James Augustine

Emergency Department Operational Metrics, Measures and Definitions: Results of the Second Performance Measures and Benchmarking Summit

There is a growing mandate from the public, payers, hospitals, and Centers for Medicare & Medicaid Services (CMS) to measure and improve emergency department (ED) performance. This creates a compelling need for a standard set of definitions about the measurement of ED operational performance. This Concepts article reports the consensus of a summit of emergency medicine experts tasked with the review, expansion, and update of key definitions and metrics for ED operations. Thirty-two emergency medicine leaders convened for the Second Performance Measures and Benchmarking Summit on February 24, 2010. Before arrival, attendees were provided with the original definitions published in 2006 and were surveyed about gaps and limitations in the original work. According to survey responses, a work plan to revise and update the definitions was developed. Published definitions from key stakeholders in emergency medicine and health care were reviewed and circulated. At the summit, attendees discussed and debated key terminology and metrics and work groups were created to draft the revised document. Workgroups communicated online and by teleconference to reach consensus. When possible, definitions were aligned with performance measures and definitions put forth by the CMS, the Emergency Nurses Association Consistent Metrics Document, and the National Quality Forum. The results of this work are presented as a reference document.

Optimal positioning for cervical immobilization.

STUDY OBJECTIVE We hypothesized that optimal positioning of the head and neck to protect the spinal cord during cervical spine immobilization can be determined with reference to external landmarks. In this study we sought to determine the optimal position for cervical spine immobilization using magnetic resonance imaging (MRI) and to define this optimal position in a clinically reproducible fashion. METHODS Our subjects were 19 healthy adult volunteers (11 women, 8 men). In each, we positioned the head to produce various degrees of neck flexion and extension. This positioning was followed by quantitative MRI of the cervical spine. RESULTS The mean ratio of spinal canal and spinal cord cross-sectional areas was smallest at C6 but exceeded 2.0 at all levels from C2 to T1 (P < .05). At the C5 and C6 levels, the maximal area ratio was most consistently obtained with slight flexion (cervical-thoracic angle of 14 degrees) (P < .05). For a patient lying flat on a backboard, this corresponds to raising the occiput 2 cm. More extreme flexion or extension produced variable results. CONCLUSION In healthy adults, a slight degree of flexion equivalent to 2 cm of occiput elevation produces a favorable increase in spinal canal/spinal cord ration at levels C5 and C6, a region of frequent unstable spine injuries.

Association of Emergency Department and Hospital Characteristics with Elopements and Length of Stay

BACKGROUND As the Centers for Medicare & Medicaid Services (CMS) core measures in 2013 compare Emergency Department (ED) treatment time intervals, it is important to identify ED and hospital characteristics associated with these metrics to facilitate accurate comparisons. STUDY OBJECTIVES The objective of this study is to assess differences in operational metrics by ED and hospital characteristics. ED-level characteristics included annual ED volume, percentage of patients admitted, percentage of patients presenting by ambulance, and percentage of pediatric patients. Hospital-level characteristics included teaching hospital status, trauma center status, hospital ownership (nonprofit or for-profit), inpatient bed capacity, critical access status, inpatient bed occupancy, and rural vs. urban location area. METHODS Data from the ED Benchmarking Alliance from 2004 to 2009 were merged with the American Hospital Associations Annual Survey Database to include hospital characteristics that may impact ED throughput. Overall median length of stay (LOS) and left before treatment is complete (LBTC) were the primary outcome variables, and a linear mixed model was used to assess the association between outcome variables and ED and hospital characteristics, while accounting for correlations among multiple observations within each hospital. All data were at the hospital level on a yearly basis. RESULTS There were 445 EDs included in the analysis, from 2004 to 2009, with 850 observations over 6 years. Higher-volume EDs were associated with higher rates of LBTC and LOS. For-profit hospitals had lower LBTC and LOS. Higher inpatient bed occupancies were associated with a higher LOS. Increasing admission percentages were positively associated with overall LOS for EDs, but not with rates of LBTC. CONCLUSIONS Higher-volume EDs are associated with higher LBTC and LOS, and for-profit hospitals appear more favorably in these metrics compared with their nonprofit counterparts. It is important to appreciate that hospitals have different baselines for performance that may be more tied to volume and capacity, and less to quality of care.

Volume-Related Differences in Emergency Department Performance

BACKGROUND Emergency departments (EDs) are an important source of care for a large segment of the population of the United States. In 2009 there were more than 136 million visits to the ED each year, and more than half of hospital admissions begin in the ED. Measurement and monitoring of emergency department performance has been prompted by The Joint Commissions patient flow standards. A study was conducted to attempt to correlate ED volume and other operating characteristics with performance on metrics. METHODS A retrospective analysis of the Emergency Department Benchmarking Alliance annual ED survey data for the most recent year for which data were available (2009) was performed to explore observed patterns in ED performance relative to size and operating characteristics. The survey was based on 14.6 million ED visits in 358 hospitals across the United States, with an ED size representation (sampling) approximating that of the Emergency Medicine Network (EM Net). RESULTS Larger EDs (with higher annual volumes) had longer lengths of stay (p < .0001), higher left without being seen rates (p < .0001), and longer door-to-physician times (p < .0001), all suggesting poorer operational performance. Operating characteristics indicative of higher acuity were associated with worsened performance on metrics and lower acuity characteristics with improved performance. CONCLUSION ED volume, which also correlates with many operating characteristics, is the strongest predictor of operational performance on metrics and can be used to categorize EDs for comparative analysis. Operating characteristics indicative of acuity also influence performance. The findings suggest that ED performance measures should take ED volume, acuity, and other characteristics into account and that these features have important implications for ED design, operations, and policy decisions.

Emergency Department Operations Dictionary: Results of the Second Performance Measures and Benchmarking Summit

The public, payers, hospitals, and Centers for Medicare and Medicaid Services (CMS) are demanding that emergency departments (EDs) measure and improve performance, but this cannot be done unless we define the terms used in ED operations. On February 24, 2010, 32 stakeholders from 13 professional organizations met in Salt Lake City, Utah, to standardize ED operations metrics and definitions, which are presented in this consensus paper. Emergency medicine (EM) experts attending the Second Performance Measures and Benchmarking Summit reviewed, expanded, and updated key definitions for ED operations. Prior to the meeting, participants were provided with the definitions created at the first summit in 2006 and relevant documents from other organizations and asked to identify gaps and limitations in the original work. Those responses were used to devise a plan to revise and update the definitions. At the summit, attendees discussed and debated key terminology, and workgroups were created to draft a more comprehensive document. These results have been crafted into two reference documents, one for metrics and the operations dictionary presented here. The ED Operations Dictionary defines ED spaces, processes, patient populations, and new ED roles. Common definitions of key terms will improve the ability to compare ED operations research and practice and provide a common language for frontline practitioners, managers, and researchers.

Lessons in emergency evacuation from the Miamisburg train derailment

Hazardous materials incidents result from the release of materials considered to be harmful or potentially harmful to human beings or the environment. This article describes a train derailment and subsequent hazardous materials release with the evacuation of approximately 50,000 citizens. The hazardous materials release took five days to control and resulted in 561 patient visits to local emergency departments for symptoms related to chemical exposure. The evacuation and emergency medical operations are described and serve as a model for developing community emergency preparedness plans and managing victims involved in hazardous materials incidents.

Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study

Study objective: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high‐performing, low‐performing, and high‐performance improving hospitals to reduce ED crowding. Methods: In this mixed‐methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case‐mix‐adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). Results: We engaged 4 high‐performing, 4 low‐performing, and 4 high‐performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length‐of‐stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data‐driven management, and performance accountability. Conclusion: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.

Association among Emergency Department Volume Changes, Length of Stay, and Leaving Before Treatment Complete

Abstract The authors examined the association between the size of an emergency department (ED), volume increases over time, length of stay (LOS), and left before treatment complete (LBTC). EDs participating in the Emergency Department Benchmarking Alliance providing at least two years of data from 2004 to 2011 were included in the analysis. The impact of volume on LOS and LBTC varied depending on annual ED volume. Based on this, EDs can anticipate better how changes in volume will impact patient throughput in the future.

Overall ED efficiency is associated with decreased time to percutaneous coronary intervention for ST-segment elevation myocardial infarction

BACKGROUND Performance of percutaneous coronary intervention (PCI) within 90 minutes of hospital arrival for ST-segment elevation myocardial infarction patients is a commonly cited clinical quality measure. The Centers for Medicare and Medicaid Services use this measure to adjust hospital reimbursement via the Value-Based Purchasing Program. This study investigated the relationship between hospital performance on this quality measure and emergency department (ED) operational efficiency. METHODS Hospital-level data from Centers for Medicare and Medicaid Services on PCI quality measure performance was linked to information on operational performance from 272 US EDs obtained from the Emergency Department Benchmarking Alliance annual operations survey. Standard metrics of ED size, acuity, and efficiency were compared across hospitals grouped by performance on the door-to-balloon time quality measure. RESULTS Mean hospital performance on the 90-minute arrival to PCI measure was 94.0% (range, 42-100). Among hospitals failing to achieve the door-to-balloon time performance standard, median ED length of stay was 209 minutes, compared with 173 minutes among those hospitals meeting the benchmark standard (P < .001). Similarly, median time from ED patient arrival to physician evaluation was 39 minutes for hospitals below the performance standard and 23 minutes for hospitals at the benchmark standard (P < .001). Markers of ED size and acuity, including annual patient volume, admission rate, and the percentage of patients arriving via ambulance did not vary with door-to-balloon time. CONCLUSION Better performance on measures associated with ED efficiency is associated with more timely PCI performance.