The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
99 Chauncy Street, 11th Floor, Boston, MA 02111
617-753-8000 

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN AUERBACH
COMMISSIONER	
Circular Letter: DHCQ 12-01-555
	
TO:		Chief Executive Officers
		Emergency Department Directors
		Acute Care Hospitals

FROM: 	Madeleine Biondolillo, MD, Bureau Director

CC: 		Iyah Romm, Special Assistant to the Director
		Anuj Goel, Massachusetts Hospital Association
		Boarding and Patient Flow Task Force		

DATE:		January 13, 2012 [UPDATED February 1, 2012]

RE:		Emergency Department Data Collection Update 

The purpose of this letter is to inform facilities of changes the Department is making to the emergency department data collection process, originally outlined in circular letter 09-01-505, dated 01/23/2009 http://www.mass.gov/eohhs/docs/dph/quality/hcq-circular-letters/hospital-ed-0901505.pdf.

Submission of the Data Elements
Since 2009, facilities have been required to submit three emergency department data elements to the Department of Public Health’s Hospital Capacity Website.  
Due to unforeseen circumstances and effective immediately, hospitals will no longer be using the Hospital Capacity Website to submit their data.  Beginning with the data collected for January 2012 (the submission deadline is hereby extended for data from January and February 2012 to February 28, 2012), facilities will instead be required to submit their emergency department data as a spreadsheet file via email to Dph-Eddata@massmail.state.ma.us.  See the attached page of Instructions for Collection and Submission of Hospital Emergency Department Data. Going forward data will be due to the Department on the 15th of each month. Department staff will routinely contact each hospital that does not submit the monthly data in a timely fashion. 

Current Data Elements

ED 1: Number of ED visits per month.

ED 2: Median time (in minutes) from ED arrival to ED departure for admitted ED patients, per month (NQF measure ED-001-08).

ED 3: Median time (in minutes) from ED arrival to ED departure for discharged ED patients, per month (NQF measure ED-002-08).

New Data Elements

At the October 25, 2011 meeting of the Department’s Boarding and Patient Flow Task Force, as part of the discussion of the extended lengths of stay in emergency departments of patients with behavioral health issues (including psychiatric and substance abuse diagnoses), the members proposed adding several data elements to those that are already collected. After further discussion subsequent to that meeting, the Department is asking hospitals to submit each month the following four additional data elements: 

For purposes of these elements, “behavioral health diagnosis” is defined 
as having an ICD-9 code of 290.0-319.

ED 4: Total number of all patients remaining in the emergency department for 12 or more hours from ED arrival to ED departure including ED observation-stay (where “departure” is defined as admission, transfer, or discharge). 

ED 5: Total number of patients identified in ED 4 with a behavioral health diagnosis.

ED 6 (optional): Payer-mix of all patients identified in ED 5 (% each: Medicare, Medicaid, Commercial, and Uninsured)

      ED 7 (optional): Describe key factors contributing to long-term patient boarding as identified in ED 5 (narrative response). 
	
In addition to these new elements, hospitals will be asked to respond to the following ‘demographic’ questions for the first response only: 

(New initial response only): Does your hospital utilize an ED observation-stay unit or ED observation designation for mental health patients (yes/no), substance abuse patients (yes/no), or any other patients (yes no)?
 
In July 2012, the Department will reassess the necessity of ongoing collection of data for measures ED 4-7. 

If you have any questions about data submission, please email Andrew Sinatra at Andrew.Sinatra@state.ma.us. 

Instructions for Collection and Submission of Hospital Emergency Department Data

Starting January 15th 2012, hospitals will no longer be using the Hospital Diversion Website to submit their emergency department data. Instead, hospitals will be required to submit their emergency department data to the Department via email as an electronic spreadsheet file. The data must be filled out using a spreadsheet template provided by the Department. 

The spreadsheet template is available in both Microsoft Excel and CSV file formats, and will be posted on the Department’s website at the following address by February 4, 2012:  
http://www.mass.gov/eohhs/provider/licensing/facilities/health-care-facilities/hospitals/hospital-circular-letters.html#ed. 

In addition to the new measures described below, a brief series of additional ‘demographic’ questions will be included for your first response only. 

(New initial response only): Does your hospital utilize an ED observation-stay unit or ED observation designation for mental health patients (yes/no), substance abuse patients (yes/no), or any other patients (yes no)?

Below are the three original data measures plus two new mandatory, and two new optional measures for collection:

ED 1: Number of ED visits per month.

ED 2: Median time (in minutes) from ED arrival to ED departure for admitted ED patients, per month (NQF measure ED-001-08).

ED 3: Median time (in minutes) from ED arrival to ED departure for discharged ED patients, per month (NQF measure ED-002-08).

ED 4: Total number of all patients remaining in the emergency department for 12 or more hours from ED arrival to ED departure including ED observation-stay (where “departure” is defined as admission, transfer, or discharge). 

(New) ED 5: Total number of patients identified in ED 4 (above) with a behavioral health diagnosis.

(New) ED 6 (optional): Payer-mix of all patients identified in ED 5 (% each: Medicare, Medicaid, Commercial, and Uninsured)

      (New) ED 7 (optional): Describe key factors contributing to long-term patient boarding as identified in ED 5. 

The left side of the spreadsheet is broken up into seven sections, each representing one of the required or optional data measures. Under each section, a submitter is required to fill in the name of the hospital for which he/she is reporting. Submitters are allowed to fill in more than one hospital on a single spreadsheet if they need to report data for more than one hospital. 

The columns to the right of this section should be labeled with the month/year of the corresponding value. Each submission should contain one month of data; however, hospitals may also use the spreadsheet to submit multiple months of data, in the event they have to submit missing past data points. A blank spreadsheet template and an example of a properly filled out spreadsheet will be available on the program’s website after 2/4/12. Once the spreadsheet is completed, the file should be sent as an attachment via email to the following email address: Dph-Eddata@massmail.state.ma.us