Transfer Ready DtTm tmp entry

Projects
Active?:	active
Program:	CC and Med
Requestor:	internal
Collection start:	2020-10-15
Collection end:

Collection instructions

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 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. 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.

We need a consistent approach to how we handle the following scenarios: We can assume that in all scenarios there is no other clear documentation. 1. Discharge order, or a progress note written with date but no time. (either same day of discharge or day prior) 2. Discharge order written with date and time, but the order is to discharge the following day or on a specific date (reasons for the delay are some times clearly documented,ie.if they are waiting for homecare services or transportation etc), or discharge post last dose IV ABX, discharge after dialysis. This is likely not an issue at SBGH because their notes would be automatically date and time stamped. At HSC when there is an order without a time for the day of discharge, we generally use 1000 as the time, as rounds happen between 9-1100, or should we just use the dispo date and time? For those orders that are written the day prior and the reason is waiting for services or transportation we would use the date the order is written with the time 1000, for those that are waiting for medical treatments we use the dispo date and time. We also investigate, so that if the prior order is date and time stamped well after 1000, then we obviously cannot use the 1000 so we would use the dispo date and time.

• SMW

• Cargo

• Categories

EXCEPTIONS:

In an ICU, take the following to indicate transfer ready to a lower level of care even if they have not written that explicitly:

• care is stepped down to ward frequency (q4hrs or less) of vitals AND off all forms of life support except possibly intermittent dialysis
• HSC_IICU consult is written
• patient is made ACP-C

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:

• order is written to change all iv meds to po AND remove monitoring
• patient is made ACP-C
• BUT in the absence of some clear indication (a discharge order, or a progress note, or one of the 2 items immediately above), do NOT try to guess at the transfer ready timing. For example, if there is no such order, and no note saying that the patient was ready to leave or ready for transfer to a lower level of care, but the patient was discharged or transferred, in this case assign the transfer ready timing as the actual Dispo DtTm or the date and time of the next Boarding Loc
  • for lateral moves ie. acute medicine ward to another medicine ward, or ICU to ICU there would be no Transfer Ready DtTm so the checkbox would be checked

For purposes of transfer ready the following services are considered to be a lower level of care:

• WRHA non-Medicine (e.g. surgery, family med, OB, etc) AND lower acuity ward in acute care hospital, whatever flavour of the month word they use for this, incl. rehab, geri-rehab, palliative care unit, etc

• To be clear here, we DO consider these locations "lower" levels than are Medicine wards, and the reason is that a major purpose of the levels is to be able to count up "wasted" bed-days in ICUs or Medicine wards. But of course the care provided in some of these other locations are not truly lower levels.

See Level of care hierarchy for further information.

• Special Note regarding Transfer Ready from a ward: 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.

Data entry instructions

• A "Transfer Ready" line is automatically created for each Boarding Loc entry.
  • Project: Transfer Ready DtTm
  • Item: the only available item is "Transfer Ready DtTm", just like the project entry.
  • Date and Time vs checkbox:
    • Collector needs to enter one of the following:
      • First Date and Time during the stay at this Boarding Loc that patient was transfer ready as per #What is Transfer Ready above; do not "carry forward" a transfer ready from any prior Boarding Loc
        • i.e. this is the transition to transfer ready, so if they arrived already transfer ready at a Boarding Loc you should not enter the start of that Boarding Loc and instead enter the date of a subsequent new first transfer ready status at this second Boarding Loc

OR

• checkbox checked if the patient is not transfer ready (ie. moves to a higher level of care, moves to an equal level of care, or leaves AMA)

OR

if there is no clear Transfer Ready DtTm enter the Dispo DtTm if discharged from hospital or use the date and time of the subsequent Boarding Loc if transferred to a lower level of care.

Example:

Mr Jones went from MICU to SICU. In MICU he was transfer ready but at no time after transfer did the team caring for him in the SICU write that he was transfer ready. Thus he will have a transfer ready date/time from the MICU boarding loc, but not from the SICU boarding loc.

Combining Transfer Ready DtTm tmp entry and Boarding Loc records

• There needs to be one Transfer Ready DtTm tmp entry for each Boarding Loc and vice versa. To mark which entries belong together, use the same integer number in the "combiner" field in Patient Viewer Tab Cognos ADT2 for both records and in sequential order according to Boarding start_dt and start_tm. The presence of matching records is validated by query s_tmp_check_combined_Boarding_Loc_and_TransferReadyDtTm, and their sequential status by query s_tmp_check_combined_BL_and_TRDtTm_nonsequential.
• the integer number should be entered at the time that the paired Boarding Loc and Transfer Ready DtTm tmp entry are entered, as Julie uses this data early to report on

Patient doesn't become #Transfer Ready before leaving unit

• 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.
• 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.

Transfer ready to serveral different lower levels of care

• If there is clearly written as transfer-ready to a lower level, and then while in the same location he/she is written as transfer-ready to an even lower level of care, only enter the first date and time.

What if the pt ends up transferred to a higher level of care

The original Transfer Ready DtTm tmp entry does not change. We want the first one one only.

Expand for details why

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. After discussion with medicine, Allan reported back that they want the 'first medically stable only (Task Team Meeting - Rolling Agenda and Minutes 2021#ICU Database Task Group Meeting – June 15, 2021).

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.

Data Use / Purpose

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 (Critical Care).

Background

This isn't so much a project as a change to Transfer Ready DtTm collection to allow us to collect more than one Transfer Ready DtTm per patient-program-stay. See Change from Service Location to Service, Boarding Loc and Transfer Ready DtTm tmp entry for why we needed to change to this.

Data Integrity Checks (automatic list)

	App	Status
Query check ICD10 needs awaiting if TR Dt and Dispo Dt on diff days	CCMDB.accdb	declined
Query check TISS each day	CCMDB.accdb	declined
Query check ICD10 awaiting has Transfer Ready DtTm	CCMDB.accdb	implemented
Query check transfer DtTm during admission	CCMDB.accdb	implemented
Query check has transfer ready date or checkbox	CCMDB.accdb	implemented
Query s tmp check combined Boarding Loc and TransferReadyDtTm	CCMDB.accdb	implemented
Query s tmp check Boarding Loc and TransferReadyDtTm pairs	CCMDB.accdb	implemented
Query check Transfer DtTm after paired BL and before later BL	CCMDB.accdb	implemented
Query Check BL TR combiner null	CCMDB.accdb	implemented
Query check tmp 2 BL TR S same tm	CCMDB.accdb	implemented
Query check long transfer delay	CCMDB.accdb	needs review
Function Validate Transfer Ready DtTm	CCMDB.accdb	retired
Function Transfer Ready DtTm vs status	CCMDB.accdb	retired
Query check transfer ready tmp for each Boarding Loc	CCMDB.accdb	retired
Query check tmp Transfer Ready not before Boarding Loc	CCMDB.accdb	retired
Query s tmp check combined BL and TRDtTm nonsequential	CCMDB.accdb	retired

Log

2021-07-08 - Change from Awaiting/delayed dx codes to Transfer Ready DtTm for data back to 2021-07-01

Legacy

Similar to the old Transfer Ready DtTm field and Transfer Ready date and time, but we eliminated special cases and differences between medicine and critical care.

Related articles