e Title Median Admit Decision Time to ED Departure Time for Admitted Patients e Identifier ( Authoring Tool) 111 e Version number 5.1.000 NQF Number 0497 GUID 979f21bd-3f93-4cdd- 8273-b23dfe9c0513 ment Period Steward Developer Endorsed By Description Copyright January 1, 20XX through December 31, 20XX Centers for Medicare & Medicaid Services (CMS) Oklahoma Foundation for Medical Quality National Quality Forum Median time (in minutes) from admit decision time to time of discharge from the emergency department for emergency department patients admitted to inpatient status. specifications are in the Public Domain LOINC(R) is a registered trademark of the Regenstrief Institute. This material contains SNOMED Clinical Terms(R) (SNOMED CT[C]) copyright 2004-2015 International Health Terminology Standards Development Organization. All rights reserved. Disclaimer These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty. CMS has contracted with Mathematica Policy Research and its subcontractors, Lantana and Telligen, for the continued maintenance of this electronic measure. Scoring Type Item Count Stratification Risk Adjustment Rate Aggregation Continuous Variable Process Encounter, Performed: Encounter Inpatient Report total score and the following strata: Stratum 1 - all patients seen in the ED and admitted as an inpatient who do not have an inpatient encounter principal diagnosis consistent with psychiatric/mental health disorders Stratum 2 - all patients seen in the ED and admitted as an inpatient who have an inpatient encounter principal diagnosis consistent with psychiatric/mental health disorders Calculate the duration in minutes between the Decision to Admit time and the discharge time for each ED encounter in the measure population; report the median time for all calculations performed. The specification provides elements from the clinical electronic record required to calculate for each ED encounter, i.e., the duration the patient was in the Emergency Department after the decision to admit, also stated as: the Datetime
difference between the Emergency Department facility location departure date/time and the Decision to Admit date/time. The calculation requires the median across all ED encounter durations. Rationale Clinical Recommendation Statement Improvement Notation Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. According to a 2002 national U.S. survey, more than 90 percent of large hospitals report EDs operating "at" or "over" capacity. Approximately one third of hospitals in the U.S. report increases in ambulance diversion in a given year, whereas up to half report crowded conditions in the ED. In a recent national survey, 40 percent of hospital leaders viewed ED crowding as a symptom of workforce shortages. ED crowding may result in delays in the administration of medication such as antibiotics for pneumonia and has been associated with perceptions of compromised emergency care. For patients with non-st-segment-elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. Overcrowding and heavy emergency resource demand have led to a number of problems, including ambulance refusals, prolonged patient waiting times, increased suffering for those who wait, rushed and unpleasant treatment environments, and potentially poor patient outcomes. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised. The most common cause of ED crowding is the boarding of admitted patients in the ED. Numerous studies have demonstrated the potential for errors, life threatening delays in treatment, and diminished overall quality is enormous. Improvement noted as a decrease in the median value Diercks DB, et al. Prolonged emergency department stays of non-st-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events. Ann Emerg Med. 2007;50:489-96. Derlet RW, Richards JR. Emergency department overcrowding in Florida, New York, and Texas. South Med J. 2002;95:846-9. Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000;35:63-8. Fatovich DM, Hirsch RL. Entry overload, emergency department overcrowding, and ambulance bypass. Emerg Med J. 2003;20:406-9. Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc. 2006;54:270-5.
Definition Guidance Institute of Medicine of the National Academies. Future of emergency care: Hospital-based emergency care at the breaking point. The National Academies Press 2006. Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med. 1994;12:265-6. Kyriacou DN, Ricketts V, Dyne PL, McCollough MD, Talan DA. A 5-year time study analysis of emergency department patient care efficiency. Ann Emerg Med. 1999;34:326-35. Nawar ED, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007; (386):1-32. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184:213-6. Sprivulis PC, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184:208-12. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20:402-5. United States General Accounting Office GAO. Hospital Emergency Departments: crowded conditions vary among hospitals and communities. 2003; GAO-03-460. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Cutrona SL, Bor DH, Himmelstein DU. Waits to see an emergency department physician: U.S. trends and predictors, 1997-2004. Health Aff (Millwood). 2008;27:w84-95. This measure specification defines how to determine the duration from a Decision to Admit and the discharge from an Emergency Department stay. Reporting requires the median of all admit decision to ED discharge durations defined as [Encounter: encounter ED] facility location departure date and time minus [Encounter: encounter ED] ED admit decision date and time. Calculate the ED time in minutes for each person in the measure population; report the median time for all calculations performed. The specification provides elements from the clinical electronic record required to calculate for each ED encounter, i.e., the length of time the patient was in the Emergency Department from the time of decision to admit, also stated as: the Datetime difference for the Emergency Department facility location departure date/time minus the Decision to Admit date/time. The calculation requires the median across all ED encounter durations. For each population, results should be reported without stratification and then with each stratum applied. For this measure, the number of encounters that fall into the Initial are reported without stratification, then reported according to the defined stratification. The number of encounters that fall into the are reported
without stratification, then reported according to the defined stratification. The computed continuous variable defined by the Observation is reported for the also, then reported according to the defined stratification. Transmission Format Initial Exclusions Observations Supplemental Data Elements TBD Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days, and where the decision to admit was made during the preceding emergency department visit at the same physical facility Equals initial population Emergency department encounters being transferred from another hospital setting (any different facility, even if part of the same hospital system) Time (in minutes) from Decision to Admit to ED facility location departure for patients admitted to the facility from the emergency department For every patient evaluated by this measure, also identify payer, race, ethnicity and sex Table of Contents Criteria Data Criteria (QDM Variables) Data Criteria (QDM Data Elements) Supplemental Data Elements Risk Adjustment Variables Criteria Initial = o AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient o AND: "Occurrence A of Encounter, Order: Decision to Admit to Hospital Inpatient" starts during "Occurrence A of Encounter, Performed: Emergency Department Visit" = o AND: Initial Exclusions = o OR: "Transfer From: Hospital Settings" <= 6 hour(s) ends before or concurrent with start of "Occurrence A of Encounter, Performed: Emergency Department Visit" Observation = o Median: Datetimediff: "Occurrence A of Encounter, Performed: Emergency Department Visit (facility location departure datetime)" "Occurrence A of Encounter, Order: Decision to Admit to Hospital Inpatient (start datetime)" Stratifications = o Stratification 1 =
AND NOT: Intersection of: Occurrence A of $EncounterInpatient "Encounter, Performed: Encounter Inpatient (principal diagnosis: Psychiatric/Mental Health Patient)" o Stratification 2 = AND: Intersection of: Occurrence A of $EncounterInpatient "Encounter, Performed: Encounter Inpatient (principal diagnosis: Psychiatric/Mental Health Patient)" Data Criteria (QDM Variables) $EncounterInpatient = o "Encounter, Performed: Encounter Inpatient" satisfies all: (length of stay <= 120 day(s)) ends during "ment Period" Data Criteria (QDM Data Elements) "Encounter, Order: Decision to Admit to Hospital Inpatient" using "Decision to Admit to Hospital Inpatient Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.295)" "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.292)" "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)" "Transfer From: Hospital Settings" using "Hospital Settings SNOMEDCT Value Set (2.16.840.1.113762.1.4.1111.126)" Attribute: "Principal diagnosis: Psychiatric/Mental Health Patient" using "Psychiatric/Mental Health Patient Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.299)" Supplemental Data Elements "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)" "Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)" "Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)" "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeGender Value Set (2.16.840.1.113762.1.4.1)" Risk Adjustment Variables Set Emergency Department