Recommendation Document:
Standard Data Elements Suggested for Inclusion on Hospital Inter-facility Transfer Forms and Face
Sheets to Facilitate Large-scale Emergency Patient Evacuation
Purpose: This document provides a list of standard data elements that hospitals are encouraged to
include on existing inter-facility transfer forms and patient face sheets, in order to ensure that transfer
forms and patient face sheets can be effectively used during large-scale evacuations of healthcare
facilities. This list was compiled by the Patient Movement Workgroup (see description below). It is the
workgroup’s belief that the inclusion of these elements by hospitals throughout the NYC region will
facilitate appropriate staging, transfer and triage of patients during emergency events which require or
result in large-scale patient evacuation from one hospital to another.
Patient Movement Workgroup: Launched in February 2015, the Patient Movement Workgroup (PMW)
is jointly led by the NYC Department of Health and Mental Hygiene (DOHMH) and the Greater New York
Hospital Association (GNYHA). Bringing together emergency managers, clinicians, health IT specialists,
transfer center leadership and others from more than ten hospitals and health systems, as well as
government agencies and medical transport organizations, the PMW has worked to tackle several
related challenges experienced during Hurricanes Irene (2011) and Sandy (2012) which hampered
patient evacuation.
Problem(s) of Interest: During Hurricanes Sandy and Irene, basic clinical and demographic information
was not always available to the clinicians and staff responsible for staging at the sending hospital,
facilitating appropriate transport, and triage at the receiving hospital. Regardless of clinical
conversations that may occur between providers at both hospital, it is imperative that staff involved
with patient care throughout the evacuation and transport process, which can take several hours,
possess basic clinical and demographic information in order to appropriately care for the patient during
this transition period. Furthermore, having a set of standard data elements used across institutions will
ensure that regardless of the origin or destination of the patient, at a regional level clinicians know what
information they can expect when receiving a patient.
A Potential Solution: While some jurisdictions have developed a stand-alone patient evacuation form
for such purposes, it was the opinion of the PMW members that use of day-to-day systems and
documents would result in higher adherence during a stressful situation and therefore would result in
better outcomes. The PMW considered several potential sources of clinical and demographic
information. The group determined that the use of inter-facility transfer forms and patient face sheets
held the greatest promise. These two documents are ubiquitous at hospitals across the region, and in
the case of inter-facility transfer forms, their day-to-day purpose closely mimics the purpose such forms
would have in a patient evacuation scenario.
The PMW collected and examined nearly a dozen examples of such forms, assessing the frequency with
which various elements were used and weighing the importance of these elements for safe patient
staging, transport and triage during an evacuation scenario. This process resulted in the development of
the list of recommended standard data elements detailed below.
Recommended Standard Data Elements: Inter-facility Transfer Form
Demographic
Information
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Name
Date of Birth
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Transport-related
Information
Clinical Information
Patient Information
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Medical Record Number/NYS DOH eFinds Number
Height/Weight/Sex
Preferred Language
Patient Mobility Level (Ambulatory, Wheelchair, Non-ambulatory)
If an ambulance required, ALS or BLS
Bariatric
IV Medication requirements during transport
ECMO or IABP (requires transport team)
Oxygen Requirements (eg. BiPAP, CPAP)
Ventilator Settings
Settings/Sizes of lifesaving equipment (eg. trach)
Behavioral Concerns/Safety Risks
Fall Risk/Restraints
Hospital Bed Number at sending and, if known, at receiving facility
Nurse or physician contact Information at sending and receiving facility
Date and time of departure and arrival with signature lines
Primary Diagnosis
Secondary Diagnosis
Relevant Comorbidities
Most Recent Vitals
Current Medications including pain management medications
Timing and dosage of medications
Allergies
Isolation Status/Presence of Infectious Disease
IV Access
DNR/Advanced Directive/Healthcare Proxy
Transplant List Status
Progress Notes Section
Mental Status
Personal Assistive Devices transferred with patient such as glasses or
hearing aid
Diet information
Bariatric
Presence of pressure ulcers
Seizure precautions
Drug research protocol
Recommended Standard Data Elements: Patient Face Sheet
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Name
Medical Record Number/NYS DOH eFinds Number
Social Security Number
Sex
Date of Birth
Address
Emergency Contact Information/Next of Kin
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Primary Care Physician Name and Number
Parent/Guardian Information for Minors
Insurance Information
Guarantor Information
ADL
Room and Bed Number
Primary Diagnosis
Suggested Internal Process: As an outcome of the PMW, DOHMH and GNYHA urge all hospitals in the
NYC region to compare the list of recommended data elements provided above to their current interfacility transfer forms and patient face sheets, and determine which elements are already included and
which are not. In order to successfully advocate for the addition of these elements to your hospital’s
standard documents, you should consider two elements:
1. Educate key staff within your hospital regarding the need to integrate these data elements.
While each institution is different, these staff may include: emergency managers, nursing
leadership, transfer center staff, and EMS/transport leadership.
2. Understand the process by which changes to forms occurs in your hospital.
Working in collaboration with key staff in your hospital, following your institution’s standard process,
and tying your efforts to this larger regional initiative, you will likely be able to integrate many of these
elements into your existing documents.
Creating Complimentary EMR Reports: Either in parallel, or at the conclusion of the paper form revision
process, we suggest working with your facility’s Health Information Technology staff to create standard
EMR reports that can automatically populate the required variables on the inter-facility transfer form
and patient face sheet. The creation of such reports has the potential to increase speed and accuracy
during an emergency event as well as during routine inter-facility transfers.
How DOHMH and GNYHA Can Assist: We have created the attached Process Change Workflow to assist
you in tracking your internal efforts. We are also committed to tracking progress on this initiative at a
system level. To this end, we plan to contact all member institutions during late 2015 to understand
which standard data elements are currently included on their inter-facility transfer forms and patient
face sheets. Approximately one year later, in late 2016, we will follow up again to determine which
missing elements have been successfully adopted and offer assistance as needed.
Additional Clinical Documentation: Depending upon the particular circumstances of the emergency
patient evacuation, hospitals should consider sending additional clinical documentation with each
patient. Below we have provided a list developed by the PMW in order from highest to lowest priority.
As part of its emergency plan development and review process, hospitals should consider if and how
they could produce the documents below. At the time of an emergency event requiring patient
evacuation, Incident Command leadership should determine what documentation from the list should
be produced for each patient as part of the preparation and staging process.
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Medical Chart including:
o Most recent set of complete medical Orders
o Medication Administration Sheets
o History and Physicals
o Operative/Consultation Reports
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o Most recent set of labs
o Radiology/EKG
o Blood and Blood Product Transfusion Records
Doctor/RN Transfer notes
DNR
Healthcare Proxy
Advance Directives
Critical Care Equipment Settings for Critical Patients
Restraints Order
If you have questions about the Patient Movement Workgroup, this recommendation document or the
suggested internal process set forth, please contact Jenna Mandel-Ricci (jmandel-ricci@gnyha.org)
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