of emergency care have been made [7], but evidence for these frameworks is still lacking.

Swedish national quality registries are predominantly observational clinical registries [8] created with the overall objective of monitoring and improving quality of care, but their use has expanded to benchmarking and research. These registries are typically based on a specific diagnosis, condition, or treatment, while a smaller number of registries reflect care based on a medical specialty or level of care, for example, the Intensive Care Registry [9]. In the case of emergency medicine, the field encompasses patients presenting with symptoms representing a broad spectrum of diagnoses.

Currently, 12 hospitals corresponding to 14 emergency departments (ED), of the around 70 Swedish EDs, deliver data to SVAR. This corresponds to a catchment area of approximately 4 million of Sweden’s total population of approximately 10 million [10]. Data are automatically exported daily from the eHR from each participating center using XML formatted files to the registry where it is automatically incorporated in the database. There is no manual registration other than structural variables which are registered annually. Quality control of data is performed at each exporting site by comparing final SVAR data with the original source data.

A standard set of variables including standardized definitions is used. The initial choice of variables was based on Welch et al. [11] and consensus in the steering committee and was chosen to reflect the Donabedian model of health care analysis [12] and the six dimensions of quality of care [13]. The number of data variables is in the process of being expanded to include variables, for example, laboratory, radiology, and inhospital data.

Each reporting center has full access to its own data, and comparisons with national and regional data on group level are available online. Data acquisition for research is based on an application to the steering committee, including a research proposal and ethics permission from the Swedish Ethical Review Authority [14].

A total of 4 891 446 ED visits have been registered in SVAR between 1 January 2015 and 31 December 2022. Examples from SVAR show that half of these visits were made by women and that 51% of the ED visits were triaged to the lowest level of urgency and 4% to the highest. A total of 23% of the patients arrived in the ED by ambulance. Patients leaving the ED without being seen by a physician comprised 2% of the visits. Figure 1 shows an example of data retrieved from SVAR of the most common chief complaints and mortality rates. The most common chief complaint in SVAR is abdominal pain and the chief complaint with the highest mortality rate is coma/decreased level of consciousness.

Fig. 1.

(a) Most common (>1%) chief complaints in the National Swedish Emergency Registry, SVAR, up to 31 December 2022. (b) Selected chief complaints and mortality, in the entire National Swedish Emergency Registry, SVAR, up to 31 December 2022. LOC, level of consciousness.

SVAR has, since its inception, applied automated data capture, which is a prerequisite for a functional emergency care registry. SVAR is today one of the largest medical quality registries in Sweden. A 10-digit personal identification number is used in Sweden in all official contexts, including healthcare, allowing for the accurate merging of data on an individual level and enabling a unique register infrastructure. The SVAR registry is usable for short- and long-term operational planning and surveillance. Information available online enables benchmarking and comparisons between centers as data are delivered to SVAR every 24 h.

We believe that emergency medicine needs comprehensive registries, which are designed using a ‘one stop shop’ approach for data collection. This means that data are registered continuously in real-time, that they are readily accessible online, accurate, and reflective of all emergency care processes. This, in turn, requires the inclusion of both structural, process, and outcome variables [12], in addition to including both prehospital and hospital-based emergency care. Only then can the emergency medicine community make comparisons between different services and emergency care systems, monitor the quality of care and patient safety in real time, and truly act preventively. The first step is to systematically collect information, that is, to measure [15]. With this type of comprehensively collected data, it will be possible to construct quality indicators and reliably assess the value of the care.

We believe that SVAR is a useful model for the construction of an emergency care registry. Its greatest accomplishment is the use of automated data capture from a wide range of eHRs and its easily applicable IT formatting. The greatest remaining challenge is to obtain complete national coverage including measures reflective of the entire emergency care system. For the near future, the most important task for us in emergency medicine is to identify quality indicators for care. This cannot be done without measuring variables reflective of the delivered care.

Acknowledgements

This article was written on behalf of SVARs steering committee. The authors sincerely acknowledge the hard work of the steering committee over several years.

Conflicts of interest

There are no conflicts of interest.