Recently, I asked an emergency room physician a question that got a chuckle.
What, exactly, is "the door" -- as in "door-to-decision," "door-to-bed," "door-to-balloon," "door-to-scan" or "door-to-departure"?
How do you know when the patient actually came in "the door," to measure the speed of care, which of course closely relates to quality of care?
And while we're at it, what is really meant by "departure" from the ED, given the vagaries of the time so many patients spend on gurneys parked along hospital hallways?
The physician laughed, but in a good way, as if I had posed a question many other providers have also been asking. "Good question" was the response.
Now coalitions of emergency physicians and emergency nurses have taken the first steps to find some answers and define words or phrases commonly used in ED care, but which have meant different things in different settings – and resolve what has been a long-standing battleground over terminology.
"There's been a problem with people in EDs measuring different metrics, and there's been a problem with different definitions of metrics," says Sandra Schneider, president of the American College of Emergency Physicians, which participated in both coalitions.
It has to be done because ED care, arguably the most fast-paced and most vulnerable part of a hospital's operation, should be a place where everyone who says a word or phrase means the same thing, so care can be measured and compared as it is or is about to be in most other parts of healthcare services. There must be consistency.
That's especially important because over the next two years, CMS expects hospitals to begin tracking and reporting their median times for two National Quality Forum-approved benchmarks for emergency care:
- The number of minutes between the time the patient arrives at the ED to the time they depart the premises of the ED to be admitted to the hospital.
- The time between the moment a decision is made by the ED physician to admit the patient to a hospital bed to the time the patient departs the ED and is actually placed in an inpatient bed, a period sometimes referred to as "boarding."
At some point, the results will become public on hospitalcompare.hhs.gov.
For now, there is no payment or penalty tied to this reporting, but that will probably come.
CMS has not defined the terms for these EDs. So these groups are trying to gather consensus so that everyone is on the same page.
"We want CMS to be aware of the fact that many patients in hospitals around the country are spending exorbitant amounts of time in the ED before they can get to a hospital bed," said Schneider.
"And we know that patients who spend long amounts of time in the ED have increased numbers of medical errors, delays in getting pain medication, and from a recent paper, we know that patients with heart attacks, when they're diverted from a hospital, have higher mortality...
"We can draw attention to them. We can say look at these numbers. Do they look rational to you, that the average patient spends eight hours in the ED between the time they come in and time they go to the floor? And that some might stay as many as 17? The average person would say that's too long," said Schneider.
She emphasizes that there have been concerns that some hospitals have been, perhaps, a bit too vague in the way they define certain time elements in ED settings. So of course there have been some controversies, and arguments, such as:
- How does one define the door?
- How do you define the interval of boarding? Shouldn't it end when the patient is placed in a bed?
- At what point does a patient brought by paramedics become the responsibility of the ED (at the moment the gurney crosses the threshold, or the time that patient is seen by a physician or triage nurse, or greeter)?
"In some places, the EMS squad might bring a non-critical patient, but may actually wait a half an hour to an hour until room until the ED can accept the patient," Schneider says.
All of these were controversial, Schneider says. But the groups buckled down and came to a compromise.
"As we are going through healthcare reform, and we're trying to be more transparent and look more for quality improvements, we want to compare ourselves and so it's important to measure things the same way. If you don't, you can never compare yourself to someone else," she says.
In fact, there are more than 140 metrics that could be applied to evaluate emergency room care, says Shari Welch, another member of the committee grappling with these issues and an emergency physician with Utah Emergency Physicians.
Welch, a research fellow with Intermountain Institute for Health Care Delivery Research, said in an interview this spring that there are emergency room metrics that could apply "for every specialty, door-to-orthopedic doc for bone fractures, to-antibiotic for pneumonia, door- to-CT for acute stroke. The sheer volume worries me," she said.
All emergency room physicians realize that some of them will soon come onto CMS' radar, for tracking, and "maybe for not paying," Welch quipped.
Sometime down the line, most emergency room physicians I've talked with agree, CMS will start rewarding performance in the ED. "We all assume that at some point, payment will be tied to this," said James Augustine, vice president of the ED Benchmarking Alliance and a member a coalition trying to get stakeholders to agree on what these terms mean.
Frankly, one of the concerns is that some hospitals have been taking some advertising liberties, which confuses the issue even more.
Suzanne Stone-Griffith, RN and a member of both coalitions said that "there's a growing number of ad campaigns out there, with lots of spinning going on. They'll say, 'We have a 30-minute promise, that if you come to our ED you'll be seen in 30 minutes.' Well, what does that mean? Be seen by whom?" Or seen by a clerk at a sign-in table?
As of now, two important events have taken place:
1. A coalition of physicians and nurses who make up the Emergency Department Benchmarking Alliance have published a lengthy paper this month in the Annals of Emergency Medicine that precisely defines
- Timestamps, such as arrival time, provider contact time, admit decision time and departure time.
- Time intervals, such as door-to-doc or length of stay, or treatment space to provider time.
- Subcycle intervals, such as EMS offload interval, triage interval, or laboratory interval.
2. As reported this month, the Emergency Nurses Association, in collaboration with the American College of Emergency Physicians, the National Association of EMS Physicians and six other emergency care specialists, developed a consensus statement, settling on definitions for six terms on whose definitions they all could agree:
- What is an ED
- What is an ED arrival time
- What is an ED offload time
- What is the ED transfer of care from pre-hospital providers time
- What is an ED triage time
- What is an ED treatment space time
Only by agreeing on these and other definitions can hospitals get truly serious about reducing wait times. And, only then can providers be sure they're doing everything they can to measure and improve the quality of emergency room care.
I think in time, we'll look back and say that by defining what we expect of emergency room care, we will not just reach better benchmarks, we will also save a lot of money, because we will have reduced the severity of outcomes, while saving many lives.