Overstay Predictor Project

Purpose

A small number of patients overstays for a significant amount of time after they are medically ready for discharge. Though the number of patients is small, a significant proportion of bed-days is wasted in the process. We are piloting a process at the Grace where an "overstay coordinator" will be assigned to patients at risk of overstaying. Whether a patient is at risk is determined by the ward nurse assessing risk factors on a form, and by an assessment algorithm that takes into account the values mentioned as mandatory above; the combination of these results in a chart being assigned a colour sticker, and the transition coordinators monitor these chart stickers.

Primary Investigator

Primary Investigator: Dr. Dan Roberts

• Overstay Predictor Project for Medicine - Dec 5.11 collection team meeting discussion item 6

Pilot Information

Official pilot start data for the Grace has been delayed, meeting to discuss new plans is scheduled for May 3.

1. is there any update from this meeting?
   • no update. Project still on hold until further notice.Trish Ostryzniuk 16:26, 2012 June 12 (CDT)

Please continue the informal testing that has been going on for the last few days. Thanks! Ttenbergen 14:19, 2012 April 30 (CDT)

• thank you Stephanie and Sheila for super feedback.Trish Ostryzniuk 15:32, 2012 April 30 (CDT)

Instructions

For every medicine patient at the Grace hospital, as soon as possible, but definitely within 48 business hrs of admission:

• find the new "Overstay" form on the chart
• for the first 6 check boxes on the form, create a record for each in tmp entries and check the checkbox if the answer is Yes. (one to one from the form, no interpretation necessary)
• (I will add a picture of the form here once we have a final version)

1. so if the answer to the question is "yes" we check the box, then if the answer is "no" we do not check the box,; the current prototype form I have also has "unknown" as a possible answer-how would we note this? Template:Discussion.

• Also, enter at least all the following as part of minimal dataset
  • DOB
  • Admit Date
  • ADLs
  • ??whether there was any CVA or Dementia as a comorbid??? Template:Discussion CVA in comorbid??
  • whether there was a permanent & severe neurological or spinal insult as an admit or complication diagnosis.

• Click the new “Overstay” button on the patient viewer form next to the notes field and it will turn a colour (colors based on an underlying algorithm too complicated to get into here, but based on tmp entries, age, comorbids, admit dxs and ADLs):
  • GREEN - low/no risk for discharge issues
  • YELLOW - some risk for discharge issues
  • RED - significant risk for discharge issues.
  • GRAY - if some needed data is missing

• If the chart already has a sticker the same colour then you are done
• if the colour in the program is different from the one on the chart put a sticker of the program colour over the sticker on the chart. Stickers will be supplied.

Outstanding Issues & Questions

If you can't find data Question

• I have emailed Linda to please fill in who the collector should talk to if there are problems with the Overstay form or the other data required for the project in a timely manner.

1. has this been determined?

Ttenbergen 14:45, 2012 April 23 (CDT)

Overstay Predictor Diagnosis Code Used

June 12.12- the list of Overstay Predictor Diagnosis Code Used to be used for the overstay predictor algorithm was approved by Dan Roberts. Submitted to Julie Mojica & Linda Hathout.Trish Ostryzniuk 17:03, 2012 June 12 (CDT)

• Julie will connect with Rodrigo and update him. Rodrigo is the person working on algorhythm.--Trish Ostryzniuk 16:25, 2012 June 12 (CDT)
  • April 27.12-only CVA 505 is included in the algorithm to generate the colour only data pertaining to CVA 505 was given to Rodrigo (the programmer) for overstay analysis as per Tina.

working diagnoses Question

Template:Discussion Occasionally the working diagnosis written by the MD is CVA but this has not been confirmed by CT; should this be coded in admission diagnosis anyway and then removed later if not confirmed?

• Will confirm processTtenbergen 12:02, 2012 May 2 (CDT)

Programming Stuff

testing for consistent data

Template:Discussion I intentionally left out one of the overstay questions in the temp file expecting to get a gray overstay predictor score indicating missing information but am getting yellow-is this correct?

• Program should not have let this through, I'll need to look into that. Ttenbergen 12:02, 2012 May 2 (CDT)

button colour persistence

Template:Discussion every time I exit the Database and then reenter, I have to repress the overstay button as it has gone gray; this is still an issue May 8

• Will confirm processTtenbergen 12:02, 2012 May 2 (CDT)

1. is the dx code for violent behaviour secondary to dementia included in the list?
2. would it be helpful for us to note the reason the pt has stayed past the date it is noted they are medically stable somewhere; the chart usually notes whether the pt is being panelled, waiting for services or assessments etc. or whether the pt becomes "unstable" again while waiting for d/c
3. does the algorithm include age, and/or whether the pt originally comes from a nursing home? pts from an existing nursing home bed will not overstay as frequently as those from home
4. is it possible for the 6 overstay requirements in the temp file to be generated automatically like the postal code is rather than having to add the 12 items manually? we then would just have to check the box to answer each question

Questions

location of form and sticker

Template:Discussion Where on the chart will this new form be and will it be a colored form?Trish Ostryzniuk 10:43, 2012 April 24 (CDT)

• not known yet, will add details when we get them. Ttenbergen 12:56, 2012 April 27 (CDT)

• What is the purpose of putting the sticker on the chart; will this be looked for by other disciplines to identify the need for their intervention?
  • see #Purpose Ttenbergen 11:56, 2012 May 2 (CDT)

no need to document sticker colour changes

1. Will it be necessary to document a difference in sticker colours if we need to change the colour once the algorithm has run?
   • no need. The original colour is based on the items you enter into tmp, so we can go back from that if needed. Ttenbergen 12:47, 2012 April 27 (CDT)

test scenarios for colours

1. How can I test the yellow colour?-I can only get the overstay button to be red or green using multiple different combinations of the check boxes
   • yellow would be based on a combination of comorbids and ADLs and age. Make a patient a little less sick and they will become yellow. Sorry, can't give you exact instructions, the algorithm is pretty messy. Ttenbergen 12:47, 2012 April 27 (CDT)

admission times and conditions at admission

The time we use as the time of admission will be different than the time of admission to the unit, and often significant time has passed between the 2 times so the information collected is different e.g. pt is confused at our admission time but by the time the patient goes to the unit, the patient is now A & O etc or vice versa. Will this affect the algorithm?

• Use the data as you would have entered before as that is what the algorithm was based on. I hope that helps, since I know some collectors used to collect this much later. Pls let me know if you need more info. Ttenbergen 12:47, 2012 April 27 (CDT)

1. what if our assessment differs from that of the admitting nurse e.g. they ask the pt/family on admission if they have fallen within the past 6 months and are told no or the information is not available, and we see from looking through the chart that falls have been documented within this timeframe?

1. is the admission information the only source used or will the complications be taken into consideration e.g. if the pt develops a new cva as a complication do we redo the overstay predictor?