AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits
Electronic Reports
Transfer Risk Report
Table 1. Sample High-Risk Transfer Report
Facility Name:
Unit:
Report Date:
| Resident Name and Advance Directive Status | # ED Visits Within: | ED Discharge Diagnosis | # Hospital Admits Within: | Hospital Discharge Diagnosis | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Age | DNR,DNH, MOLST, or POLST Order in Place | 0-7 Days | 8-30 Days | 31-90 Days | For Most Recent ED Visit | 0-7 Days | 8-30 Days | 31-90 Days | For Most Recent Hospital Stay | LOS for Most Recent Hospitalization | |
| Resident A | 79 | 2 | Fever - unknown origin | 1 | Myocardial infarction | 5 | |||||
| Resident B | 81 | 1 | 1 | Urinary tract infection | 1 | Cellulitis | 10 | ||||
| Resident C | 82 | 1 | Anemia | 1 | 1 | COPD | 4 | ||||
| Resident D | 80 | 1 | Gastroenteritis | 1 | GI bleed | 3 | |||||
| Resident E | 76 | 1 | 1 | Altered mental status | 2 | ||||||
| Resident F | 84 | 1 | |||||||||
| Total Residents | 2 | 0 | 2 | 2 | 1 | 2 | 4 | ||||
Table 1. Sample High-Risk Transfer Report (continued)
| Resident Name and Advance Directive Status | High-Risk Diagnoses Associated With Transfer Risk | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Age | DNR,DNH, MOLST, or POLST Order in Place | Congestive Heart Failure | Myocardial Infarction | Angina | Pneumonia or Bronchitis | Asthma or COPD | Urinary Tract Infection | Sepsis or Fever or Infection | |
| Resident A | 79 | X | |||||||
| Resident B | 81 | 1 | X | X | X | ||||
| Resident C | 82 | X | X | ||||||
| Resident D | 80 | X | |||||||
| Resident E | 76 | ||||||||
| Resident F | 84 | 1 | |||||||
| Total Residents | 2 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |
Table 1. Sample High-Risk Transfer Report (continued)
| Resident Name and Advance Directive Status | High-Risk Diagnoses Associated With Transfer Risk | |||||||
|---|---|---|---|---|---|---|---|---|
| Age | DNR,DNH, MOLST, or POLST Order in Place | Dehydration | Circulatory Problems* | Renal Failure | Diabetes or Hypoglycemia | Anemia | Gastroenteritis | |
| Resident A | 79 | X | X | |||||
| Resident B | 81 | 1 | X | X | ||||
| Resident C | 82 | X | X | |||||
| Resident D | 80 | X | X | X | ||||
| Resident E | 76 | X | ||||||
| Resident F | 84 | 1 | X | X | ||||
| Total Residents | 2 | 4 | 1 | 2 | 2 | 2 | 1 | |
Table 1. Sample High-Risk Transfer Report (continued)
| Resident Name and Advance Directive Status | Current Clinical Conditions Contributing to Transfer Risk | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Age | DNR,DNH, MOLST, or POLST Order in Place | Oxygen Therapy | Catheter or Ostomy Present | Stage II or > Pressure Ulcer | Fall Risk | Late-Loss ADL Score ≥12 | Cognitive Impairment | Medical Conditions** | High-Risk Medications*** | |
| Resident A | 79 | X | 1 | X | ||||||
| Resident B | 81 | 1 | X | X | X | 2 | X | |||
| Resident C | 82 | X | X | 1 | X | |||||
| Resident D | 80 | X | X | 2 | X | |||||
| Resident E | 76 | X | 1 | |||||||
| Resident F | 84 | 1 | X | X | X | |||||
| Total Residents | 2 | 1 | 2 | 1 | 4 | 3 | 1 | 5 | 4 | |
Table 1. Sample High-Risk Transfer Report (continued)
| Resident Name and Advance Directive Status | Polypharmacy | High-Risk Change in Condition (Based on Assessment Data Within 7 Days of Report Date) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Age | DNR,DNH, MOLST, or POLST Order in Place | Medication Total ≥15 | CHF or Chest Pain or MI | Pneumonia or Bronchitis | Mental Status Change or Neurological Symptoms | Urinary Tract Infection | Sepsis or Fever or Infection | Dehydration | |
| Resident A | 79 | 1 | 1 | 1 | |||||
| Resident B | 81 | 1 | X | 1 | 1 | 1 | |||
| Resident C | 82 | X | 2 | 2 | 1 | ||||
| Resident D | 80 | 1 | 1 | ||||||
| Resident E | 76 | X | 2 | ||||||
| Resident F | 84 | 1 | X | 1 | |||||
| Total Residents | 2 | 4 | 2 | 2 | 2 | 1 | 3 | 3 | |
Key: ED=emergency department; DNR=Do Not Resuscitate; DNH=Do Not Hospitalize; MOLST=Medical Order for Life-Sustaining Treatment; POLST=Physician Order for Life-Sustaining Treatment; LOS=length of stay; COPD=chronic obstructive pulmonary disease; GI=gastrointestinal; ADL=activities of daily living.
* Circulatory problems include vascular disease, and venous and arterial ulcer.
** Certain medical conditions include cellulitis, hypertension, deep vein thrombosis, moderate dementia, peripheral neuropathies, quadriplegia, paraplegia, and hemiparesis.
*** High-risk medications include insulin, anticoagulants, antibiotics, alpha blockers, antipsychotics, antianxiety, sedative /hypnotics, anticonvulsants, antihypertensives, opioids, and diuretics.
