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Median Admit Decision Time to ED Departure Time for Admitted Patients

Measure Information 2023 Reporting Period
CMS Measure ID CMS111v11
Short Name ED-2
NQF Number Not Applicable
Description

Median time (in minutes) from admit decision time to time of departure from the emergency department (ED) for emergency department patients admitted to inpatient status

Initial Population

Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED

Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Continuous Variable measure
Measure Type Process measure
Improvement Notation

Improvement noted as a decrease in the median value

Guidance

This measure specification delineates how to calculate the duration from the Decision to Admit to the departure from an Emergency Department (ED) visit.

Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission and since admission processes vary at different hospitals this can use either of the following:

1. An Order- A) admission order (this may be an operational order rather than the hospital admission to inpatient status order), B) disposition order (must explicitly state to admit), C) documented bed request, or D) documented acceptance from admitting physician. This is not the "bed assignment time" or "report called time". Or

2. An Assessment- an ED evaluation that results in a decision to "Admit Inpatient"

The decision to admit inpatient must be performed during the ED visit that is within one hour of the inpatient admission and prior to the patient departing the ED.

The specification provides elements from the clinical electronic record required to calculate the median time, i.e., the duration from the decision to admit to the time the patient physically departed the ED.

Patients with behavioral health emergencies are stratified because often these situations are confounded by policies and practices in the community that are beyond the control of any individual hospital and present the hospital with quality and safety circumstances different from those of the acute medical patients (Joint Commission, 2012). Recent peer-reviewed studies also demonstrate the need for dedicated emergency mental health services, supplying evidence that the clinical needs for these patients substantively differ from the non-psychiatric population (American College of Emergency Physicians (ACEP), 2017; Lester, 2018).

The measure population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Meaningful Measure Admission and Readmissions to Hospitals
Next Version No Version Available
Previous Version

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Measure Information 2021 Reporting Period 2022 Reporting Period 2023 Reporting Period
Name Median Admit Decision Time to ED Departure Time for Admitted Patients Median Admit Decision Time to ED Departure Time for Admitted Patients Median Admit Decision Time to ED Departure Time for Admitted Patients
CMS Measure ID CMS111v9 CMS111v10 CMS111v11
Short Name ED-2 ED-2 ED-2
NQF Number Not Applicable Not Applicable Not Applicable
Description

Median time (in minutes) from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status

Median time (in minutes) from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status

Median time (in minutes) from admit decision time to time of departure from the emergency department (ED) for emergency department patients admitted to inpatient status

Initial Population

Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED

Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED

Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED

Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Continuous Variable measure Continuous Variable measure Continuous Variable measure
Measure Type Process measure Process measure Process measure
Improvement Notation

Improvement noted as a decrease in the median value

Improvement noted as a decrease in the median value

Improvement noted as a decrease in the median value

Guidance

This measure specification delineates how to calculate the duration from the Decision to Admit to the departure from an Emergency Department (ED) visit.

Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission and since admission processes vary at different hospitals this can use either of the following:

1. An Order- A) admission order (this may be an operational order rather than the hospital admission to inpatient status order), B) disposition order (must explicitly state to admit), C) documented bed request, or D) documented acceptance from admitting physician. This is not the "bed assignment time" or "report called time". Or

2. An Assessment- an ED evaluation that results in a decision to "Admit Inpatient"

The decision to admit inpatient must be performed during the ED visit that is within 1 hour of the inpatient admission and prior to the patient departing the ED.

The specification provides elements from the clinical electronic record required to calculate the median time, i.e., the duration from the decision to admit to the time the patient physically departed the ED.

This eCQM is an episode-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

This measure specification delineates how to calculate the duration from the Decision to Admit to the departure from an Emergency Department (ED) visit.

Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission and since admission processes vary at different hospitals this can use either of the following:

1. An Order- A) admission order (this may be an operational order rather than the hospital admission to inpatient status order), B) disposition order (must explicitly state to admit), C) documented bed request, or D) documented acceptance from admitting physician. This is not the "bed assignment time" or "report called time". Or

2. An Assessment- an ED evaluation that results in a decision to "Admit Inpatient"

The decision to admit inpatient must be performed during the ED visit that is within 1 hour of the inpatient admission and prior to the patient departing the ED.

The specification provides elements from the clinical electronic record required to calculate the median time, i.e., the duration from the decision to admit to the time the patient physically departed the ED.

Patients with behavioral health emergencies are stratified because often these situations are confounded by policies and practices in the community that are beyond the control of any individual hospital and present the hospital with quality and safety circumstances different from those of the acute medical patients (Joint Commission, 2012). Recent peer-reviewed studies also demonstrate the need for dedicated emergency mental health services, supplying evidence that the clinical needs for these patients substantively differ from the non-psychiatric population (American College of Emergency Physicians (ACEP), 2017; Lester, 2018).

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

This measure specification delineates how to calculate the duration from the Decision to Admit to the departure from an Emergency Department (ED) visit.

Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission and since admission processes vary at different hospitals this can use either of the following:

1. An Order- A) admission order (this may be an operational order rather than the hospital admission to inpatient status order), B) disposition order (must explicitly state to admit), C) documented bed request, or D) documented acceptance from admitting physician. This is not the "bed assignment time" or "report called time". Or

2. An Assessment- an ED evaluation that results in a decision to "Admit Inpatient"

The decision to admit inpatient must be performed during the ED visit that is within one hour of the inpatient admission and prior to the patient departing the ED.

The specification provides elements from the clinical electronic record required to calculate the median time, i.e., the duration from the decision to admit to the time the patient physically departed the ED.

Patients with behavioral health emergencies are stratified because often these situations are confounded by policies and practices in the community that are beyond the control of any individual hospital and present the hospital with quality and safety circumstances different from those of the acute medical patients (Joint Commission, 2012). Recent peer-reviewed studies also demonstrate the need for dedicated emergency mental health services, supplying evidence that the clinical needs for these patients substantively differ from the non-psychiatric population (American College of Emergency Physicians (ACEP), 2017; Lester, 2018).

The measure population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Meaningful Measure Admissions and Readmissions to Hospitals Admission and Readmissions to Hospitals Admission and Readmissions to Hospitals
Next Version CMS111v10 CMS111v11 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Added acronym to introduce emergency department (ED) early in the specification to clarify its use.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Standards/Technical Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards/Technical Update

  • Updated guidance to indicate patients in Acute Hospital Care at Home programs are included in the denominator population and updated to improve readability.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Updated grammar and punctuation to improve readability.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

Value set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Psychiatric/Mental Health Diagnosis (2.16.840.1.113883.3.117.1.7.1.299): Added 3 ICD-10-CM codes (F32.A, F78.A1, F78.A9) based on review by technical experts, SMEs, and/or public feedback. Deleted 2 ICD-10-CM codes (F78, Z91.5) based on new or changed coding guidelines. Added 1 SNOMED CT code (472945003) based on terminology update. Deleted 4 SNOMED CT codes (3503000, 50878001, 106014008, 162702000) based on terminology update.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 15, 2022