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Measure Summary
This measure is endorsed by the National Quality Forum
Title
Emergency department transfer communication: percentage of patients transferred to another healthcare facility whose medical record documentation indicated that patient information elements were communicated to the receiving facility within 60 minutes of departure.
Source(s)
Stratis Health, Minnesota Department of Health. Data collection guide: ED transfer communication measures. Minneapolis (MN): University of Minnesota, Rural Health Research Center; 2013 Mar 18. 19 p.

Measure Domain

Primary Measure Domain
Clinical Quality Measures: Process
Secondary Measure Domain
Does not apply to this measure

Brief Abstract

Description

This measure is used to assess the percentage of patients transferred to another healthcare facility whose medical record documentation indicated that patient information elements were communicated to the receiving facility within 60 minutes of departure.

Patient information elements:

  • Name
  • Address
  • Age
  • Gender
  • Significant others contact information
  • Insurance

Emergency department transfer communication is reported by means of a summary measure. The summary measure incorporates items of information that should be provided by the referring rural hospital when a patient is transferred to another healthcare facility. Each patient care element receives a score of 0 when documentation is not available in the patient record and a score of 1 when the documentation is available. Each of the seven measures is scored by summing the 0-1 scores for all elements that are part of the measure.

See the National Quality Measures Clearinghouse (NQMC) summaries of the other six measures:

Note: This measure applies to rural hospitals with less than 50 beds.

Rationale

Communication problems are a major contributing factor to adverse events in hospitals, accounting for 65% of sentinel events tracked by The Joint Commission. In addition, research indicates that deficits exist in the transfer of patient information between hospitals and primary care physicians in the community, and between hospitals and long-term facilities. Transferred patients are excluded from the calculation of most national quality measures, such as those used in Hospital Compare. The Hospital Compare Web site was created to display rates of Process of Care measures using data that are voluntarily submitted by hospitals. The Joint Commission has adopted National Patient Safety Goal 2, "Improve the Effectiveness of Communication Among Caregivers." Requirement 2E for this goal requires all accredited hospitals to implement a standardized approach to hand off communications, including nursing and physician handoffs from the emergency department (ED) to inpatient units, other hospitals, and other types of health care facilities. The process must include a method of communicating up-to-date information regarding the patient's care, treatment, and services; condition; and any recent or anticipated changes.

Limited attention has been paid to the development and implementation of quality measures specifically focused on patient transfers between EDs and other facilities. These measures are important for all health care facilities, but especially so for small rural hospitals that transfer a higher proportion of ED patients to other hospitals than larger urban facilities.

While many aspects of hospital quality are similar for urban and rural hospitals (e.g., providing heart attack patients with aspirin), the urban/rural contextual differences result in differences in emphasis on quality measurement. Because of its role in linking residents to urban referral centers, important aspects of rural hospital quality include triage-and-transfer decision making about when to provide a particular type of care, transporting patients, and coordinating information flow to specialists beyond the community.

Emergency care is important in all hospitals, but it is particularly important in rural hospitals. Because of their size, rural hospitals are less likely to be able to provide more specialized services, such as cardiac catheterization or trauma surgery. Rural residents often need to travel greater distances than urban residents to get to a hospital initially. In addition, their initial point of contact is less likely to have specialized services and staff found in tertiary care centers, so they are also more likely to be transferred. These size and geographic realities increase the importance of organizing triage, stabilization, and transfer in rural hospitals which, in turn, suggests that measurement of these processes is an important issue for 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. They are applicable to patients with a wide range of medical conditions (e.g., acute myocardial infarction, heart failure, pneumonia, respiratory compromise and trauma) and are relevant for both internal quality improvement purposes and external reporting to consumers and purchasers. The results of the field tests (see "Extent of Measure Testing" field) suggest that significant opportunity exists for improvement on these measures.

Evidence for Rationale
Baldwin LM, MacLehose RF, Hart LG, Beaver SK, Every N, Chan L. Quality of care for acute myocardial infarction in rural and urban US hospitals. J Rural Health. 2004 Spring;20(2):99-108. PubMed External Web Site Policy

Cortes TA, Wexler S, Fitzpatrick JJ. The transition of elderly patients between hospitals and nursing homes. Improving nurse-to-nurse communication. J Gerontol Nurs. 2004 Jun;30(6):10-5; quiz 52-3. [5 references] PubMed External Web Site Policy

Ellerbeck EF, Bhimaraj A, Perpich D. Organization of care for acute myocardial infarction in rural and urban hospitals in Kansas. J Rural Health. 2004 Fall;20(4):363-7. PubMed External Web Site Policy

Joint Commission on Accreditation of Healthcare Organizations. Sentinel events statistics. [internet]. [accessed 2007 Jul 18].

Klingner J, Moscovice I, Washington Rural Healthcare Quality Network and StratisHealth, Minnesota Quality Improvement Organization. Rural hospital emergency department quality measures: aggregate data report. Minneapolis (MN): University of Minnesota, Division of Health Services Research & Policy; 2007 Mar. 12 p.  (Flex Monitoring Team data summary report; no. 3).

Klingner J, Moscovice I. Development and testing of emergency department patient transfer communication measures. J Rural Health. 2012 Jan;28(1):44-53. [16 references] PubMed External Web Site Policy

Kripalani S, Lefevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007 Feb 28;297(8):831-41. [133 references] PubMed External Web Site Policy

Newgard CD, McConnell KJ, Hedges JR. Variability of trauma transfer practices among non-tertiary care hospital emergency departments. Acad Emerg Med. 2006 Jul;13(7):746-54. PubMed External Web Site Policy

University of Minnesota Rural Health Research Center, Stratis Health (Minnesota's Quality Improvement Organization), HealthInsight (Nevada and Utah's Quality Improvement Organization). Refining and field testing a relevant set of quality measures for rural hospitals. Final report submitted to the Centers for Medicare & Medicaid Services under contract no. 500-02-MN01. Bloomington (MN): Stratis Health; 2005 Jun 30.

US Department of Health and Human Services. Hospital compare Web site. [Web site]. [accessed 2011 Feb 25].

Wakefield DS, Ward M, Miller T, Ohsfeldt R, Jaana M, Lei Y, Tracy R, Schneider J. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. J Rural Health. 2004 Fall;20(4):394-400. PubMed External Web Site Policy

Westfall JM, Van Vorst RF, McGloin J, Selker HP. Triage and diagnosis of chest pain in rural hospitals: implementation of the ACI-TIPI in the High Plains Research Network. Ann Fam Med. 2006 Mar-Apr;4(2):153-8. PubMed External Web Site Policy
Primary Health Components

Rural health; emergency department (ED) transfer; communication; patient information

Denominator Description

All patients who are transferred to another healthcare facility (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients transferred to another healthcare facility whose medical record documentation indicated that all of the following patient information elements were communicated to the receiving facility within 60 minutes of departure:

  • Name
  • Address
  • Age
  • Gender
  • Significant others contact information
  • Insurance

See the related "Numerator Inclusions/Exclusions" field.

Evidence Supporting the Measure

Type of Evidence Supporting the Criterion of Quality for the Measure
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal
Additional Information Supporting Need for the Measure
  • Nearly 19% of rural hospital admissions and 13% of urban hospital admissions are transferred to another facility.
  • Patient safety studies have identified the emergency department (ED) as the location within a hospital that has the highest percentage of preventable and negligent adverse events. Increasing attention is being paid to prevention of medical errors in ED settings, but considerable work still needs to be done to develop performance measures for ED care.
  • The ED patient transfer communication measure set incorporates conceptual elements from the Federal Emergency Medical Treatment and Active Labor Act and the Continuity of Care Record (CCR). The CCR is a standard specification developed jointly by the American Society for Testing and Materials International, the Massachusetts Medical Society, the Healthcare Information and Management Systems Society (HIMSS), and the American Academy of Family Physicians. It is intended to foster and improve continuity of patient care, to reduce medical errors, and to ensure at least a minimum standard of health information transportability when a patient is referred to, transferred to, or otherwise seen by, another provider. The objective of the CCR is to improve continuity of care, reduce medical errors, and ensure secure health information transportability when a patient is referred or transferred to another provider.
Evidence for Additional Information Supporting Need for the Measure
American Academy of Family Physicians, Center for Health IT. ASTM continuity of care record. [internet]. Leawood (KS): American Academy of Family Physicians (AAFP); [accessed 2011 Mar 19].

Klingner J, Moscovice I, Washington Rural Healthcare Quality Network and StratisHealth, Minnesota Quality Improvement Organization. Rural hospital emergency department quality measures: aggregate data report. Minneapolis (MN): University of Minnesota, Division of Health Services Research & Policy; 2007 Mar. 12 p.  (Flex Monitoring Team data summary report; no. 3).

Klingner J, Moscovice I. Development and testing of emergency department patient transfer communication measures. J Rural Health. 2012 Jan;28(1):44-53. [16 references] PubMed External Web Site Policy

Schenkel S. Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med. 2000 Nov;7(11):1204-22. [127 references] PubMed External Web Site Policy

University of Minnesota Rural Health Research Center, Stratis Health (Minnesota's Quality Improvement Organization), HealthInsight (Nevada and Utah's Quality Improvement Organization). Refining and field testing a relevant set of quality measures for rural hospitals. Final report submitted to the Centers for Medicare & Medicaid Services under contract no. 500-02-MN01. Bloomington (MN): Stratis Health; 2005 Jun 30.

Welch S, Augustine J, Camargo CA Jr, Reese C. Emergency department performance measures and benchmarking summit. Acad Emerg Med. 2006 Oct;13(10):1074-80. PubMed External Web Site Policy
Extent of Measure Testing

In previous work, a model for measuring rural hospital quality was developed, with a focus on the special issues posed by the rural hospital context. The development of rural relevant hospital quality measures was completed over several steps. With the assistance of expert panels consisting of rural hospital and hospital quality measurement experts, an initial core set of quality measures relevant to rural hospitals with fewer than 50 beds was identified. Established hospital quality measures were examined and the list consolidated.

The team evaluated existing quality indicator and performance measurement systems to assess their relevance for rural hospitals. Existing quality indicator and performance measurement systems (e.g., those developed by The Joint Commission, Agency for Healthcare Research and Quality [AHRQ], National Quality Forum [NQF], Centers for Medicare & Medicaid Services [CMS]) and four rural-oriented performance measurement systems, Apples to Apples, Rural Wisconsin Health Cooperative, Maryland Hospital Association QI Project, Georgia Hospital Association CARE, were reviewed. Four criteria were used to evaluate rural hospital quality measures:

  • Prevalence in rural hospitals with less than 50 beds
  • Ease of data collection effort in rural hospitals with less than 50 beds
  • Internal usefulness for rural hospitals with less than 50 beds
  • External usefulness for rural hospitals with less than 50 beds

The research partners further refined this draft set of existing quality measures to fit the rural context and identified emergency department care as both an important quality assessment measurement category for rural hospitals and missing from existing measurement sets.

Throughout the field studies, strong emphasis was placed on obtaining expert and hospital staff insights. Evaluation of the measures, data collection, report usefulness, and the overall process was requested from hospital representatives at many points. Hospital, network, quality improvement organization (QIO) and consulting staff were asked to maintain a log of comments regarding the project including suggestions for improvements. Feedback forms and contact information for participants involved in this project were provided during training sessions. Each time a hospital was contacted, comments were requested regarding the project. Hospitals were invited to call the QIO, network, consulting or university staff at any time with questions, comments, or concerns. Three expert panels were convened to review data and measurement definitions and specifications.

The three field tests of rural hospital quality measures were conducted in 2004, 2006, and 2008 to access the feasibility of data collection, the ease of different data collection methods, the usefulness of the measures for improvement and reporting, and three different training mechanisms. The measures were field tested in 68 rural hospitals in eight states. Twenty-two rural hospitals participated in the first field test of the measures, including 14 hospitals in Minnesota, 4 hospitals in Utah, and 4 hospitals in Nevada. Staff members from these hospitals were trained in person in measurement abstraction by University of Minnesota and Stratis Health QIO staff. For the second field test, the University of Minnesota and Stratis Health collaborated with the Washington Rural Health Quality Network (RHQN). A total of 18 rural hospitals in Washington State participated. This field test used a "Train the Trainer" method to disseminate the measurement abstraction information. The University of Minnesota and Stratis Health staff trained RHQN staff, who in turn trained hospital staff in small group settings. For the third field test the University of Minnesota collaborated with PMI and Stroudwater Consultants. Three different training methods were used: direct training, train the trainer and video training. Overall, the elements of the transfer communication measure were found to be easily abstracted and to provide many opportunities for documentation and communication improvement. These results suggest that quality improvement in rural hospitals is feasible and useful for reporting and improvement when hospital staff are appropriately trained and provided ongoing technical support.

Evidence for Extent of Measure Testing
Klingner J, Moscovice I. Development and testing of emergency department patient transfer communication measures. J Rural Health. 2012 Jan;28(1):44-53. [16 references] PubMed External Web Site Policy

Moscovice I, Wholey DR, Klingner J, Knott A. Measuring rural hospital quality. Minneapolis (MN): University of Minnesota; 2004 Apr. 63 p. (Working paper; no. 53). 

University of Minnesota Rural Health Research Center, Stratis Health (Minnesota's Quality Improvement Organization), HealthInsight (Nevada and Utah's Quality Improvement Organization). Refining and field testing a relevant set of quality measures for rural hospitals. Final report submitted to the Centers for Medicare & Medicaid Services under contract no. 500-02-MN01. Bloomington (MN): Stratis Health; 2005 Jun 30.

State of Use of the Measure

State of Use
Current routine use
Current Use
Care coordination
Decision-making by businesses about health plan purchasing
Decision-making by consumers about health plan/provider choice
Internal quality improvement

Application of the Measure in its Current Use

Measurement Setting
Emergency Department
Hospital Inpatient
Rural Health Care
Skilled Nursing Facilities/Nursing Homes
Transition
Type of Care Coordination
Coordination across provider teams/sites
Professionals Involved in Delivery of Health Services
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Least Aggregated Level of Services Delivery Addressed
Single Health Care Delivery or Public Health Organizations
Statement of Acceptable Minimum Sample Size
Unspecified
Target Population Age

All ages

Target Population Gender
Either male or female

National Strategy for Quality Improvement in Health Care

National Quality Strategy Aim
Better Care
National Quality Strategy Priority
Effective Communication and Care Coordination
Prevention and Treatment of Leading Causes of Mortality

Institute of Medicine (IOM) National Health Care Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Timeliness

Data Collection for the Measure

Case Finding Period

Unspecified

Denominator Sampling Frame
Patients associated with provider
Denominator (Index) Event or Characteristic
Encounter
Institutionalization
Denominator Time Window
Does not apply to this measure
Denominator Inclusions/Exclusions

Inclusions
All patients who are transferred to another healthcare facility

Include patients with a discharge disposition code of 3, 4, 5:

  • 3 Hospice -- Health Care Facility
  • 4a Acute Care Facility -- General Inpatient Care
  • 4b Acute Care Facility -- Critical Access Hospital
  • 4c Acute Care Facility -- Cancer Hospital or Children's Hospital
  • 4d Acute Care Facility -- Department of Defense or Veteran's Administration
  • 5 Other Health Care Facility

Exclusions
Exclude patients with a discharge code of 1, 2, 6, 7, 8:

  • 1 Home
  • 2 Hospice -- Home
  • 6 Expired
  • 7 Left Against Medical Advice (AMA)
  • 8 Not Documented or Unable to Determine (UTD)
Exclusions/Exceptions
Patient factors addressed
Numerator Inclusions/Exclusions

Inclusions
Number of patients transferred to another healthcare facility whose medical record documentation indicated that all of the following patient information elements were communicated to the receiving facility within 60 minutes of departure:

  • Name (Not applicable [NA] if refused)
  • Address (NA if refused)
  • Age (NA if refused)
  • Gender
  • Significant others contact information (NA if refused)
  • Insurance (NA if refused)

Data Collection Note:

  • This subcategory is calculated using an all-or-none approach. Each element included in this subcategory must be documented in the medical record for every patient transferred to another acute care hospital to be included in the numerator for this subcategory.
  • Items scored as NA (not applicable) are counted in the measure as a positive, or 'yes,' response.

Electronic Medical Records Clarification:

  • For hospital systems with electronic medical records, documentation must indicate that data elements had been entered into the data system and were available to the receiving facility within 60 minutes of departure. Test and procedure results that become available after the 60-minute timeframe are assumed to be entered into the data system and available to the receiving facility when the tests are completed.
  • If the receiving facility does not have access to the sending hospitals record electronically, then physical copies must be sent or faxed.

Refer to the original measure documentation for detailed data collection instructions.

Exclusions
Unspecified

Numerator Search Strategy
Institutionalization
Data Source
Administrative clinical data
Electronic health/medical record
Paper medical record
Type of Health State
Does not apply to this measure
Instruments Used and/or Associated with the Measure

Data Collection Transfer Tool

Computation of the Measure

Measure Specifies Disaggregation
Does not apply to this measure
Scoring
Rate/Proportion
Interpretation of Score
Desired value is a higher score
Allowance for Patient or Population Factors
Unspecified
Standard of Comparison
External comparison at a point in, or interval of, time
Internal time comparison

Identifying Information

Original Title

ED transfer communication: patient information.

Submitter
University of Minnesota Rural Health Research Center - Academic Institution
Developer
Regents of the University of Minnesota Rural Health Research Center - Academic Affiliated Research Institute
Funding Source(s)
  • The Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS), Contract No. 500-02-MN01. The Government Task Leader for the project was Edwin Huff, PhD, CMS Boston Regional Office. The materials do not necessarily reflect CMS policies. 7SOW-MN-1C-05-15.
  • Federal Office of Rural Health Policy, Health Resources and Services Administration, USDHHS PHS Grant No. U27RH01080
Composition of the Group that Developed the Measure

The development of rural relevant hospital quality measures was completed over several steps. With the assistance of expert panels consisting of rural hospital and hospital quality measurement experts, an initial core set of quality measures relevant to rural hospitals with fewer than 50 beds was identified. This measure was developed by the University of Minnesota Rural Health Research Center working in partnership with Stratis Health, the Minnesota Quality Improvement Organization.

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Endorser
National Quality Forum
NQF Number
0294
Date of Endorsement

2013 Sep 17

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC
2013 Mar
Measure Maintenance

Annually

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: Flex Monitoring Team. Emergency department: transfer communication measurement specifications. Minneapolis (MN): University of Minnesota; 2008 Aug. 2 p.

The measure developer reaffirmed the currency of this measure in March 2014.

Source(s)
Stratis Health, Minnesota Department of Health. Data collection guide: ED transfer communication measures. Minneapolis (MN): University of Minnesota, Rural Health Research Center; 2013 Mar 18. 19 p.
Measure Availability

The individual measure, "ED Transfer Communication: Patient Information," is published in "Data Collection Guide: ED Transfer Communication Measures." This document is available in Portable Document Format (PDF) from the University of Minnesota Rural Health Research Center Web site External Web Site Policy.

For more information, please contact Ira Moscovice and Jill Klingner, University of Minnesota Rural Health Research Center, 2520 University Ave SE, Suite 201, Minneapolis, Minnesota 55414; Phone: 612-624-6151.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 13, 2010. The information was verified by the measure developer on July 30, 2010.

This NQMC summary was retrofitted into the new template on August 4, 2011.

This NQMC summary was updated by ECRI Institute on December 24, 2012. The information was verified by the measure developer on February 21, 2013.

The information was reaffirmed by the measure developer on March 3, 2014.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

Call Ira Moscovice at the University of Minnesota at 612-624-6151 for further information.

Disclaimer

NQMC Disclaimer

The National Quality Measures Clearinghouse™ (NQMC) does not develop, produce, approve, or endorse the measures represented on this site.

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