Implementing ACEP’s Geriatric Emergency Department Accreditation (GEDA) Supports ECAT and AFHM Compliance

Boarding, Older Adults, and System-Level Action

If you work in an emergency department (ED), you are most likely familiar with boarding — the practice of holding admitted patients in the ED while they wait for an inpatient bed. Over the last decade, ED boarding, prolonged wait times, and access bottlenecks have gotten worse, with real clinical, financial, and operational consequences.

In response, the Centers for Medicare & Medicaid Services (CMS) have introduced two clinical quality measures designed to address the systemic gaps we see every day as clinicians:

1.  The Age-Friendly Hospital Measure (AFHM) – Composed of five domains, this measure asks hospitals to confirm whether they have protocols in place to reduce boarding for older patients (see Domain 3, Statement 4). The purpose of the AFHM is to hold health systems accountable for building the structures and processes older adults need to receive safe, goal-concordant care.
2. The Emergency Care Access & Timeliness (ECAT) Measure — ECAT assesses ED crowding and boarding as a patient-safety issue, based on access failure criteria. Unlike the AFHM, it applies to all patients, not just those 65 and above. Its goal is to reduce patient harms and improve outcomes by measuring and addressing variations in ED care access, as well as time to admission or discharge.

Another key difference is that the AFHM is an attestation measure only. ECAT, on the other hand, will become a mandatory reporting measure by 2028, with payment consequences in 2030.

For hospitals seeking to satisfy ECAT reporting requirements and meet the AFHM, there’s good news: The American College of Emergency Physicians’ (ACEP) Geriatric Emergency Department Accreditation (GEDA) program is an efficient, established, and evidence-based vehicle for achieving both.

Two CMS Measures Addressing ED Boarding

ECAT

ECAT (CMS1244 for OQR; CMS1264 for Rural Emergency Hospitals) is an episode-based, proportion-scored intermediate-outcome measure in which a lower score indicates better performance. The denominator is all ED visits ending in the measurement period, with no exclusions, and the numerator counts visits with any one of four access gaps (CMS, 2025):

• Component 1 — The patient waited longer than 60 minutes after ED arrival to be placed in a treatment room or dedicated treatment area with audiovisual privacy
• Component 2 — The patient left the ED without being evaluated (replaces the traditional “left without being seen” metric)
• Component 3 — The patient was boarded (held after an admission decision) for longer than 4 hours (240 minutes)
• Component 4 — The patient had an ED length of stay (ED arrival to ED departure) longer than 8 hours (480 minutes)

Results are stratified by age group (adult or pediatric) and mental-health diagnosis status, with payer, race, ethnicity, and sex as supplemental data elements (CMS, 2025).

AFHM: Domain 3, Statement 4

The AFHM is a structural, attestation-based measure reported under the Hospital IQR Program. It assesses a hospital’s commitment to improving care for patients aged 65 and older. Domain 3, Statement 4 specifically asks whether the hospital has a protocol in place for ED throughput that mitigates the risk of delirium posed by ED environmental factors. In practice, this would translate to a process for transferring a targeted percentage of older adults out of the ED within 3 hours of the admission decision, or within 8 hours of arrival.

Older Adults May Be at Risk

While both measures seek to improve patient outcomes and address system-wide structural issues, there is still a risk that older adults will fall through the cracks. First, ECAT does not stratify by older age. An institution can therefore perform acceptably overall while older adults experience disproportionate boarding. And for the AFHM, a key implementation risk is that hospitals interpret the measure narrowly or attest without reliable, encounter-level processes. The measure does not specify adherence thresholds, or which subpopulations must be reached (Adler-Milstein et al., 2025).

Why The System Should Care About Older ED Patients

Older adults are more likely than younger patients to be admitted, and experience prolonged ED stays. For this population, time in the ED is a clinical exposure that increases the risk of incident delirium (Bo et al., 2016, Elder et al., 2023), adverse drug events (Skains et al., 2024), and mortality (Roussel et al., 2023). All this considered, older adults in the ED, when not treated with geriatric-specific care processes, are at risk of prolonged length of stay and poorer patient outcomes. This leads to continuing the system-level throughput issues that lead to ED boarding, thus propagating the cycle.

GEDA – A Clear Path to Safely Reducing Boarding

GEDA supplies three things that quality measures alone do not: (1) an interprofessional, evidence-trained team with named physician and nurse leadership and an executive sponsor; (2) standardized, evidence-based care processes whose eligibility and adherence are explicitly defined; and (3) a metric-based quality improvement (QI) structure, including required geriatric boarding metrics that share ECAT’s 4-hour threshold while meeting AFHM Domain 3, Statment 4. Peer-reviewed evidence associates geriatric ED care with lower admission rates, lower 30-day mortality, shorter ED length of stay, and lower Medicare expenditures (Gettel et al., 2023; Hwang et al., 2018, 2021; Qian et al., 2026).

GEDA asks hospitals applying for accreditation to select from a list of care processes that address key areas of focus in geriatric ED care. For these processes, the site must specify the responsible staff, workflow location, follow-up actions, staff education, and adherence monitoring. Importantly,  GEDA requires that sites define the eligible population (denominator) and track adherence (numerator) for each care process. It also requires age-related metrics that compare the proportion of older adults boarding with younger adults (ACEP, 2023a). This addresses the gap in the AFHM and ensures that boarding is being stratified by older adults for a more comprehensive ECAT report.

GEDA’s Care Process List Aligns With CMS Measures

Since the 2023 revision of the GEDA Guidelines, two care processes have addressed boarding directly:

1. F.1 — Minimize ED boarding for older adults or a high-risk subgroup such as patients with delirium
2. F.2 — Optimize care of older adults boarding for extended periods

Adler-Milstein et al. (2025) identify GEDA as the program that specifies how to minimize mentation risk by reducing ED boarding time — precisely the content of AFHM Statement 3D and ECAT criteria ③ and ④.

GEDA Care Processes Addressing Geriatric ED Length of Stay

Beyond F.1 and F.2, a number of other care processes can address drivers of prolonged length of stay — a key factor that fuels the boarding cycle. Table 1 shows how some of these care processes directly or indirectly target the issue.

ACEP’s GEDA program provides a vehicle for successfully reducing boarding while providing the structural framework for successful ECAT reporting and AFHM attestation. A hospital pursuing GEDA accreditation is, in effect, building the very infrastructure — dashboards, quality-improvement tracking, transitional-care staffing, standardized order sets, and discharge/placement pathways — that substantiates its AFHM attestation and reduces its ECAT Component 4 rate for older adults in the ED.

There is one caveat: ECAT Component 4 counts all ED visits, so GEDA’s geriatric-focused interventions can only move the portion attributable to older-adult encounters. A hospital’s overall rates will still be heavily influenced by non-geriatric boarding and throughput, which GEDA criteria do not directly address