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Median Admit Decision Time to ED Departure Time for Admitted Patients

eCQMs for 2022 Reporting Period

General eCQM Information

CMS Measure ID CMS111v10
Short Name ED-2
NQF Number Not Applicable
Measure 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

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 Type Process
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 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.

Meaningful Measure Admission and Readmissions to Hospitals
Previous Version

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Revised and updated the rationale section to include recent citations.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Revised and updated the clinical recommendation section to include recent citations.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Annual Update

  • Added clarifying language to the guidance section of episode-based measures to define the episode.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added guidance to explain why the measure stratification includes psychiatric/mental health populations.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Shortened the names of AdmitDecisionUsingAssessmentDuringLastEDBeforeDeparture and ​admitDecisionUsingEncounterOrderDuringLastEDandBeforeDepartureto AdmitDecisionUsingAssessment and AdmitDecisionUsingEncounterOrder to improve readability.

    Measure Section: Initial Population

    Source of Change: Annual Update

  • Added a 'let' clause AdmitAssessment: 'AdmitDecisionUsingAssessmentDuringLastEDBeforeDeparture'(EncounterInpatient) to streamline the text used to express the logic in the NormalizeInterval function in the ED Encounter with Decision to Admit definition.

    Measure Section: Initial Population

    Source of Change: Annual Update

  • Removed the word 'from' and added parentheses to group logic to ensure intent is captured in the ED Encounter with Decision to Admit definition.

    Measure Section: Definitions

    Source of Change: Annual Update

  • Updated Global.'Inpatient Encounter' definition by adding 'day of' to ensure all cases within the measurement period are captured and evaluated in the initial population.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Definitions

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    Measure Section: Functions

    Source of Change: Standards Update

  • Corrected the spelling of the word 'occurred' within the inline comment of the function AdmitDecisionUsingEncounterOrderDuringLastEDandBeforeDeparture.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Relocated the 'EDEvaluation.result' in 'Admit Inpatient' clause in the logic to improve calculation efficency and added starts to the timing to ensure intent is captured in the AdmitDecisionUsingAssessment function.

    Measure Section: Functions

    Source of Change: Annual Update

  • Revised the approach for identifying the location period end date by adding the Global.'HasEnd' function. The Global.'HasEnd' function more clearly and consistently identifies when the Emergency Department Visit location period interval has an end date.

    Measure Section: Functions

    Source of Change: Standards 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 Decision to Admit to Hospital Inpatient (2.16.840.1.113883.3.117.1.7.1.295): Added 1 SNOMED CT code (432661000124104) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Psychiatric/Mental Health Diagnosis (2.16.840.1.113883.3.117.1.7.1.299): Added 2 SNOMED CT codes (160822004, 817962007) based on terminology update. Deleted 8 SNOMED CT codes (106013002, 111476001, 191539009, 192118006, 229729009, 231475006, 28857002, 82096005) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Admit Inpatient (2.16.840.1.113762.1.4.1111.164): Deleted 6 SNOMED CT codes (183767005, 183768000, 183783005, 183789009, 185970004, 185971000) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 08, 2021