There is huge value to timely data collection and sharing within an individual emergency department and between emergency departments.
Explore This IssueACEP Now: Vol 39 – No 03 – March 2020
Several national surveys create a statistical picture of the emergency system in America, including the National Hospital Ambulatory Medical Care Survey, which covers 1992–2016, and the annual Emergency Department Benchmarking Alliance (EDBA) survey, which has reported on ED performance measures since 1994.1,2
The National Emergency Department Inventory (NEDI)-USA database is maintained by the Emergency Medicine Network (EMNet) at Massachusetts General Hospital in Boston.3 NEDI-USA contains data on all U.S. emergency departments, including hospital-affiliated satellite freestanding emergency departments (FSEDs) and autonomous FSEDs. According to NEDI-USA, there were 5,381 U.S. emergency departments that collectively managed 155,946,509 visits in 2016. Within NEDI-USA, all U.S. emergency departments can be found in the free smartphone app EMNet findERnow, including specific information such as total annual ED visit volume and whether the hospital is a verified trauma or burn center.
But creating a national picture has only a small value to emergency physicians and their patients compared to a comprehensive understanding of local needs and services. And local data has the greatest value when it is used for emergency planning, problem-solving, and solution creations at the local level. Emergency department leaders, emergency physicians, and nurse managers must have useful, well-defined data and the context to understand and utilize it. Having systems programmed to collect the data allows managers to build an understanding of the results, put the results in context and trends, and utilize the results and trends to compare their site with similar emergency departments. Data snapshots and trend lines allow hospital administrators to make good decisions to support evolving ED operations and address issues like flu surges and seasonal volume changes.
Using a well-constructed set of site data, ED leaders can identify effective processes and initiate a system for continuous process improvement. A comprehensive view of the emergency department has about 20 operating statistics. ED leaders collect these numbers from the hospital operating and financial systems—and increasingly from digital management systems in the emergency department.
The 20 ED performance measures (see Table 1) are the basis for effective department discussions and leadership. In short, they help answer these questions:
- Who are the patients?
- How effective are ED processes?
- What diagnostic services and treatments are needed for quality care?
- What are the outcomes for patients, ED staff, and the hospital?
All elements serve as the basis for continuous process improvements.
Using Your Data to Improve Your ED
The first, and most important, use of data is to inform the ED staff about the patients they serve and the key performance indicators for that emergency department. Table 2 is a sample staff information chart. These “patient per day” measures are the basis for effective ED management and should be posted in the staff lounge and bathroom (the most important communication site in most emergency departments). Smart ED leaders also understand what measures change on certain days (Monday in most emergency departments) and will recognize that staffing and operational changes are needed for days where predictable patient surges will occur.
Table 1: ED Performance Management Measures
|1. Patients per day (the most important driver of ED operations)|
|2. Percentage of pediatric patients, defined as under age 18|
|3. Percentage of high-acuity patients, defined as physician CPT code level 99284, 99285, and 99291|
|4. Percentage of patients arriving by EMS|
|5. Percentage of EMS patients admitted|
|6. Median time from door to doctor|
|7. Median length of stay for all patients|
|8. Median length of stay for treat-and-release patients|
|9. Median length of stay for admitted patients|
|10. Median “boarding time” (decision to admit until admitted patient leaves the ED)|
|11. Percentage of patients who leave before treatment complete (an important and inclusive term, counting any patient who leaves at any time in the ED process)|
|12. Number of ECGs per 100 patients seen|
|13. Number of images per 100 patients seen|
|a. CT scans|
|b. MRI scans|
|c. Ultrasound studies|
|14. Percentage of patients placed in an inpatient unit, either full admission or observation|
|15. Percentage of total hospital admissions processed through the ED|
|16. Percentage of patients transferred to another hospital|
|17. Patient experience-of-care scores|
|18. ED staff satisfaction, measured by personnel turnover rate|
|19. Revenue per patient for the ED|
|20. For ED patients who are admitted, the financial contribution to hospital per patient|
Note: The definitions of these data points are in the literature.2 The process for analysis of these data is summarized in an article by Shari Welch, MD, FACEP, and in ongoing Benchmarking and Special Ops articles in ACEP Now.4
The personnel and financial descriptors of acuity and the ED service are often shared at department meetings but not on a public chart. Those ultimately reflect on the longevity of ED managers. If ED staff and patient satisfaction are not high, a new group of managers may be analyzing the measures at future staff meetings.
The 20 numbers concept is used in other industries. The performance literature from other industries can be applied to some ED operations, but administrative decisions that affect ED performance must be driven by the demand for high-quality care and patient safety. The 20 numbers provide data to measure the successful execution of the emergency care mission.
Table 2: A Day in Our ED
|140||Patients to be seen|
|17||Are under age 18|
|30||Are seen in and dispositioned from the fast track or greeting area|
|25||Arrive by EMS; of those, 11 are admitted|
|2||Are seen and then transferred to another hospital|
|172 minutes||The average length of stay for all patients|
|290 minutes||The average length of stay for patients being admitted, of which 120 minutes is boarding time|
|90||Are administered medications|
|3||Need some form of restraint, and seven need mental health management|
|43||Have an ECG performed|
|115||Imaging procedures will be done, of which 60 are plain films, 36 are CT scans, two are MRIs, and 10 are ultrasounds|
|30||Are placed in an inpatient unit, either full admission or observation, representing 70 percent of the 43 patients placed in inpatient units in a day|
|4||Will be transferred|
|1125||Orders will be entered via computerized physician order entry (CPOE)—eight orders per patient|
|0.22||Of the hospital’s total CPOE orders each day come from the ED|
|0.87||Patient experience score for the year to date|
|0.01||Left before treatment complete rate for the year to date|
- Rui P, Kang K, Ashman JJ. National Hospital Ambulatory Medical Care Survey: 2016 emergency department summary tables. 2016. Centers for Disease Control and Prevention website.
- Wiler JL, Welch S, Pines J, et al. Emergency department performance measures updates: proceedings of the 2014 Emergency Department Benchmarking Alliance consensus summit. Acad Emerg Med. 2015:22(5):542-553.
- 2016 National Emergency Department Inventory – USA. Emergency Medicine Network website.
- Welch SJ, Augustine JJ, Dong L, et al. Volume-related differences in ED performance. Jt Comm J Qual Patient Saf. 2012:38(9):395-402.