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|description='''Transfer Delay''' is the difference between [[Dispo_DtTm]] and [[#Time patient is ready for transfer]] in decimal days.
|description='''Transfer Delay''' is the difference between [[Dispo_DtTm]] and [[#Time patient is ready for transfer]] in decimal days.
Other terms use to call it are '''Beds Occupied by transferable patients''', '''Wasted Beds''', '''Avoidable Days'''.
Other terms use to call it are '''Beds Occupied by transferable patients''', '''Wasted Beds''', '''Avoidable Days'''.
|created_raw=created
|created_raw=Created
|Program=Medicine
|Program=Medicine
|indicator_start_date=2003-10-01
|indicator_start_date=2003-10-01
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|program=Medicine
|program=Medicine
}}
}}
See also [[Transfer Delay (Critical Care)|Transfer Delay]].


{{DT |
See also [[Transfer Delay (Critical Care)]].
* According to the discussion at Task on 2022-04-20 this will need to be updated once the reporting is updated. Something about 30 minutes grace time for all? [[User:Ttenbergen|Ttenbergen]] 20:59, 2022 April 20 (CDT)
* And there was a scenario HOBS -> ward -> HOBS2, what would we use as an end date for the ward in the middle? Julie was going to check how she has implemented this and then document here. I hope the start of HOBS2 is the end date 15:50, 2022 April 27 (CDT)
** changes done as per Minutes. --[[User:JMojica|JMojica]] 14:42, 2022 April 29 (CDT)}}


== Use ==
== Use ==
* The purpose is to determine the amount of time the patient is occupying a bed in a High Observation ward or a regular ward setting when the patient is no longer needing that [[Level of care hierarchy| level of care]] from the [[Transfer Ready DtTm]] until the [[Dispo DtTm]] or end date and time of this level of care.  
* The purpose is to determine the amount of time a patient is occupying a bed in at a given [[Level of care]] (High Observation ward or a regular ward) when the patient is no longer needing that [[Level of care]].
 
* This is relevant because:
** If patients are at a higher level of care than they need this can indicate that beds at a lower level are not available and more might be needed.
** It might also indicate that beds at a higher (and more expensive) level of care might be reduced if patients could consistently move to the appropriate level of care.
** A patient who doesn't need to be in a hospital runs the risk of nosocomial complications if they remain in hospital.


== Definition ==
== Definition ==
*Actual Transfer delay is the difference between '''End Dttm''' of a given level of care and [[#Time patient is ready for transfer]] in decimal days.
* ''Transfer Delay'' is the difference in decimal days between the time the pt is first transfer ready at a [[Level of care]] and the time that they leave that level
*Two '''End Dttm'''
** '''starts''' at the [[Transfer Ready DtTm]] corresponding to the first [[Boarding Loc]] of a given [[Level of care]]
**If the  patient stayed in one or more wards having the same level of care, the '''end dttm''' is the [[Dispo DtTm]].
** '''ends''' as a patient leaves that level of care in one of the following ways:
**if the patient stayed  in both High Observation ward and regular ward which have different  level of care, the '''end dttm''' is the last dttm of  this same level of care which is the start dttm of the different level of care.
*** to a [[Dispo]] location (ie [[Dispo DtTm]])
*** Example a  scenario HOBS1 -> regular ward -> HOBS2 -> Home - the delays for first HOBS [[Transfer Ready DtTm]] is until the Start dttm of the arrival to the regular ward; the regular ward  [[Transfer Ready DtTm]] is until the Start dttm of the arrival to the HOBS2 and the HOBS2 [[Transfer Ready DtTm]] is until [[Dispo DtTm]].
*** to a [[Boarding Loc]] with a ''different''(higher or lower) [[Level of care]] (ie the start of that next [[Boarding Loc]])
**** transfer to another [[Boarding Loc]] at the ''same'' [[Level of care]] does not reset the clock/generate a new delay
 
{{ex |
* Scenario: arrive HOBS1 -> ready to transfer to reg ward -> regular ward -> ready to transfer out -> HOBS2 -> Home  
** first transfer delay is (start of reg ward) - (ready to transfer to reg ward)
** second transfer delay is (start of hobs) - (ready to transfer out)
** three is no transfer ready between HOBS2 and home, so no additional delay
}}
 
{{DJ |
* How about scenario Med(with TR) -> HOBS -> Med(with TR) -> hosp discharge
* According to the definition that would result in two delays but we only get a single Delay metric per record. So is it
::(a) sum (time from TR1 to start of HOBS, time from TR2 to hosp discharge)
::(b) sum (time from TR1 to start of HOBS, entire time at subsequent med level of care locations)
* In [[Beds occupied by transferrable patients (Medicine)]] you state that the metric is per patient, but is it really per patient, per record or per boarding loc? So if a patient goes from a boarding loc to another and back to the first, you presumably report the sum of the time at that loc for that pt, but for an average, would the N be 1 patient or 2 records? To take that further, if the pt goes to ICU and then comes back, would the N become 3? the inclusion criteria on that page don't really clarify how this is resolved.
I realize we were breaking out these indicators and trying to have each explained all on page for ease of use by report users, but this is an example where I think it would be better to define things like 'the transfer delay complex' as individual indicators, individual stratifiers, and then possibly define a compound indicator that combines them, but refers to the earlier definitions. It makes it slightly harder to follow, but hopefully anyone who actually looks at a data definition value coherence of the details over light reading.
* Also, I realize it's more friendly to read in indicators that something is "per patient", but I think it is also important to be specific about this, so suggest we should change this to be the actual N used in any of our indicators.
* in file 20_... for GRA data Julie provides an explanation that may resolve this question. I am putting it below. If I understand that one correctly,
** W1 - W1TR - W2 - H1 - W3 - W3TR - Dispo would result in a delay of dispo-W1TR
** W1 - W2 - W2TR - H1 - W3 - W3TR - Dispo would result in a delay of dispo-W3TR
* Is that the right understanding? If Julie agrees the discussion can go.
}}
# If patient stayed in HOBS only to discharge , then its transfer ready dttm is considered, otherwise the first transfer ready from regular ward is used.
# If patient both stayed first in HOBS  then  regular ward to discharge, the first transfer ready from regular ward is used.
# If there are more than one transfer ready dttm from regular ward then to regular ward to discharge, the first transfer ready dttm is used.
# If there is coming back and forth from High Obs to regular to HOBS to regular to discharge , then the first transfer ready dttm from regular going to regular (same) or lower level of care is used.
 
== Calculation of Transfer Delay ==
* As agreed in JALT meeting March 22, 2023, transfer delays will be reported based on actual delays at each [[Level of care]] with no more allowances of less than n hours.
*Before Jan 2023, Transfer delay calculation is done similarly with the Critical Care calculation which is substracting ''n'' hrs from all actual delay time and for Medicine, ''n'' is 4 hours.
*In the meeting held Jan 11, 2023, Critical Care agreed to change the calculation of  transfer delays which Medicine will do similarly  for consistency as follows: (a) ignore such transfer delays < 4 hrs, but (b) for all delays >=4 hrs to use the actual delay time.  The process is to be done on the transfer delay at each [[Level of care]].


== Implementation ==
== Implementation ==
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Starting Oct 1, 2020, it will need to be calculated differently.  
Starting Oct 1, 2020, it will need to be calculated differently.  


It is not reported by ward, it is reported only per episode / profile.  
It is not reported by ward, it is reported only per [[Definition of a Medicine Program Admission| episode / profile]].  


Julie sums up the multiple transfer delays that might be present.  
Our [[statistician]] sums up the multiple transfer delays that might be present and reports them all aggregated to their [[Dispo DtTm]]. It is done this way because only once we have a complete record with a [[Dispo DtTm]] we have reliable Transfer Ready data, so it's the only way we can report on this without becoming inconsistent with data reported earlier.


Start time is first transfer ready per level of care; end is either last of this level of care, or dispo.  
Start time is first transfer ready per level of care; end is either last of this level of care, or dispo.  


*Before Oct 1, 2020, it is calculated by [[Created_Variables_Common_maker query]] and stored in [[Created_Variables_Common table]] in [[CFE]].
*Before Oct 1, 2020, it was calculated by [[Created_Variables_Common_maker_2021 query]] and stored in [[Created_Variables_Common_2021 table]] in [[CFE]].


*Starting Oct 1, 2020, it will be added but haven't started.  
*The new definition has only been implemented in SAS and is not available in [[CFE]].


{{Todo
=== Implementation in CFE ===
| who = Tina
For now, a "Transfer Ready Med testing" button on the main form of CFE needs to be pressed to generate this data. Once we are comfortable with it this generating will be included in the [[Calc created variables button]].  
| todo_added = 2021-08-03
| todo_action = 2021-08-17
| question =_dev_CFE
* Make that available in CFE.
* add the updated calculation based on the new process to [[Created Variables]]. }}


=== Which Transfer Ready DtTm To Use? ===
[[Sub populate_created_transferDelay()]] loads [[created_TransferReady query]] (which generates transfer ready dates) and [[created_BoardingLoc_plus_historical query]] and writes delays to [[created_transferDelay table]].
==== Before Oct 1, 2020 ====
 
== Which Transfer Ready DtTm To Use? ==
This is now implemented in [[Created_TransferReady query]].
 
=== [[Admit DtTm]] or [[Dispo DtTm]] < 2020-10-01 00:00 ===
* for each patient in ICU and  Medicine ward, the transfer date and time is taken from the [[Transfer Ready DtTm field]].
* for each patient in ICU and  Medicine ward, the transfer date and time is taken from the [[Transfer Ready DtTm field]].
==== Starting Oct 1, 2020 ====
* for each record and each boarding location in Medicine, the transfer date and time is taken from the [[Transfer Ready DtTm tmp entry]].
* for each record, it is possible to have one or more entries of [[Transfer Ready DtTm]] corresponding to one or more boarding locations.
* for each record, it is possible to have more than one [[Level of care hierarchy]] namely
** WRHA HOB Medicine ward
*** HSC-GH7S - from May 1, 2005 to April 14, 2020, Aug 8,2020 to present
*** HSC-GB2 - from April 14, 2020 to Aug 8, 2020
*** SBGH-L2ME - from Oct 1, 2018 to April 1,2019
** WRHA regular Medicine ward (CTU or NTU)
* for each record if the patient moves to various locations, the '''first''' [[Transfer Ready DtTm]] from a [[Boarding Loc]]  with the '''same''' [[Level of care hierarchy| level of care]] will be used
** for example, a Med patient stays in high obs bed and then move to regular ward bed and then another regular ward bed. There are two [[Level of care hierarchy| levels of care]] - one  for high obs and another which is lower, for the regular ward.  At least two [[Transfer Ready DtTm]] intent are expected here - first intent for high obs ready to go to a regular ward and the second intent is from a regular ward to be discharged to another lower [[Level of care hierarchy| level of care]] or home or PCH. Assuming that there are transfer orders both at regular ward 1 and regular ward 2 and both are with same [[Level of care hierarchy| level of care]], the ''first'' [[Transfer Ready DtTm]] time will be used in calculating the wasted bed for that lower [[Level of care hierarchy| level of care]].  There will be another wasted bed to be calculated for the high Obs [[Level of care hierarchy| level of care]] from the [[Transfer Ready DtTm]] to the time the patient left the high obs bed (ie the [[Dispo DtTm]] or the next [[Boarding Loc]] start DtTm.  Transfer delays for high obs and regular ward will be separately reported.
** if the Med patient stays in more than one regular wards (or boarding location), all locations are considered with the same [[Level of care hierarchy| level of care]], the wasted bed is calculated from  the first [[Transfer Ready DtTm]] until [[Dispo DtTm]].


==== Why collect per ward in medicine when we only report per admission? ====
=== [[Admit DtTm]] or [[Dispo DtTm]] >= 2020-10-01 00:00 ===
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.
* the transfer date and time is taken from the [[Transfer Ready DtTm tmp entry]].
* for each record, it is possible to have one or more entries of [[Transfer Ready DtTm]] corresponding to one or more [[Boarding Loc|boarding locations]], which may or may not be at a different level in the [[Level of care hierarchy]], namely regular wards (CTU or NTU) and [[High-Obs Wards]]
* for the purpose of Transfer Delay (Medicine), we will have a transfer delay for each group of [[Boarding Loc]]s at the same [[Level of care hierarchy| level of care]], i.e. there may be more than one per CCMDB record. To accommodate more than one line per record, this is stored in its own table.
* the '''first''' [[Transfer Ready DtTm]] from a [[Boarding Loc]]  with the '''same''' [[Level of care hierarchy| level of care]] will be used
{{ex|
* for example, a Med patient stays in high obs bed and then move to regular ward bed and then another regular ward bed. There are two [[Level of care hierarchy| levels of care]] - one  for high obs and another which is lower, for the regular ward.  At least two [[Transfer Ready DtTm]] intent are expected here - first intent for high obs ready to go to a regular ward and the second intent is from a regular ward to be discharged to another lower [[Level of care hierarchy| level of care]] or home or PCH. Assuming that there are transfer orders both at regular ward 1 and regular ward 2 and both are with same [[Level of care hierarchy| level of care]], the ''first'' [[Transfer Ready DtTm]] time will be used in calculating the wasted bed for that lower [[Level of care hierarchy| level of care]].  There will be another wasted bed to be calculated for the high Obs [[Level of care hierarchy| level of care]] from the [[Transfer Ready DtTm]] to the time the patient left the high obs bed (ie the [[Dispo DtTm]] or the next [[Boarding Loc]] start DtTm.  Transfer delays for high obs and regular ward will be separately reported.  
}}


== Calculation when transfer time missing ==
* Before Oct 1,2020 - The following definitions are used by Julie in reporting from SAS, and by [[centralized_data_front_end.accdb]] to calculate the created_variables query.
** if discharge time  < 1200 HR then dummy=0001 HR (12:01 am) ,
** else if discharge time  >=  1200 HR dummy=1200HR  (12:00 noon)
This is as per approval by [[Dr. Dan Roberts]].
* Starting Oct 1,2020, transfer time is always present.
== Reporting of Transfer Delays ==
== Reporting of Transfer Delays ==
*Reported as count, Mean (average), Sum (Total), and Cumulative counts and percentage separately for High Obs  and regular ward
* Include all cases with transfer ready dttm  (who went to same/lower/higher level of care or died).  
*A - Determine the patients who left alive to a lower level of care in the [[Dispo field]] and
* Refer to indicator [[Beds occupied by transferrable patients (Medicine)|Beds occupied by transferrable patients]]
** A1 - Have  transfer delays
** A2 - Have no transfer ready dttm - assign them as zero transfer delay
** Total True delays = Transfer delays from A1 + zeroes from A2 ;  Total N = A1 + A2; Average True Delays=Total True Delays / Total N
** Total transfer delays > 4 hours  - sum up those patients from A1 by excluding those with transfer delays <= 4 hours  and compute the Average.
** Distribution of true transfer delays - counts, cumulative counts and percentage
***zero
***<= 4 hours
***>4h - 12h
***>12h - 1d
***>1d - 2d
***>2d - 3d
***>3d - 7d
***>10d - 14d
***>10d
 
*B - Determine and report the number of patients with transfer delays who had left alive and went to a higher or same level of care in the [[Dispo field]] .  
*C - Determine and report the number of patients with transfer delays who died in the [[Dispo field]] before going anywhere


== SAS Program==
== SAS Program==
*S:\MED\MED_CCMED\Julie\SAS_CFE\CFE_macros\logphi_TR.sas
*S:\MED\MED_CCMED\Julie\SAS_CFE\CFE_macros\logphi_TR_Jan2023.sas
**  %Med_tready
**  %Med_tready
*S:\MED\MED_CCMED\Julie\SAS_CFE\CFE_macros\prep_Tmp_BoardServiceTransfer.sas  (macro %boardtransf)
*S:\MED\MED_CCMED\Julie\SAS_CFE\CFE_macros\prep_Tmp_BoardServiceTransfer.sas  (macro %boardtransf)


==Data use==
==Data use==
[[Beds occupied by transferrable patients (Medicine)|Beds occupied by transferrable patients]]
*[[Transfer Delay (Medicine)|Transfer Delay]]
*[[Beds occupied by transferrable patients (Medicine)|Beds occupied by transferrable patients]]


{{Data Integrity Check List}}
{{Data Integrity Check List}}
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