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Transfer Ready DtTm tmp entry: Difference between revisions

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|ProjectActive=active
|ProjectActive=active
|ProjectProgram=CC and Med
|ProjectProgram=CC and Med
|ProjectRequestor=internal  
|ProjectRequestor=internal
|ProjectCollectionStartDate=2020-10-15
|ProjectCollectionStartDate=2020-10-15
|Project=Transfer Ready DtTm tmp entry
|Project=Transfer Ready DtTm tmp entry
}}
}}


=== Transfer Ready ===
== Collection instructions ==
The status of "transfer ready" is about the time of an '''intent''' to move a patient to level of care that is lower in the [[Level of care hierarchy]] if there was an available bed there. Whether or not the patient actually moves does not matter, just that at some point there was an intent to move the pt.
=== What is Transfer Ready ===
* The status of "transfer ready" is about the date/time of an '''intent''' to transfer a patient to '''lower''' level of care in the [[Level of care hierarchy]] if there was a bed available. Whether or not the patient actually moves does not matter, just that at some point there was an intent to move the pt. It also does not matter whether after such a determination the care team changed their minds about such a desired transfer.
* Obviously we don't always know the team's ''intentions'', but if they do write them down, then '''use that info'''.
** In making this delineation, except as for the exceptions listed immediately below, only consider a clearly written intent that the team now desires the patient to be transferred to such a lower level of care. 
*** In particular, when a ward patient is transferred (e.g. home) without any notes stating the team’s intention to do so in advance or even an order to discharge, collectors ''should '''not''' attempt to make educated guesses'' from the notes of when the patient was ''probably'' clinically ready to leave and the checkbox is checked.


Obviously we don't always know the team's ''intentions'', but if they do write them down, then '''use that info'''.
See [[Level of care hierarchy]] for further information.


Some considerations:
==== Specifically for ICU ====
*The phrase '''"medically stable"'' could mean that the person is improved enough to go elsewhere, but it '''does not''' necessarily mean that.  For example it could technically indicate that the condition is not changing lately, which may or may ''not'' mean that they're ready to go elsewhere.
'''In an ICU''', take the following to indicate transfer ready to a lower level of care even if they have not written that explicitly:
**Thus, by itself that phrase cannot be used alone to suggest the patient is transfer ready
* Care is stepped down to '''ward frequency''' (q4hrs or less) of vitals AND off '''all''' forms of life support except possibly intermittent dialysis
{{Ex |
* [[HSC_IICU]] consult is written  
*e.g. Deconditioned patient may be medically stable but intention can be to leave them where they are for now to re-condition
* patient is made '''[[ACP-C|ACP-C]]'''
*e.g. Patient is medically stable but still needs a sitter --> another situation in which just being "medically stable" isn't sufficient to tell us if they're transfer ready
* for organ donors, see [[Guideline for coding organ donation after death]]
}}
* if the patient is a '''potential organ donor and then deemed not to be''', the Transfer Ready tmp DtTm will be when that determination is made
*In an '''ICU setting''', you can take the following to indirectly indicate transfer ready to a lower level of care when nothing has been written:
* for those patients who are declared brain dead, and do '''not become actual or potential organ donors''', use the time of [[Brain death]] as the Transfer Ready DtTm tmp entry, and the time of cardiac death as the [[Dispo DtTm]]
**care is stepped down to '''ward frequency''' (q4hrs or less) of vitals, off '''all''' forms of life support except possibly intermittent dialysis
**[[HSC_IICU]] consult is written  
*In a '''ward setting''', you can take the following to indirectly indicate transfer ready to a lower level of care when nothing has been written:
**care is stepped down to change iv meds to po, remove monitoring
*In either '''ICU or ward setting''' being made '''[[ACP C|ACP-C]]''' can be taken as indirect evidence of being transfer ready.
 
==== What if the pt ends up transferred to a higher level of care ====
'''The original transfer {{PAGENAME}} does not change. '''
{{Collapsable
| always= Expand for details why
| full= 
It might '''seem''' that a patient who was transfer ready but then moves to a higher level of care should be excluded, since they did not actually get transferred to a lower level of care. However, when the patient was deemed transfer ready, additional time in the ward was "wasted time" - if we could have sent them elsewhere we would have. If the patient later crashes, that doesn't make it not-wasted time - they could have crashed anywhere. So the interpretation that a pt moving to a higher level of care after transfer ready is not wasted time is not right. We discussed this repeatedly at task and steering meetings. The only way this makes sense is if it is done by intent.
}}


== Data Collection Instructions ==
====Specifically for Medicine ====
For '''each [[Boarding Loc]]'''  entry (incl the original ER one, if present), enter the following:
'''On a medicine ward''', take the following to indicate transfer ready to a lower level of care even if they have not written that explicitly:
* Project: '''Transfer Ready DtTm'''
*For SBGH If there is no discharge order, then the DC summary date/time that the attending signs off can be used, however if the date and time is after the DC time then it may be documented in a nursing or allied health IPN. Also, for SBGH often bed utilization will document when they are waiting on a transfer to an LAU or other facility, or rehab services will document when they are on the central wait list, or long term care (LTC) will document when they are approved for a PCH bed.  
* Item: '''Transfer Ready DtTm'''  
*For HSC if there is no discharge order, then check the IPN notes (nursing, allied health etc), often bed utilization will document when they are waiting on a transfer to an LAU or other facility, or rehab services will document when they are on the central wait list, or long term care (LTC) will document when they are approved for a PCH bed. 
* Transfer Ready Date: Date as defined in section [[#Transfer Ready]] above
* Order is written to change all iv meds to po AND monitor discontinued/vital sign frequency is reduced
* Transfer Ready Time: Time as defined in section [[#Transfer Ready]] above
* Patient is made '''[[ACP-C|ACP-C]]'''
* checkbox: '''to be checked only if a transfer ready date never became available'''
* When [[Dispo]] is PCH, use the date and time of the pre-panel checklist initiation as the [[Transfer Ready DtTm]], this will usually be documented in the  notes by one of the allied health workers or LTC
* comment (under 'q'): '''only if TR date not available (ie if checkbox checked), enter either "not ready" or "not available" into the comment field.
* If a discharge order is written during the preceding day(s) prior to discharge:
** and a specific date and time for discharge is documented in that order, the transfer ready date and time would be the date and time specified in the order. 
** and If the order is to discharge after a specific test or procedure/treatment ie. dialysis or last dose of antibiotics, then the transfer ready date and time would be the time they finish the treatment or procedure.
** and there is no specific date and time documented for discharge or another order for discharge is written, then check the checkbox or use that new discharge order date and time


=== initial pre-entered record ===
* The discharge medication reconciliation form should NOT be used as transfer ready date and time.
A first entry is added automatically to each new patient entered on the laptop.


The first time the patient becomes [[#Transfer Ready]], enter the date and time into this pre-entered record.
* '''PT/OT Assessment''': Before going home, some ward patients get a home safety evaluation from PT and OT, and if deemed safe for home get a homecare evaluation before going home. The transfer ready date/time in such a situation should be only after the PT/OT evaluation has deemed them safe to go home, i.e. before homecare has seen them.  The rationale is that homecare evaluation can occur after discharge, but a hospitalized patient who “fails” their home safety evaluation will end up going to LTC, not home.
* exception to this would be for those patients that are waiting for transfer to a rehab ward (Geri, stroke, amp, neuro etc) The date and time they are placed on the wait list for rehab can be used as their transfer ready date and time


=== additional records if there are additional [[Boarding Loc]]s ===
== Data entry instructions ==
For '''every''' additional [[Boarding Loc]] (whether it is at different [[Level of care hierarchy]] or not):
* A "Transfer Ready" line is automatically created for each [[Boarding Loc]] entry.
* leave the original line as is
** Project: '''Transfer Ready DtTm'''
* enter a new {{PAGENAME}}
** Item: the only available item is "Transfer Ready DtTm", just like the project entry.
** if the pt '''changes''' from ''not'' being [[#Transfer Ready]] to being [[#Transfer Ready]] during the stay at that [[Boarding Loc]] enter that dttm
** Date and Time vs checkbox:
** if the pt ''doesn't change '''to''' [[#Transfer Ready]] state'', enter the checkbox and "not available"
***  Collector needs to enter one of the following:
{{Ex |
**** '''First''' Date and Time during the stay '''at this [[Boarding Loc]]''' that patient '''became''' transfer ready as per [[#What is Transfer Ready]] above
Enter "not available" if any of the following:  
::OR
* arrived transfer ready
:::* checkbox checked if a clear transfer ready date and time are never documented, both must be present to be considered a valid Transfer Ready DtTm
* left location still not transfer ready
}}


=== Patient arrives transfer ready ===
{{Combined instructions for Transfer Ready DtTm and Boarding Loc}}
If a patient at any [[Boarding Loc]] and is already [[#Transfer Ready]] enter the same date into [[Transfer Ready DtTm field]] as the time of the respective [[Boarding Loc]] entry.


==== Patient doesn't become [[#Transfer Ready]] before leaving unit ====
=== Collection for each Boarding Loc ===
If pt never becomes [[#Transfer Ready]], check the checkbox to say so. This is so we can be sure the entry wasn't just forgotten.  
We currently only use the first entry per [[Level of care]] to calculate [[Transfer Delay]], but we collect both because:
* It gives us the flexibility to report per location if requested
* To make it easier for data collectors. This way, collectors don't have to try and go back and figure out if there was or was not a transfer ready in a prior location. They only need be concerned about the notes and orders from THIS boarding loc.


Enter either "not ready" or "not available" into the comment field so we know how to interpret the entry.
== Start DtTm/Legacy ==
We used the old [[Transfer Ready DtTm field]] '''for transfer ready dttms''' before 2020-10-15, and use this new entry for dttms after.


'''Don't check this until the patients actually leaves that [[Boarding Loc]] (either to a next one or to [[Dispo]]) and you are sure a date never became available.
The data during the transition period for [[PatientFollow Project]] is inconsistent, so we use all the new and the old in [[Created TransferReady query]].
 
=== Status changing back and forth while on same [[Boarding Loc]] ===
If a patient changes from being transfer ready back to not being transfer ready, collect the '''first''' time they are [[#Transfer Ready]] at a given [[Boarding Loc]]. If they become no longer transfer ready, leave it alone, and if they become transfer ready again at the same level of care, retain only the original Transfer Ready DtTm for that level.
 
== Start DtTm ==
We used the old [[Transfer Ready DtTm]] field '''for transfer ready dttms''' before 2020-10-15, and use this new entry for dttms after.


== Data Use / Purpose ==
== Data Use / Purpose ==
Critical care and Medicine programs want to know this to better understand patient flow and bed utilization.
Critical care and Medicine programs want to know this to better understand patient flow and bed utilization.


Used to generate [[Transfer_Delay]] and [[Avoidable Days in ICU]].
Used via [[Created_TransferReady query]] and [[Created_transferDelay table]] to generate [[Transfer Delay]] and [[Avoidable Days (Critical Care)]].


=== How will these be matched with [[Boarding Loc]] entries, is additional data needed? ===
{{DJ  |
We will determine each [[Boarding Loc]]'s [[Level of care hierarchy]] using the [[s_level_of_care table]]. Depending on data needs we will then be able to provide [[Transfer Delay]] either by unit or by [[Level of care hierarchy | level of care]]. To provide it by level of care we would choose the first dttm after (or at) arrival to the first [[Boarding Loc]] at a given level of care.
* Grace Hospital not filled this out according to instructions documented here, but some old version instead. That makes data between GRA and other sites problematic to compare. Lisa and Gail have more info. We should document which version they have been using so it can be accounted for when using this data. }}


== Background ==
== Background ==
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{{Data Integrity Check List}}
{{Data Integrity Check List}}
== Log ==
2021-07-08 - [[Change from Awaiting/delayed dx codes to Transfer Ready DtTm]] for data back to 2021-07-01


== Legacy ==
== Legacy ==
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[[Category:Data Collection Guide]]
[[Category:Data Collection Guide]]
[[Category:Admit/Discharge]]
[[Category:Admit/Discharge]]
[[Category:End-of-life related data]]
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