Updated CAH MBQIP ED Training
Emergency Department Transfer Communication (EDTC)
Date:9/9/15
Mary Guyot
Principal
207-650-5830 (C)
mguyot@stroudwater.com
Phase 3: ED Transfer Communication (EDTC)
Official Start Was = October 1, 2014
Your start date will be [Qtr. X, 20XX
2
Phase 3 – ED Transfer Communication
Emergency Department: Transfer Communication Measures
 Measures are approved by:
 NQF National Quality Forum
http://www.qualityforum.org/Home.aspx
 NQMC National Quality Measure Clearinghouse
http://www.qualitymeasures.ahrq.gov/
 The following instructions to abstract data are based on:
Minnesota Statewide Quality Reporting and
Measurement System – Last Update Jan. 2015 (do
away with the October 2013 version and June 2014)
 Prepared by StratisHealth, in collaboration with the
University of Minnesota Rural Health Research Center
3
ED Transfers Communication – Rationale
 Communication problems are a major factor to adverse
events in hospitals, accounting to 65% of sentinel events
tracked by the Joint Commission
 Research indicate that deficits exists in the transfer of
patient information between hospitals and primary care
physicians in the community and between hospitals and
long-term care facilities.
 Hospital Compare does not yet track and report ED
transfer communication
 The Joint Commission has adopted National Safety Goal
2 to “Improve the Effectiveness of Communication
Amongst Caregivers”.
 Given the lack of services in rural, it stands to reason
that more patients are transferred from the rural
hospitals
 The ED Transfer Communication measures aim to provide
a means of assessing how well key patient information is
communicated from an ED to any healthcare facility
4
ED Transfers Communication – Pilot Project
 In 2003, an expert panel convened by the University of
Minnesota Rural Health Research Center and
StratisHealth identified ED care as an important quality
assessment measurement category for rural hospitals.
 These measures were piloted by rural hospitals in
Minnesota, Utah, Nevada, Washington, Ohio,
Pennsylvania, New York and Hawaii; projects took place
from October 2005 through Dec 2010.
 Results of the pilot projects indicated room for
improvement in ED care and transfer communication.
 Aggregate project results are available at
http://flexmonitoring.org/documents/DataSummaryRepo
rtNo8_Rural-Hospital-ED-Quality-Measures.pdf and
http://flexmonitoring.org/documents/FlexDataSummaryR
eport3.pdf.
5
ED Transfers Communication – Pilot Project Outcome
6
ED Transfers Communication – Pilot Project Outcome
7
ED Transfers Communication – Measure Elements
 Emergency Department Transfer Communication (EDTC)
EDTC SUB-1:
Administrative Communication
EDTC SUB-2:
Patient Information
EDTC SUB-3:
Vital Signs
EDTC SUB-4:
Medication Information
EDTC SUB-5:
Physician or Practitioner Generated
Information
EDTC SUB-6:
Nurse Generated Information
EDTC SUB-7:
Procedures and Tests
8
ED Transfers Communication – Measure Elements
 EDTC SUB-1: Administrative Communication
 Nurse to nurse communication
 Physician to physician communication
 EDTC SUB-2: Patient Information
 Name
 Address
 Age
 Gender
 Significant others contact
information (name & tel.#)
 Insurance (company name and policy #)
9
ED Transfers Communication – Measure Elements
 EDTC SUB-3: Vital Signs
 Pulse
 Respiratory rate
 Blood pressure
 Oxygen saturation
 Temperature
 Glasgow score or other neuro assessment
for trauma, cognitively altered or neuro
patients only
 EDTC SUB-4: Medication Information
 Medications administered in ED
 Allergies & Reactions
 Home medications
10
ED Transfers Communication – Measure Elements
 EDTC SUB-5: Practitioner Generated Information
 History and physical
 Reason for transfer and/or plan of care
 EDTC SUB-6: Nurses Information






Assessments/interventions/response
Sensory Status (formerly Impairments)
Catheters
Immobilizations
Respiratory support
Oral limitations
 EDTC SUB-7: Procedures & Tests
 Tests and procedures done
 Tests and procedure results sent
11
ED Transfers Communication – Abstraction Coding
 Inclusions
3: Hospice – healthcare facility
4a: Acute Care Facility – General IP Care Hospital
(includes sent to the ED of a General IP Care
Hospital)
4b: Acute Care Facility – CAH
4c: Acute Care Facility – Cancer Care Hospital or
Children’s Hospital
4d: Acute Care Facility – Department of Defense or VA
5: Other healthcare facility (Nursing Facilities (LTC or
SNF), Acute Rehab Hospital/Unit, Psych
Hospital/Unit, or any other facilities with 24 hr
nursing supervision (see clarification on next
slide)
12
ED Transfers Communication – Abstraction Coding
 Inclusions
Note:
It has been clarified that distinct part units (DPU),
though physically located on the same site as the
acute inpatient hospital with their own CMS
Certification Numbers and separate billing from the
acute stays should be considered as transfers to other
healthcare facilities.
Further emphasized:
ED patients who are been put in observation status,
no matter what location that is in the hospital, and then
are transferred to another hospital or health care
facility should be included.
13
ED Transfers Communication – Abstraction Coding
 Exclusions
• Home
• Assisted Living
• Care Home
• Hospice – home
• Expired
• AMA
• Not documented/unable to determine
• Jail
• Facilities without 24 hr nursing supervision
• Admitted to your own facility for general acute care,
psych unit, hospice, SB/SNF, LTC, Acute Rehab (all
considered an admission to your hospital)
14
Phase 3 – ED Transfer Communication
Emergency Department: Transfer
Communication
Description: Percent of charts that had
medical record documentation indicating that the
following patient care elements were sent with the
patient or within 60 minutes of departure.
Measurement collection is done by the sending
hospital.
This measure assesses the sending hospital’s
completeness of communication to a receiving
facility.
15
Phase 3 – ED Transfer Communication
Emergency Department: Transfer Communication
Denominator Statement:
All patients who are transferred to another healthcare facility are
included in the measure for all 7 elements / sub categories
Numerator Statement:
It’s All
or
None!
Percent of patients transferred to another healthcare facility whose
medical record documentation indicated that each of the
following elements were communicated to the receiving facility
within 60 minutes of departure.
Note: Check yes for the 60 minutes if sent with EMS even if it takes
them longer than 60 minutes to get to the receiving hospital. Must be
within 60 minutes if electronically sent.
16
All-Or-None Measure Calculation
 Each of the seven measures is calculated using an
all-or-none approach. Data elements are identified for
each measure.
 If the data element is not appropriate for the patient,
items scored as NA (not applicable) are counted in
the measure as a positive, or ‘yes,’ response and the
patient will meet the measure criteria.
 The patient will either need to meet the criteria for all of
the data elements (or have an NA) to pass the measure.
 Note: NA on the excel spreadsheet provided is
documented as a 1 (same as yes)
17
Electronic Transfer of Information
 For health systems with shared electronic medical
records, documentation must indicate that data
elements had been entered into the data system
and were available to the receiving facility prior
to transfer for Administrative Measures or within
60 minutes of discharge for all other measures.
 If there are no shared records, “sent” means that
medical record documentation indicates the
information went with the patient or via fax or scan
 Note: ED Face Sheet is considered part of the
Medical Record
18
Electronic Transfer of Information
Note:
 A check on the transfer form which states that the “ED Medical
Record was sent” is sufficient but chart must be reviewed to
ensure that it contained each required data element
 If there is a “sent box” but it is not checked, that is to be
abstracted as ED record was NOT sent unless there was some
other documentation to indicate that it was. If not, the only data
elements you may be able to answer yes for are the nurse to
nurse and physician to physician communication.
 If test results are not ready at the time of the transfer and the
transfer documentation does NOT mention a plan for
communicating them when complete, this must be abstracted as
a “No”
19
Electronic Transfer of Information
Q: Can we assume that the “Transfer Record”
“Medical Necessity Certificate” and “Transfer
Summary” gets sent to the receiving hospital?
A: No. If you are using these forms as
documentation that certain data elements were
sent, then you would need to know that the form
was sent.
Q: Can the ambulance transfer form be used for
abstracting?
A: No, we need the hospital assessment.
20
Electronic Transfer of Information
Q: If a facility has an ED packet that is sent with EMS (flight
crew/ambulance/etc,) with the patient and in the medical record
they have the ability to document/check what items were sent – will
this fulfill the requirement? What if all they do is check that the
packet was sent?
A: We need to know that the data elements being asked for were
documented as either being sent with the patient or available in the
electronic health record within 60 minutes of the patient’s transfer.
So for this question, you would need to see documentation in the
record that the packet was sent and what was contained in it. If the
packet contains the required data elements and there was
indication it was sent, then you could say yes to those elements
being sent. If we don’t know what was in the packet and all you had
was documentation indicating that it was sent, then there is no way
for us to know which, if any of the required data elements were
sent.
21
Getting Inclusion list from HIM
3: Hospice
51 = Discharged/Transferred to a Hospice Facility
Does not include home with hospice
4a: Acute Care Facility – General IP Care
02 = Discharged/transferred to another short term general hospital
4b: Acute Care Facility – Critical Aspect Hospital
66 = Discharged/Transferred to a CAH
4c: Acute Care Facility – Cancer Care Hospital or Children’s Hospital
05 = Discharged/transferred to a designate cancer center or
children’s hospital
Use CMS D/C disposition
codes to pull reports for
inclusions and exclusions
22
Getting Inclusion list from HIM
4d: Acute Care Facility – Department of Defense or VA
43 = Discharge/Transferred to a Federal Hospital Department of
Defense hospitals; VA hospitals; or VA nursing facilities
(Note: VA = Veteran Affairs)
5:
Other healthcare facility
03 = Discharged/Transferred to a Skilled Nursing Facility (SNF) with
Medicare Certification in Anticipation of Skilled Care.
04 = Discharged/Transferred to an Intermediate Care Facility
62 = Discharged/Transferred to an Inpatient Rehabilitation Facility
Including Distinct Part Units of a Hospital
63 = Discharged/Transferred to Long Term Care Hospitals
64 = Discharged/Transferred to a Nursing Facility Certified Under
Medicaid but not Certified Under Medicare
65 = Discharged/Transferred to a Psychiatric Hospital or Psychiatric
Distinct Part Unit of a Hospital
23
ED Transfer Communication - Inclusions
Q: Do we include a return to a LTC facility or other facilities as
“Other healthcare facility”?
A: Yes, include patients who arrived from a SNF to ED or ICF to ED
(even though the latter is considered their residence) and
transferred back to their SNF/ICF.
Same goes for transfer back to a psych unit/hospital, a rehab
hospital etc
Q: How do we complete “physician to physician communication” in
the above scenarios since there is most often no physician to call
at those facilities?
A: In the above cases, mark physician to physician communication
as “N/A” when abstracting – so, the only physician to physician
communication expected at this time is when transferring the
patient to another hospital IP or ED
24
ED Transfer Communication - Inclusions
Q: Are ED patients placed in ED Observation and
then transferred to another healthcare facility
kept in the EDTC measure population, or are
they excluded?
A: They would be kept in because they were never
made an inpatient. We would still want to make
sure transfer information was available to the
receiving healthcare facility – therefore, consider
as an inclusion
25
ED Transfer Communication
Inclusion or Exclusions?
Q: Often, accepting hospitals ask the rural hospital to transfer the
patient to the receiving hospital’s ED – is that considered an
inclusion?
A: Any transfers to another acute care hospital are included
regardless if the patient goes directly to general IP care or to
the ED at the receiving hospital.
Q: How do we deal with ED transfers to a the CAHs owned
hospital-based psych, acute rehab unit or SNF – is that
considered an admission or transfer? Do we include these in
our ED transfer abstraction?
A: Exclude – these are considered “an admission to your hospital
and not a transfer”
26
Sample Size Requirements
 May review 100% of patients’ meeting criteria but only
report up to the maximum
 May sample: monthly or quarterly
 Hospitals who’s initial patient population size is less
than the minimum # of cases per quarter for the
measure set cannot sample
 Important to ensure that the sampling procedures
consistently produce statistically valid and useful data
 Due to exclusions, hospitals selecting sample cases
MUST submit AT LEAST the minimum required sample
size
27
Sample Size Requirements: Monthly
But, based on a Q&A response from StratisHealth:
if the hospital has less than 15 in one month and can make it up in another, we
would like them to get to the 45 per quarter if possible”
28
Sample Size Requirements: Quarterly
Sampling Procedure
Take the # of transfers from ED that met the inclusion criteria in the month and divide
by 15 since you need 15 charts per month (the minimum) – ie: 45 transfers per month /
15 = 3 so you would review every 3rd transfers that met criteria
NOTE: The HRSA Report can only take 45 charts per quarter therefore
do not exceed
29
EDTC SUB-1 = Administrative Communication
Total of 2 elements (both or none)
1) Nurse communication with receiving facility
2) Physician communication with receiving physician
Numerator Statement:
Number of patients transferred to another acute care facility whose medical
record documentation indicated that all of the elements were
communicated to the receiving facility prior to the transfer
Denominator Statement: ED transfers to another healthcare facility
30
EDTC SUB-1 = Administrative Communication
This EDTC Sub-1 Measure is the only one where this must
occur prior to the patient leaving the ED
Allowable Values for Nurse to Nurse
Y (Yes) Select this option if there is documentation of the ED
nurse communicating with the nursing staff of the receiving
facility.
N (No) Select this option if there is no documentation of the
ED nurse communicating with the nursing staff of the
receiving facility.
Note: there is no NA
31
EDTC SUB-1 = Administrative Communication
communication states that it must be done “prior to
the discharge of the patient” – in reality, the sending nurse
may be calling the receiving nurse after the patient is
safely in the ambulance at times – then, the nurse has time
to call the report. Often, they can call while they are waiting
for the ambulance but not always. I do not think it would be
against best practice to call as the patient is leaving.
Q: Nurse
A: This has come up as a question in many hospitals and
shared with University of Minnesota. At this point it still
requires to be prior to discharge but with some clarification
(see next slide)
32
EDTC SUB-1 = Administrative Communication
Notes for Abstractions for Nurse to Nurse:
 Documentation must indicate that nurse to nurse communication
occurred prior to transfer.
 Date and time of contact can be used to verify that communication
occurred prior to transfer. If communication is given to a transfer
coordinator at the receiving facility, the coordinator must be a nurse
to select yes.
 House supervisor is assumed to be a nurse
 This does not need to be full report. Acceptable communication
includes assuring the availability of appropriate bed and staff
for the patient.
 As small rural hospitals increasingly use staffing models which
include paramedics and EMTs in ED roles, note that communication
for this data element may occur between these staff (paramedics and
EMTs) and nurses at the receiving facility.
 Cannot be a social worker or unit clerk
 Acceptable to give the report to an LPN when transferring patients to
facilities such as nursing facilities
33
EDTC SUB-1 = Administrative Communication
Allowable Values for Physician to Physician
Y
(Yes) Select this option if there is documentation of the
ED physician/APN/PA discussion of the patient’s
condition with physician/APN/PA staff at the receiving
facility.
N
(No) Select this option if there is no documentation of the
ED physician/APN/PA discussion of the patient’s
condition with physician/APN/PA at the receiving facility.
N/A (Not Applicable) Select this option if the transfer is to a
non-acute care healthcare facility.
34
EDTC SUB-1 = Administrative Communication
Notes for Abstractions for Physician to Physician:
 Must include the names of the two communicating
providers.
• Cannot put yes if the receiving hospital is refusing
to give the accepting physician’s name
 Documentation must indicate that ED physician/APN/PA to
ED physician/APN/PA communication occurred prior to
transfer.
 Date and time of contact can be used to verify that
communication occurred prior to transfer
35
EDTC SUB-1 = Administrative Communication
Q: Sometimes the CAH physician talks to a trauma
coordinator who relays the information to the
receiving physician. The physician than accepts the
patient. Is this acceptable?
A: Yes, the thought is that if the physician is accepting
the patient, the information must have been
communicated. We would just need to make sure
that all this is documented; we need to know there
was communication and the name of the accepting
physician must be there.
36
EDTC SUB-1 = Administrative Communication
Q: When it is obvious that there was physician-tophysician communication prior to transfer, is it
necessary to have a time? For instance, the
physician-to-physician communication is
documented on the H&P which was dictated prior
to transfer.
A: If the H&P was dictated prior to transfer and
documentation indicated there was physician-tophysician communication with name of the
physician the communication was with, that would
be acceptable. We need to know the
communication occurred prior to the transfer.
37
EDTC–2 = Patient Information
Total of 6 elements (all or none)
1)
2)
3)
4)
5)
6)
Name
Address
Age
Gender
Significant others contact information
Insurance
Numerator Statement: Number of patients transferred to another
healthcare facility whose medical record documentation indicated that all
of the elements were communicated to the receiving facility within 60
minutes of departure.
Denominator Statement - ED transfers to another healthcare facility
38
EDTC SUB–2 = Patient Information
Notes for Abstraction for Name, Address and Age
• If the patient is a John/Jane Doe, and/or is altered
neurologically select NA
• If the patient has a potential brain/head injury select
NA.
• If the patient refuses to answer the question select
NA.
39
EDTC SUB–2 = Patient Information
Notes for Abstraction for Contact Information
• The patient’s contact can be a family member,
significant other or friend.
• Contact information must include both a name and
phone number – otherwise select NO
• Can have more than one contact but must have at
least one.
• If the patient is a John/Jane Doe and/or is altered
neurologically select NA.
• If the patient has a potential brain/head injury select
NA.
• If the patient refuses to answer the question select
NA.
40
EDTC SUB–2 = Patient Information
Notes for Abstraction for Insurance Information
• Information must include both the insurance
company name and policy number.
• If you have the insurance company but not the
policy #, select no
• If patient does not have insurance and
uninsured status is documented, select yes.
• If the patient is a John/Jane Doe and/or is altered
neurologically select NA.
• If the patient has a potential brain/head injury select
NA.
• If the patient refuses to answer the question select
NA.
41
EDTC SUB–2 = Patient Information
Q: What if the patient refuses to give us his age –
how do I abstract that?
A: If nurse left the age space blank then report as
“No”. If the nurse wrote patient’s refusal, then
report as NA (Not available) and count as a yes.
Q: The age space on the chart is blank but there is a
note of the year the patient was born - can I count
that as documentation of the patients age?
A: Yes
42
EDTC–2 = Patient Information
Q: How do I abstract “insurance” is reported on the
face sheet marked as “self-insured” for patients with
no insurance?
A: Report it as “Yes” the insurance status was reported
Q: How do I abstract patient information when the
patient is not conscious or not capable of answering
questions including his/her name?
A: Answer NA = not available and consider this as a
“yes” on the abstraction form.
43
EDTC–3 = Vital Signs
Total of 6 elements: (all that pertain or none)
1)
2)
3)
4)
5)
6)
Pulse
Respiratory rate
Blood pressure
Oxygen saturation
Temperature
Glasgow score or other neuro assessment for trauma (cognitively altered
or neuro patients only)
Numerator Statement: Number of patients transferred to another
healthcare facility whose medical record documentation indicated that all
of the elements were communicated to the receiving facility within 60
minutes of departure.
Denominator Statement: ED transfers to another healthcare facility
44
EDTC SUB–3 = Vital Signs
Q: How do I abstract the B/P if the patient was a very young child?
A: Report as NA (Not Applicable) and count as yes if the patient is less
than or equal to 3 years of age.
Q: The patient was too agitated or uncooperative for them to take a B/P
and they documented such. How do I abstract?
A: Abstract as NA if they documented such. Abstract NO if they did not
explain why no B/P
Q: The patient was in ED with no provider documentation to suspect
infection, hypothermia or heat disorder and there is no temperature
documented. How do I count that?
A: Though it is routine to take the temperature on all ED patients, if not
done and there is no provider documentation that they suspect an
infection, hypothermia or heat disorder, you report as NA (Not
Applicable) and count as a yes for the data abstraction.
45
EDTC SUB–3 = Vital Signs
Q: Our hospital requires nursing to complete a Glascow scale
or neuro assessment on all patients. What if I am
abstracting a chart where neuro checks were not required
and they did not do it though it is a policy at the hospital –
how do I report that?
A: Report as NA (Not Applicable) and count as yes regardless of
your policy since it is only required for patients with
documentation of:
• Altered consciousness • Possible brain/head injury
• Post seizure • Trauma • Stroke • TIA
On the other hand, when the patient meets criteria for neuro
assessment, you must look for the presence of :
• Glasgow coma scale and/or • Neuro flow sheets
46
EDTC SUB-4 = Medication Information
Total of 3 elements (all or none)
1)
2)
3)
Medications given
Allergies / Reaction
Medications from home
Numerator Statement: Number of patients transferred to another
healthcare facility whose medical record documentation indicated that
all of the elements were communicated to the receiving facility within
60 minutes of departure.
Denominator Statement: ED transfers to another healthcare facility
47
EDTC SUB-4 = Medication Information
Notes for Abstraction for Medication Given:
•
If no medications were given during the ED visit,
documentation must state that there were no
medications given to select yes.
•
Medication information documented anywhere in the ED
record is acceptable.
•
Select NO even if there is no medication order, no entry
in the MAR section of the ED record when there is not
documentation that their were no medication administered if
not found elsewhere in the medical record sent within 60
minutes of departure
48
EDTC SUB-4 = Medication Information
Notes for Abstraction for Allergies / Reactions:
Inclusion Guidelines for Abstraction:
• Food allergies/reactions
• Medication allergies/reactions
• Other allergies/reactions
NOTE: Reactions must be documented to select YES (ie: rash, N/V,
headache, restless, itchiness, dry cough, dizziness etc….) or NKA
or a note that the patient does not remember the reaction
Notes for Home Medication:
• OTC medication or complementary/alternative medication as a yes if
that is all they take
• If documentation indicates patient is not on any home medications,
select yes.
• If documentation is sent that home medications are unknown, select
yes
49
EDTC-4 = Medication Information
Q: How do I abstract if the nurse documented that the home
medications are unknown
A: Select yes since there is a note that this was addressed
Q: Do we count OTC medication or
complementary/alternative medication as a yes if that is
all they take
A: Yes
50
EDTC-5 = Physician or Practitioner Generated Information
Total of 2 elements: (all or none)
1) History and physical
2) Reason for transfer and/or plan of care
Numerator Statement: Number of patients transferred to another
healthcare facility whose medical record documentation indicated that
all of the elements were communicated to the receiving facility within 60
minutes of departure
Denominator Statement: ED transfers to another healthcare facility
51
EDTC-5 = Physician or Practitioner Generated Information
Q: If the transfer sheet indicates that the H&P was sent with the
patient but it wasn’t dictated/transcribed until after transfer,
can we use it for abstracting the elements?
A: Yes if it was sent to the receiving hospital within 60 minutes of
the transfer time but No if it was dictated to late to send within
60 minutes
Q: A provider’s H&P must minimally include
• history of the current ED episode,
• a focused physical exam and
• relevant chronic conditions.
What if the patient is neurologically altered and cannot answer
his chronic condition – do I have to put “No” for this question?
A: Put “Yes” if the rest is there since chronic conditions may be
excluded if the patient is neurologically altered.
52
EDTC SUB-5 = Physician or Practitioner Generated Information
Q: We have a physician who most frequently document
reason for transfer as “for higher level of care”. Is that
sufficient to put “yes” for reason for transfer and/or plan of
care?
A: Though not ideal, you may answer Yes
Q: What do I do if the physician states that he reviewed H&P
with the receiving physician but the H&P was only written
greater than 60 minutes post discharge – may I use the
H&P for chart abstraction?
A: NO since the hospital did not get the full ED medical
record within 60 minutes of departure.
53
EDTC SUB-6 = Nurse Generated Information
Total of 6 elements: Nurse documentation includes:
1)
2)
3)
4)
5)
6)
Assessment/interventions/response (nurse’s notes)
Sensory Status (formerly called Impairments)
Catheters
Immobilizations
Respiratory support
Oral limitations
Numerator Statement: Number of patients transferred to another
healthcare facility whose medical record documentation indicated that
all of the elements were communicated to the receiving facility within 60
minutes of departure
Denominator Statement: ED transfers to another healthcare facility
54
EDTC SUB-6 = Nurse Generated Information
 Examples of Nurses’ Notes include nursing assessment,
intervention, response or SOAP notes
 Does the medical record documentation indicate that the
patient was assessed for sensory impairments?
• mental • speech • hearing • vision • sensation
 Allowable values:
• Y (Yes) Select this option if there is documentation that
assessment of sensory impairment was done by nurse
or provider and information was sent to the receiving
facility – or if the documentation indicates that the
patient is unresponsive
•
N (No) Select this option if there is no documentation
that assessment of impairment was done and/or the
information was not sent to the receiving facility.
55
EDTC SUB-6 = Nurse Generated Information
Notes for Abstraction for Sensory Status (formerly
Impairment):
 Select Yes if documentation indicates that patient is
unresponsive.
 Otherwise, select yes if documentation includes the patient
being assessed for mental, speech, hearing, vision, and
sensation impairment.
 Documentation of the assessment is acceptable if found in the
nurses’ or provider’s documentation (see examples)
56
EDTC SUB-6 = Nurse Generated Information
Notes for Abstraction for Sensory Status (formerly
Impairment):
 For example:
• A History and Physical that includes the following would be
acceptable
o ENT WNL – indicates assessment of speech and
hearing
o Oriented - indicates assessment of mental status
o Has or denies tingling/numbness – indicates
assessment of sensation
• Nursing Notes that indicate the following would be
acceptable:
o Wears eyeglasses – indicates assessment of vision
o Has hearing aid – indicates assessment of hearing
57
EDTC SUB-6 = Nurse Generated Information
Inclusion Guidelines for Abstraction for Catheters/IV:
• IV (intravenous)
• If no order for such then
N/A
• IT (intrathecal)
• If order and info was sent
• Urinary
then = Yes
• Heparin Lock
• If order but info not sent
• Central line
then = 0
Inclusion Guidelines for Abstraction for Immobilizations:
• Backboard
• If no order for such then
• Casts
N/A
• If order and info was sent
• Neck brace
then = Yes
• Other braces (such as splints)
• If order but info not sent
then = 0
For this purpose – braces/splints only include what is
meant to stabilize a body part – does not include
prosthesis, orthosis…
58
EDTC SUB-6 = Nurse Generated Information
Inclusion Guidelines for Abstraction for Respiratory
Support:
• If no order for such then
• Bronchial drainage
N/A
• Intubations
• If order and info was sent
• Oxygen (includes Bi-Pap, C-Pap)
then = Yes
• Ventilator support
• If order but info not sent
then = 0
Inclusion Guidelines for Oral Limitation Abstraction:
• NPO
• If no order for such then
• Clear liquids
N/A
• If order and info was sent
• Soft diet
then = Yes
• Low NA diet
• If order but info not sent
then = 0
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EDTC SUB-6 = Nurse Generated Information
Q: How do I abstract a chart from an ED transfer from and to
“other facility” who had a catheter before arriving to the ED
– our ED did not insert the catheter.
A: There should be some documentation that the patient had a
catheter, regardless of if it was placed in the ED or was
there prior. So, code “Yes”
Q: If the ambulance crew applies a splint (not the hospital)
does the hospital need to communicate it?
A: Only if it is still on the patient at the time of transfer out of
the hospital.
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EDTC SUB-6 = Nurse Generated Information
Q: Impairment assessment and documentation includes negative or
positive findings of the following:
• mental • speech • hearing • vision • sensation
What if there is no documentation for 2 of them – all that is
present in the documentation are the positive findings, do I
abstract that as a “yes”?
A: No – requires documentation of actual deficits or within normal
limits or no abnormal findings etc.. for all 5 elements in order to
respond yes
Note: University of Minnesota noted that documentation by
exception is not best practice so not documented as
assessed – not done – Also, the goal is to have automatic
abstraction in this nation going forward therefore
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positive and negative data must be documented
EDTC-6 = Nurse Generated Information
Q: Does a Heparin lock count as an IV catheter?
A: Yes
Q: How do I abstract a chart from an ED transfer from and to
“other facility” who had a catheter before arriving to the ED
– our ED did not insert the catheter.
A: There should be some documentation that the patient had a
catheter, regardless of if it was placed in the ED or was
there prior. So, code “Yes”
Q: If the ambulance crew applies a splint (not the hospital)
does the hospital need to communicate it?
A: Only if it is still on the patient at the time of transfer out of
the hospital.
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EDTC-6 = Nurse Generated Information
Q: Is “deterioration” considered an “impairment”?
Can pain be considered to be an impairment?
A: A note indicating deterioration alone isn’t specific enough to
mean anything. Is it mental or physical deterioration?
Similarly a mention of hip pain alone would not be enough as it
doesn’t align with the specifics of mental, vision, speech, etc.
It isn’t that we are looking for “impairments” specifically, but
rather a completion of an assessment of the patients vision,
hearing, speech, mental and sensation is done. If it is, and
documentation indicates it was sent to the receiving facility,
then you can answer yes to this question, even if it just
indicates these things are normal. They don’t have to have an
issue, but you we need to see documentation of the
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assessment findings.
EDTC-7 = Procedures and Tests
Total of 2 elements: (both or none)
1) Tests and procedures done
2) Tests and procedure results sent
Numerator Statement: Number of patients transferred to another
healthcare facility whose medical record documentation indicated that all
of the applicable elements were communicated to the receiving facility
within 60 minutes of departure, or were sent when available.
Note: Some test results may not be available within 60 minutes of the
patient’s departure, but it is important to have a mechanism in place to
ensure communication of test and procedure results that become
available after the 60-minute window of time.
Denominator Statement: ED transfers to another healthcare facility
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EDTC SUB-7 = Procedures and Tests
Notes for Abstraction:
 If shared medical record with the receiving hospital then tests
and procedures done and results are considered sent –
select yes
 If results are not available yet and no shared medical record
with the receiving hospital then documentation must include a
plan to communicate results – select yes
 If none of the above – select no unless there were no
test/procedures done in which case you would document NA
 Inclusion Guidelines for Abstraction: • If no order for such then
N/A
• Lab work ordered
• If order and info was sent
• X-rays
then = Yes
• Procedures performed
• If order but info not sent
then = 0
• EKGs
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EDTC SUB-7 = Procedures and Tests
Q: May I report as “yes” if we have a policy that all results
of tests are to be reported to the hospital where the
patient was transferred to as soon as they are
available?
A: No, if results are not available at the time of transfer
then the documentation needs to reflect that the
results are not available and indicate what is the plan
to communicate them to the receiving facility when
they are available
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EDTC Abstraction & Reporting Tools
 StratisHealth EDTC Data Collection Guide
(Last updated in Jan 2015)
http://www.stratishealth.org/documents/ED_Transfer_
Data_Collection_Guide_Specifications.pdf
 Paper Abstracting Tool
 Appendix B: List of Data Elements (Y, N, NA)
 EDTC Chart Abstraction Quick Tool
 EDTC Excel Spreadsheet Data Collection & Reporting
Tool (you will be getting a new one for Q4-2015)
Note: Please email us if you have ANY questions or in need of the
tools above.
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MBQIP Phase 3 – EDTC
Abstracting Processes (discussion)
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EDTC = Reporting Procedure
 Timeframe for your hospital
• October 1, 2015
• Test yourselves as discussed ASAP
• Notify Mary Guyot mguyot@stroudwater.com ASAP if you have any questions about the
process or abstracting
 Use provided excel spreadsheet to track and submit the data:
• NOTE: Save your reports on a monthly basis as you wish - don’t forget to use the Report
Tab for graph to be used as you wish for your QI reports on a monthly basis
• On a quarterly basis, submit your data to Angie Allen (Angie.Allen@tn.gov) – SORH – as
follows:
• Email the FLEX REPORT Tab only from the excel spreadsheet by the 15th of the month
following the end of the quarter:
– Jan 15, 2016 for Q4, 2015
– April 15, 2016 for Q1, 2016
– July 15, 2016 for Q2, 2016
– Oct 15, 2016 for Q3, 2016
 Also notify her if you were not able to participate for some reason or other to prevent having
her tracking you down!
 As per any abstraction process, it is good practice to audit a % of your charts to ensure being
able to duplicate the report regardless of the person abstracting.
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Phase 3 – ED Transfer Communication
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Remember
It takes a team ……………
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