Quality Improvement Tool

ChartReview of Acute Care Transfers

Name:Click here to enter text.Facility:Click here to enter text.

The NY-RAH QI Tool (chart review tool) is designed to help you analyze hospital transfers and identify opportunities to reduce transfers that might be preventable. NY-RAH recommends that this tool be completed by clinicians for each hospital transfer or a sample of hospital transfers at larger facilities in order to identify common reasons for transfers. The NY-RAH QI Tool is a hybrid of the INTERACT and AMDA guidelines to gather information and to begin to identify root causes of hospital transfers

PHASE 1:INVESTIGATION

SECTION1: Describe Resident Characteristics

  1. Resident Medicare ID Number: Click here to enter text.
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  1. Resident Medicaid ID Number:Click here to enter text.

  1. Facility Resident ID: Click here to enter text.
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  1. Date of Birth: Click here to enter text.

  1. Date of Transfer:Click here to enter a date.
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  1. Name of Transfer Hospital:Click here to enter text.

  1. Date of most recent admission to nursing home: Click here to enter a date.

  1. Resident hospitalized in the past 30 days?
No ☐Yes ☐ (list dates and discharge diagnosis)
Click here to enter a date. Click here to enter text.
Click here to enter a date. Click here to enter text. /
  1. Resident hospitalized in the past 12 months?
No ☐Yes ☐ (list dates and discharge diagnosis)
Click here to enter a date. Click here to enter text.
Click here to enter a date. Click here to enter text.

SECTION 2: Describe the Acute Change of Condition (ACOC)

  1. Date and time the change in condition first noticed Click here to enter a date.Time: Hour: MinuteAM or PM
  2. Were there related signs or symptoms documented before the ACOC occurred? No ☐Yes ☐
  3. Stop and Watch used? No ☐Yes ☐
  4. Check the specific change, symptom, or sign that led to the transfer (Check no more than 3 items):

☐Abdominal pain, distension, discomfort / ☐Dizziness / lightheadedness / ☐Hypoxia/Pulse ox low / ☐Sore throat
☐Abrasion / ☐Drug levels (serum) elevated or toxic / ☐Incontinence of urine or stool (new/worse) / ☐Speech, abnormal
☐Agitation or behavioral disturbance / ☐Dyspnea / ☐Itching (pruritus) / ☐Sprains / strains
☐Ambulation, altered / ☐Earache / ☐Laceration / ☐Suicide potential
☐Appetite, diminished / ☐Edema / ☐Medication error or adverse drug event / ☐Swallowing difficulty (dysphagia)
☐Back pain / ☐EKG, abnormal / ☐Memory loss / ☐Toothache
☐Behavior, change / ☐Eye injuries / ☐Nausea and vomiting / ☐Tube out/dislodged:
☐Blisters / ☐Fainting (syncopal episode) / ☐Nocturia / ☐Suprapubic ☐Trach
☐Blood pressure (high or low) / ☐Falls / ☐Nosebleed / ☐Peg/feeding ☐Foley/indwelling catheter
☐Bruise / ☐Fever / ☐Pain: / ☐Urinary hesitancy or retention
☐Burns / ☐Fracture and dislocations / ☐Limbs ☐Facial / ☐Vaginal discharge
☐Cellulitis / ☐Gait disturbance / ☐PICC dislodged or replaced / ☐Vision, partial or complete loss
☐Chest pain, pressure or tightness / ☐Glucose, abnormal (hyper/hypo) / ☐Pressure ulcers / ☐Vomiting blood (hematemesis)
☐Confusion / ☐Headache / ☐Pulse, abnormal / ☐WBC count, elevated leukocytosis
☐Conjunctivitis / ☐Head injuries / ☐Puncture wounds / ☐Weakness, general
☐Convulsions or seizures / ☐Hearing loss (acute) / ☐Rash / ☐Weakness or paralysis, arm or leg
☐Cough / ☐Hematocrit / hemoglobin, abnormal / ☐Respiratory rate, abnormal / ☐Wounds, new or non-healing and/or worsening
☐Depressed mood / ☐Hematuria / ☐Seizure activity or convulsions / ☐Other – describe: Enter text.
☐Diabetes, poorly controlled / ☐Hemoptysis / ☐Sleep disturbance / ☐Other – describe: Enter text.
☐Diarrhea / ☐Hypothermia / ☐Sodium, abnormal (hypo/hyper) / ☐Other – describe: Enter text.

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Quality Improvement Tool

ChartReview of Acute Care Transfers

SECTION 3: Describe Action(s) Taken to Evaluate and Manage the Change in Condition Prior to Transfer

a.Which nursing staff member was it initially reported to? When? What did he or she do about it?

  1. 1stWho: Click here to enter text. When:Click here to enter text. What did they do: Click here to enter text.
  2. 2ndWho: Click here to enter text. When: Click here to enter text. What did they do: Click here to enter text.

b. Practitioner notification:

  1. Primary MD☐ Covering MD☐ NP or PA☐ None ☐

Whenwas the practitionerfirst notified?Click here to enter text.

  1. How was the practitioner notified? Telephone ☐ On-site ☐ Fax☐
  1. Was SBAR used? No ☐Yes ☐
  1. What did the practitioner do? Click here to enter text.

c. Whichtests were done at the facility before transfer?

Blood tests ☐ / EKG ☐ / Venous Doppler ☐ / None ☐
X-ray ☐ / U/A and C/S☐ / Other (specify) ☐Enter Text

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Quality Improvement Tool

ChartReview of Acute Care Transfers

d. Medication Evaluation:

Is there any specific evidence or documentation that medications were evaluated as a potential cause of the ACOC? No ☐Yes ☐

e. Identify and document the likely cause of the ACOC.

  1. Before the transfer, did the facility identify a likely cause of the acute change?

No ☐Yes ☐ Cause:Click here to enter text.

  1. How was the likely cause identified?

Click here to enter text.

  1. Was a specific cause documented by the practitioner? No ☐Yes ☐
  1. Management of ACOC in the Facility:What appropriate, supportive interventions were ordered by the practitioner for initial treatment of the ACOC?

1.Intervention: Antibiotic ☐ Other medication ☐ Oxygen ☐ IV ☐ Other: Click here to enter text.

2.Did the practitioner adjust interventions and goals based on the resident’s response to treatment? No ☐ Yes ☐

3.Did the facility follow a protocol or procedure for determining if and when the resident needed to be sent elsewhere (e.g., hospital or ER) to manage this ACOC? No ☐Yes ☐

  1. Identify appropriate treatment goals and objectives that consider the resident’s wishes.

1. Which advance directives were available in the record?

Do Not Resuscitate (DNR)☐ / Do Not Hospitalize (DNH)☐ / No feeding tube☐
Do Not Intubate (DNI)☐ / No IV fluids ☐ / No antibiotics ☐
NYS Health Care Proxy ☐ / None☐
  1. Is there documentation that the advance care planning or advance directives were considered in evaluating/managing the change? No ☐Yes ☐

3. If yes, were the relevant advance directives modified as a result of this change in clinical condition?

No ☐Yes ☐

  1. Monitor the resident’s progress.
  1. Did the practitioner do any in person visits during the ACOC? No ☐Yes ☐
  2. Which practitioner?Primary MD☐ Covering MD☐ NP or PA☐ Visit Date(s):Enter text
  3. Were the visits documented in progress notes:No ☐Yes ☐
  4. If treatment was initiated at the facility but the resident’s condition failed to stabilize or improve, did the practitioner re-examine the original review of causes and reconsider the appropriateness of current treatments? No ☐Yes ☐
  1. If yes, how long after the first visit was treatment initiated? Days:Enter text
  2. Was the re-examination documented in progress notes?No ☐Yes ☐
  1. Was there a nursing evaluation and review of overall progress during the ACOC documented in the nurse’s notes? No ☐Yes ☐

How often?Every shift: ☐Daily: ☐ Every 2 days:☐

SECTION 4: Describe the Hospital Transfer

  1. Date of transfer:Click here to enter a date.Time: Hour: MinuteAM or PM
  2. Day of Week:Mon☐Tu☐ Wed☐ Th☐ Fri☐ Sa☐ Su ☐
  3. How much time elapsed between when the acute change in condition was first noted and transfer occurred? (Use the information in Section 2, Question A and Section 4, Question A to answer)

Days:Enter textHours:Enter text

  1. Clinician authorizing transfer: Primary MD☐ Covering MD☐ NP or PA☐ Other (specify)☐ Enter text
  2. Outcome of transfer: ED visit only☐Held for observation☐ Admitted inpatient☐
  3. Primary Hospital diagnosis(es), if available:

Click here to enter text.

  1. Resident died in ED or hospital: No ☐Yes ☐ Unknown☐
  2. In retrospect, was there anything the facility or team could have done differently that might have prevented the transfer? No ☐Yes ☐
  3. If yes, describe how the acute change in condition could have been evaluated and/or managed differently, or whether the change could have been prevented all together: (Please consider prevention, staff education, communication within the facility and with external providers, diagnostics and interventions attempted at the facility, and documentation.) Click here to enter text.

PHASE 2:ANALYSIS

SECTION 5: Unplanned Hospital Transfers – Root Cause Analysis

AMDA Transitions of Care Clinical Practice Guidelines

Directions: Review all of the options in each column, one column at a time, considering all Aspect of Care categories. Choose no more than 2 responses in each column, focusing on only the most significant issues for this transfer.

☐spect of Care Category / Avoidable (1 – 27) / Possibly Avoidable (28 – 45) / Unavoidable (46 – 54)
Recognition /
  1. ☐Examination and review by a nurse and/or practitioner was inadequate.
  2. ☐Resident had a condition or problem that was known or could have been anticipated.
  3. ☐Resident’s condition was not significantly unstable (i.e., beyond the identified capacity of the facility to monitor and manage).
  4. ☐Attending or covering practitioner was not notified of condition change in a timely fashion.
  5. ☐Monitoring equipment was unavailable or malfunctioning.
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  1. ☐Nursing or practitioner assessment was suboptimal.
  2. ☐Staffing issues hindered ability to adequately monitor a somewhat unstable resident.
  3. ☐Resident’s condition was mildly unstable.
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  1. ☐Resident’s condition was too complex or unstable to be adequately managed in the facility.

Assessment /
  1. ☐Problem was characterized incorrectly or inadequately (e.g., resident described as unresponsive was little different than usual; nature, intensity, and other specific features of chest pain were not defined).
  2. ☐Diagnostics were available in a timely fashion but were not used.
  3. ☐Diagnostics should have been available when needed, but were not.
  4. ☐Resident’s condition change reflected a known or readily identifiable problem that should have been diagnosed at the time it occurred.
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  1. ☐Some diagnostics were available but their use was delayed.
  2. ☐Cause could not be immediately identified, but the resident’s condition was sufficiently stable that more time could have been taken to perform the evaluation at the facility.
  3. ☐It is unclear whether the resident’s condition change was related to a problem that was known or could have been anticipated.
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  1. ☐It was not feasible for the facility to obtain relevant diagnostics.
  2. ☐Symptoms were too obscure to be readily diagnosed or related to a known or potentially identifiable cause.

Treatment /
  1. ☐A condition change had been identified but was not addressed in a timely fashion.
  2. ☐Aggressive medical treatment was not indicated for the resident.
  3. ☐An available treatment was not used.
  4. ☐Caregiving staff did not recognize that the resident’s condition, although not fully resolved, was stable or improving.
  5. ☐Treatment in the hospital was similar to the treatment the resident could have received at the facility.
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  1. ☐Resident was not responding rapidly to treatment, but treatment had only been initiated within the previous 24 hours.
  2. ☐Resident was sent to the ER or the hospital but sent back to the facility within 48 hours.
  3. ☐Resident was place on observation status and not admitted.
/
  1. ☐Treatment was too complex to be managed internally.
  2. ☐Resident’s condition was worsening despite several days of treatment in the facility.

Ethical issues /
  1. ☐Resident’s condition and prognosis had not been discussed adequately or in a timely fashion.
  2. ☐Physician had not discussed in a timely fashion whether hospitalization was a potentially beneficial treatment option.
  3. ☐Advance directives or other care instructions had indicated no hospital transfer but were unavailable or overlooked.
/
  1. ☐There had not been much time, or the family had not been readily available, to discuss ethical issues.
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  1. ☐Hospitalization had been selected as desired option in the event of a condition that was too severe or unstable to be managed readily within the facility.

Family issues /
  1. ☐The family had not been adequately informed of the resident’s condition or prognosis, or of the facility’s capacity to manage certain condition changes without transfer.
/
  1. ☐Family demanded hospital transfer despite efforts to explain why it was not necessary.
  2. ☐Religious issues.
  3. ☐Cultural issues.
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  1. ☐Conflict among the family about scope and aggressive of medical treatment could not readily be resolve.

Practitioner issues /
  1. ☐An attending or covering practitioner failed to respond in a timely fashion to notification of a condition change.
  2. ☐Upon responding, the practitioner insisted on transfer before discussing the case adequately with a nurse.
  3. ☐Wrong practitioner was notified of the condition change.
  4. ☐Attending practitioner could not be reached or had insufficient backup coverage to respond.
/
  1. ☐Practitioner was adequately informed about the resident’s condition but remained unsure of the seriousness or cause(s) of the situation and therefore was unable to readily initiate empirical treatment.
  2. ☐Practitioner was unsure if the facility could provide the care required.
/
  1. ☐Practitioner identified significant medical concerns about the resident that were beyond the scope of the facility’s capabilities or required a higher level of monitoring or more complex treatment than the facility could readily provide.

Miscellaneous /
  1. ☐Relevant policy or procedure was unavailable or available but not used.
  2. ☐A procedure was not followed correctly.
  3. ☐Appropriate supervisory staff were not consulted as they should have been.
  4. ☐Pertinent documentation (e.g., previous hospital discharge information, diagnoses, family consents) was not on the resident’s chart, not available, or not reviewed.
  5. ☐Facility has not adequately identified the degree to which it can monitor and manage medically unstable residents.
/
  1. ☐Relevant policy or procedure did not adequately cover the situation.
  2. ☐Appropriate supervisory staff were consulted but were not sure what to do.
  3. ☐Some necessary care might have exceeded the scope of the facility’s capabilities, staffing, equipment, and supplies.
/
  1. ☐Required care would have exceeded the scope of the facility’s capabilities, staffing, equipment, and supplies.
  1. ☐Resident refused critical treatment (i.e. hemodialysis)
  1. ☐Resident demanded transfer to hospital and/or called 911 to initiate transfer.

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