A few years ago, emergency department leaders were given a valuable gift. The Joint Commission and then the Centers for Medicare & Medicaid Services (CMS) identified hospitals reducing the boarding of admitted patients as a priority for safety and quality of care. This was an opportunity to bend the curve on the amount of time patients spent in the ED, a curve that had been on an upward trajectory for years in many hospitals. This time interval, referred to in the ED literature as “boarding time,” requires management by ED leaders and hospital administrators. Both groups promoted measures with The Joint Commission that reduced boarding time. They wrote standards that emphasized the importance of ED flow to minimize ED boarding.

Then in 2011, CMS published a set of performance measures that highlighted the ED. “ED-1, Admit Decision Time to ED Departure Time for Admitted Patients” was an important measure. The CMS defined the measure in a positive fashion: median time from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status. The rationale for this measure was the opportunity for emergency physicians to influence behavior by hospital administration and the admitting medical staff of the hospital. As the measure states, “Reducing the time patients remain in the emergency department can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.”

The measure was implemented in 2012 and was subject to public reporting in 2013. The simple definition and explanatory language became a very complicated process for many hospitals. The challenge was to define “admit decision time.” The Emergency Department Benchmarking Alliance (EDBA) asked its 1,100 ED leaders to describe the time marker that had been implemented in their hospital. The reported definitions included actions by the ED clerk (placing a bed order), the ED charge nurse (contacting the bed coordinator), the admitting physician (writing an admission order), and the emergency physician (changing status to admitted in the ED information system). From the hundreds of answers to this question, it was apparent that there were wide variations in the definition of this time stamp.

The EDBA initiated collection of the performance measure in 2012. Unlike CMS, which reports all EDs as one group, the EDBA reports the measure by cohorts. The median ED boarding times for the years 2012, 2013, and 2014 are summarized in Table 1. Reporting the data by cohort gives ED leaders a much more precise comparison based on ED volume and patient population served. The highest number is found in adult EDs and those EDs seeing between 80,000 and 100,000 patients per year. These EDs have boarding times of around 160 minutes. The low-volume EDs, seeing fewer than 20,000 patients, have boarding times that average 65 minutes, nearly a 100-minute difference. The boarding time median of 119 minutes in 2012 has been decreased to 112 minutes in 2014.