AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training
Facilitator Training Slide Presentation
Slide 1: Introduction to Preventable Hospital and ED Visits Reports
AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits Training
Introduction to Preventable Hospital and ED Visits Reports
Slide 2: Preventable Hospital and ED Visits Electronic Reports
- Electronic Reports:
- Transfer Risk Report—High Risk.
- Transfer Risk Report—Medium Risk.
- ED Treat and Release Report.
- Monthly Transfers by Facility or Nursing Unit.
- Monthly Transfers by Provider.
- Key Metrics Trend Report.
Slide 3: Teaching the Preventable Hospital and ED Visits Electronic Reports
- The teaching sessions for each report should include the following content:
- Purpose of the report.
- Content of the report.
- Calculation details.
- Quizzes and exercises.
Slide 4: Transfer And Intake Notes
Transfer And Intake Notes
Slide 5: Transfer and Intake Notes
- Provide documentation of a patient’s transfer from and readmission to the nursing home.
Slide 6: Transfer Note
- A transfer note provides a high-level summary of the reasons for transfer and what treatments (if any) were provided before transfer.
- A standard set of data elements must be documented in the electronic medical record (EMR); however, use of transfer or intake notes is not required.
Slide 7: Transfer Note
- Displays the following:
- Transfer date and time.
- Transfer to location (hospital or ED).
- Reason for transfer (grouped according to symptom or condition, or treatment not available at transferring facility).
- Treatments provided in the nursing home before transfer.
- Providers who saw the resident within 24 hours of transfer.
- Person authorizing the transfer to hospital or ED.
Slide 8: Intake Note
- Provides a standard set of information about the hospital or ED visit upon return to the nursing home that may be used by nursing home staff for reporting, monitoring, and care management purposes.
- Serves as a mechanism to capture important details about the resident’s care across settings.
Slide 9: Intake Note
- Completed for each resident upon admission or readmission to the nursing home.
- Displays the following:
- Admit date and time.
- Admit to unit (e.g., long-term care, subacute, or rehab).
- Intake type (e.g., ED visit, observation stay, or hospital admission).
- Hospital length of stay or hospital admission date.
- Treatment received in the ED (if applicable).
- Discharge diagnoses from hospital (primary & secondary).
- Surgical procedures received (if applicable).
Slide 10: Check Your Understanding: Transfer and Intake Notes Quiz
Slide 11: Transfer Risk Reports: High Risk and Medium Risk
- Provides a weekly snapshot of residents at risk for transfer to a hospital or ED.
- Designed to help nursing staff see the changes in resident clinical status earlier and identify residents at risk for transfer.
- Displays transfer risk factors by resident each week.
Slide 12: Transfer Risk Reports: High Risk and Medium Risk
- Displays the following:
- ED visits.
- Hospital admissions.
- High-risk diagnoses.
- Current clinical conditions contributing to transfer risk.
- Polypharmacy.
- High-risk change in condition within 7 days.
Slide 13: Rules for High and Medium Transfer Risk
Risk Factors | Risk Level | |||||||
---|---|---|---|---|---|---|---|---|
Row No. | Prior ED Visit or Hospital Admission | Active High-Risk Diagnoses | Clinical Conditions Contributing to Risk | Poly-pharmacy | High-Risk Change in Condition Within 7 Days | High | Medium | |
1 | X | X | X | |||||
2 | X | X | X | |||||
3 | X | X | X | |||||
4 | X | X | X | |||||
5 | At least 4 in these 2 categories | X | X | |||||
6 | X | X | X | |||||
7 | X | X | X | |||||
8 | X | X | ||||||
9 | X | X | ||||||
10 | X | X | ||||||
11 | X | X | ||||||
12 | X |
Slide 14: Rules for Determining High Risk
- A resident is considered at “high risk” for a hospital or ED visit based on one of three rules:
- Rule 1: High risk based on prior ED or hospital visit AND at least one high-risk factor, including:
- Active high-risk diagnosis.
- Current clinical conditions contributing to risk.
- Polypharmacy (15 or more medications).
- High-risk change in condition within 7 days.
Example: A resident with an ED visit within 90 days of report date and a high-risk diagnosis of COPD within 7 days would trigger Rule 1.
Slide 15: Rules for Determining High Risk
- Rule 2: High risk based on polypharmacy AND at least 4 risk factors from existing high-risk diagnoses or clinical conditions contributing to risk combined.
- Examples:
- A resident with a medication profile showing16 active medications during the report week, active high-risk diagnoses of pneumonia and renal failure, and presence of oxygen therapy and Foley catheter use during the report week.
- A resident with a medication profile showing 15 active medications during the report week, active high-risk diagnosis of UTI, stage III pressure ulcer, and two medical conditions: cellulitis and hypertension.
- Examples:
Slide 16: Rules for Determining High Risk
- Rule 3: High risk based on high-risk change in condition within last 7 days and at least one high-risk diagnosis or polypharmacy.
- Examples:
- A resident with new cough within 7 days of report date and active high-risk diagnosis of CHF.
- A resident with new or worsened urinary incontinence within 7 days of report date and two active high-risk diagnoses: renal failure and diabetes.
- Examples:
Slide 17: Rules for Determining Medium Risk
- A resident is considered at “medium risk” for an ED or hospital visit if one of the following is true:
- Prior hospital or ED visit within 90 days of report date.
- At least one current clinical condition contributing to risk.
- Polypharmacy.
- At least one high-risk change in condition within 7 days.
Slide 18: Sample Transfer Risk Report
Resident Name and Advance Directive Status | # ED Visits Within: | ED Discharge Diagnosis | # Hospital Admits Within: | Hospital Discharge Diagnosis | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Age | DNR,DNH, MOLST, or POLST Order in Place | 0-7 Days | 8-30 Days | 31-90 Days | For Most Recent ED Visit | 0-7 Days | 8-30 Days | 31-90 Days | For Most Recent Hospital Stay | LOS for Most Recent Hospitalization | |
Resident A | 79 | 2 | Fever - unknown origin | 1 | Myocardial infarction | 5 | |||||
Resident B | 81 | 1 | 1 | Urinary tract infection | 1 | Cellulitis | 10 | ||||
Resident C | 82 | 1 | Anemia | 1 | 1 | COPD | 4 | ||||
Resident D | 80 | 1 | Gastroenteritis | 1 | GI bleed | 3 | |||||
Resident E | 76 | 1 | 1 | Altered mental status | 2 | ||||||
Resident F | 84 | 1 | |||||||||
Total Residents | 2 | 0 | 2 | 2 | 1 | 2 | 4 |
Table (continued)
Resident Name and Advance Directive Status | High-Risk Diagnoses Associated With Transfer Risk | ||||||||
---|---|---|---|---|---|---|---|---|---|
Age | DNR,DNH, MOLST, or POLST Order in Place | Congestive Heart Failure | Myocardial Infarction | Angina | Pneumonia or Bronchitis | Asthma or COPD | Urinary Tract Infection | Sepsis or Fever or Infection | |
Resident A | 79 | X | |||||||
Resident B | 81 | 1 | X | X | X | ||||
Resident C | 82 | X | X | ||||||
Resident D | 80 | X | |||||||
Resident E | 76 | ||||||||
Resident F | 84 | 1 | |||||||
Total Residents | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
Table (continued)
Resident Name and Advance Directive Status | High-Risk Diagnoses Associated With Transfer Risk | |||||||
---|---|---|---|---|---|---|---|---|
Age | DNR,DNH, MOLST, or POLST Order in Place | Dehydration | Circulatory Problems* | Renal Failure | Diabetes or Hypoglycemia | Anemia | Gastroenteritis | |
Resident A | 79 | X | X | |||||
Resident B | 81 | 1 | X | X | ||||
Resident C | 82 | X | X | |||||
Resident D | 80 | X | X | X | ||||
Resident E | 76 | X | ||||||
Resident F | 84 | 1 | X | X | ||||
Total Residents | 2 | 4 | 1 | 2 | 2 | 2 | 1 |
Table (continued)
Resident Name and Advance Directive Status | Current Clinical Conditions Contributing to Transfer Risk | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
Age | DNR,DNH, MOLST, or POLST Order in Place | Oxygen Therapy | Catheter or Ostomy Present | Stage II or > Pressure Ulcer | Fall Risk | Late-Loss ADL Score ≥12 | Cognitive Impairment | Medical Conditions** | High-Risk Medications*** | |
Resident A | 79 | X | 1 | X | ||||||
Resident B | 81 | 1 | X | X | X | 2 | X | |||
Resident C | 82 | X | X | 1 | X | |||||
Resident D | 80 | X | X | 2 | X | |||||
Resident E | 76 | X | 1 | |||||||
Resident F | 84 | 1 | X | X | X | |||||
Total Residents | 2 | 1 | 2 | 1 | 4 | 3 | 1 | 5 | 4 |
Table (continued)
Resident Name and Advance Directive Status | Polypharmacy | High-Risk Change in Condition (Based on Assessment Data Within 7 days of Report Date) | |||||||
---|---|---|---|---|---|---|---|---|---|
Age | DNR,DNH, MOLST, or POLST Order in Place | Medication Total ≥15 | CHF or Chest Pain or MI | Pneumonia or Bronchitis | Mental Status Change or Neurological Symptoms | Urinary Tract Infection | Sepsis or Fever or Infection | Dehydration | |
Resident A | 79 | 1 | 1 | 1 | |||||
Resident B | 81 | 1 | X | 1 | 1 | 1 | |||
Resident C | 82 | X | 2 | 2 | 1 | ||||
Resident D | 80 | 1 | 1 | ||||||
Resident E | 76 | X | 2 | ||||||
Resident F | 84 | 1 | X | 1 | |||||
Total Residents | 2 | 4 | 2 | 2 | 2 | 1 | 3 | 3 |
* Circulatory problems include vascular disease, and venous and arterial ulcer.
** Certain medical conditions include cellulitis, hypertension, deep vein thrombosis, moderate dementia, peripheral neuropathies, quadriplegia, paraplegia, and hemiparesis.
*** High-risk medications include insulin, anticoagulants, antibiotics, alpha blockers, antipsychotics, antianxiety medications, sedative-hypnotics, anticonvulsants, antihypertensives, opioids, and diuretics.
Slide 19: Reviewing Calculation Details for the Transfer Risk Report
- Advanced directive status.
- ED visits within last 90 days.
- ED discharge diagnosis.
- Hospital visits within last 90 days.
- Hospital discharge diagnosis.
- Length of stay for most recent hospitalization.
- Active high-risk diagnoses.
- Clinical conditions that contribute to high risk.
- Polypharmacy.
- High-risk changes in condition (HRCC).
Slide 20: Documentation Elements and High-Risk Change in Condition
- Each HRCC category may be linked to clinical symptoms.
- Each HRCC receives a score based on the number of symptoms noted.
- Points are totaled for each HRCC and displayed in the Transfer Risk Report.
- More total symptoms noted suggests higher risk.
Slide 21: Documentation Elements and High-Risk Change in Condition
Documentation Element | CHF/Chest Pain/MI | Pneumonia/ Bronchitis | Mental Status Change | UTI | Sepsis/ Fever/ Infection | Dehydration |
---|---|---|---|---|---|---|
Cardiopulmonary | ||||||
Shortness of breath (SOB): Unrelieved or new SOB at rest; unable to lie flat | 1 | |||||
SOB: Labored breathing | 1 | |||||
Wheezing and chest tightness at rest | 1 | |||||
Inability to sleep without sitting up | 1 | |||||
Chest pain: New or unrelieved | 1 | |||||
Chest pain: With inspiration or coughing | 1 | |||||
Cough: New or worsening cough | 1 | 1 | ||||
Sputum production: New or increased | 1 | |||||
Dizzy/lightheaded upon standing | 1 | |||||
Edema: Worsening edema lower extremities or worsening edema generalized | 1 | |||||
Fatigue: Easily fatigued/weakness | 1 | |||||
Difficulty swallowing | 1 | |||||
Gastrointestinal | ||||||
Diarrhea (recurrent for last 24 hours) | 1 | |||||
Nausea or vomiting (recurrent for last 24 hours) | 1 | 1 | ||||
Genitourinary | ||||||
Abdominal pain: Lower | 1 | |||||
Hematuria | 1 | |||||
Incontinence: New or worsened | 1 | |||||
Urination: Painful or burning or increased urgency/frequency | 1 | |||||
Infection | ||||||
IV fluids given | 1 | 1 | ||||
Blood cultures obtained | 1 | |||||
Mental or Behavior | ||||||
Agitation: New or worsened | 1 | |||||
Anxiety: New or worsened | 1 | 1 | ||||
Confusion or disorientation: New or worsened | 1 | |||||
Depressive symptoms: New or worsened | 1 | 1 | ||||
Inattention or lack of focus or withdrawn or distracted or not attending activities | 1 | |||||
Nutrition | ||||||
Appetite: Poor or loss of appetite | 1 | 1 | 1 | 1 | 1 | |
Decreased oral intake over the last 24 hours | 1 | 1 | 1 | 1 | ||
Diuretic use | 1 | |||||
Vital Signs | ||||||
Orthostatic hypotension | 1 | |||||
Weight loss 5% ≤30 days; 10% ≤180 days | 1 | |||||
Weight gain of >5 lb in 3 days | 1 | |||||
Fever: Temp >102°F | 1 | 1 | 1 | 1 | 1 | |
Fever: Temp >100°F | 1 | 1 | 1 | |||
Fever: Two or more temps >99°F | 1 | |||||
Fever: Increase in temp >2 degrees above baseline | 1 | 1 |
Slide 22: Check Your Understanding: Transfer Risk Reports Quiz
Slide 23: ED Treat and Release Report
- Allows clinicians to identify and analyze underlying patterns and trends in the reasons for residents’ ED transfers, as well as potential root causes.
- Provides insights to improve care coordination and management of these residents.
- Reduces the need to manually compile data.
- Enhances quality improvement monitoring and root cause analysis efforts.
Slide 24: ED Treat and Release Report
- Displays a list of all residents with an ED visit within 30 days of the report date.
- Displays residents with multiple transfers multiple times.
- Can be generated to display information at the unit or facility level.
Slide 25: Sample ED Treat and Release Report
Average Daily Census | 30 | Total Transfers (Obs, ED) | 11 |
Resident Days (including bed holds) | 300 | Total Residents (Obs, ED) | 10 |
ED Visit | ||
---|---|---|
Resident | ED Visit Date | ED Discharge Diagnosis |
Resident A | 11/11/2013 | Angina |
Resident B | 11/20/2013 | UTI |
Resident C | 11/15/2013 | Anemia |
Resident D | 11/13/2013 | COPD |
Resident G | 11/2/2013 | Gastroenteritis |
Resident G | 11/11/2013 | Fracture |
Resident J | 11/20/2013 | G tube replacement |
Resident P | 11/10/2013 | Dehydration |
Resident R | 11/1/2013 | Pneumonia |
Resident T | 11/30/2013 | Asthma |
Resident Y | 11/30/2013 | Laceration |
Total reasons | 21 | |
% Total reasons |
Table (continued)
Reason for Transfer | |||||||
---|---|---|---|---|---|---|---|
Resident | Cardiac/ Circulatory Symptoms |
Respiratory Symptoms |
Mental/ Psychiatric/ Neurological Symptoms |
Gastrointestinal/ Genitourinary Symptoms |
Endocrine/ Metabolic/ Nutrition Issues |
Wound or Skin Issues |
|
Resident A | X | ||||||
Resident B | X | ||||||
Resident C | |||||||
Resident D | X | ||||||
Resident G | X | X | |||||
Resident G | |||||||
Resident J | X | ||||||
Resident P | X | X | |||||
Resident R | X | ||||||
Resident T | X | ||||||
Resident Y | |||||||
Total reasons | 1 | 3 | 1 | 3 | 2 | 0 | |
% Total reasons | 5 | 14 | 5 | 14 | 10 | 0 |
Table (continued)
Reason for Transfer | |||||||
---|---|---|---|---|---|---|---|
Resident | Injury: Fall Related | Injury: Not Fall Related | Musculoskeletal Symptoms | Abnormal Labs or Anemia | Fever/Possible Infection | Malaise/Fatigue | Possible Surgical Complication |
Resident A | |||||||
Resident B | |||||||
Resident C | X | X | |||||
Resident D | X | ||||||
Resident G | X | ||||||
Resident G | X | ||||||
Resident J | |||||||
Resident P | X | X | |||||
Resident R | X | X | |||||
Resident T | X | ||||||
Resident Y | X | ||||||
Total reasons | 1 | 1 | 0 | 4 | 3 | 2 | 0 |
% Total reasons | 5 | 5 | 0 | 19 | 14 | 10 | 0 |
Table (continued)
Reason for Transfer: Treatment Unavailable at Facility | Authorized by: | ||||||||
---|---|---|---|---|---|---|---|---|---|
Resident | Diagnostics: Radiology, Imaging | IV Access: PICC, Central, Periph; Meds or Fluids | Transfusion | Catheter Insertion/ Reinsertion |
Primary Care Physician | Covering Provider | Medical Director | Medicare Managed Care Organization | Outside Clinic or Service |
Resident A | X | ||||||||
Resident B | X | ||||||||
Resident C | X | X | |||||||
Resident D | X | ||||||||
Resident G | X | ||||||||
Resident G | X | ||||||||
Resident J | X | X | |||||||
Resident P | X | ||||||||
Resident R | X | X | |||||||
Resident T | X | ||||||||
Resident Y | X | ||||||||
Total reasons | |||||||||
% Total reasons |
Table (continued)
Nursing Home Treatments 24 Hours Prior to Transfer | ||||||||
---|---|---|---|---|---|---|---|---|
Resident | Labwork Obtained | X Rays Obtained | IV Fluids/ Subcutaneous Fluids |
Oxygen | Respiratory Treatment | Respiratory Suctioning | Medications: IV, Intramuscular, or SQ | Medications: Oral |
Resident A | X | X | ||||||
Resident B | X | |||||||
Resident C | X | |||||||
Resident D | X | X | ||||||
Resident G | X | X | ||||||
Resident G | ||||||||
Resident J | ||||||||
Resident P | X | X | ||||||
Resident R | X | X | X | X | X | |||
Resident T | X | X | ||||||
Resident Y | ||||||||
Total reasons | ||||||||
% Total reasons |
Table (continued)
Seen by (Within 24 Hours Prior to Transfer): | Prior ED Visit | Prior Hospital Discharge | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Resident | Primary Care Physician | Covering Provider | Consulting Physician | Nurse Practitioner or Physician's Assistant | Respiratory Therapist | Other | 0-3 Days | 4-30 Days | 0-7 Days | 8-30 Days |
Resident A | X | |||||||||
Resident B | X | 1 | ||||||||
Resident C | X | 1 | ||||||||
Resident D | 1 | |||||||||
Resident G | X | |||||||||
Resident G | 1 | |||||||||
Resident J | 1 | |||||||||
Resident P | X | 3 | 1 | |||||||
Resident R | X | |||||||||
Resident T | X | 1 | 1 | |||||||
Resident Y | ||||||||||
Total reasons | ||||||||||
% Total reasons |
Slide 26: Calculation Details for the ED Treat and Release Report
- Displays the following data:
- ED Visit (date and discharge diagnosis).
- Reason for Transfer.
- Reason for Transfer: Treatment Not Available at Facility.
- Authorized by (primary care physician, covering provider, etc.).
- Nursing Home Treatment 24 Hours Prior to Transfer.
- Seen by (Within 24 Hours Prior to Transfer) (primary care physician, covering physician, etc.).
- Prior ED Visit (0-3 Days or 4-30 Days).
- Prior Hospital Discharge (0-7 Days or 8-30 Days).
- Weeks at High Risk.
- Weeks at Medium Risk.
Slide 27: Check Your Understanding: ED Treat and Release Report Quiz
Slide 28: Monthly Transfers by Facility or Nursing Unit Report
- Provides counts of hospital and ED visits for the month by unit or by facility.
- Enables clinicians to understand the overall picture of reasons for transfer and discharge diagnoses for all transfers.
Slide 29: Monthly Transfers by Facility or Nursing Unit Report
- Displays:
- Total number of transfers.
- Total number of residents transferred.
- Reasons for each transfer.
- Potential preventable discharge diagnoses.
- Displays information pulled from the On-Time Transfer Note, Intake Note, and other EMR documentation.
Slide 30: Sample Monthly Transfers by Facility or Nursing Unit Report
Average Daily Census | 30 | TOTAL Transfers (In/Out, No Returns) | 23 |
Resident Days (including bed holds) | 900 | Total Residents Transferred | 20 |
Reason for Transfer | ||||||||
---|---|---|---|---|---|---|---|---|
Transfers That Result in Observation Stays or ED Visits or Hospital Visits |
Total Counts | Mental Disorders /Neuro Symptoms/ Psych |
Cardiac/ Circulatory Symptoms |
Pneumonia/ Respiratory Symptoms |
Gastrointestinal/ Genitourinary |
Endocrine/ Nutritional/ Metabolic |
Musculoskeletal/ Joint Symptoms |
Wound or Skin |
Observation Stays | 9% | |||||||
# Observations | 2 | 2 | ||||||
# Residents | 2 | 2 | ||||||
ED Visits | 48% | |||||||
# ED Visits | 11 | 2 | 1 | |||||
% Total Transfers | 18% | 9% | ||||||
# Residents | 10 | 2 | 1 | |||||
Top 5 (Rank Order) | 2 | 3 | ||||||
Hospital Visits | 13% | |||||||
# Hospital Visits | 3 | 2 | 1 | |||||
% Total Hospital Visits | 67% | 33% | ||||||
# Residents | 3 | 2 | 1 | |||||
Top 5 (Rank Order) | 1 | 2 | ||||||
Transfers Out, No Return | 9% | |||||||
# Transfers | 2 | 1 | ||||||
% Total Transfers | 50% | |||||||
# Residents | 2 | 1 | ||||||
Top 5 (Rank Order) | 1 | |||||||
Transfers In/Out Prior Month | 22% | |||||||
# Transfers | 5 | 2 | 3 | |||||
% Total Transfers | 40% | 60% | ||||||
# Residents | 3 | 1 | 2 | |||||
Top 5 (Rank Order) | 2 | 1 | ||||||
Unit Totals | ||||||||
TOTAL Transfers (In/Out, No Returns) | 23 | 0 | 5 | 3 | 3 | 0 | 0 | 3 |
Total Residents | 20 | 0 | 4 | 3 | 3 | 0 | 0 | 2 |
Table (continued)
Reason for Transfer | ||||||||
---|---|---|---|---|---|---|---|---|
Transfers That Result in Observation Stays or ED Visits or Hospital Visits |
Total Counts | Fall-Related Injury | Non-Fall-Related Injury | Abnormal Lab Results | Fever/Possible Infection | Malaise/Fatigue | Potential Surgical Complication | Treatment Unavailable at Facility |
Observation Stays | 9% | |||||||
# Observations | 2 | |||||||
# Residents | 2 | |||||||
ED Visits | 48% | |||||||
# ED Visits | 11 | 2 | 1 | 3 | 1 | 1 | ||
% Total Transfers | 18% | 9% | 27% | 9% | 9% | |||
# Residents | 10 | 2 | 1 | 2 | 1 | 1 | ||
Top 5 (Rank Order) | 2 | 3 | 1 | 3 | 3 | |||
Hospital Visits | 13% | |||||||
# Hospital Visits | 3 | |||||||
% Total Hospital Visits | ||||||||
# Residents | 3 | |||||||
Top 5 (Rank Order) | ||||||||
Transfers Out, No Return | 9% | |||||||
# Transfers | 2 | 1 | ||||||
% Total Transfers | 50% | |||||||
# Residents | 2 | 1 | ||||||
Top 5 (Rank Order) | 1 | |||||||
Transfers In/Out Prior Month | 22% | |||||||
# Transfers | 5 | |||||||
% Total Transfers | ||||||||
# Residents | 3 | |||||||
Top 5 (Rank Order) | ||||||||
Unit Totals | ||||||||
TOTAL Transfers (In/Out, No Returns) | 23 | 2 | 1 | 4 | 1 | 0 | 0 | 1 |
Total Residents | 20 | 2 | 1 | 3 | 1 | 0 | 0 | 1 |
Table (continued)
Discharge Diagnosis: Potentially Preventable | ||||||||
---|---|---|---|---|---|---|---|---|
Transfers That Result in Observation Stays or ED Visits or Hospital Visits |
Total Counts | Congestive Heart Failure |
Pneumonia | Urinary Tract Infection |
Sepsis or Fever or Infection |
Skin Ulcers or Cellulitis |
Dehydration or Metabolic |
Chronic Obstructive Pulmonary Disease |
Observation Stays | 9% | |||||||
# Observations | 2 | 1 | ||||||
# Residents | 2 | 1 | ||||||
ED Visits | 48% | |||||||
# ED Visits | 11 | 2 | 3 | |||||
% Total Transfers | 18% | 27% | ||||||
# Residents | 10 | 2 | 2 | |||||
Top 5 (Rank Order) | 2 | 1 | ||||||
Hospital Visits | 13% | |||||||
# Hospital Visits | 3 | 2 | 1 | |||||
% Total Hospital Visits | 67% | 33% | ||||||
# Residents | 3 | 2 | 1 | |||||
Top 5 (Rank Order) | 1 | 2 | ||||||
Transfers Out, No Return | 9% | |||||||
# Transfers | 2 | |||||||
% Total Transfers | ||||||||
# Residents | 2 | |||||||
Top 5 (Rank Order) | ||||||||
Transfers In/Out Prior Month | 22% | |||||||
# Transfers | 5 | |||||||
% Total Transfers | ||||||||
# Residents | 3 | |||||||
Top 5 (Rank Order) | ||||||||
Unit Totals | ||||||||
TOTAL Transfers (In/Out, No Returns) | 23 | 2 | 1 | 1 | 2 | 0 | 3 | 0 |
Total Residents | 20 | 2 | 1 | 1 | 2 | 0 | 2 | 0 |
Table (continued)
Discharge Diagnosis: Potentially Preventable | |||||||||
---|---|---|---|---|---|---|---|---|---|
Transfers That Result in Observation Stays or ED Visits or Hospital Visits | Total Counts | Asthma | Circulatory Problems | Hypertension or Renal Failure | Gastroenteritis | Angina Pectoris | Falls /Trauma | Anemia | Diabetes |
Observation Stays | 9% | ||||||||
# Observations | 2 | 1 | |||||||
# Residents | 2 | 1 | |||||||
ED Visits | 48% | ||||||||
# ED Visits | 11 | 2 | 2 | 1 | 1 | ||||
% Total Transfers | 18% | 18% | 9% | 9% | |||||
# Residents | 10 | 2 | 2 | 1 | 1 | ||||
Top 5 (Rank Order) | 2 | 2 | 3 | 3 | |||||
Hospital Visits | 13% | ||||||||
# Hospital Visits | 3 | ||||||||
% Total Hospital Visits | |||||||||
# Residents | 3 | ||||||||
Top 5 (Rank Order) | |||||||||
Transfers Out, No Return | 9% | ||||||||
# Transfers | 2 | ||||||||
% Total Transfers | |||||||||
# Residents | 2 | ||||||||
Top 5 (Rank Order) | |||||||||
Transfers In/Out Prior Month | 22% | ||||||||
# Transfers | 5 | ||||||||
% Total Transfers | |||||||||
# Residents | 3 | ||||||||
Top 5 (Rank Order) | |||||||||
Unit Totals | |||||||||
TOTAL Transfers (In/Out, No Returns) | 23 | 2 | 0 | 0 | 1 | 0 | 2 | 1 | 1 |
Total Residents | 20 | 2 | 0 | 0 | 1 | 0 | 2 | 1 | 1 |
Table (continued)
Discharge Dx: All Other | |||||
---|---|---|---|---|---|
Transfers That Result in Observation Stays or ED Visits or Hospital Visits | Total Counts | Myocardial Infarction | Cerebrovascular Accident | GI Bleed | Other |
Observation Stays | 9% | ||||
# Observations | 2 | ||||
# Residents | 2 | ||||
ED Visits | 48% | ||||
# ED Visits | 11 | ||||
% Total Transfers | |||||
# Residents | 10 | ||||
Top 5 (Rank Order) | |||||
Hospital Visits | 13% | ||||
# Hospital Visits | 3 | ||||
% Total Hospital Visits | |||||
# Residents | 3 | ||||
Top 5 (Rank Order) | |||||
Transfers Out, No Return | 9% | ||||
# Transfers | 2 | ||||
% Total Transfers | |||||
# Residents | 2 | ||||
Top 5 (Rank Order) | |||||
Transfers In/Out Prior Month | 22% | ||||
# Transfers | 5 | ||||
% Total Transfers | |||||
# Residents | 3 | ||||
Top 5 (Rank Order) | |||||
Unit Totals | |||||
TOTAL Transfers (In/Out, No Returns) | 23 | 0 | 0 | 0 | 0 |
Total Residents | 20 | 0 | 0 | 0 | 0 |
Slide 31: Calculation Details for the Monthly Transfers by Facility or Nursing Unit Report
- Average Daily Census.
- Resident Days (Including Bed Hold).
- Total Transfers.
- Total Residents Transferred.
- Total Observation Stays/# Residents.
- Total ED Visits/# Residents.
- Total Hospital Admissions/# Residents.
- Observation Stays - Reason for Transfer.
- Observation Stays - # Residents.
- ED Visits - # Residents.
- ED Visits - Percent Total Transfers.
- ED Visits Top 5 (Rank Order).
- Hospital Visits - Reason for Transfer.
- Hospital Visits - # Residents.
- Hospital Visits - Percent Total Hospital Visits.
- Hospital Visits - Top 5 (Rank Order).
- Facility/Unit Totals.
Slide 32: Check Your Understanding: Monthly Transfers by Facility or Nursing Unit Report Quiz
Slide 33: Monthly Transfers by Provider Report
- This report provides counts of ED visits, observation stays, and hospitalizations for the month by provider.
- Further investigation can determine if these transfers were for potentially preventable conditions.
- Each transfer is counted only once at the highest level of care provided.
Slide 34: Sample Monthly Transfers by Provider Report
Primary Care Provider | Authorizing Provider | ED Visits | Observation Stays | Hospitalizations | Total Transfers |
---|---|---|---|---|---|
Brown, B. | PCP | 2 | 0 | 1 | |
Brown, B. | Covering MD | 4 | 1 | 0 | |
Total | 8 | ||||
White, W. | PCP | 1 | 0 | 1 | |
Total | 2 | ||||
Franklin, B. | PCP | 2 | 1 | 1 | |
Franklin, B. | Medical Director | 1 | 0 | 0 | |
Franklin, B. | Managed Care Case Manager | 1 | 0 | 0 | |
Total | 6 |
Slide 35: Calculation Details for the Monthly Transfers by Provider Report
- Displays the following data:
- Primary Care Provider.
- Authorizing Provider.
- ED Visits.
- Observation Stays.
- Hospital Visits.
- Total Transfers.
Slide 36: Check Your Understanding: Monthly Transfers by Provider Report Quiz
Slide 37: Key Metrics Report
- Summarizes and trends key metrics related to rates of transfer to ED and hospital.
- Calculates key rates each month and presents trends over time (e.g., 30-day hospital readmission rate).
- Enables clinicians to track patterns, follow up on areas of decline, and monitor progress of new prevention strategies and programs.
- Can be used in discussions with hospital stakeholders or managed care organizations.
Slide 38: Key Metrics Report
- Displays for observations stays and hospital and ED visits:
- Number and rate of transfers.
- Number and percentage of residents.
- Number and percentage of hospitalizations with preventable diagnoses:
- Number of residents rehospitalized within 3, 7, 30, 90, or 180 days of a prior hospitalization.
Slide 39: Sample Key Metrics Report
Transfer to Hospital and ED Key Metrics Trend Report | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sept | Oct | Nov | Dec |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Unit Name: | ||||||||||||
Monthly Census (ADC) | 30 | 28 | 35 | 35 | 31 | 30 | 30 | 23 | 24 | 27 | 32 | 30 |
Resident Days (Including Bed Holds) | 900 | 840 | 1,050 | 1,050 | 930 | 900 | 900 | 690 | 720 | 810 | 960 | 900 |
Total Transfers From Nursing Home to ED or Hospital | 24 | 14 | 14 | 14 | 16 | 25 | 11 | 11 | 12 | 11 | 3 | 15 |
Total Residents Transferred From Nursing Home to ED or Hospital | 19 | 10 | 14 | 9 | 20 | 14 | 14 | 10 | 10 | 10 | 3 | 17 |
Following information based on returns to nursing home | ||||||||||||
Observation Stays | ||||||||||||
# Observation Stays | 2 | 3 | 1 | 0 | 3 | 5 | 5 | 2 | 1 | 0 | 0 | 3 |
Observation Stay Rate: # Observation Stays/1,000 Resident Days | 2.2 | 3.6 | 1.0 | 0.0 | 3.2 | 5.6 | 5.6 | 2.9 | 1.4 | 0.0 | 0.0 | 3.3 |
# Residents in Observation Stays | 2 | 3 | 1 | 0 | 1 | 3 | 4 | 2 | 1 | 0 | 0 | 2 |
Residents in Observation Stays/Monthly Census (ADC) (%) | 7% | 11% | 3% | 0% | 3% | 10% | 13% | 9% | 4% | 0% | 0% | 7% |
ED Visits (Treat and Return to Nursing Home) | ||||||||||||
# ED Visits | 10 | 8 | 3 | 10 | 11 | 5 | 3 | 4 | 3 | 5 | 0 | 10 |
ED Visit Rate: # ED Visits/1,000 Resident Days | 11.1 | 9.5 | 2.9 | 9.5 | 11.8 | 5.6 | 3.3 | 5.8 | 4.2 | 6.2 | 0.0 | 11.1 |
# Residents to ED | 9 | 4 | 3 | 8 | 10 | 3 | 2 | 3 | 2 | 3 | 0 | 10 |
Residents to ED/Monthly Census (ADC) (%) | 30% | 14% | 9% | 23% | 32% | 10% | 7% | 13% | 8% | 11% | 0% | 33% |
# Residents With >1 ED Visit in Last 30 Days | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
Hospital Visits | ||||||||||||
# Hospital Visits (Admissions to Nursing Home From Hospital) | 12 | 3 | 10 | 4 | 2 | 15 | 3 | 5 | 8 | 6 | 3 | 2 |
# Hospital Visits With Preventable Discharge Diagnosis | 4 | 0 | 8 | 4 | 2 | 1 | 1 | 1 | 3 | 4 | 2 | 1 |
Hospital Visits With Preventable Discharge Diagnosis/Total Hospital Visits (%) | 33% | 0% | 80% | 100% | 100% | 7% | 33% | 20% | 38% | 67% | 67% | 50% |
Hospital Visit Rate: # Hospital Visits/1,000 Resident Days | 13.3 | 3.6 | 9.5 | 3.8 | 2.2 | 16.7 | 3.3 | 7.2 | 11.1 | 7.4 | 3.1 | 2.2 |
# Residents Hospitalized (Residents Readmitted to Nursing Home From Hospital) | 8 | 3 | 10 | 1 | 9 | 8 | 8 | 5 | 7 | 7 | 3 | 5 |
Residents Hospitalized/Monthly Census (ADC) (%) | 27% | 11% | 29% | 3% | 29% | 27% | 27% | 22% | 29% | 26% | 9% | 17% |
Hospital Readmissions (All Cause) | ||||||||||||
# Residents Readmitted With Previous Hospital Discharge in Last 3 Days | 1 | 1 | 3 | 0 | 3 | 0 | 0 | 0 | 0 | 1 | 0 | 0 |
# Residents Readmitted With Previous Hospital Discharge in Last 7 Days | 1 | 1 | 3 | 0 | 4 | 0 | 0 | 0 | 3 | 1 | 0 | 0 |
# Residents Readmitted With Previous Hospital Discharge in Last 30 Days | 3 | 1 | 5 | 0 | 4 | 0 | 2 | 1 | 4 | 1 | 0 | 0 |
# Residents Readmitted With Previous Hospital Discharge in Last 90 Days | 4 | 1 | 5 | 0 | 4 | 0 | 2 | 1 | 7 | 3 | 0 | 0 |
# Residents Readmitted With Previous Hospital Discharge in Last 180 Days | 5 | 1 | 6 | 1 | 5 | 0 | 5 | 1 | 7 | 5 | 0 | 0 |
Slide 40: Calculation Details for the Key Metrics Report
- Monthly Census.
- Resident Days (including bed hold).
- Total Transfers to ED or Hospital.
- Total Residents Transferred to ED or Hospital.
- Observation Stays.
- ED Visits.
- Hospital Visits.
- Hospital Readmissions.