Patient volume is increasing in emergency departments (EDs), requiring close management of ED processes and staffing. The boarding of inpatients in the ED is a significant impediment to efficient operations. Boarding time for inpatients in the ED is a function of overall hospital operations. Because roughly 68 percent of hospital admissions are processed through the ED, this “front door” function to inpatient resources is very important to hospitals. Approximately 19 percent of all ED visits result in hospital admission, which makes efficient processing of inpatients a critical determinant of how all ED patients can flow.

The Emergency Department Benchmarking Alliance (EDBA) recognized the need for definitions and convened the first Emergency Department Performance Measurement Summit Meeting on February 23, 2006, in Atlanta. The 18 participating organizations developed the basic definitions of critical time marks and intervals that were adopted across the industry to allow consistent quality measures to be adopted. Those marks and intervals have now served for 20 years to allow comparisons, trending, and application of practice improvement initiatives.¹ It is important to use precise definitions related to boarding that everyone understands and uses consistently. The definitions have been stretched recently.

In 2013, hospitals were required to report ED boarding time—“ED-2”—to the Centers for Medicare & Medicaid Services (CMS) and post it to the CMS Hospital Compare website. That reporting requirement was eliminated in 2022, curiously in the middle of reporting COVID impacts on ED operations.²

ED Time Marks and Time Intervals

There is a basic set of definitions that relate to a point in time for an ED patient. Most of these are now fixed by a computer system:

• Arrival time. The time that the patient is first recognized and recorded by the ED system as requesting services.
• Practitioner contact time. The time of first contact by the physician or advanced practice practitioner (APP) with the patient to initiate the medical screening exam.
• Decision-to-admit time. The time at which the physician or APP makes the decision to place the patient in an inpatient or observation status in that facility.
• Decision-to-transfer time. The time at which the physician or APP makes the decision to transfer the patient to another facility.
• ED disposition time. The time at which a discharged, admitted, or transferred patient physically leaves the ED treatment area.

From those time stamps, ED time intervals are calculated:

• Door to practitioner. Arrival time until practitioner contact time;
• Door to decision. Arrival time to decision time, whether for admission or transfer;
• Boarding time. Decision time to ED disposition time; and
• ED length-of stay. Arrival time to disposition time.

The EDBA analysis of time markers for process flow has found that an arithmetic mean does not characterize the function of the ED as well as the median number. So, the median statistic is used for all time parameters in the EDBA survey.