Originally published by Becker’s Healthcare.
Hospital and health system leaders have more emergency department data in front of them than ever.
However, without adjusting for patient acuity and comparing against a cohort of similar departments, much of that data can be more misleading than useful, according to two emergency department physicians with decades of combined experience studying ED performance data.
James Augustine, MD, vice president of the Emergency Department Benchmarking Alliance, and Matt Ledges, MD, vice president of clinical analytics at TeamHealth, spoke with Becker’s separately about the current state of ED performance measurement and shared the metrics, peer comparisons and tactical steps hospital leaders should prioritize to get a more accurate read on how their EDs are actually performing.
A fragmented data landscape
Hospital leaders trying to understand where their EDs stand against peers must often navigate a highly fragmented and opaque data landscape. Federal data is lacking, and many hospitals consider their ED operational data private.
When it comes to comparing ED metrics against peers, hospitals in large systems have an advantage: access to multiple EDs within a system can give leaders a clearer point of comparison for where their own department stands. This is more difficult for smaller and independent EDs, Dr. Augustine noted.
For three decades, the CDC’s National Center for Health Statistics published a federal report on emergency department utilization, patient demographics and care patterns across the U.S. This effort tracked the long-term climb in patient age, the rising acuity of ED visits, and shifts in the racial and ethnic mix of patients since the early 1990s. However, the report effectively ended with its final data year in 2022 amid agency cuts and restructurings, according to Dr. Augustine. What remains at the federal level is limited and often lacks the context needed for meaningful comparisons, particularly because it does not account for patient acuity.
Amid this backdrop, voluntary registries such as the EDBA have become a key source for ED data. The group formed in 1994 to give EDs a way to measure their operational performance against peers of similar size and patient mix.
The reporting structure is built on the understanding that a 15,000-visit rural ED and a 90,000-visit urban level 1 trauma center are fundamentally different, and their metrics should not be compared one to one. The EDBA publishes an annual report on ED metrics, which is shared with participating members. In 2024, the report included data from 1,934 EDs representing 41 million visits.
ED performance measurement traps
Even when data is available, many hospital leaders fall into common traps that can distort how they interpret ED performance.
The first trap rests on the word “benchmarking” itself, which Dr. Augustine said can now hold a negative connotation.
“When we founded the EDBA in 1994, benchmarking was a good thing. It has subsequently not been a good thing,” he said, arguing that the term is now sometimes used to promote targets that may not reflect comparable peers or real-world operating conditions.
His advice for leaders: Stop asking what the benchmark is, and start asking who the right comparators are. “The sophisticated systems no longer say, ‘What’s a benchmark for this?’” he said. “A good administrator says, ‘We want to be in the top 10% in boarding times, in EMS arrivals, in our cohort of emergency departments.’”
Dr. Ledges echoed this sentiment, noting that one of the most common mistakes he sees is leaders comparing their ED to others based on volume alone.
While many benchmarking efforts group departments by annual visit counts, that approach can be misleading. ED performance metrics do not change in a simple, linear way as volume increases. Instead, operations shift at key inflection points — such as when departments move from single-provider to multi-provider coverage — which can affect throughput metrics independently of visit counts.
“It’s not a linear association with a lot of throughput metrics,” Dr. Ledges said.
Volume also does not account for patient acuity, which he emphasized is a critical driver of ED performance. Departments with higher admission and transfer rates will naturally see differences in metrics such as length of stay.
Without accounting for both volume and acuity, comparisons can quickly become “apples to oranges,” he said.
Dr. Ledges’ advice: Treat performance data like a clinical problem. “Diagnosis before treatment,” he said. “If you don’t have the data and the comparator data sets, you can’t really diagnose the problem.”
What leaders should measure — and what to do next
Both physicians emphasized that improving ED performance starts with using the right metrics and interpreting them in the right context.
Dr. Ledges said benchmarking is most precise when volume and acuity are evaluated on a spectrum rather than grouped into broad categories.
For acuity, he favors a facility’s combined admission-and-transfer rate, as the measure better reflects how sick patients are.
“Transfers are admits — it’s just being admitted somewhere else,” he said, noting that at lower-volume EDs, transfer rates of 5% to 10% are common. Excluding those patients can distort comparisons and understate how complex a department’s case mix really is.
When it comes to day-to-day performance, Dr. Ledges pointed to three metrics hospital leaders should prioritize:
- Left-without-being-seen: “Patients are voting with their feet,” he said, calling it the best overall indicator of ED efficiency and one that is difficult to manipulate. By contrast, metrics such as door-to-provider time can be artificially improved.
- Discharge length of stay: Treat-and-release patients account for roughly 78% to 80% of ED volume and represent the portion of care the department can most directly influence. Improvements in front-end metrics mean little if overall length of stay and LWBS rates do not improve alongside them.
- Boarding time: Longer boarding times are associated with higher patient risk, including increased morbidity and mortality, Dr. Ledges said.
For hospital leaders looking to take action, Dr. Augustine recommended starting with the fundamentals: Audit internal data collection processes against standardized definitions, such as those published by the Emergency Department Benchmarking Alliance. Inconsistent definitions remain one of the biggest barriers to meaningful comparisons across EDs, he said.
From there, leaders should focus on a small set of high-impact metrics, such as boarding times and diagnostic test utilization, and evaluate them against comparable departments.
Both physicians also pointed to the value of participating in collaborative data efforts such as the EDBA.
With shifting payer mix, rural hospital closures and rising patient acuity expected to reshape ED demand, both said the need for accurate, well-contextualized data is only growing.
“The knee-jerk reaction to build more beds doesn’t always pan out if you really understand the data,” Dr. Ledges said. “If you can better manage your length of stay, you may be able to account for a 10% or 15% or more rise in volume.”
