Emergency Department

Ensuring the efficiency and quality of care provided in rural emergency departments is critical to improving patient outcomes. The Emergency Department Transfer Communication (EDTC) measure focuses on seamless transitions of care, while OP-18 and OP-22 measure the timeliness of care and follow-up communication. These tools provide a framework for hospitals to optimize emergency department operations and meet the unique challenges of rural healthcare.

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View the emergency department report of your hospital by entering its CCN below.

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Current reporting period: None

Your Name

Reporting Period

Phone

Hospital CCN

Number of Records Reviewed

All EDTC Measures

EDTC-1

EDTC-2

EDTC-3

EDTC-4

EDTC-5

EDTC-6

EDTC-7

EDTC-8

View the emergency department report of your hospital

Reports

The MBQIP Emergency Department Reports offer comprehensive insights into the performance of rural emergency care. Focusing on the Emergency Department Transfer Communication (EDTC) measure, these reports assess the effectiveness of patient transfer communications, ensuring seamless transitions and continuity of care. In addition, the OP-18 and OP-22 measures evaluate the timeliness of care delivery and follow-up communications—critical factors in addressing the unique challenges of rural healthcare. The reports compile data from all participating rural hospitals, presenting a complete picture of emergency department performance nationwide.

Measure Information

Emergency Department Transfer Communication (EDTC) Percent of Patients who are transferred from an ED to another healthcare facility that have all necessary communication made available to the receiving facility in a timely manner.

Encounter Periods

Q1 (January 1 – March 31)
Q2 (April 1 – June 30)
Q3 (July 1 – September 30)
Q4 (October 1 – December 31)

Submission Deadlines

Q1 encounters (January 1 – March 31) DUE April 30
Q2 encounters (April 1 – June 30) DUE July 31
Q3 encounters (July 1 – September 30) DUE October 31
Q4 encounters (October 1 – December 31) DUE January 31
Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter where applicable.

Measure Description

Percent of Patients who are transferred from an ED to another healthcare facility that have all necessary communication made available to the receiving facility in a timely manner.

Measure Rationale

Timely, accurate, and direct communication facilitates the handoff to the receiving facility, provides continuity of care and avoids medical errors and redundant tests.

Numerator

Number of patients discharged, transferred, or returned to another healthcare facility whose medical record documentation indicated that ALL 8 data elements were documented and communicated to the receiving hospital in a timely manner.

Denominator

ED patients who are discharged, transferred, or returned to another healthcare facility

Exclusions

AMA (left against medical advice)
Expired
Discharged to Home includes: Assisted Living Facilities, Board and care, foster or residential care, group or personal care homes, and homeless shelters
Discharged to Court/Law Enforcement – includes detention facilities, jails, and prison
Discharged Home with Home Health Services
Discharged to Outpatient Services including outpatient procedures at another hospital, Outpatient Chemical Dependency Programs, and Partial Hospitalization
Discharged to Hospice-at home
Not Documented/Unable to determine discharge location
Discharged to Observation Status

Improvement Noted As

Increase in the rate

Measure Population (Determines the cases to abstract/submit)

Patients admitted to the emergency department who were then discharged, transferred, or returned to any type of acute care facility, or other care facility

Sample Size Requirements

Quarterly
0-44 - submit all cases
> 45 - submit 45 cases
Monthly
0-15 - submit all cases
> 15 - submit 15 cases

The following measure specific sampling requirements exist:
Hospitals need to submit a minimum of 45 cases per quarter from the required population. A hospital may choose to sample and submit more than 45 cases. Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. Hospitals whose initial patient population size is less than the minimum number of 45 cases per quarter for the measure cannot sample and should submit all cases for the quarter.

Calculations

This measure is calculated using an all or none approach. The overall EDTC Measure can be calculated as the percent of patients that met all the eight data elements divided by all transfers from ED to another healthcare facility.

Data Source

Manual Chart Abstraction. Retrospective data sources for required data elements include administrative data and medical records.

Data Collection Approach

Chart Abstracted, composite of EDTC data elements 1-8, using an all or none approach

Data Elements

Home Medications
Allergies and/or Reactions
Medications Administered in ED
ED Provider Note
Mental Status/Orientation Assessment
Reason for Transfer and/or Plan of Care
Tests and/or Procedures Performed
Tests and/or Procedures Results

Measure Submission and Reporting Channel

Submission process directed by state Flex Program

OP-18 - Time from ED Arrival to ED Departure Median time from Emergency Department (ED) arrival to time of departure from the emergency room for patients discharged from the ED.

Encounter Periods

Q1 (January 1 – March 31)
Q2 (April 1 – June 30)
Q3 (July 1 – September 30)
Q4 (October 1 – December 31)

Submission Deadlines

Q1 encounters (January 1 – March 31) DUE August 1
Q2 encounters (April 1 – June 30) DUE November 1
Q3 encounters (July 1 – September 30) DUE February 1
Q4 encounters (October 1 – December 31) DUE May 1
Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter where applicable.

Measure Description

Median time from Emergency Department (ED) arrival to time of departure from the emergency room for patients discharged from the ED.

Measure Rationale

Reducing the time patients remain in the emergency department (ED) can improve access to treatment, increase quality of care, and potentially improve access to care specific to the patient's condition. It also increases the capability to provide additional treatment. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, this phenomenon has spread to suburban and rural healthcare organizations. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised.

Exclusions

Patients who expired in the emergency department

Improvement Noted As

Decrease in median value (time)

Measure Population (Determines the cases to abstract/submit)

Patients seen in a Hospital Emergency Department that have an E/M code in Appendix A, OP Table 1.0 of the CMS Hospital OQR Specifications Manual.

Sample Size Requirements

Quarterly
0-900 - Submit 63 cases
> 900 - Submit 96 cases
Monthly
0-900 - Submit 21 cases
> 900 - Submit 32 cases
Note: Monthly sample size requirements for this measure are based on the quarterly patient population.

Data Source

Hospital tracking

Data Collection Approach

Retrospective data sources for required data elements include administrative data and medical record documents. Some hospitals may prefer to gather data concurrently by identifying patients in the population of interest. This approach provides opportunities for improvement at the point of care/service. However, complete documentation includes the principal or other ICD-10-CM diagnosis and procedure codes, which require retrospective data entry.

Data Elements

Arrival Time
Discharge Code
E/M Code
ED Departure Date
ED Departure Time
ICD-10-CM Principal Diagnosis Code
Outpatient Encounter Date

Measure Submission and Reporting Channel

Hospital Quality Reporting (HQR) via Outpatient CART/Vendor

OP-22 - Left Without Being Seen Percent of patients who leave the Emergency Department (ED) without being evaluated by a physician/advanced practice nurse/physician’s assistant.

Encounter Period

Calendar Year (January 1 – December 31)

Submission Deadlines

May 15, 20XX
Data submission deadlines on a federal holiday or weekend (Saturday or Sunday) will default to the first business day thereafter where applicable.

Measure Description

Percent of patients who leave the Emergency Department (ED) without being evaluated by a physician/advanced practice nurse/physician’s assistant (physician/APN/PA).

Measure Rationale

Reducing patient wait time in the ED helps improve access to care, increase capability to provide treatment, reduce ambulance refusals/diversions, reduce rushed treatment environments, reduce delays in medication administration, and reduce patient suffering.

Numerator

The total number of patients who left without being evaluated by a physician/APN/PA

Denominator

The total number of patients who presented to the ED

Improvement Noted As

Decrease in rate (percent)

Sample Size Requirements

No sampling - report all cases

Data Collection Approach

Hospital Tracking

Measure Submission and Reporting Channel

Hospital Quality Reporting (HQR) via Online Tool (HARP)