Quality Performance Measures Track ED Throughput

ACEP News 
June 2009

By Martha Taggart

ACEP News Contributing Writer

The National Quality Forum (NQF) has issued a new set of emergency department performance measures. And not surprising at a time when attention is focused on ED crowding and wait times, 5 of the 10 new measures address throughput, while the remainder look at clinical management protocols.

These measures follow a previous set issued in November 2007 (phase 1) that focused on ED communications and acute myocardial infarction care during ED transfers. Together, they are part of an NQF project to increase public accountability and quality improvement for emergency care. A third set, aimed at prehospital care and care coordination, is envisioned.

As a voluntary consensus standards-setting organization, NQF brought together a steering committee for the project comprising major specialty groups and organizations involved in emergency medicine.

The endorsed measures were selected out of a pool of recommendations submitted by public and private entities.

"All these organizations are interested in process improvement and quality improvement," said Dr. John Moorhead, an ACEP past president who chaired the NQF steering committee. A professor of emergency medicine at the Oregon Health & Science University School of Medicine, he is a director on the American Board of Emergency Medicine.

"Our hope is that as measures like these get identified, they're used across the board--not some measures for one group and some for another," Dr. Moorhead said.

"We want this to be relevant and done in a way that's consistent across all the organizations," he added--whereas if the same groups worked independently to develop performance measures, there would be the risk of redundancy and multiple reporting channels, with attendant burdens on EDs.

Crowding and Wait Times in EDs

Dr. Dennis Beck, chairman of ACEP's Quality and Performance Committee, said the NQF's approach is well-considered and points the specialty in a good direction.

"Crowding and boarding problems are among the many challenges facing ACEP and our patients," he said. "These proposed measures shine a light on a critical problem."

NQF statistics show that from 1994-2004, ED visits increased by 18%--to 120 million visits a year--while the number of EDs decreased by more than 12%.

In addition to coping with their own capacity problems, EDs "are sometimes forced to shoulder the burden for other hospital departments," Dr. Beck said.

For example, they are often blamed for long ED stays and delays in inpatient admission that result from shortages of beds or personnel in other hospital departments.

One new measure, in particular, gets at the heart of that boarding function by recording the median time from admit decision to time of departure from the ED for patients admitted to inpatient status. This measure and two additional measures--recording median time from ED arrival to ED departure both for patients admitted to the facility and those discharged from the ED--were originally submitted to NQF for consideration by the Centers for Medicare and Medicaid Services (CMS).

Additional throughput measures would record time of first contact in the ED to being seen by a physician or provider and percent of patients leaving without being seen by a physician.

Although some EDs are already keeping track of this information, Dr. Beck said, "what the measures do is set specifications around when the clock starts and what needs to be measured. This makes it precise."

Throughput Performance May Become Part of CMS Reporting

At least two of the throughput measures endorsed by NQF are likely to be included in CMS reporting and performance initiatives by 2011 or sooner, according to ACEP's Director of Quality and Health IT, Angela Franklin.

"Whenever CMS wants to use performance measures, it is required by statute to go through a consensus body [such as NQF]," Ms. Franklin said.

For starters, door-to-departure and decision-to-departure measures for ED patients who are admitted as inpatients have been included in the "Specifications Manual for National Hospital Inpatient Quality Measures" that went online in April 2009 (www.qualitynet.org). They are also expected to be included in proposed Inpatient Prospective Payment System rule published in April 2009.

Following a 60-day comment period, "CMS will have to decide if they want to tie hospital annual payment update to reporting of these two measures," Ms. Franklin said.

While most signs point that way, some parties, including the American Hospital Association, have argued that hospital EDs have different demands placed on them depending on the communities they serve, and that some sort of risk adjustment should be built into the measures.

Along with the throughput measures, NQF endorsed five measures of clinical care. They include management protocols for severe sepsis and septic shock, confirmation of endotrachael tube placement, and documentation of weight in kilograms for children 13 years old or younger.

In addition, there are two measures submitted by ACEP that aim to improve care by standardizing pregnancy tests in females presenting with abdominal pain and anticoagulation therapy for patients with acute pulmonary emboli.

"These measures are just some we hope people will report on," said Dr. Moorhead, the NQF panel cochair. "They're clinically relevant issues for which data are readily available, so collecting them won't place too much of a burden on EDs personnel.

"But they're also [our attempt] to get EDs used to reporting data," he said. "We anticipate more efforts to capture additional data of this sort down the line."

Even Ostriches Can't Miss the Signs

Joining Dr. Moorhead as cochair was Emergency Nurses Association member Suzanne Stone-Griffin, R.N., MSN. Assistant vice president of clinical services at the Hospital Corporation of America, Ms. Stone-Griffin admits to be being "passionate" about data collection. That's one of the tools she's using to address crowding and holding in her company's 179 EDs, representing 5.5 million annual visits--close to% of the entire country's annual total.

"At HCA, we took steps a year ago to measure every month how much crowding and holding is going on in our EDs," Ms. Stone-Griffin said. "We already know these measures relate to patient satisfaction, and now we're beginning to see studies of how throughput affects outcomes and quality of care."

Like others, she recognizes that EDs often face circumstances beyond their control, "but if we're going to shape emergency care, we need to know," she said.

"Crowding is not going away. EDs own a piece of it, and should be at the table," she noted. "But some of these metrics that are critically important to the function and care of the patient in our EDs are not within the control of the ED."

And that might be where the new measures can help.

"There's still a tremendous amount of work to be done in drilling down each standard, but they're a good roadmap for any facility," Ms. Stone-Griffin said. "If I were an ED director who hadn't been addressing these priorities--in other words, an ostrich with my head in the sand--I would now know that potentially, this is what's coming, here's my roadmap for evolving standards of emergency care.

"We're not playing the spin game," she continued. "The data are what they are. What do we need to do to make that data change for better or for worse? We should all be working on that collectively--and sharing what we learn."

Final detailed reports on the NQF Phase 2 ED measures are at the NQF website (www.qualityforum.org). Follow the link to "Projects" and click on "Completed Projects."

NQF Measures Join Growing List Of Quality Improvement Efforts

In November, ACEP convened a Quality and Performance Summit in Washington, D.C. The group discussed ways that emergency medicine may be integrated into future quality initiatives at the national level.

ACEP has long been involved in quality improvement, and has generated more than 22 evidence-based clinical guidelines since publishing its first, on chest pain, in 1990.

This latest set of NQF measures is a good addition to the quality field, several speakers acknowledged. But, much work lies ahead to develop metrics for different aspects of emergency care.

In ACEP's view, the process should be clearly defined, deliberative, risk-adjusted, pilot-tested and phased in across a variety of specialties and practice settings. It also helps if measures are developed by physicians with expertise in the area of care in question, and based on factors directly under their control.

So ACEP will continue to work with all relevant parties to ensure that happens.

NQF's focus will likely turn to coordination of care, according to NQF Senior Vice President for Performance Measures Dr. Helen Burstin. She appealed to emergency physicians to think about their role in coordination of care as well as the collective responsibility across all care settings.

Well-coordinated care across all providers is a national goal, she said. Emergency physicians offer valuable input because they often sit at the nexus between the office-based physician practice and the hospital.

Accordingly, ACEP is working on the NQF panel and participating in the concurrent AMA workgroup focusing on coordination of care.

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