REMCS Measure Topic Prioritization  

Project Status: Completed

Regionalized Emergency Medical Care Services (REMCS) Measure Topic Prioritization

Access the Final Report: REMCS: Emergency Department Crowding and Boarding, Healthcare System Preparedness and Surge Capacity 

The Opportunity

The Institute of Medicine highlighted the strain on the nation’s emergency medical care systems in 2006 and called for analysis and improvement.1,2 Some of the major issues highlighted in the report included emergency department (ED) crowding with ED boarding as a major cause for crowding, and the need to hospitals to prepare for potential surges of patients during a disaster. Since that time, the ED literature has consistently reported associations between crowding, boarding and negative patient-oriented outcomes.3,4,5,6,7 In addition, there have been several naturally occurring disasters that have resulted in surges of patients, such as Hurricane Katrina in 2005 and H1N1 in 2009, that highlight the critical role of our nation’s healthcare infrastructure in the safe delivery of medical care during a national crisis.

These events highlight the importance of measuring and improving crowding in U.S. EDs, not only to improve patient care, but also to ensure that hospitals are prepared for and can respond to surges of patients during a disaster. The possibility of mass casualty incidents or medical surges in a hospital or healthcare system was also recently reemphasized as a threat to the nation’s emergency medical systems. In January 2012, the Office of the Assistant Secretary for Preparedness and Response (ASPR) released national guidance for system preparedness which sought to provide guidance and prepare hospitals, healthcare systems and their Emergency Support Function (ESF) #8 partners (Public Health and Medical Services Annex) to prevent, respond to, and rapidly recover from these threats; such preparation is critical for protecting and securing our Nation’s healthcare system and public health infrastructure.8,9 

Along with crowding, one of the major issues in emergency care is the lack of connection between hospitals when supply outstrips demand requiring diversion of critically ill patients to other hospitals and also when critically ill patients require transfer to other facilities when time-critical illness is identified (i.e. stroke, trauma, acute myocardial infarction, post cardiac arrest).10,11 The concept of “regionalization” is the process of tying hospitals together for a combined goal of reducing system-wide crowding, promoting timely care for all patients at the population-level, and ensuring that patients with time-critical illness receive the highest quality care.12 Holding hospitals and regions accountable for acute care quality and population health through performance measurement is vital in meeting this goal.

About the Project

Building on prior work done in Phase 1 of the Regionalized Emergency Medical Care Services (REMCS) project to endorse a framework for REMCS and to assess current REMCS measures, this project seeks to provide guidance for measure development to ASPR’s prioritized areas of 1) ED crowding, including a specific focus on boarding and diversion, 2) emergency preparedness, and 3) surge capacity.

NQF’s most recent scan yielded fully specified and tested measures from federal sources related to overall emergency preparedness, but only measure concepts in the priority areas of crowding, diversion and boarding. The scan also confirmed that the measurement of regionalization is still in its infancy; however, regionalization of emergency care services has important implications to quality of care, hospital economics, and ensuring that critically ill patients receive the care they need in a timely manner. The ability to measure these concepts in the EDs at a national level is critical to understanding the baseline level of preparedness and potential capacity in the overall emergency care system. There is also general agreement that grounding these measures geographically—at the hospital, health system, community and regional level—would be a key enabler, but defining that geography remains an open question.

This work expands NQF’s previous consensus development process work in the emergency care arena (Emergency Care: Phase I and Emergency Care: II Report), which endorsed consensus standards for emergency care providers and system performance.  


Using the recently completed environmental scan on ED crowding and emergency preparedness as a baseline, NQF will convene an expert panel through an in-person meeting and several conference calls/webinars to:  

  • Review the measures and measure concepts available in the following areas: ED crowding and boarding, emergency preparedness, surge capacity, and any other areas identified by the panel;
  • Identify gaps and barriers to fully specifying and testing the measures;
  • Prioritize measure concepts in those areas defined above that could be targeted for further development and testing; and
  • Provide recommendations for how such measures could be aggregated from the individual level to higher levels (e.g., on a regional level, by geographical unit).

The purpose of this report will be to tie together the concepts of ED crowding, preparedness, and regionalization, specifically with regard to how these concepts are measured and reported at the facility and regional level. This report would also be used to shape future measure development efforts in this area, and lay the groundwork for a potential future measure endorsement project.  

NQF Related Work 


This project is funded under a contract provided by the Department of Health and Human Services. 

Contact Information 

For further information, send an email to


  1. Institute of Medicine (IOM), Hospital-Based Emergency Care: At the Breaking Point, Washington, DC: The National Academies Press; 2007.
  2. IOM, Emergency Medical Services at the Crossroads, Washington, DC: The National Academies Press; 2007.
  3. Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1-10.
  4. Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP, DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35(6):1477-1483.
  5. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: Population based cohort study from Ontario, Canada. BMJ. 2011;342:d2983.
  6. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51(1):1-5
  7. Singer AJ, Thode HC,Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-1329.
  8. HHS, Office of the Assistant Secretary Preparedness and Response (ASPR). Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness. Washington, DC:HHS; 2012. Available at Last accessed September 2012.
  9. Emergency Support Function (ESF) #8 — Health and Medical Services provides coordinated Federal assistance to supplement State and local resources in response to public health and medical care needs following a major disaster or emergency, or during a developing potential medical situation.
  10. Carr BG, Matthew Edwards J, Martinez R; 2010 Academic Emergency Medicine consensus conference, Beyond Regionalization: Integrated Networks of Care. Regionalized care for time-critical conditions: lessons learned from existing networks. Acad Emerg Med. 2010 Dec;17(12):1354-8.
  11. Carr BG, Asplin BR; 2010. Regionalization and emergency care: the institute of medicine reports and a federal government update. Academic Emergency Medicine consensus conference, Beyond Regionalization: Integrated Networks of Care. Acad Emerg Med. 2010 Dec;17(12):1351-3.
  12. IOM, Regionalizing Emergency Care: Workshop Summary, Washington, DC: The National Academies Press; 2010.

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