Emergency Care Access & Timeliness (HOQR)

This measure assesses the variation in access and timeliness of emergency care to support hospital quality improvement for patients requiring emergency care in an emergency department (ED). This measure is designed to align with incentives to promote improved care both in EDs and the broader health system to help identify where patients do not receive timely access to emergency care.

Emergency care access and timeliness gaps are inclusive of several concepts pertaining to boarding and crowding in an ED, including significantly longer ED wait times, higher left without being seen rates, longer boarding times, and longer total length of stay in the ED.

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ICD-10 copyright 2024 World Health Organization. All Rights Reserved.

CPT(R) contained in the Measure specifications is copyright 2004-2024 American Medical Association.

These performance specifications are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

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Stratification 1: Pediatric With No Mental Health Diagnosis 
All patients aged less than 18 years seen in the ED who do not have an ED encounter principal diagnosis consistent with mental health diagnosis. Patients who have an ED encounter principal diagnosis consistent with substance use disorders will be included in this stratification.

Stratification 2: Adult With No Mental Health Diagnosis
All patients aged 18 years and older seen in the ED who do not have an ED encounter principal diagnosis consistent with mental health diagnosis. Patients who have an ED encounter principal diagnosis consistent with substance use disorders will be included in this stratification.

Stratification 3: Pediatric With Mental Health Diagnosis
All patients aged less than 18 years seen in the ED who have an ED encounter principal diagnosis consistent with mental health diagnosis.

Stratification 4: Adult With Mental Health Diagnosis
All patients aged 18 years and older seen in the ED who have an ED encounter principal diagnosis consistent with mental health diagnosis.

The measure will utilize volume standardization to address differences in patient population between hospitals. Volume standardization is harmonized with other existing measures and accommodates a “like to like” comparison among hospitals. Large volume EDs will always be compared to large volume EDs, while smaller volume EDs will always be compared to EDs of similar size. No logic definitions are specified for Risk Adjustment.

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This measure aims to reduce patient harm and improve outcomes for patients requiring emergency care in an ED by addressing the variation in emergency care and measuring access and timeliness of emergency care. There are long-standing concerns about parameters that impact access and timeliness of care in the ED. Currently, there are no national metrics to assess the proportion of patients impacted by access and timeliness of ED care.

The goal of the Emergency Care Access & Timeliness (ECAT) measure is to assess and improve the safety of the 140 million ED visits that patients experience each year (Centers for Disease Control and Prevention [CDC], 2021). Limitations in access and timeliness of emergency care have been shown to be associated with harm, such as increases in mortality, delays in care, preventable errors, poor patient experience, and staff burnout. These quality limitations are also associated with increased costs of care. The ECAT measure under consideration is intended for use in CMS’s Hospital Outpatient Quality Reporting (HOQR) program. The numerator is comprised of all ED visits with a quality gap in access as defined in the numerator criteria. Challenges related to emergency care access and timeliness have been increasing and have prompted public calls for action. This measure improves upon previous efforts as it measures the mean instead of the median to highlight the presence of extreme quality gaps, and captures several indicators of quality gaps by using multiple numerator criteria. Implementation of this measure, which captures multiple components of access and timeliness, can help identify facilities where patients do not receive timely access to emergency care as defined in the numerator criteria. This measure, therefore, could positively impact millions of patients who seek treatment in the ED and help address long-standing disparities in emergency care, including for patients with mental health diagnoses.

Decreased score indicates improvement

Reference Type: Citation

Reference Text: 'American College of Emergency Physicians. (2018). Definition of Boarded Patient. Policy Statements. https://www.acep.org/patient-care/policy-statements/definition-of-boarded-patient'

Reference Type: Citation

Reference Text: 'American Medical Association. (2022). What is Behavioral Health. https://www.ama-assn.org/delivering-care/public-health/what-behavioral-health'

Reference Type: Citation

Reference Text: 'Centers for Disease Control and Prevention. (2021). Emergency Department Visits. https://www.cdc.gov/nchs/fastats/emergency-department.htm '

Reference Type: Citation

Reference Text: 'eCQI Resource Center. (n.d). Median Admit Decision Time to ED Departure Time for Admitted Patients.'

Boarding:
The practice of holding inpatients in the emergency department after admission to the hospital because no hospital inpatient bed is available. (American College of Emergency Physicians [ACEP], 2018).

ED Observation:
Observation stays are inclusive of both ED observation care in which a patient initially evaluated in the ED is cared for under observation status for an extended period of time in the ED or in a care area dedicated to observation care, as well as hospital observation stays in which a patient initially evaluated in the ED is cared for in observation status often in a hospital bed used for both inpatient or observation status admissions. Because these two forms of observation stays cannot be easily distinguished in a standardized fashion in existing electronic health record data ontologies, for the purposes of this quality measure all observation stays have been considered an exclusion from both numerator criteria 3 and 4. 

Left Without Being Seen (LWBS):
Patients arrive to the ED for evaluation and leave before seeing a physician, advanced practice nurse, or physician’s assistant.

Mental Health: 
Mental health generally refers to mental health diagnoses, life stressors and crises, and stress-related physical symptoms (American Medical Association [AMA], 2022). For this measure, mental health conditions will be defined separately from substance use disorders.

Measure Score Calculation
The measure score is first calculated at the individual ED level as the proportion of ED visits where any one of the four outcomes occurred, as defined by the numerator. Scores will be standardized z-scores by ED case volume strata (defined in ED visit volume bands of 20,000 visits). For CMS Certification Numbers (CCNs) with more than one ED, volume-adjusted z-scores are then combined as a weighted average for that CCN. A z-score of greater than zero means worse performance and less than zero means better performance, compared to like EDs.

For the purposes of this measure, a decision to admit can be captured using any of the following: 
  - an evaluation that results in a decision to admit
  - an order to admit to inpatient
  - an order for a bed assignment
  - start of inpatient admission

This eCQM is an episode-based measure. An episode is defined as an ED visit that ends during the measurement period. 

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI Resource Center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All ED visits that end during the measurement period for all patients

Equals Initial Population

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The numerator is comprised of ED visits meeting the denominator criteria and where the patient experiences any of the following quality gaps in access:
1. The patient waited longer than 60 minutes (1 hour) after arrival to the ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination, or 
2. The patient left the ED without being evaluated, or  
3. The patient boarded (time from Decision to Admit order to ED departure for admitted patients) in the ED for longer than 240 minutes (4 hours), or
4. The patient had an ED length of stay (LOS) (time from ED arrival to ED departure as defined by the ED departure timestamp indicating when the patient physically left the ED) of longer than 480 minutes (8 hours).

ED encounters with ED observation stays are excluded from numerator criteria #3 (boarding) and #4 (ED LOS). To clarify, patients who have a ‘decision to admit’ after an ED observation stay remain excluded from numerator criteria #3 (boarded) calculations.

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex