Gaining information about resident transfers is an important goal of the OPTIMISTC project. CMS also requires us to report these data. This form is where data relating to long stay transfers are to be recorded. The INTERACT QI Tool was used to create this document. If you have any questions regarding data collection please contact Merih Bennett mtzeggai@iupui.edu or Tom Tuttle tuttleto@iupui.edu. The * are questions asked only for a planned transfer. *Your Name *Nursing Facility SECTION 1: Resident Characteristics a. *Resident Name *MRN b. *DOB *Transfer Type? Acute or Planned d. Clinician ordering transfer (first and last name): f. Conditions that put resident at risk for hosp. admission/readmission: Hospitalization in Dementia + behaviors the last 6 months CHF COPD Cancer, on active chemo or dose change or new radiation therapy med within 48 hrs. Stroke in last 3 months of transfer Other Surgery in the last 3 months c. *Date of Transfer e. *Time of Transfer g. *Resident Hospitalized in the past 30 days? Yes No SECTION 2: Acute Change in Condition and Factors that Contributed to the Transfer a. Date change in condition first noticed b. Briefly describe the change, symptom, sign or other factor(s) that led to the transfer.
c. Check all that apply and designate primary and secondary reasons for transfer below (if planned procedure please specify what the procedure is): New Symptoms or Signs Abnormal Labs or Tests Anemia Falls w/o obvious injury Blood Sugar Abdominal pain Fever CBC Bloody stool Head trauma EKG Behavioral symptoms Hypertension Kidney Function (BUN, Bleeding (other than GI) Hypotension Creatinine) Bradycardia infection Pulse oximetry Confusion or worsening Limb swelling Urinalysis or urine culture cognitive function Loss of consciousness Venous Doppler Change in Appetite Malaise X-ray Change in Mental status New neurologic Other Cough weakness Chest pain Planned Write in lab or test results Critical lab value Procedure Dizziness Pain Depressive affect Seizure Diarrhea Suicidal ideation Fluid imbalance Suspected soft tissue Falls w/ injury Shortness of breath/high respiratory rate Tachycardia Unresponsiveness Urinary Symptoms or incontinence Vomiting Other d. List Primary reason for transfer (from check boxes above) e. List Secondary reason (from check boxes above) f. List Primary and Secondary Diagnoses THAT LED TO THE TRANSFER (if known at time of transfer): Adverse Drug reaction Anemia Asthma Atrial fibrillation Bronchitis Cancer (any) Cardiac arrhythmia Cellulitis COPD CHF Dehydration Delirium Depression Diabetes Diverticulitis Electrolyte Imbalance Fracture other than hip GI bleeding Hip fracture Hypertension Intestinal obstruction Leukemia acute Leukemia chronic Lower respiratory infection Pneumonia Psychosis Pulmonary embolus Seizure Renal failure acute Renal failure chronic Respiratory Failure Sepsis Stroke/TIA Subdural Hematoma UTI Urosepsis
Dementia Multiple myeloma Myocardial infarction Peripheral vascular disease Other Unknown g. List Primary diagnosis at time of transfer (from check boxes above) h. List Secondary diagnosis at time of transfer (from check boxes above) SECTION 3: Describe Action(s) taken to Evaluate and Manage the Change in Condition Prior to Transfer a. Briefly describe how the changes in section 2 were evaluated and managed: b. Actions taken to Evaluate and Manage the Change in Condition Prior to Transfer. Check all that apply Tools Used Stop and Watch SBAR Care path(s) Change in Condition File Cards Acute Care Transfer Form (or an equivalent electronic version) Advance Care Planning Tools Other Structured Tool or form Medical Evaluation Telephone only NP or PA visit MD visit OPTIMISTIC NP visit Other Who Initiated transfer? Family or Resident preference MD/NP/PA decision OPTIMISTIC Staff NF staff Other Testing Blood tests EKG Urinalysis and/ or culture Venous Doppler X-ray Other Who else was involved in the transfer? (check all that apply) Family or Resident preference MD/NP/PA decision OPTIMISTIC Staff NF staff Interventions New medication IV or subcutaneous fluids Oxygen Other c. *Was the Advance Care Plan reviewed at the Time of Transfer? Y / N / Not able to be found d. *Were the advance directives followed? Y / N/ Authorized representative changed AD at time of transfer/requested alternative treatment Explain? e. Did the POST form/out of Hospital DNR go to the hospital? -Yes No -N/A Unknown SECTION 4: Identify Opportunities for Improvement a. Check all that apply
Transfer Tracking and QI Form The new sign, symptom, or other change might have been detected earlier SECTION 4: Identify Opportunities for Improvement continued: Changes in the resident's condition might have been communicated better among NH staff, with MD/NP/ PA, or with ER staff The condition might have been managed safely in the facility with available resources Resources were not available to manage the change in condition safely or effectively (Check all that apply) On-site primary Staffing Lab or other care clinician Other diagnostic Pharmacy services tests a. Check all that apply Resident and family preferences for hospitalization might have been discussed earlier Advance directives and/or palliative or hospice care might have been put in place earlier Other(describe) b. ln retrospect, do you/ OPTIMISTIC staff/ facility staff/ other providers think this transfer might have been prevented? (Circle one then describe below) 1) Definitely not avoidable, 2) probably not avoidable, 3) probably avoidable, 4) definitely avoidable c. In retrospect, you/ OPTIMISTIC staff/ facility staff/ other providers think this resident might have been transferred sooner? Y / N (If yes, describe) d. After review of how this change in condition was evaluated and managed, have you/ OPTIMISTIC staff/ facility staff/ other providers identified any opportunities for improvement? Y / N (If yes, describe specific changes the team can make in care processes and related education as a result of this review) *Time (in minutes) to complete this form (sections 1-4) After collecting all of data for sections 1 through 4, you will enter the information into the REDCap screen located here: https://redcap.uits.iu.edu/surveys/?s=cnxvsf
After the resident has been discharged from their acute hospital stay, has expired or is transferred to another facility you should be able to collect the information for sections 5 and 6. You will enter this information into a separate REDCap screen located here: https://redcap.uits.iu.edu/surveys/?s=qwcdes Transfer Follow Up Your Name Nursing Facility Resident Characteristics Resident First Name Last Name MRN DOB Original Date of Transfer out of the facility Date returned to the facility (only if applicable) SECTION 5: Data on Hospital Transfer (completed on hospital discharge) a. Outcome of Transfer Hospital Name ED visit only Admitted, inpatient Admitted, observation Admitted, status uncertain Other b. Hospital Discharge Diagnosis (primary) (ICD-9 codes) c. Hospital Discharge Diagnosis (secondary) (ICD-9 codes) d. Did the resident transfer back to the facility die in the hospital or transfer to another setting e. Was the resident admitted after going out for a planned transfer Y/N SECTION 6: Transfer Back to Facility a. Was a discharge summary received from the hospital? Y / N
b. What information was provided by the hospital on the resident s return to the facility? (check all that apply) Discharge Diagnosis Relevant Comorbidities Relevant Hospital/Surgical Course Current Medications c. Did the same POST form/out of Hospital DNR return with the resident? Yes No, a different POST form/out of Hospital DNR returned with the resident Code status (Out of Hospital DNR or POST Form) Call back number/name of on-coming nurse and contact information for discharging MD No, the resident returned to the facility without a POST form/out of Hospital DNR N/A Unknown d. If a different order came back from the hospital what was the order? -Out of hospital DNR -new or modified POST (check all that apply) Section A: CPR DNR Section B: Comfort Measures Limited Additional Interventions Full Treatment Section B intentionally left blank Section C: Antibiotics for infection only Antibiotics consistent with treatment goals Section C intentionally left blank Section D: No artificial nutrition Defined Trial (Length: Goal: ) Long term Section D intentionally left blank