Emergency Care Capacity and Quality

standards need to be set, data needs to be collected, and there has to be incentive to fix boarding.  my mother was admitted into the hospital in august 2024, and she spent multiple days in the er when she should have been transferred to another room after about 14 hours.  not only was this harmful to here - she never left the hospital and died there - but this also harmed others who needed the emergency room care.  this is the wealthiest country on this planet.  there is no excuse for this being an issue in the first place and needs to be fixed immediately.

I have observed a decline in quality of care in emergency rooms.  This seems to be a combination of factors including inadequate supervision of new graduates, prolonged boarding where no team is fully attentive to the care of the patient and a rush to push people out without thorough assessments.  

In considering ED boarding, risks to patients include lack of full team attention, prolonged exposure to lights/noise interfering with circadian rhythms and thus healing and increased exposure to other ill patients increasing their risk.  I support measures to address this.

When my husband developed a fever of 104 and had difficulty breathing we when to Ronald Reagan Hospital in Westwood, CA. We spent 7 days boarding in the ER. It was the most traumatic experience of our lives. As a public school administrator, I understand working in an under-resourced setting, but I had no idea of the criminal conditions experienced in US hospitals.  No doubt it is more profitable for hospitals to operate without empty beds, but spending days in an Emergency Room hallway violates standards of care. 

My 70-year-old, 6'2" tall husband ended up on a hallway gurney directly outside the trauma room. His feet and ankles dangled off the foot of the bed, often resting on the metal arm of the vistor's chair pressed tightly against the bed. There wasn't enough room to rotate the ch and hold his legs in my lap. There was no space for a table, so meals & water cups were placed on the small flat surface created when the head of the gurney was raised. 

When an ambulance arrived, the glass doors would slide open and a gust of wind would blow dirt and leaves down the hallway and into his water cup. During his 48 hours in the hallway, his kidney function plummeted and the to small gurney cause severe back pain that became his entire focus. 

Doctors couldn't identify what kind of infection he had, hospital staff was required to glove and gown before "entering" the space around his gurney, a tragic bit of theater as there was no way to shield his airspace from those around him.  The accordion screen couldn't be put up because it impeded the movement of gurneys in and out of the trauma room. 

My husband has sensory sensitivities and a history of anxiety and depression. The light and noise was perpetual. Our hallway abutted the psychiated hallway where patients waited for a bed, screaming, swearing and desperate streams of mania never stopped.

On the third day, we were transferred to a 10-bed ER ward. Though conditions there were better, a real hospital bed, a trashcan, three walls... the 24-hour flow of noise and light continued. My husband became convinced he was a prisoner of war, and I thought it was a perfectly reasonable conclusion. 

Our experience happened before the winter respiratory infection surge; I can't imagine what will happen over the next weeks. The situation is untenable. Our medical system needs to retain doctors, nurses and support staff. Forcing them to do an already difficult job in cramped and substandard conditions will only drive up the attrition rates. Patient care, mental health, privacy standards are all undermined by ER boarding. 

I support the proposed measure as drafted.

As I have unfortunately learned from experiences within my own family, being parked in the hallway for FAR too long--ER Boarding--is a huge problem even in otherwise highly regarded hospitals. Creating standards, collecting data, and creating financial incentives to fix the boarding problem seem like a no-brainer: please approve this quality measure!

Patients should not be stuck waiting hours to days in the ER due to overly full hospitals - this leads to unsafe patient care and increased death. It is essential for hospitals to include measures of ER boarding in their annual assessment, because available and transparent data will hopefully lead to changes in this area.

I would like to voice my support on a proposed clinical quality measure that would set standards, collect data, and help create financial incentives to fix boarding, so that ER patients don't get stuck hours (or days...) waiting for appropriate ER space.  This should be a formal element of how hospitals and facilities with ER service are evaluated.

I fully support this new metric.  

Emergency Departments must be equipped to handle the volume of patients at any given time. This issue requires long-term thinking and solutions. "Emergency Room boarding" is a real problem. In Maine we see this in particular with mental health emergencies. We need to do better! Ramping up capacity is crucial, as this problem will not go away on its own.

Thank you.

I recently met a friend in the ER at UNC Hospital in Chapel Hill, NC. She had just been in a terrible automobile accident. I was with her for three hours until her family could arrive. This was at 1:00 p.m. on a Monday. I was shocked and saddened by the back up in the waiting room and hallways of the ER. They were slammed. I saw almost no movement over the course of the time I was there. It greatly saddened me. We need medical health houses in communities, especially low-wealth communities, where people can go when they first get or feel sick. We can and should and must do better for everyone. This is a travesty.

This measure is an important tool that can be used to assess the quality of care and track systems change efforts meant to improve patient outcomes. I strongly support adoption. In addition, I believe that an equity metric should be included so that potential disparities in treatment can be identified and remediated. In addition to stratification by age, I think it would be important to be able to stratify based (at a minimum) on payer type, race, and gender, as there are known widespread treatment disparities by these types. It will assist health systems in observing, monitoring, and improving disparities to have this metric disaggregated in this manner.

We need standards, collect data, and help create financial incentives to fix boarding - please approve.

I am in favor of this new measure as a means of understanding and preventing what happened to my husband 1 year and 9 months ago.  We both caught COVID for the first and only time.  As soon as we tested positive we contacted our doctors and got scripts for Paxlovid and began taking them.  We were at the tail end of the effectiveness of our vaccination at 5 months from having been vaccinated.  But that evening by 10 pm it quickly it became clear that my husband wasn’t doing well, he had a high fever and became confused.  I rushed him to the ER of a relatively new hospital that was close by.  There was one other patient waiting.  Still despite nearly falling out of his chair it took an hour to get him into a room in the ER and another couple of hours (while they started an IV and took a bedside lung xray) to be seen by the ER resident (who turned out to be a former excellent student of mine, that was a relief).  That resident doc immediately became concerned that my husband had developed a secondary bacterial infection that was rapidly intensifying and possibly necrotizing in his COVID compromised lungs.  He got together with the supervising doc and they decided to put my husband on IV antibiotics while waiting for lab work to identify the bacteria and which antibiotics would be useful.  They also decided to admit him.  However my husband continued to languish in the ER room for over 18 hours before they could find him an actual hospital bed.  They got the culture and sensitivity back and put him on two additional IV antibiotics.  But in the meantime he’s still waiting for an actual room with staff.  My husband began feel a little better and wanted something to eat.  He asked an aid.  No meal was provided.  He had to ask two more times over the next 4 hours before he was given a sandwich out of a vending machine.  When they finally got him to a room he said the care greatly improved.  He was in the hospital for three days before they decided he was well enough to come home.  This is one example of why it is important for this measure to be implemented.  

We had other experiences such as when I developed appendicitis a many years ago.  I was not admitted but was sent to get a CT scan, after the scan no one told us what to do so we went home.  An hour later we got a call telling me to come back because it was appendicitis and I needed emergency surgery.  I fell through the cracks because I was ambulatory, but also because no one was taking care of following me.  I did get emergency surgery that night and went home the next day.

The increasing incidence of emergency room "boarding" needs to be addressed. Two members of my own family have been directly impacted by this practice, one who went to the ER for a COPD exacerbation and the other who went to the ER for high blood pressure and heart issues. One of them was kept in the hallway for over 24 hours! Both of them are elderly and neither received the quality of care that they should have in these circumstances. Thankfully, they both came out of their respective health crises alive and well, though the outcome could have easily been so much different. Hospitals should be required to have enough beds to accommodate the size of the respective cities or communities they cover, as well as adequate nursing staff on the payroll and on the floor to cover those beds. It's long past time that hospitals stop putting profits over people. 

I strongly encourage the consistent inclusion of question(s) about boarding of patients in the ER in the surveys that hospitals are required to complete.

Please support the proposed clinical quality measure that would require hospitals to set standards, collect data, and help create financial incentives to fix boarding 

A local hospital that was known for high quality service was recently acquired by a large, for-profit healthcare management company, following which complaints skyrocketed, particularly regarding long waits for services in or even outside of emergency rooms. Local ambulance services were strained by having to provide emergency care for hours while waiting for availability of beds. Though the COVID emergency was part of the problem, the decline in quality of services and loss of competent staff were general and largely attributed to lack of support from administration to staff. Careful attention to this problem in future by regulatory authorities would be very helpful.

Dear PQM,

In my state, there is an organization that gives numbers for people boarding who are awaiting inpatient psych beds, but it does not track how long those people boarded.  This is just as important as raw numbers of patients.
For one thing, psych patients being boarded do not get treatment  unless they have a doctor already who is connected with the ER/hospital (at least in my state.). This is like someone with a broken leg remaining entirely untreated until they are moved to the right hospital floor.
If it is tracked, it should be broken out for minors vs. adults -- when my child (early onset schizophrenia, age 10) was needing inpatient, the time boarding was often at least a week, and sometimes two -- and this was before the pandemic.

I am in favor of this program to inprove quality healthcare.

The problem of escalating Er "boarding" (i.e. where patients get stuck waiting hours to days in the ER due to overly full hospitals, leading to unsafe patient care and increased death) must be addressed.

I am strongly in favor this proposed clinical quality measure that the U.S. government would require of hospitals. It would set standards, collect data, and help create financial incentives to fix boarding if approved.

Yes, please implement this measure.  It would help to decrease crowding and boarding of patients in the emergency room and lead to better outcomes for those individuals.

I am writing in support of this measure. My uncle - who recently passed away from cancer - spent nights in the ER waiting for care during his illness. Those nights were absolutely terrifying experiences for him and for our family. We must do all we can to fix this fundamental logistics issue that threatens us all. 

This must stop. People are dying and it is abusive to the workers too, esp RNs.

Hospitals should have plans in place and financial incentives to address unsafe boarding and wait times in emergency departments. What advanced civilization can claim a high standard of living without providing the public safe and accessible emergency medical care?

It is difficult to believe that U.S. government health officials actually have to meet to discuss how not to kill people in emergency rooms -- the very places sick people go or are sent in the fervent belief it will save their life or that of loved ones.

To discover there is an escalating problem of emergency room “boarding”—where patients get stuck waiting hours to days in the ER due to overly full hospitals, leading to unsafe patient care and increased death is impossible to believe.

I fully endorse any proposed clinical quality measures that the U.S. government can take to require of hospitals to follow set standards, collect data, and help create financial incentives to fix boarding if approved.

I think U.S. citizens, who pay an extraordinary amount for health care to begin with, would be outraged to learn a situation such as ER boarding even exists.

Maybe our For-Profit model of healthcare approved some 22 years ago needs to be re-examined and "boarded!"

I support the ECCQ eQCM. Thanks.

It is critical that hospitals on safety and quality include data on ER boarding in their annual hospital assessment. It is very important that this measure be included in each hospital’s annual assessment. This would be exceptional news, as it would mean more data and incentivization for hospitals to address the problem.

Emergency room boarding causes incredible suffering to people in their most vulnerable moments. Patients need to be seen, attended to, and admitted or have their needs addressed, not left to languish. A metric measuring emergency room boarding supports these changes. In addition, emergency room boarding should be decreased with increased staffing and increased hospital bed capacity (for mentally and physically ill patients). It should NOT be accomplished by putting pressure on already burnt-out staff or sending patients home prematurely.

I support this measure. I had a bad experience as my husband was in a hallway bed overnight. It was a horrible experience and I needed to be there to advocate for him. I can't imagine what that would have been like for someone alone. There need to be standards set, data collected, and consequences to incentivize ending this practice.

ACEP commends the Partnership for Quality Measurement for including a measure that addresses boarding in the emergency department (ED) for endorsement consideration. The issue of patients “boarding” in the ED, a scenario where patients are placed in a holding pattern for extended periods of time while waiting for an inpatient bed after admission to the hospital or transfer to another facility, is overwhelming emergency physicians, non-physician clinicians, nurses, and other staff who are doing all they can to treat or stabilize every patient that needs care.

Boarding has become its own public health emergency. Our nation’s safety net is on the verge of breaking beyond repair; EDs are gridlocked and overwhelmed. And this breaking point is entirely outside the control of the highly skilled emergency physicians, nurses, and other ED staff doing their best to provide equitable, high quality and safe care.

Boarding is a systemic problem that hinders patients’ access to care. Any emergency patient can find themselves boarded, regardless of their condition, age, insurance coverage, income, or geographic area. Patients in need of intensive care may board for hours in ED beds not set up for the extra monitoring they need. Those in mental health crisis, often children or adolescents, can board for months in chaotic EDs while waiting for a psychiatric inpatient bed to open anywhere. Patients may delay or avoid emergency care and risk their physical and mental health because of these systemic bottlenecks.

ED boarding and crowding are not caused by ED operational issues or inefficiency; rather, they stem from broader health system dysfunction. This dysfunction also leads to negative patient outcomes, as a substantial body of evidence has shown that ED boarding and crowding lead to increased cases of mortality related to downstream delays  of treatment for both high and low acuity patients.[1]^{, [2]} Boarding can also lead to ambulance diversion, increased adverse events, preventable medical errors, lower patient satisfaction, violent episodes in the ED, emergency physician and staff burnout, and higher overall health care costs.

Measurement is essential to identifying, diagnosing, and solving the complex boarding problem. Unfortunately, our ability to measure this problem has recently become limited, as the Centers for Medicare & Medicaid Services (CMS) eliminated an important measure regarding ED overcrowding, wait times, and boarding. In the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS) final rule, CMS decided to sunset ED-2, the Admit Decision Time to ED Departure Time for Admitted Patients measure, starting in 2024. ACEP strongly opposed the removal of this measure as it was not only a specific measure capturing ED boarding, but also one of the only measures available to track this statistic and provide incentives and enforcement to help reduce wait times and boarding. 

In the Calendar Year (CY) 2024 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment system proposed rule, CMS again proposed to eliminate another boarding and crowding-related measure, the Left Without Being Seen (LWBS) Measure, due to indications that (1) limited evidence linked the measure to improved patient outcomes; (2) the assertion that increased LWBS rates may reflect poor access to timely clinic-based care rather than intrinsic systemic issues within the ED; and (3) unintended effects on LWBS rates caused by other policies, programs, and initiatives may lead to skewed measure performance. ACEP strongly opposed the removal of this measure as well, and we were pleased that CMS reversed its position in the final OPPS rule by retaining the measure. Since we strongly believe that it is important to track the ongoing issue of ED boarding, and there is a paucity of measures that CMS currently uses to do so, ACEP supports the Partnership for Quality Measurement’s endorsement of this measure. 

The ECCQ eCQM seeks to capture variation in equity of emergency care and measure capacity and quality of emergency care to support hospital quality improvement by measuring the proportion of emergency department (ED) visits that meet at least one of four outcomes:

1. The patient waited longer than 1 hour to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination; or
2. The patient left the ED without being evaluated by a physician/advanced practice nurse/physician’s assistant, or
3. The patient boarded (time from Decision to Admit (order) to ED departure for admitted patients) in the ED for longer than 4 hours, or

4. The patient had an ED length of stay (LOS) (time from ED arrival to ED physical departure as defined by the ED depart timestamp) of longer than 8 hours.

    

History of the Measure

In January 2024, the Yale Center for Outcomes Research and Evaluation (CORE), being contracted by CMS to develop a measure of emergency care capacity and quality for the Hospital Outpatient Quality Reporting (OQR) Program, issued a request for public comment on an earlier iteration of this measure, with the outcomes differing slightly:

1. The patient waited longer than 1 hour to be placed in a treatment space in the ED.
2. The encounter ended without the patient undergoing a completed medical screening examination (MSE) by qualified medical personnel (QMP).
3. The patient boarded (time from admission order to patient departure from the ED for admitted patients) in the ED for longer than 4 hours.

4. The patient had an ED length of stay (LOS) (time from ED arrival to ED departure) of longer than 8 hours.

    

ACEP made extensive comments on these outcomes, and we appreciate that Yale CORE incorporated some of our suggestions into the final version now up for endorsement consideration. Our suggestions and Yale’s responses included the following:

Outcome 1: The patient waited longer than 1 hour to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination

Due to the boarding crisis, emergency physicians administer care in any available physical space they can find, including hallway stretchers, hallway chairs, overflow tents, and even chairs in the waiting room. Thus, we had recommended that “treatment space” as written in the initial outcome be revised as “treatment room or a dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination,” and that hallway beds and public waiting rooms should be explicitly excluded from the definition of treatment space/room. We appreciate that our suggestion was accepted by Yale CORE.

Outcome 2: The patient left the ED without being evaluated by a physician/advanced practice nurse/physician’s assistant

Outcome 2 previously used the terminology “medical screening exam” (MSE), and ACEP expressed concern due to ambiguity and variation of possible definitions of this term. While an MSE is a legal concept in the context of the Emergency Medical Treatment and Labor Act (EMTALA), Yale CORE proposed to use electronic health records (EHRs) as the means of reporting this measure. We expressed concern that there may be inconsistencies between sites and institutions with respect to what constitutes an MSE, despite the legal definition. Thus, we appreciate the new wording offered in this outcome.

We further asked for clarity on the inclusion of patients who leave the ED without being seen (LWBS) and patients leaving the ED against medical advice (AMA) in this measure, with recommendation for inclusion of the former, and exclusion of the latter. We appreciate the clarification and acceptance of our suggestions in the revised version of this outcome’s specifications.

Outcome 3: The patient boarded (time from Decision to Admit (order) to ED departure for admitted patients) in the ED for longer than 4 hours

ACEP supports the 4-hour maximum timeframe that all admitted patients should remain in the ED between admission order and patient departure referred to in this outcome. We emphasize that this 4-hour threshold should not be treated as a mean or median target but as an absolute maximum limit. Total time in the ED should never exceed 8 hours. 

We also feel strongly that future performance targets should move towards shorter time periods as the quality gap closes; for example, a target of 6 hours of total time in the ED and a target of 2 hours from decision/intent to admit to departure. For patients who are admitted to intensive care units (ICUs) and older adults aged 65 and older, who are disproportionately adversely affected by ED boarding, ^[3],[4] boarding times should be kept as short as possible for these high-risk groups. 

Outcome 3, as previously written, only applied to admitted patients, including patients who are transferred in from other facilities and admitted at the receiving facility. We requested that ED visits with a disposition status of transfer to another acute care facility (transfer out) should be excluded. Emergency physicians are bound by EMTALA, which requires hospitals to provide a to every individual who “comes to the emergency department.” To meet the obligations under EMTALA, larger hospitals in urban areas usually accept rural ED transfers. Rural hospitals often experience difficulty finding destination hospitals to accept patients with needs that extend beyond the capabilities of their rural hospital. Hospitals bear the responsibility of ensuring the prompt care coordination of interfacility transfer patients and should develop appropriate mechanisms to meet increased patient needs. Thus, we appreciate the updated wording of Outcome 3 and believe that it appropriately addresses our prior concerns. 

Measure Stratification

The ECCQ eCQM is stratified into four groups: age (18+/<18) and mental health diagnoses (with, and without). We appreciate the stratification proposed in the measure, as it will help to ensure hospitals address boarding appropriately while remaining fair to external barriers that tend to affect patients with behavioral health needs more than non-behavioral. Additionally, we had previously recommended separating pediatric visits within EDs that see all ages to measure the gravity of the boarding problem for the pediatric population and that whenever possible, pediatric EDs be reported separately from adult EDs at the facility level. Thus, we support the proposed stratification. We additionally see value in further stratifying the age 18+ population group into two groups, patients aged 18-65 and 65+, as geriatric patients are more acutely negatively affected by ED boarding as referenced above.

Measure Calculation

Standardization

As written, the ECCQ eCQM will utilize volume standardization to address differences in patient population between hospitals. Volume-standardization is harmonized with other existing measures and accommodates a “like to like” comparison among hospitals. While we agree with this approach for Outcomes 1, 2, and 4, “like to like” comparison is not appropriate for Outcome 3. All hospitals, regardless of ED volume, have an equal opportunity and responsibility to manage the hospital so that boarding times are kept at a minimum. Therefore, while we acknowledge Outcome 3 may vary by hospital size, we recommend reporting without standardization by volume. 

Measure Type

The ECCQ eCQM is currently formatted as an intermediate outcome measure; a patient encounter that meets one of the outcomes is weighted the same as a patient encounter that meets multiple outcomes. Therefore, from a quality assessment standpoint, it is extremely difficult to discern which of the four outcomes needs the most improvement and impossible to identify any correlations between outcomes. Structuring the measure as a composite measure instead would allow for more granular analysis of specific deficiencies rather than capturing the universe of deficiency as a whole and may allow for analysis of patterns in overlapping negative ED encounter outcomes. 

ACEP recognizes that all four outcomes proposed reflect quality gaps in patient experience in the ED. However, we feel that boarding is the number one priority that needs to be measured and rectified. Thus, if the ECCQ eCQM is structured as a composite measure, Outcome 3 should be weighted more heavily than Outcomes 1, 2, and 4 (40% to 20%). While Outcomes 1 and 2 are influenced by boarding, they may also be influenced by other factors (such as ED staffing) that are related to, but not always, downstream effects of boarding.

Applicability to Quality Reporting Programs

The ECCQ eCQM is being considered for the Hospital OQR Program and the Rural Emergency Hospital Quality Reporting (REHRQ) Program, with slightly differing specifications for each program. We strongly encourage endorsement for inclusion in the Hospital OQR Program but recommend against inclusion in the REHRQ Program. 

Facilities designated as REHs have 50 or fewer beds, are required to provide 24-hour emergency and observation services, and can elect to furnish other outpatient services. An REH cannot have inpatient beds, except those furnished in a distinct part unit licensed as a skilled nursing facility. Despite ACEP’s prior recommendations, a physician with experience in emergency medicine (either a board-certified emergency physician or a family physician with significant expertise in emergency medicine) is not required to provide the care or oversee the care delivered by non-physician practitioners in an REH; rather, a doctor of medicine (MD) or doctor of osteopathy (DO), a physician assistant, a nurse practitioner, or a clinical nurse specialist with training or expertise in emergency care must always be onsite or on-call and available onsite within 30 minutes, or within 60 minutes if certain frontier or remote area criteria are met. 

As such, REHs have constraints that may skew data or have external factors that contribute to extended wait times or boarding outside of the REH’s control. For example, as previously mentioned, rural hospitals often experience difficulty finding destination hospitals to accept patients with needs that extend beyond the capabilities of their rural hospital. Thus, the receiving facility should be evaluated for the time from patient admission to patient transfer, rather than the facility that lacks the capabilities necessary to treat the patient. 

[1] Hsuan C, Segel JE, Hsia RY, Wang Y, Rogowski J. Association of emergency department crowding with inpatient outcomes. Health Serv Res. 2023 Aug;58(4):828-843. doi: 10.1111/1475-6773.14076. Epub 2022 Oct 12. PMID: 36156243; PMCID: PMC10315392.

[2] do Nascimento Rocha HM, da Costa Farre AGM, de Santana Filho VJ. Adverse Events in Emergency Department Boarding: A Systematic Review. J Nurs Scholarsh. 2021 Jul;53(4):458-467. doi: 10.1111/jnu.12653. Epub 2021 Mar 31. PMID: 33792131.

[3] Mohr NM, Wessman BT, Bassin B, Elie-Turenne MC, Ellender T, Emlet LL, Ginsberg Z, Gunnerson K, Jones KM, Kram B, Marcolini E, Rudy S. Boarding of Critically Ill Patients in the Emergency Department. Crit Care Med. 2020 Aug;48(8):1180-1187. doi: 10.1097/CCM.0000000000004385. PMID: 32697489; PMCID: PMC7365671.

[4] Roussel M, Teissandier D, Yordanov Y, Balen F, Noizet M, Tazarourte K, Bloom B, Catoire P, Berard L, Cachanado M, Simon T, Laribi S, Freund Y; FHU IMPEC-IRU SFMU Collaborators; FHU IMPEC−IRU SFMU Collaborators. Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023 Dec 1;183(12):1378-1385. doi: 10.1001/jamainternmed.2023.5961. PMID: 37930696; PMCID: PMC10628833.