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Median Admit Decision Time to ED Departure Time for Admitted Patients

Last updated: May 10, 2019

CMS Measure ID: CMS111v8
Version: 8
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 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 unless the ED and admitting hospital share the same CCN

Measure Population:

Initial Populationinfo-icon

Measure Observations:

Time (in minutes) from Decision to Admit to ED facility location departure for patients admitted to the facility from the emergency department

Measure Steward: Centers for Medicare & Medicaid Services (CMS)
Short Name: ED-2
Previous Version:
Measure Scoring: Continuous Variable
Measure Type: Process
Improvement Notation:

Improvement noted as a decrease in the median value

Guidance:

This measure specificationinfo-icon defines how to determine the duration from a Decision to Admit and the departure from an Emergency Department stay. Reporting requires the median of all admit decision to ED departure durations defined as [Encounter: encounter ED] facility location departure date and time minus [Encounter: encounter ED] ED admit decision date and time.

Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission. Specification: as admission processes vary at different hospitals, this can use any of the following: 1) admission order (this may be an operational order rather than the hospital admission to inpatient status order), 2) disposition order (must explicitly state to admit), 3) documented bed request, or 4) documented acceptance from admitting physician. This is not the bed assignment time or report called time.

Calculate the ED time in minutes for each patient 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 stratificationinfo-icon and then with each stratum applied. For this measure, the number of encounters that fall into the Initial Populationinfo-icon are reported without stratification, then reported according to the defined stratification. The number of encounters that fall into the Measure Population are reported without stratification, then reported according to the defined stratification. The computed continuous variableinfo-icon defined by the Measure Observation is reported for the Measure Population also, then reported according to the defined stratification.

Meaningful Measure: Admissions and Readmissions to Hospitals

Specifications

Release Notes

Header

  • Updated eCQMinfo-icon version number.

    Measure Section: eCQM Version number

    Source of Change: Annual Update

  • Updated NQFinfo-icon number to 'Not Applicable.'

    Measure Section: NQF Number

    Source of Change: Standards Update

  • Updated endorsed by field to 'None.'

    Measure Section: Endorsed By

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added definition statement indicating the CMS Certification Number (CCN) is the hospital's identification number that is used for CMS certification to clarify number to assess.

    Measure Section: Definition

    Source of Change: ONC Project Tracking System (JIRA)info-icon: CQMinfo-icon-3356

  • Updated guidance section wording related to the decision to admit to align with logic and intent.

    Measure Section: Guidance

    Source of Change: ONC Project Tracking System (JIRA): CQM-3253

  • Updated initial populationinfo-icon statement to include 'unless the ED and inpatient facility share the same CNN' to clarify intent.

    Measure Section: Initial Population

    Source of Change: ONC Project Tracking System (JIRA): CQM-3356

Logic

  • Replaced 'Encounter' alias with 'EncounterInpatient' to mitigate confusion in define statements.

    Measure Section: Stratificationinfo-icon

    Source of Change: Measure Lead

  • Replaced 'Encounter' alias with 'EncounterInpatient' to mitigate confusion in define statements.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Replaced 'Encounter' alias with 'EncounterInpatient' to mitigate confusion in define statements.

    Measure Section: Measure Population Exclusions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (CQL)info-icon definitions, functions, and/or aliases for clarification and to align with CQL Style Guideinfo-icon.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7info-icon Standard: Clinical Quality Language Specificationinfo-icon, Release 1 STUinfo-icon 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MATinfo-icon) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Psychiatric/Mental Health Diagnosis (2.16.840.1.113883.3.117.1.7.1.299): Added 3 SNOMED CT codes (62792007, 765176007, 766822004) and deleted 11 SNOMED CT codes (191530008, 191538001, 191615005, 191632009, 192122001, 192523000, 229025005, 280377008, 280378003, 300960003, 61771000119106).

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Standardized purpose statement language in value sets across eCQMsinfo-icon. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

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