AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits
Hospital Transfer Self-Assessment Worksheet
Purpose
The Hospital Transfer Self-Assessment Worksheet can help nursing home staff identify and review care that they provide that may lead to avoidable transfers to the hospital or emergency department. The worksheet addresses the following questions:
- Is the nursing home providing appropriate and timely responses to changes in health, or is the care insufficiently responsive, resulting in declines leading to hospitalization?
- Are some discharges preventable because the nursing home could have cared for the resident in the nursing home safely?
- Could residents with some adjustments to resources be treated in the nursing home safely?
- Does the nursing home identify who is at high risk for hospitalization?
- Do they provide preventive care to reduce the number of unnecessary hospitalizations?
Description
The assessment has four sections:
- Screening for hospitalization risk,
- Averting preventable transfers through symptom recognition,
- Communication practices, and
- Investigations or root cause analysis of preventable transfers.
Users and Potential Uses
The main user is the preventable nursing home transfers change team. The completed worksheet shows the nursing home’s practices around screening for conditions and symptoms that may lead to a hospital or ED visit, communication about risk, and care planning and interventions to avert preventable transfers that the team can use to identify gaps in their clinical practice. A Facilitator guides these discussions and helps the staff identify how to use On-Time reports to fill in gaps in processes or to redesign or streamline processes.
This self-assessment tool is aimed at two types of nursing homes. First are nursing homes that are not using an electronic medical record (EMR) for preventable hospital and ED visits but have access to the On-Time Preventable Hospital and ED Visits Risk Reports from their health information technology vendor and have decided to use these reports to create electronic risk information to help avert preventable hospital and ED visits. Conducting the self-assessment tool is an important first step in implementing the reports into current workflow.
Second are nursing homes that lack access to On-Time in an EMR but want to understand their current practices and identify opportunities for improvement without using electronic records. This assessment should show how well the nursing home:
- Identifies hospitalization risk factors using information from multiple sources,
- Develops interventions specific to the risk factors to mitigate the risk,
- Communicates the intervention to all staff using multiple processes, and
- Investigates the root cause of hospital transfers to determine if any were preventable.
The worksheet covers the following:
- Section 1: Screening for Hospital Transfer Risk
- Section 2: Preventable Hospital and ED Visits - Prevention Plan
- Section 3: Communication Practices
- Section 4: Investigations/Root Cause Analysis of Potentially Preventable Acute Care Transfers
Section 1: Screening for Hospital Transfer Risk
- Does your facility have a written policy and procedure for assessing residents at risk of hospital transfers? Yes |___| No |___| Not Sure |___|
If no, skip to question 2.
A. Does your policy and procedure on assessing risk for hospital transfers include the following items?
Yes No Tools for resident evaluation (e.g., care paths) |___| |___| Tools for communication with emergency medical service providers, physician, and hospital (e.g., SBAR) |___| |___| Identification of factors that put a resident at risk for hospital/ED transfer |___| |___| B. What guidelines or evidence-based practice is your policy and procedure based on? Check all that apply.
|___| INTERACT (Interventions to Reduce Acute Care Transfers)
|___| RARE (Reducing Avoidable Readmissions Effectively)
|___| Advancing Excellence
|___| Project Boost
|___| RED (Re-Engineered Discharge)
|___| AMDA's Clinical Practice Guidelines for Transitions of Care in Long Term Care Continuum
|___| None of the above
|___| Other ______________________________________C. Does your policy and procedure include a provision for regular exchange of information with acute care providers? Yes |___| No |___|
If no, skip to Question 2.
i. Warm handoffs (verbal report to triage nurse) Yes |___| No |___| ii. Use of a standard interagency referral form Yes |___| No |___| iii. Care transitions meetings Yes |___| No |___| - Does your facility use a hospital transfer risk-factor screening tool? Yes |___| No |___|
If no, skip to Question 4.
- If yes, does the tool screen for any of the following?
Yes No >1 hospitalization or ED visit in the past 3 months |___| |___| >1 fall in the past 3 months |___| |___| Active high-risk diagnoses (e.g., CHF, MI/angina, pneumonia/bronchitis, COPD, dehydration, UTI, infection, renal failure, diabetes, gastroenteritis) |___| |___| Poor prognosis/end-stage disease |___| |___| Lack of advance care planning |___| |___| Lack of documented code status |___| |___| Oxygen dependency |___| |___| Confusion/mental status change |___| |___| Any full thickness wound (e.g., pressure ulcers [Stage II or greater], surgical wound, stasis ulcer) |___| |___| Polypharmacy (15 or more medications) |___| |___| Presence of catheter or ostomy |___| |___| Fall risk |___| |___| ADL Late Loss score ≥ 12 based on RUG-III |___| |___| Use of high-risk medications (anticoagulants, insulin, psychotropic medications, cardiac medications, etc.) |___| |___| Other (specify): |___| |___| - Does your facility have a formal system for documenting a hospital transfer risk assessment on each resident?
A. Long-term care residents Yes |___| No |___| B. Short-term care residents Yes |___| No |___| C. New admissions only Yes |___| No |___| - When are residents screened for hospital transfer risk? Check all that apply.
|___| Upon admission/readmission
|___| Monthly
|___| Quarterly
|___| With a change in condition
|___| With each MDS assessment
|___| After every ED visit
|___| After every observation stay
|___| Annually
|___| Other (specify): __________________________________________________________ - Who is responsible for completing the transfer risk assessment?
|___| Admitting nurse
|___| Charge/unit/floor nurse
|___| Nurse manager
|___| Nursing supervisor
|___| Director of Nursing
|___| Social Services
|___| Other (specify): __________________________________________________________ - Is the resident/family/caregiver involved in the risk assessment? Yes |___| No |___|
- If the resident is not currently at risk, is there a plan to rescreen at regular intervals? Yes |___| No |___|
- Do you screen residents with the following diagnoses for hospitalization risk?
A. Congestive heart failure Yes |___| No |___| B. Diabetes Yes |___| No |___| C. Circulatory problems Yes |___| No |___| D. COPD Yes |___| No |___| E. Dementia Yes |___| No |___| F. HIV/AIDS Yes |___| No |___| G. Chest pain Yes |___| No |___| H. Pneumonia or bronchitis Yes |___| No |___| I. Dehydration Yes |___| No |___| J. Renal failure Yes |___| No |___| K. Chronic pressure ulcers Yes |___| No |___| L. Recurrent UTI Yes |___| No |___| M. Anemia Yes |___| No |___| N. Fever Yes |___| No |___| O. Sepsis or infection Yes |___| No |___| P. Gastroenteritis Yes |___| No |___|
Section 2: Preventable Hospital Transfer and ED Visits - Prevention Plan
For residents at risk:
1. Do you develop a care plan for residents at risk for hospital transfers?
If no, skip to Section 3. A. If yes, does your plan include: |
Yes |___| | No |___| |
i. Standing daily weight orders for residents with CHF? | Yes |___| | No |___| |
ii. Standing hypo/hyperglycemic orders for residents with diabetes? | Yes |___| | No |___| |
iii. Standing rescue orders for residents with COPD? | Yes |___| | No |___| |
iv. Standing orders for other diagnoses (specify) __________________ | Yes |___| | No |___| |
2. Does your plan include interventions for treating in place? | Yes |___| | No |___| |
3. Does your plan include ongoing discussions about advance care planning with resident and/or family? | Yes |___| | No |___| |
4. Does your plan include interventions for code status? | Yes |___| | No |___| |
5. Does your plan include interventions for hospitalization transfer wishes (e.g., Do Not Hospitalize, Medical Orders for Life-Sustaining Treatment, Physician Orders for Life-Sustaining Treatment)? | Yes |___| | No |___| |
6. Is the plan readily accessible by all members of the interdisciplinary team? | Yes |___| | No |___| |
7. Does your plan include regular rescreening for hospitalization risk factors for residents currently at risk for hospitalization? | Yes |___| | No |___| |
Section 3: Communication Practices
- This section of the assessment will help identify how your facility communicates the hospital prevention care plans to the interdisciplinary team. Please review the following list of meetings. For every meeting that occurs at your facility, indicate how often it occurs, who leads the meeting, and who attends.
Meeting Hospital/ED Transfer Prevention Discussed (Yes/No) Meeting Chair/Leader Name and Discipline Staff Invited and in Attendance (A – Always, V- Varies as Needed) Frequency of Meeting (Weekly, Biweekly, Monthly, Quarterly, Change in Condition, As Needed) a. Daily morning meetings b. Report or brief with CNAs c. Report or brief with department heads d. Medical staff e. QAPI or Performance Improvement Plan meeting f. Care plan meeting g. MD/APRN rounds h. Report or brief with Dietary Department i. Report or brief with Social Services Department j. Report or brief with Therapy Department k. Report or brief with Other - Training
Indicate the date of the most recent training.
Topic Participants Date a. Standardized CHF education such as "Heart Talk"1 b. Standardized COPD education such as "Lung Talk"2 c. Warm handoffs3 d. Effective communication between nurse and providers (e.g., Use of SBAR, Chief Complaint [Context/Code Status], History, Assessment/Exam) e. Reporting subtle changes in conditions f. Zones for residents with CHF/COPD to help self-manage4 g. Care paths5 - Does your facility provide training to nursing/medical staff on how to accurately assess a change in condition that may put a resident at risk for hospitalization? Yes |___| No |___|
- Does your facility provide education to certified nursing assistants regarding their role in identifying and reporting a change in resident condition? Yes |___| No |___|
Section 4: Investigations/Root Cause Analysis of Potentially Preventable Acute Care Transfers
- Do you investigate each hospital transfer to determine if the transfer could have been prevented with better preventive care during the resident's stay?
Yes |___| No |___| Not Sure |___|
If No, Stop here.
- What guides your investigation? Check all that apply.
|___| Organizational protocols/policy and procedures
|___| Root Cause Analysis
|___| INTERACT
|___| Tree/Fishbone Diagrams
|___| Others ______________________________________________ - Who participates in the investigation? Check all that apply.
|___| Director of Nursing/Assistant Director of Nursing
|___| Nursing Supervisor
|___| Administrator
|___| Medical Director
|___| Nurse managers/charge nurses
|___| Social worker
|___| Nursing assistants
|___| Primary care provider/NP/PA
|___| Other
- What guides your investigation? Check all that apply.
- How often does the team meet?
Yes No a. Weekly |___| |___| b. Monthly |___| |___| c. Quarterly |___| |___| d. Annually |___| |___| e. After each transfer |___| |___| - In the course of your investigation, what actions take place? Check all that apply.
|___| Review of medical record for condition changes prior to transfer going back at least 14 days
|___| Interview/discussion with charge nurse initiating the transfer for details on events leading up to the transfer
|___| Interview/discussion with clinician authorizing transfer
|___| Other (specify) ____________________________________________________ - Does your team make a determination as to whether the hospital transfer was preventable? Yes |___| No |___|
- If yes, does the multidisciplinary team evaluate the resident's care plan and implement new approaches to prevent recurrence? Yes |___| No |___|
- How is the new plan to prevent future hospital transfers communicated to all staff? Check all that apply.
|___| Shift report
|___| Brief
|___| Care plan meeting
|___| Nursing staff meeting
|___| Risk meeting
|___| Department head meeting
|___| Other (specify) __________________________________________________
- The investigation may reveal that a particular action should have been taken to address a condition change (e.g., increased fluids for suspected UTI, increased assistance with ambulation for new weakness, respiratory treatment for increased shortness of breath). How would you ascertain that an intervention had been identified as necessary but was not implemented?
_______________________________________________________________________________
_______________________________________________________________________________
- Are there any particular barriers or challenges to investigating the root cause of preventable hospital transfers?
_______________________________________________________________________________
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1 Available at Heart Talk Video Series.
2 Available at Lung Talk Video Series.
3 Available at What is a Handoff?.
4 Available at Exacerbation Action Plan & Protocol.
5 Available at Interventions to Reduce Acute Care Transfers (INTERACT).
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