Wait Time Standards for Emergency Departments

Timely access to health services aims to achieve optimum health outcomes and patient experience of care. Longer wait times negatively affect the patient experience of care, perceptions of information, instructions, and the overall treatment provided by physicians and other caregivers. Multiple complicated and interrelated factors may affect patient wait times. Therefore, the standards set forth in this circular must not supersede sound clinical judgment and management of critical resources to provide high quality patient care.

The standards, which are operational goals of the IHS, can change for reasons beyond IHS control such as, but not limited to, facility resources, patient medical needs, emergency response, etc., and without notice to the patient. Therefore, when possible, patients must be informed that IHS patient wait times are not guaranteed.

1. ED Arrival Time. The earliest documented time a patient arrives to the emergency department to be seen.
2. ED Departure Time. The documented time a patient physically departs from the ED.
3. Left Without Being Seen. Percent of patients who leave the ED without being evaluated by a Physician/Advanced Practice Nurse/Physician’s Assistant (Physician/APN/PA).

1. Median Time from ED Arrival Time to ED Departure Time for discharged ED patients of 120 minutes or less.
2. Left Without Being Seen of 2% or less.

All IHS hospitals with an ED will report the ED Core Measure Set at least quarterly to governance.

This IHS Circular is effective upon the date of signature.

Collection and reporting of ED access data is needed to ensure the delivery of adequate and timely access to care in EDs. Reporting of all three measures demonstrates that facility governance emphasizes quality of care and reporting to CMS and the public IHS's commitment to quality care.

Rationale of the Specific Measures: "Reducing the time patients remain in the ED 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. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. According to a 2002 national U.S. survey, more than 90 percent oflarge hospitals report EDs operating 'at' or 'over' capacity. Overcrowding and heavy emergency resource demand have led to a number of problems, including ambulance refusals, prolonged patient waiting times, increased suffering for those who wait, rushed and unpleasant treatment environments, and potentially poor patient outcomes. Approximately one third of hospitals in the U.S. report increases in ambulance diversion in a given year, whereas up to halfreport crowded conditions in the ED. In a recent national survey, 40 percent of hospital leaders viewed ED crowding as a symptom of workforce shortages. ED crowding may result in delays in the administration of medication such as antibiotics for pneumonia and has been associated with perceptions of compromised emergency care. For patients with non-ST-segment­elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised."

1. Method of Measurement: Hospitals shall report the data of OP-18 and OP-22 on a quarterly report to the Centers for Medicare & Medicaid Services (CMS). Data analytics software can be used for extraction from Resource and Patient Management System (RPMS). The component measures shall be collected utilizing instructions found in the Hospital Outpatient Quality Reporting Specifications Manual, vl 0.0a.
   1. Short-Term: Area Chief Medical Officers (CM Os) shall report to Headquarters (HQ) through a survey whether facilities are reporting data on both measures.
   2. Long-Term: Area CM Os shall report the performance of each of the IHS hospitals with EDs.
2. Strategy for Sampling or Grouping Data: Area CMOs are encouraged to review dashboard-level measures from each of these hospitals.
3. Frequency of Measuring and Reporting: Quarterly.

1. Measure Executive Sponsor: IHS National CMO
2. Measure Owner: Chief Clinical Consultant for Emergency Medicine
3. Person(s) Conducting and Collecting Measurements: Hospital-level Quality Assessment and Performance Improvement (QAPI) reports on the OP-18 and OP-22 through the Area CMO and governance. Performance data is reviewed by the Area CMO. Area CMO reports summary data (number of hospitals that have successfully reported each of these three metrics over the past quarter) to the IHS National CMO.
4. Person(s) Developing Charts and Reports: Area CMO or designee reports quarterly to the IHS National CMO through the National Accountability Dashboard for Quality collection tool.
5. Person(s) Obtaining and Entering Data in the Measure Report: IHS Area CMP or designee