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	
	
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:		February 1, 2012

RE:		Clarification to Circular Letter DHCQ 12-01-555

To Whom It May Concern: 

The Department recently announced two additional mandatory data elements to be reported by all emergency departments (EDs) in Massachusetts. These elements were developed in close consultation with the Boarding and Patient Flow Task Force, the Massachusetts Hospital Association, and several key physician leaders. The goal of the measures was to better understand challenges faced by emergency departments and other providers in managing the flow of patients needing emergency care. 

In response to the first iteration of new data elements published on January 13, 2012, the Department has received extensive feedback. Emergency department leaders appreciated that Measure ED-4 separated wait times from patient boarding. However, the measure, initially defined to begin at the time of disposition, presented significant challenges for data collection. Therefore ED-4 has been revised to be time from ED arrival to ED departure. Hospitals also noted the potential for discrepancy introduced by disparate utilization of observation-stay status. Therefore, we have included a new ‘demographic’ measure to distinguish between institutions with ED observation-stay units, or an ED observation designation, and those without. In response to this feedback, we have amended Circular Letter DHCQ 12-01-555 accordingly. The amended letter is attached and will be posted by February 4, 2012 at http://www.mass.gov/eohhs/provider/licensing/facilities/health-care-facilities/hospitals/hospital-circular-letters.html#ed

In this amended Circular Letter, ED-4 now reads:

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). 

To clarify our intended data capture of these measures, we offer the following examples: 

Example 1
Patient A arrives at emergency department with chest pain at 1300 hours. Evaluation is conducted by ED staff. The patient requires extensive imaging studies and two service-line consults. Patient A is placed into ED observation after 13 hours in the ED. S/he isdischarged 10 hours later to home. Total time in ED is 23 hours. Total time prior to placement into observation is 13 hours.

Patient A is counted in ED-4 as s/he was in the ED for more than 12 hours.

Patient A is not counted in ED-5 as s/he did not have a
primary behavioral health diagnosis

Example 2
Patient B arrives at 1300 hours with a chief complaint of suicidal ideation. After immediate medical clearance by ED staff, the Emergency Service Provider (ESP) team is contacted. Three hours after arrival, the decision is made to transfer the patient to an in-patient psychiatric unit at another hospital. While waiting for bed-placement, Patient B is placed into observation status within the ED. Patient remains in the ED for 20 additional hours (total of 23 hours in the ED).

Patient B is counted in ED-4 as s/he was in the ED for more than 12 hours.

Patient B is counted in ED-5 as s/he had a primary behavioral health diagnosis.

We appreciate your thoughtful feedback as we collectively identify a simple set of measures to best capture the incidence of boarding across the Commonwealth. 

If you have any questions about data submission, please contact Andrew Sinatra, Andrew.Sinatra@State.MA.US