As hospitals are filled with patients beyond capacity, boarding times in the ED rise. A recent study of 46 million ED visits found that more than one in four admitted patients now wait beyond the four-hour safety standard for an inpatient bed. Crowded EDs also push more patients to leave without ever being seen.
Delayed access to emergency care and variations in care quality are serious concerns for both patients and health systems alike. To address these concerns, CMS has finalized a new electronic clinical quality measure called Emergency Care Access and Timeliness (ECAT). This measure is meant to improve care for the millions of patients who seek treatment in the ED each year and address long-standing gaps in hospital care.
With voluntary reporting for ECAT beginning Jan. 1, 2027, and mandatory reporting starting Jan. 1, 2028, leading healthcare organizations are preparing now. To learn more about readying for ECAT, Becker’s Healthcare recently spoke with two experts: Arjun Venkatesh, MD, MBA, MHS, chair of the department of emergency medicine at Yale School of Medicine and chief of emergency medicine at Yale New Haven (Conn.) Hospital and Eric Beck, DO, MPH, chief executive of ESO.
Emergency care quality is moving out of the shadows
The ECAT measure captures the proportion of ED visits in which patients experienced any of four gaps in access: waiting longer than 60 minutes after arrival to be placed in a treatment room or dedicated treatment area for evaluation and initial workup; leaving the ED without being evaluated; boarding in the ED for more than four hours after the decision to admit; or an ED length of stay exceeding eight hours.
CMS already publishes hospital quality measures on its Care Compare website. ECAT is expected to be added to those metrics and feed into Star ratings and other consumer-facing quality information.
ECAT is designed to make emergency and hospital care access and timeliness — two of the biggest patient safety issues in hospital care — more visible. This is critical because the more visible a problem becomes and the more it’s tied to accountability programs, the more resources healthcare organizations will allocate to fix it. “I think that’s why ECAT is really important to emergency medicine, and also to hospital care writ large across the country,” Dr. Venkatesh said.
Healthcare leaders can’t ignore ECAT. EDs have always served as the hospital front door. Dr. Beck explained that in markets where consumers have different choices, ECAT will make the quality of emergency care and accessibility highly visible. That’s important for organizational sustainability, since ED market share and ED admissions drive meaningful economics for acute care hospitals, as well as reputation.
ECAT performance: A hospital-wide operational issue
According to Dr. Venkatesh, the ED is the canary in the coal mine for hospitals. When patients wait in ED hallways for inpatient beds, that’s a symptom of broader problems. At a high level, ED boarding results from an imbalance between the supply of acute care resources and patient demand. The underlying issues that cause this imbalance, however, don’t originate in the ED.
The root causes of poor ECAT performance often sit downstream of an ED. For example, some hospitals struggle to discharge inpatients promptly because nursing homes and other post-acute facilities are full. Other problems may originate upstream, when patients head to the ED for low-acuity needs. Addressing both is key to improving emergency care quality.
“Decisions made upstream and downstream of the ED are opportunities to intervene around challenges that have previously been well understood historically. That’s what’s really exciting about ECAT — it’s daylighting opportunities to better understand the drivers of emergency care quality and throughput,” Dr. Beck said.
Benefits of voluntary ECAT reporting outweigh the costs
Given the complexity of the data — and of adopting a new digital measure at all — both physicians believe hospitals stand to gain a great deal from voluntary ECAT reporting.
Because ECAT is among the first CMS measures specified entirely from EHR timestamps and standardized national value sets, the agency is issuing extensive guidance to help organizations. The voluntary period gives teams time to work out the kinks and settle local definitions.
“The train has left the station — ECAT is happening,” Dr. Venkatesh said. “The real choice is whether organizations will voluntarily report in 2027 or wait until 2028, when it’s mandatory. My opinion is there’s no cost — reputational, financial or otherwise —and much to gain with voluntary reporting in 2027.”
Diagnosing local needs and challenges is step one
Every hospital, ED and prehospital market is unique. As healthcare leaders examine the four access failures embedded in the ECAT measure, they must make a local diagnosis of their specific problems and challenges.
Until teams engage in that work, it’s difficult to prioritize the greatest ECAT improvement opportunities and allocate limited resources. ECAT’s definitions also have to be mapped to each ED’s own processes.
Every function in the hospital that influences patient throughput and patient experience needs a seat at the table. Success requires collaboration across the ED, radiology, lab, bed assignment teams, the transfer center, case managers and discharge planners.
Examining market-specific data also supports more holistic thinking about how patients access care. The ED isn’t the best care setting for all needs, yet in many hospitals it serves as the access point for a wide range of acuities. Analyzing upstream data can help health systems match patients to the right care.
Every patient who can be better served outside the ED represents capacity returned to those who truly need emergency care, Dr. Beck said. “And you will optimize your ECAT performance.”
Keys to success: Curiosity, creativity, collaboration
Looking ahead, healthcare leaders must get curious about their data and strive to understand emergency care process drivers. Once those are in focus, leaders must get creative and invite representatives from multiple functions and departments to work through challenges and potential solutions.
Collaboration is essential, whether that’s peer information-sharing, tapping into the literature base or partnering with community stakeholders like EMS and post-acute providers.
“There’s very rarely a silver bullet or quick fix for emergency care quality and throughput,” Dr. Beck noted. “But an ounce of prevention is worth a pound of cure. If opportunities exist to address problems before they have consequences, those are investments well spent.”
Learn more about what your organization can do now to get ahead of ECAT: https://www.eso.com/see-your-data-differently/
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