DataCollectionGuide

EmergencyDepartmentTransferCommunicationMeasures

July 2014

PreparedbyStratisHealthincollaborationwithDr. Jill Klingner from theUniversityofMinnesotaRuralHealthResearchCenter

StratisHealthisappreciativeofthe organizationsandagenciesthathaveprovidedfundingandsupportforthedevelopmentandrevisionsof thisdatacollectionguide:

  • MinnesotaDepartmentofHealth,Office of RuralHealthandPrimary Care,fundedbytheMedicare RuralHospitalFlexibility Program
  • MN Community Measurement,fundedby the MinnesotaDepartmentof Health
  • CentersforMedicare MedicaidServices,QualityImprovementOrganization(QIO)SpecialInnovationProject

StratisHealth,basedinBloomington,Minnesota,isanonprofitorganizationthatleadscollaborationandinnovationinhealthcarequalityandsafety,andservesasatrustedexpertinfacilitatingimprovementforpeopleandcommunities.

TableofContents

ED TransferCommunicationQUALITYMEASURESSet...... 3

BackgroundoftheMeasures...... 3

SelectedReferences...... 5

Population andSampling...... 6

MeasureCalculation...... 7

Considerations forElectronicTransferofInformation...... 7

MeasureEDTC-1...... 8

MeasureEDTC-2...... 9

MeasureEDTC-3...... 10

MeasureEDTC-4...... 11

MeasureEDTC-5...... 12

MeasureEDTC-6...... 13

MeasureEDTC-7...... 14

DataElements...... 15

Nurse to Nurse Communication...... 16

Physicianto Physician Communication...... 17

PatientName...... 18

PatientAddress...... 19

PatientAge...... 20

PatientGender...... 21

PatientContactInformation...... 22

PatientInsurance Information...... 23

Pulse...... 24

RespiratoryRate...... 25

Blood Pressure...... 26

OxygenSaturation...... 27

Temperature...... 28

NeurologicalAssessment...... 29

Medications Administered in ED...... 30

Allergies/Reactions...... 31

Home Medications...... 32

HistoryandPhysical...... 33

Reason forTransfer/PlanofCare...... 34

NursingNotes...... 35

Sensory Status (formerly Impairments)...... 36

Catheters...... 37

Immobilizations...... 38

RespiratorySupport...... 39

OralRestrictions...... 40

Tests/ProceduresPerformed...... 41

Tests/Procedure Results...... 42

AppendixA:EDTransferPaper Tool...... A-1

Appendix B: List of Data Elements...... B-1

Appendix C: Crosswalk with Meaningful Use Criteria ………………………………………………………………………..C-1

Appendix D: Crosswalk with OP–19: Transition Record with Specified Elements Received by

Discharged Patients (CMS)…………………………………………………………………………………………………..D-1

EmergencyDepartmentTransferCommunicationMeasureSpecifications

EDTransferCommunicationQUALITYMEASURESSet

MeasureID# / MeasureShortName / NQF1MeasureNumber / NQMC2
Measure
Number
EDTC-1 / Administrativecommunication / 0291 / 7535
EDTC-2 / Patientinformation / 0291 / 7536
EDTC-3 / Vitalsigns / 0291 / 7537
EDTC-4 / Medicationinformation / 0291 / 7538
EDTC-5 / Physicianorpractitionergeneratedinformation / 0291 / 7539
EDTC-6 / Nursegeneratedinformation / 0291 / 7540
EDTC-7 / Proceduresandtests / 0291 / 7541
  1. NQF National Quality Forum
  2. NQMC National Quality Measure Clearinghouse

BackgroundoftheMeasures

In 2003,an expertpanelconvenedby the University ofMinnesotaRuralHealthResearchCenterandStratisHealthidentifiedEDcareas an importantquality assessmentmeasurementcategoryforruralhospitals.Whileemergencycare isimportantinallhospitals,itisparticularlycriticalinruralhospitalswherethesize ofthehospital andgeographicrealitiesmake organizingtriage,stabilization,andtransfer ofpatientsmoreimportant.Communicationbetweenproviderspromotescontinuity of careandmay leadtoimprovedpatientoutcomes.ThesemeasureswerepilotedbyruralhospitalsinMinnesota,Utah,Nevada,Washington,Ohio,Pennsylvania,NewYorkandHawaii;projectstookplacefromOctober2005throughJuly 2014.ResultsofthepilotprojectsindicatedroomforimprovementinEDcareandtransfercommunication.

Aggregateprojectresultsareavailableat

Rationale

Communication problemsareamajorcontributingfactorto adverse eventsinhospitals,accounting for65%ofsentinel eventstrackedby TheJointCommission.Inaddition,researchindicatesthatdeficitsexistinthetransferof patientinformationbetweenhospitalsandprimarycarephysiciansinthe community,andbetweenhospitalsandlong-termfacilities.Transferredpatientsareexcludedfromthecalculationofmostnationalqualitymeasures,suchas those usedinHospitalCompare.TheHospitalCompareWebsitewascreatedto displayratesofProcessofCare measuresusingdatathatare voluntarilysubmittedbyhospitals.

TheJointCommissionhasadoptedNationalPatientSafety Goal2,"Improve the Effectivenessof CommunicationAmongCaregivers."Thisgoalrequiredallaccreditedhospitalsto implementastandardizedapproachtohand-off communications,includingnursingandphysicianhandoffsfrom the emergencydepartment(ED)to inpatient

units,otherhospitals,andothertypesof healthcare facilities.Theprocessmustincludea methodofcommunicating up-to-date informationregardingthepatient'scare,treatment,andservices; condition; andanyrecentoranticipatedchanges.(Note:The NationalPatientSafety Goals are reviewedandmodifiedperiodically.In 2013a communicationgoalfocusesonthecommunicationof testresults.)

Limitedattentionhasbeenpaid to thedevelopment andimplementationof quality measuresspecificallyfocusedon patienttransfersbetweenEDsandotherfacilities.These measuresare importantforallhealthcarefacilities,butespecially so forsmallruralhospitalsthattransfer ahigherproportion of EDpatientsto otherhospitalsthanlargerurbanfacilities.

Whilemanyaspectsofhospitalqualityaresimilarforurbanandruralhospitals(e.g.,providingheartattackpatientswithaspirin),the urban/ruralcontextual differencesresultindifferencesinemphasison qualitymeasurement. Because ofitsroleinlinkingresidentstourbanreferralcenters,importantaspectsof ruralhospital qualityincludetriage-and-transferdecisionmakingaboutwhentoprovidea particulartype ofcare,transporting patients,andcoordinatinginformationflow to specialistsbeyondthecommunity.

Emergencycare isimportantinallhospitals,butitisparticularlyimportantinruralhospitals.Because of theirsize,ruralhospitalsarelesslikely tobeabletoprovide more specializedservices,such as cardiac catheterizationor traumasurgery.Ruralresidentsoften needto travelgreaterdistancesthanurbanresidentsto gettoahospital initially.Inaddition,theirinitialpointof contactislesslikely tohavespecializedservicesand stafffoundin tertiarycarecenters, so theyarealso morelikely to betransferred.These size andgeographicrealitiesincreasetheimportance oforganizingtriage,stabilization,and transferinruralhospitalswhich,inturn,suggestthatmeasurementof these processesis an importantissueforruralhospitals.

TheEDTransferCommunicationmeasuresaim toprovideameansof assessinghow wellkeypatient informationiscommunicatedfromanED toanyhealthcarefacility.Theyareapplicabletopatientswith awiderange ofmedicalconditions(e.g.,acute myocardialinfarction,heartfailure,pneumonia,respiratorycompromiseand trauma)and arerelevantfor bothinternalqualityimprovementpurposesandexternalreportingtoconsumersandpurchasers.Theresultsof thefieldtestssuggestthatsignificantopportunity existsforimprovementonthese measures.

SelectedReferences:

BaldwinLM,MacLehoseRF,HartLG,BeaverSK,EveryN,ChanL.QualityofcareforacutemyocardialinfarctioninruralandurbanUShospitals.JRuralHealth2004Spring;20(2):99-108.

CortesTA,WexlerS,FitzpatrickJJ.Thetransitionofelderlypatientsbetweenhospitalsandnursinghomes.Improvingnurse-to-nursecommunication.JGerontolNurs2004Jun;30(6):10-5;quiz52-3.[5references]

EllerbeckEF,BhimarajA,PerpichD.OrganizationofcareforacutemyocardialinfarctioninruralandurbanhospitalsinKansas.JRuralHealth2004Fall;20(4):363-7.

JointCommissiononAccreditationofHealthcareOrganizations.Sentineleventsstatistics.[Internet].[accessed2007Jul18].

KlingnerJ,MoscoviceI,WashingtonRuralHealthcareQualityNetworkandStratisHealth,MinnesotaQualityImprovementOrganization.Ruralhospitalemergencydepartmentqualitymeasures:aggregatedatareport.Minneapolis(MN):UniversityofMinnesota,DivisionofHealthServicesResearchPolicy;2007Mar.12p.(FlexMonitoringTeamdatasummaryreport;no.3).

KlingnerJ,MoscoviceI.Developmentandtestingofemergencydepartmentpatienttransfercommunicationmeasures.JRuralHealth2012Jan;28(1):44-53.[16references]

KripalaniS,LefevreF,PhillipsCO,WilliamsMV,BasaviahP,BakerDW.Deficitsincommunicationandinformationtransferbetweenhospital-basedandprimarycarephysicians:implicationsforpatientsafetyandcontinuityofcare.JAMA2007Feb28;297(8):831-41.[133references]

NewgardCD,McConnellKJ,HedgesJR.Variabilityoftraumatransferpracticesamongnon-tertiarycarehospitalemergencydepartments.AcadEmergMed2006Jul;13(7):746-54.

UniversityofMinnesotaRuralHealthResearchCenter,StratisHealth(Minnesota'sQualityImprovementOrganization),HealthInsight(NevadaandUtah'sQualityImprovementOrganization).Refiningandfieldtestingarelevantsetofqualitymeasuresforruralhospitals.FinalreportsubmittedtotheCentersforMedicareMedicaidServicesundercontractno.500-02-MN01.Bloomington(MN):StratisHealth;2005Jun30.

USDepartmentofHealthandHumanServices.HospitalCompareWebsite.[Website].[accessed2011Feb25].

WakefieldDS,WardM,MillerT,OhsfeldtR,JaanaM,LeiY,TracyR,SchneiderJ.Intensivecareunitutilizationandinterhospitaltransfersaspotentialindicatorsofruralhospitalquality.JRuralHealth2004Fall;20(4):394-400.

WestfallJM,VanVorstRF,McGloinJ,SelkerHP.Triageanddiagnosisofchestpaininruralhospitals:implementationoftheACI-TIPIintheHighPlainsResearchNetwork.AnnFamMed2006Mar-Apr;4(2):153-8.

PopulationandSampling

EDTransferCommunication(EDTC)InitialPatientPopulation

(Update discharge codes with CMS changes as appropriate.)

Thepopulationof theEDTCmeasuresetisdefinedbyidentifyingpatientsadmittedto theemergency departmentandtransfersfromtheemergency departmentto thesefacilities:

3Hospice –healthcarefacility

4a AcuteCareFacility-GeneralInpatientCare4b Acute Care Facility-CriticalAccessHospital

4c AcuteCareFacility-CancerHospital orChildren’sHospital

4d Acute Care Facility –DepartmentofDefenseorVeteran’sAdministration5Otherhealth care facility (i.e. nursing homes, skilled nursing facilities, rehabilitation centers, swing beds; facilities with 24 hour nursing supervision.)

Note:ED patients that have been put in observation status and then are transferred to another hospital or health care facility should be included.

Exclusions:

1Home

2Hospice-home

6Expired

7AMA(leftagainstmedicaladvice)

8Notdocumented/unable todetermine

SampleSizeRequirements

Hospitalsthatchoose to samplehave the option of samplingquarterly orsamplingmonthly. A hospital maychoosetousea largersamplesizethanisrequired.Hospitalswhoseinitialpatientpopulationsizeislessthanthe minimumnumberof casesperquarterforthe measuresetcannotsample.

Regardlessofthe optionused,hospitalsamplesmustbemonitoredto ensure thatsamplingproceduresconsistentlyproduce statistically validandusefuldata. Dueto exclusions,hospitalsselectingsamplecasesMUSTsubmitATLEASTthe minimumrequiredsamplesize.

Thefollowingsamplesize tables foreachoptionautomaticallybuildinthe number ofcasesneededtoobtaintherequiredsamplesizes.For informationconcerning howto perform sampling,referto the PopulationandSamplingSpecificationssectioninthismanual.

QuarterlySampling

HospitalsperformingquarterlysamplingforEDTransferCommunicationmustensurethatitsinitialpatientpopulationandsample size meetthefollowingconditions:

QuarterlySampleSize

BasedonInitialPatientPopulationSizefortheEDTCMeasureSet

Hospital’sMeasure

AverageQuarterly
InitialPatientPopulationSize“N” / MinimumRequiredSampleSize“n”
45 / 45
1-44 / Nosampling;100%InitialPatientPopulationrequired

MonthlySampling

Hospitalsperformingmonthlysampling forEDTCmust ensurethatitsInitialPatientPopulationandsamplesizemeetthefollowingconditions:

MonthlySampleSize

BasedonInitialPatientPopulationSizefortheEDTCMeasureSet

Hospital’sMeasureAverageMonthlyInitialPatientPopulationSize“N”

MeasureCalculation

Each ofthe sevenmeasuresiscalculatedusing an all-or-none approach.Dataelementsareidentifiedforeachmeasure. Ifthedataelementisnotappropriate forthepatient,itemsscored asNA (notapplicable)arecounted inthe measureasa positive,or‘yes,’responseandthepatientwillmeetthe measurecriteria.Thepatientwilleitherneedtomeetthecriteriaforallofthedataelements(orhave an NA)to passthe measure.

ConsiderationsforElectronicTransferofInformation

For healthsystemswithsharedelectronicmedicalrecords,documentationmustindicatethatdataelementshadbeenenteredintothedatasystemandwereavailable to thereceivingfacilitypriortotransferforAdministrativeMeasuresor within60 minutesof discharge forallothermeasures.Iftherearenotsharedrecords,“sent”meansthatmedicalrecorddocumentationindicatestheinformationwentwiththepatientvia fax,phone,orinternet/ElectronicHealthRecord.

MeasureEDTC-SUB 1

MeasureInformationForm

MeasureSet:EDTransferCommunication(EDTC)

SetMeasureID#:EDTC-SUB 1

PerformanceMeasureName:Administrativecommunication

Description:PatientswhoaretransferredfromanED toanotherhealthcarehavephysiciantophysiciancommunicationandnurse tonurse communicationpriortodischarge.

Rationale:Timely,accurateanddirectcommunication facilitatesthehandofftothereceivingfacilityprovidescontinuity ofcare and avoidsmedical errors andredundanttests.

TypeofMeasure:Process

ImprovementNotedAs:Anincreaseintherate

NumeratorStatement:Numberofpatientstransferredtoanotherhealthcarefacilitywhosemedicalrecord documentationindicatedthatallof theelementswerecommunicatedtothereceivingfacilitypriortotransfer.

  • Nurseto nursecommunication
  • Physicianto physiciancommunication

DenominatorStatement:AlltransfersfromEDtoanotherhealthcarefacility

IncludedPopulations:EDTransferstoanotherhealthcarefacility

ExcludedPopulations:None

Calculation

#ofpatientswhohaveayesorNA forbothmeasures: nursetonurse communicationand

Rate=physician tophysician communication AlltransfersfromEDtoanotherhealthcarefacility

RiskAdjustment:No

DataCollectionApproach:Retrospectivedatasourcesforrequireddataelementsincludeadministrativedataandmedicalrecords.

MeasureAnalysisSuggestions:Thedataelementsfor eachofthetwocommunicationelementsprovidetheopportunitytoassesseachcomponentindividually.

Sampling:Yes,pleaserefer tothemeasuresetspecific samplingrequirements.SeethePopulationandSamplingSpecificationsSection.

MeasureEDTC- SUB 2

MeasureInformationForm

MeasureSet:EDTransferCommunication(EDTC)

SetMeasureID#:EDTC-SUB 2

PerformanceMeasureName:PatientInformation

Description:PatientswhoaretransferredfromanEDtoanotherhealthcarefacilityhavepatientidentificationinformationsenttothereceivingfacilitywithin60 minutesof discharge

Rationale:Timely,accurateanddirectcommunication facilitatesthehandofftothereceivingfacilityprovidescontinuity ofcare and avoidsmedical errors andredundanttests.

TypeofMeasure:Process

ImprovementNotedAs:Anincreaseintherate

NumeratorStatement:

Numberof patientstransferredtoanotherhealthcarefacility whose medicalrecorddocumentationindicatedthatall ofthe elementswerecommunicatedto thereceivingfacility within 60 minutesofdeparture.

  • Name
  • Address
  • Age
  • Gender
  • Significantotherscontactinformation
  • Insurance

DenominatorStatement:EDtransferstoanotherhealthcarefacility

IncludedPopulations:AlltransfersfromEDtoanotherhealthcarefacility

ExcludedPopulations: None

Calculation

#ofpatientswhohaveayesorNA forallmeasures:name,address,age,gender,contact,

Rate=insurance AlltransfersfromEDto anotherhealthcarefacility

DataCollectionApproach:Retrospectivedatasourcesforrequireddataelementsincludeadministrativedataandmedicalrecords.

MeasureAnalysisSuggestions:Thedataelementsforeachofthesixcommunicationelementsprovidetheopportunitytoassesseachcomponentindividually.

Sampling:Yes,pleaserefer tothemeasuresetspecific samplingrequirements.SeethePopulationandSamplingSpecificationSection.

MeasureEDTC-SUB 3

MeasureInformationForm

MeasureSet:EDTransferCommunication(EDTC)

SetMeasureID#:EDTC-SUB 3

PerformanceMeasureName:VitalSigns

Description:PatientswhoaretransferredfromanEDtoanotherhealthcarefacilityhavecommunicationwith the receivingfacility within 60 minutesof dischargeforpatient’svitalsigns

Rationale:Timely,accurateanddirectcommunication facilitatesthehandofftothereceivingfacilityprovidescontinuity ofcare and avoidsmedical errors andredundanttests.

TypeofMeasure:Process

ImprovementNotedAs:Anincreaseintherate

NumeratorStatement:Numberofpatientstransferredtoanotherhealth carefacilitywhosemedicalrecord documentationindicatedthatallof theelementswerecommunicatedtothereceivingfacilitywithin60 minutesof discharge.

  • Pulse
  • Respiratoryrate
  • Bloodpressure
  • Oxygensaturation
  • Temperature
  • Glasgowscore orotherneuroassessmentfortrauma,cognitivelyalteredor neuropatientsonly

DenominatorStatement:EDtransferstoanotherhealthcarefacility

IncludedPopulations:AlltransfersfromEDtoanotherhealthcarefacility

ExcludedPopulations:None

Calculation

#ofpatientswhohaveayesor NAfor allmeasures:pulse,respiration,blood pressure,Rate= oxygen saturation,temperature and neuro assessment

Alltransfersfrom EDtoanotherhealthcarefacility

RiskAdjustment:No

DataCollectionApproach:Retrospectivedatasourcesforrequireddataelementsincludeadministrativedataandmedicalrecords.

MeasureAnalysisSuggestions:Thedataelementsforeachofthesixcommunicationelementsprovidetheopportunitytoassesseachcomponentindividually.

Sampling:Yes,pleaserefer tothemeasuresetspecific samplingrequirements.SeethePopulationandSamplingSpecificationsSection.

MeasureEDTC-SUB 4

MeasureInformationForm

MeasureSet:EDTransferCommunication(EDTC)

SetMeasureID#:EDTC-SUB 4

PerformanceMeasureName:MedicationInformation

Description:PatientswhoaretransferredfromanEDtoanotherhealthcarefacilityhavecommunicationwiththe receivingfacility within 60 minutesof dischargeformedicationinformation.

Rationale:Timely,accurateanddirectcommunication facilitatesthehandofftothereceivingfacilityprovidescontinuity ofcare and avoidsmedical errors andredundanttests.

TypeofMeasure:Process

ImprovementNotedAs:Anincreaseintherate

NumeratorStatement:NumberofpatientstransferredfromanEDtoanotherhealthcarefacilitywhosemedicalrecorddocumentationindicatedthatall oftheelementswere communicatedto thereceivinghospitalwithin60 minutesof departure.

  • Medicationsadministeredin ED
  • Allergies
  • Home medications

DenominatorStatement:EDtransferstoanotherhealthcarefacility

IncludedPopulations:AlltransfersfromEDtoanotherhealthcarefacility

ExcludedPopulations:None

Calculation

#ofpatientswho haveayesor NAforallmeasures: MedicationsadministeredinED,Rate= allergiesand home medications

AlltransfersfromEDtoanotherhealthcarefacility

RiskAdjustment:No

DataCollectionApproach:Retrospectivedatasourcesforrequireddataelementsincludeadministrativedataandmedicalrecords.

MeasureAnalysisSuggestions:Thedataelementsforeachofthethreecommunicationelementsprovide the opportunity toassesseach componentindividually.

Sampling:Yes,pleaserefer tothemeasuresetspecific samplingrequirements.SeethePopulationandSamplingSpecificationsSection.

MeasureEDTC-SUB 5

MeasureInformationForm

MeasureSet:EDTransferCommunication(EDTC)

SetMeasureID#:EDTC-SUB 5

PerformanceMeasureName:PhysicianorPractitionergeneratedinformation

Description:PatientswhoaretransferredfromanEDtoanotherhealthcarefacilityhavecommunicationwiththe receivingfacility within 60 minutesof dischargeforhistoryandphysicalandphysicianordersandplan

Rationale:Timely,accurateanddirectcommunication facilitatesthehandofftothereceivingfacilityprovidescontinuity ofcare and avoidsmedical errors andredundanttests.

TypeofMeasure:Process

ImprovementNotedAs:Anincreaseintherate

NumeratorStatement:Numberofpatientstransferredtoanotherhealthcarefacilitywhosemedicalrecord documentationindicatedthatallof theelementswerecommunicatedtothereceivingfacilitywithin60 minutesof discharge.

  • History andphysical
  • Reason fortransferand/orplan of care

DenominatorStatement:EDtransferstoanotherhealthcarefacility

IncludedPopulations:AlltransfersfromEDtoanotherhealthcarefacility

ExcludedPopulations:None

Calculation:

#ofpatientswho haveayesforallmeasures: history andphysicalandreasonforRate= transferand/orplanof care

Alltransfersfrom EDtoanotherhealthcarefacility

RiskAdjustment:No

DataCollectionApproach:Retrospectivedatasourcesforrequireddataelementsincludeadministrativedataandmedicalrecords.

MeasureAnalysisSuggestions:Thedataelementsfor eachofthetwocommunicationelementsprovidetheopportunitytoassesseachcomponentindividually.

Sampling:Yes,pleaserefer tothemeasuresetspecific samplingrequirements.SeethePopulationandSamplingSpecificationsSection.

MeasureEDTC-SUB 6

MeasureInformationForm

MeasureSet:EDTransferCommunication(EDTC)

SetMeasureID#:EDTC-SUB 6

PerformanceMeasureName:NurseGeneratedInformation

Description:PatientswhoaretransferredfromanEDtoanotherhealthcarefacilityhavecommunicationwiththe receivingfacility within 60 minutesof dischargeforkeynurse documentationelementsRationale:Timely,accurateanddirectcommunication facilitatesthehandofftothereceivingfacilityprovidescontinuity ofcare and avoidsmedical errors andredundanttests.

TypeofMeasure:Process

ImprovementNotedAs:Anincreaseintherate

NumeratorStatement:Numberofpatientstransferredtoanotherhealthcarefacilitywhosemedicalrecord documentationindicatedthatallof theelementswerecommunicatedtothereceivingfacilitywithin60 minutesof departure.

  • Assessments/interventions/response
  • Sensory Status (formerly Impairments)
  • Catheters
  • Immobilizations
  • Respiratory support
  • Oral limitations

DenominatorStatement:TransfersfromanEDtoanotherhealthcarefacility

IncludedPopulations: AlltransfersfromanEDtoanotherhealthcarefacility

ExcludedPopulations:None

Calculation:

#ofpatientswho haveayesor NAforallmeasures:assessments/interventions/response,Rate= sensory status ( formerly impairments), catheter,immobilization,respiratory support,oral limitations

Alltransfersfrom EDtoanotherhealthcarefacility

RiskAdjustment:No

DataCollectionApproach:Retrospectivedatasourcesforrequireddataelementsincludeadministrativedataandmedicalrecords.

MeasureAnalysisSuggestions:Thedataelementsforeachofthesixcommunicationelementsprovidetheopportunitytoassesseachcomponentindividually.

Sampling:Yes,pleaserefer tothemeasuresetspecific samplingrequirements.SeethePopulationandSamplingSpecificationsSection.

MeasureEDTC-SUB 7

MeasureInformationForm

MeasureSet:EDTransferCommunication(EDTC)

SetMeasureID#:EDTC-SUB 7

PerformanceMeasureName:ProceduresandTests

Description:PatientswhoaretransferredfromanEDtoanotherhealthcarefacilityhavecommunicationwiththe receivingfacility within 60 minutesof dischargeoftestsdoneandresultssent.

Rationale:Timely,accurateanddirectcommunication facilitatesthehandofftothereceivingfacilityprovidescontinuity ofcare and avoidsmedical errors andredundanttests.

TypeofMeasure:Process

ImprovementNotedAs:Anincreaseintherate

NumeratorStatement:Numberofpatientstransferredtoanotherhealthcarefacilitywhosemedicalrecord documentationindicatedthatallof theelementswerecommunicatedtothereceivinghospitalwithin60 minutesof discharge.

  • Testsandproceduresdone
  • Testsandprocedureresultssent

DenominatorStatement:TransfersfromanEDtoanotherhealthcarefacility

IncludedPopulation: AlltransfersfromanEDtoanotherhealthcarefacility

ExcludedPopulations:None

Calculation:

#ofpatientswhohaveayesor NAforallmeasures: testandproceduresdoneandtestandRate= procedureresultssent

AlltransfersfromEDtoanotherhealthcarefacility

RiskAdjustment:No

DataCollectionApproach:Retrospectivedatasourcesforrequireddataelementsincludeadministrativedataandmedicalrecords.

MeasureAnalysisSuggestions:Thedataelementsfor eachofthetwocommunicationelementsprovidetheopportunitytoassesseachcomponentindividually.

Sampling:Yes,pleaserefer tothemeasuresetspecific samplingrequirements.SeethePopulationandSamplingSpecificationsSection.

EmergencyDepartmentTransferCommunicationDataElements

15

DataElementName:
NursetoNurseCommunication

CollectedFor:EmergencyDepartmentRecords:EDTC-SUB 1

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatnurse-to-nurse communicationoccurredpriorto dischargeofthepatientfromtheED toanotherhealthcarefacility?

AllowableValues:

Y(Yes)SelectthisoptionifthereisdocumentationoftheEDnurse communicating with the nursing staffofthereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationof the EDnursecommunicating with the nursing staffof the receivingfacility.

NotesforAbstraction:

  • Documentation must indicate that nurse to nurse communication occurred prior to
    transfer.
  • Date and time of contact can be used to verify that communication occurred prior to
    transfer.If communicationisgiventoatransfercoordinatoratthereceivingfacility,the coordinatormustbea nurse to selectyes.
  • House supervisor is assumed to be a nurse
  • This does notneed to be full report. Acceptable communication includes assuring the availability of appropriate bed and staff for the patient.
  • As small rural hospitals increasingly use staffing models which include paramedics and EMTs in ED roles, note that communication for this data element may occur between these staff (paramedics and EMTs) and nurses at the receiving facility.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummarydocument
  • Nursing note

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

PhysiciantoPhysicianCommunication

CollectedFor:EmergencyDepartmentrecords:EDTC-SUB 1

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatphysician/advancedpracticenurse/physicianassistant(physician/APN/PA)tophysician/APN/PAcommunicationoccurredpriortothetransferof thepatientfromthe EDtoanotherhealthcarefacility?

AllowableValues:

Y(Yes)SelectthisoptionifthereisdocumentationoftheED physician/APN/PAdiscussionof thepatient’s conditionwithphysician/APN/PAstaff at the receivingfacility.

N (No)Selectthisoptionifthereisnodocumentationof the EDphysician/APN/PAdiscussionofthepatient’s conditionwithphysician/APN/PAatthe receivingfacility.

N/A (NotApplicable)Selectthisoptionifthe transferis toa non-acute carehealthcarefacility.

NotesforAbstraction:

  • Must include the namesofthe twocommunicating providers.
  • Documentation must indicate that ED physician/APN/PA to ED physician/APN/PA communication occurred prior to transfer.
  • Date and time of contact can be used to verify that communication occurred prior to
    transfer.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummarydocument
  • EMTALAform

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

namewas sentto thereceivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthatthepatient’snamewassenttothereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthatthe patient’sname wassentto thereceivingfacility.

NA (NotApplicable)Selectthisoptionifthisinformation wasnotavailable.

NotesforAbstraction:

  • If thepatientis aJohn/JaneDoe,and/orisalteredneurologicallyselectNA
  • Ifthepatienthas apotentialbrain/headinjury selectNA.
  • Ifthepatientrefusesto answerthequestionselectNA.

SuggestedDataSources:

  • Emergency Departmentrecord
  • Facesheet
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

address wassenttothe receivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthatthepatient’saddresswassenttothereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthatthe patient’saddresswas senttothereceivingfacility.

NA (NotApplicable)Selectthisoptionifthisinformation wasnotavailable

NotesforAbstraction:

  • If thepatientis aJohn/JaneDoe,and/orisalteredneurologicallyselectNA
  • Ifthepatienthas apotentialbrain/headinjury selectNA
  • Ifthepatientrefusesto answerthequestionselectNA.

SuggestedDataSources:

  • Emergency Departmentrecord
  • Facesheet
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

agewassentto the receivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthatthepatient’sage was senttothereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthatthe patient’sage wassenttothereceivingfacility.

NA (NotApplicable)Selectthisoptionifthisinformation wasnotavailable

NotesforAbstraction:

  • If thepatientis aJohn/JaneDoe,and/orisalteredneurologicallyselectNA.
  • Ifthepatienthas apotentialbrain/headinjury selectNA
  • Ifthepatientrefusesto answerthequestionselectNA.
  • If thepatient’sdate of birth was sentselectyes.

SuggestedDataSources:

  • Emergency Departmentrecord
  • Facesheet
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatthepatientgender wassentto the receivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatgenderwas sentto thereceivingfacility.

N (No)Selectthisoptionifthereisno documentationthatgenderwassenttothereceivingfacility.

NA (NotApplicable)Selectthisoptionifthisinformation wasnotavailable or unableto bedetermined

NotesforAbstraction:SuggestedDataSources:

•Emergency Departmentrecord

•Facesheet

•TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

wentwiththepatientor wascommunicated viafaxorphone or internet/ElectronicHealthRecordconnection availabilitywithin 60 minutesof the patient’sdischarge.

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatcontactinformationfor afamily member/significantother/friend was sentto thereceivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatcontactinformationwassenttothereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthatcontactinformationwassentto thereceivingfacility.

NA (NotApplicable)Selectthisoptionifthisinformation wasnotavailable

NotesforAbstraction:

  • Thepatient’scontactcan bea family member,significantotheror friend.
  • Contactinformationmustincludeboth anameandphonenumber.
  • Can havemore thanonecontactbutmusthaveatleastone.
  • Ifthepatientis aJohn/JaneDoe and/orisalteredneurologicallyselectNA.
  • Ifthepatienthas apotentialbrain/headinjury selectNA.
  • Ifthepatientrefusesto answerthequestionselectNA.

SuggestedDataSources:

  • Emergency Departmentrecord
  • Facesheet
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

insuranceinformationwassenttothereceivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatinsuranceinformationwassentto thereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthatinsuranceinformationwas senttothereceivingfacility.

NA (NotApplicable)Selectthisoptionifthisinformation wasnotavailable

NotesforAbstraction:

  • Informationmustincludeboththeinsurance company name andpolicynumber.
  • If patientdoesnothave insuranceanduninsuredstatusisdocumented,selectyes.
  • Ifthepatientis aJohn/JaneDoe and/orisalteredneurologicallyselectNA.
  • Ifthepatienthas apotentialbrain/headinjury selectNA.
  • Ifthepatientrefusesto answerthequestionselectNA.

SuggestedDataSources:

  • Emergency Departmentrecord
  • Facesheet
  • Copyof insurancecard
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

pulsewastakenandsenttothe receivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthatthepatient’spulse was takenandsenttothereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthatthe patient’spulse wastakenand orsent tothereceivingfacility.

NotesforAbstraction:SuggestedDataSources:

  • Emergency Departmentrecord
  • Nursing Notes
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

respiratoryrate wastakenandsenttothereceivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthatthepatient’srespiratoryrate was takenandsentto thereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthatthe patient’srespiratoryratewastakenandsenttothereceivingfacility.

NotesforAbstraction:SuggestedDataSources:

•Emergency Departmentrecord

•Nursing Notes

•TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

bloodpressure wastakenandsenttothereceivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthatthepatient’sbloodpressurewastakenandsentto thereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthatthe patient’sbloodpressure was takenandsenttothereceivingfacility.

NA (NotApplicable)Selectthisoptionifthepatientislessthanorequalto3years of age.

Select this option if a Blood Pressure is unable to be assessed due to patients’ behavior or mental status.

NotesforAbstraction:SuggestedDataSources:

•Emergency Departmentrecord

•Facesheet

•TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

oxygensaturation(O2 Sat)was takenandsentto thereceivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthatthepatient’soxygensaturation(O2Sat)wastaken andwas sentto thereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthatthe patient’soxygensaturation(O2 Sat)wastaken andsentto thereceivingfacility.

NotesforAbstraction:SuggestedDataSources:

•Emergency Departmentrecord

•Nursing Notes

•TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

temperaturewastakenandsentto thereceivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthatthepatient’swastakenandthetemperaturewas senttothereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthatthe patient’stemperaturewastakenand sentto thereceivingfacility.

NA (NotApplicable)Selectthisoptionifthetemperatureisnotrequired.Seenotesforabstraction.

NotesforAbstraction:

Temperatureisrequiredforpatientswithphysician/APN/PAdocumentationof suspectedinfection,hypothermiaor heatdisorder.

SuggestedDataSources:

•Emergency Departmentrecord

•Nursing Notes

•TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethataneurologicalassessmentwasdone on patientsatriskfor alteredconsciousness andsenttothereceivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthata neuroassessmentwasdoneandsenttothereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthata neuroassessmentforthecondition wasdoneandsenttothereceivingfacility.

NA (NotApplicable)Selectthisoptionif aneurologicassessmentisnotrequireddueto nodocumentationof alteredconsciousness,possible brain/head injury,traumaor postseizure,stroke,TIAcondition.

NotesforAbstraction:Onlyrequiredforpatientswithdocumentationof:

  • Alteredconsciousness
  • Possiblebrain/headinjury
  • Postseizure
  • Trauma
  • Stroke
  • TIA

SuggestedDataSources:

  • Emergency Departmentrecord
  • Birth ordeliveryrecord
  • TransferSummarydocument
  • Glasgow comascale
  • Neuroflow sheets

ExclusionGuidelinesforAbstraction:

None

wentwiththepatientor wascommunicated viafaxorphone or internet/ElectronicHealthRecordconnection availabilitywithin 60 minutesof the patient’sdischarge.

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatthelistofmedication(s)administeredor that no medications were administered inthe EDwas sentto thereceivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatthelist ofmedicationsadministeredwere sentto thereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthatthe listofmedicationsadministeredweresenttothereceivingfacility.

NotesforAbstraction:

  • If no medicationsweregivenduringtheED visit,documentationmuststatethatthere were nomedicationsgivento selectyes.
  • Medicationinformationdocumentedanywhere inthe EDrecordisacceptable.

SuggestedDataSources:

•Emergency Departmentrecord

•MedicationAdministrationRecord(MAR)ifpartof theEDdocumentationforthecurrentencounter

•TransferSummarydocument

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

allergyhistorywassentto thereceivingfacility?

AllowableValues:

Y (Yes)Selectthisoptionifthereisdocumentationthe patient’sallergy information wassenttothereceivingfacility.

N(No)Selectthisoptionifthereisnodocumentationthepatient’sallergyinformationwas sentto thereceivingfacility.

NotesforAbstraction:

  • Seeinclusionguidelinesforwhatshouldbe containedintheallergyinformation.
  • If documentationissentthatallergiesareunknown,selectyes.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummary

InclusionGuidelinesforAbstraction:

  • Food allergies/reactions
  • Medicationallergies/reactions
  • Otherallergies/reactions

ExclusionGuidelinesforAbstraction:

None

medicationhistorywassenttothe receivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationmedicationhistorywassenttothe receivingfacility.

N (No)Selectthisoptionifthereisnodocumentationmedicationhistorywassenttothereceivingfacility.

NotesforAbstraction:

  • If documentationindicatespatientisnoton anyhome medications,selectyes.
  • If documentationissentthathome medicationsareunknown,selectyes

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummary

InclusionGuidelinesforAbstraction:

  • Complimentary medications
  • Overthe counter(OTC)medications

ExclusionGuidelinesforAbstraction:

None

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatahistory andphysicalwasdoneby thephysician/advancedpracticenurse/physicianassistant(physician/APN/PA)andsenttothereceivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationa historyandphysical wasdoneandsenttothereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthata historyandphysicalwas doneandsenttothereceivingfacility.

NotesforAbstraction:

Mustminimallyinclude history ofthe currentED episode,afocusedphysicalexamandrelevantchronicconditions.Chronicconditionsmay beexcludedifthe patientisneurologically altered.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummary

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

wentwiththepatientor wascommunicated viafaxorphone or internet/ElectronicHealthRecordconnection availabilitywithin 60 minutesof the patient’sdischarge.

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatareasonfortransferand/orplanofcarewasdone by thephysician/advancedpracticenurse/physicianassistant(physician/APN/PA)andsentto thereceivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationa reasonfortransferor planof carewas doneandsenttothereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthata reasonfortransferorplan of care wasdoneandsenttothereceivingfacility.

NotesforAbstraction:

May includesuggestionsforcaretobe received atthereceivingfacility.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummary
  • EMTALAform

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

wentwiththepatientor wascommunicated viafaxorphone or internet/ElectronicHealthRecordconnection availabilitywithin 60 minutesof the patient’sdischarge.

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatnursingnotesweresentto thereceivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatnursingnoteswere senttothe receivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthatnursingnoteswere sentto thereceivingfacility.

NotesforAbstraction:

  • Examplesof nursingnotesmay includenursingassessment,intervention,responseorSOAPnotes.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummary

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

connection availabilitywithin 60 minutesof the patient’sdischarge.

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicatethatthepatientwas assessedforimpairments?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatassessmentof sensory statuswasdone andinformationwassenttothereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthatassessmentof sensory status wasdone andinformationwassenttothereceivingfacility.

NotesforAbstraction:

Select Yes if documentation indicates that patient is unresponsive.

Documentation includesthepatientbeing assessed formental,speech,hearing,vision,andsensationimpairment.

For example:

  • A History and Physical that includes at least one the following would be acceptable
  • ENT WNL – indicates assessment of speech and hearing
  • Oriented - indicates assessment of mental status
  • Has or denies tingling/numbness – indicates assessment of sensation
  • Nursing Notes that indicate the following would be acceptable:
  • Wears eyeglasses – indicates assessment of vision
  • Has hearing aid – indicates assessment of hearing

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummary

InclusionGuidelinesforAbstraction:

None

ExclusionGuidelinesforAbstraction:

None

connection availabilitywithin 60 minutesof the patient’s discharge

SuggestedDataCollectionQuestion:DoesthemedicalrecorddocumentationindicatethattreatmentwithIV or any other catheters wasprovidedtothepatientandsentto thereceivingfacility?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatcatheterinformation wassenttothereceivingfacility.

N (No)Selectthisoptionifthereisnodocumentationthatcatheterinformationwas senttothereceivingfacility.

NA (NotApplicable)Selectthisoptionifnocatheterswere placed.

NotesforAbstraction:

SelectNAifno catheterswereplaced.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

  • IV(intravenous)
  • IT(intrathecal)
  • Urinary
  • Heparin Lock
  • Central line

ExclusionGuidelinesforAbstraction:

None

connection availabilitywithin 60 minutesof the patient’sdischarge.

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicateinformationwassentregardinganyimmobilizationprovidedforthepatient?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatimmobilizationwas done andinformationwassenttothereceivingfacility.

N (No)Selectthisoptionifthereisdocumentationthatimmobilizationwas done andinformationwasnotsentto thereceivingfacility.

NA (NotApplicable)Selectthisoptionifnoimmobilizationwasdone

NotesforAbstraction:

SelectNAifno immobilization wasdone.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

  • Backboard
  • Casts
  • Neckbrace
  • Otherbraces

ExclusionGuidelinesforAbstraction:

None

connection availabilitywithin 60 minutesof the patient’sdeparture

SuggestedDataCollectionQuestion:Doesthemedicalrecorddocumentationindicateinformationwassentregardinganyrespiratory supportprovidedtothepatient?

AllowableValues:

Y(Yes)Selectthisoptionifthereisdocumentationthatrespiratorysupportwasprovidedandinformationwassenttothereceivingfacility.

N (No)Selectthisoptionifdocumentationthatrespiratorysupportwasprovidedandinformationwasnotsentto thereceivingfacility.

NA (NotApplicable)Selectthisoptionifnorespiratory supportwas provided.

NotesforAbstraction:

Ifnorespiratory supportwasprovidedselectNA.

SuggestedDataSources:

  • Emergency Departmentrecord
  • TransferSummarydocument

InclusionGuidelinesforAbstraction:

  • Bronchialdrainage
  • Intubations
  • Oxygen
  • Ventilatorsupport

ExclusionGuidelinesforAbstraction:

None