Shari Welch

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.

Exploring New Intake Models for the Emergency Department

The objective of this article was to explore new intake models for processing patients into the emergency department (ED) and disseminate these new ideas. In the fall of 2008, the Board of Directors of the Emergency Department Benchmarking Alliance (EDBA) identified intake as an area of focus and asked its members to submit new intake strategies alternative to traditional triage. All EDBA members were invited to participate via an e-mail survey. New models could be of their own design or developed by another organization and presented with permission. In all, 25 departments provided information on intake innovations. These submissions were collated into a document that outlines some of the new models. Collaborative methodology promoted the diffusion of innovation in this organization. The results of the project are presented here as an original article that outlines some of the new and mostly unpublished work occurring to improve the intake process into the ED.

Emergency department performance measures updates: proceedings of the 2014 emergency department benchmarking alliance consensus summit.

OBJECTIVES The objective was to review and update key definitions and metrics for emergency department (ED) performance and operations. METHODS Forty-five emergency medicine leaders convened for the Third Performance Measures and Benchmarking Summit held in Las Vegas, February 21-22, 2014. Prior to arrival, attendees were assigned to workgroups to review, revise, and update the definitions and vocabulary being used to communicate about ED performance and operations. They were provided with the prior definitions of those consensus summits that were published in 2006 and 2010. Other published definitions from key stakeholders in emergency medicine and health care were also reviewed and circulated. At the summit, key terminology and metrics were discussed and debated. Workgroups communicated online, via teleconference, and finally in a face-to-face meeting to reach consensus regarding their recommendations. Recommendations were then posted and open to a 30-day comment period. Participants then reanalyzed the recommendations, and modifications were made based on consensus. RESULTS A comprehensive dictionary of ED terminology related to ED performance and operation was developed. This article includes definitions of operating characteristics and internal and external factors relevant to the stratification and categorization of EDs. Time stamps, time intervals, and measures of utilization were defined. Definitions of processes and staffing measures are also presented. Definitions were harmonized with performance measures put forth by the Centers for Medicare and Medicaid Services (CMS) for consistency. CONCLUSIONS Standardized definitions are necessary to improve the comparability of EDs nationally for operations research and practice. More importantly, clear precise definitions describing ED operations are needed for incentive-based pay-for-performance models like those developed by CMS. This document provides a common language for front-line practitioners, managers, health policymakers, and researchers.

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.

The Performance Limits of Traditional Triage

Though we equate the concept of triage with 20th-century battlefields, it was actually developed by the French during the Napoleonic Wars. In the early 19th century, the French army had to care for heavy war casualties with limited resources. In essence, they were forced to ration medical care by prioritization. Accordingly, Napoleon’s chief surgeon devised a system of ranking injuries on the battlefield that he called “triage.” Simply put, he defined a mechanism for sorting patients whereby the most serious, life-threatening but viable patients were treated first. The surgeon would continuously appraise the situation, with an underlying goal of treating the greatest number of patients possible. Disproportionate time was not given to a serious case if treating the patient would disadvantage many more viable patients. Since the Korean War, the triage process has dominated intake into acute care health settings. In the 1980s, patients were sorted, usually by a nurse, and placed in the appropriate treatment space and in the appropriate queue. When the average emergency department (ED) annual census was below 18,000 visits, the lengthier process that had evolved was still effective and useful. It became the prevalent intake model. However, in the decades since, as census and arrivals have doubled and most EDs spend part of each day with more patients than treatment spaces, triage in its current iteration is less effective. The cumbersome ED triage processes that have evolved both for regulatory compliance and operational control have resulted in triage as a bottleneck. Current ED triage creates a barrier to efficient patient flow and is antithetical to the principles and practices of battlefield triage. It is also entirely controlled by ED staff. In this issue of Annals, Weber et al report on the timeliness of ED triage at intake. The direct effect of improved timeliness at intake on health care outcomes can’t be overstated. Clinical outcomes are on the clock for a growing number of clinical entities, including acute STsegment elevation myocardial infarction, stroke, and communityacquired pneumonia. A recent study reports that people come to the ED to see the physician—and 80% will wait up to 2 hours longer to do so. Yet, increasingly EDs in the United States report the interval to first physician contact is growing longer. Nurse or emergency medical technician triage delays the patient’s first contact with the physician and thus may postpone critical clinical interventions. Physicians are skilled at identifying ill patients. Available c

Improving door-to-physician times in 2 community hospital emergency departments.

Door-to-physician time in the emergency department (ED) correlates with patient satisfaction and clinical quality and outcomes. Delays in seeing a provider result in a 3% nationwide rate of patients leaving without being seen(LWBS) after presenting for ED care. Two community hospitals had door-to-physician times of 51 and 47 minutes. The LWBS rates were 3% and 2%. A quality improvement project was initiated with a change package, including prompts, training, and feedback. Door-to-physician times decreased to 31 and 27 minutes. The change occurred in less than a month and was sustained for 6 months after the study. In addition, the LWBS rates at each facility fell by one third. Basic process improvement strategies borrowed from service industries were used in 2 EDs to improve the door-to-physician process.

Tight-fitting garments as counterpressure devices.

A case of traumatic splenic rupture in a hemodynamically stable elderly woman is presented. The patient decompensated almost immediately following the removal of a tight-fitting girdle. The implications of recognizing garments as potential counterpressure devices in emergency management are discussed. Emergency physicians are cautioned to carefully explore and reevaluate patients after the removal of tight-fitting garments.