Carnahan Jennifer L, Unroe Kathleen T, Evans Russell, Klepfer Sarah, Stump Timothy E, Monahan Patrick O, Torke Alexia M
Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Probari Inc., Indianapolis, Indiana, USA.
Innov Aging. 2022 May 11;6(4):igac031. doi: 10.1093/geroni/igac031. eCollection 2022.
Prior approaches to identifying potentially avoidable hospital transfers (PAHs) of nursing home residents have involved detailed root cause analyses that are difficult to implement and sustain due to time and resource constraints. They relied on the presence of certain conditions but did not identify the specific issues that contributed to avoidability. We developed and tested an instrument that can be implemented using review of the electronic medical record.
The OPTIMISTIC project was a Centers for Medicare and Medicaid Services demonstration to reduce avoidable hospital transfers of nursing home residents. The OPTIMISTIC team conducted a series of root cause analyses of transfer events, leading to development of a 27-item instrument to identify common characteristics of PAHs (Stage 1). To refine the instrument, project nurses used the electronic medical record (EMR) to score the avoidability of transfers to the hospital for 154 nursing home residents from 7 nursing homes from May 2019 through January 2020, including their overall impression of whether the transfer was avoidable (Stage 2). Each transfer was rated independently by 2 nurses and assessed for interrater reliability with a kappa statistic.
Kappa scores ranged from -0.045 to 0.556. After removing items based on our criteria, 12 final items constituted the Avoidable Transfer Scale. To assess validity, we compared the 12-item scale to nurses' overall judgment of avoidability of the transfer. The 12-item scale scores were significantly higher for submissions rated as avoidable than those rated unavoidable by the nurses (mean 5.3 vs 2.6, < .001).
The 12-item Avoidable Transfer Scale provides an efficient approach to identify and characterize PAHs using available data from the EMR. Increased ability to quantitatively assess the avoidability of resident transfers can aid nursing homes in quality improvement initiatives to treat more acute changes in a resident's condition in place.
以往识别疗养院居民潜在可避免的医院转诊（PAH）的方法涉及详细的根本原因分析，由于时间和资源限制，这些分析难以实施和持续开展。它们依赖于某些条件的存在，但未识别出导致可避免性的具体问题。我们开发并测试了一种可通过查阅电子病历实施的工具。
OPTIMISTIC项目是医疗保险和医疗补助服务中心开展的一项示范项目，旨在减少疗养院居民的可避免医院转诊。OPTIMISTIC团队对转诊事件进行了一系列根本原因分析，从而开发出一个包含27个条目的工具，以识别PAH的共同特征（第1阶段）。为完善该工具，项目护士利用电子病历（EMR）对2019年5月至2020年1月期间来自7家疗养院的154名疗养院居民的医院转诊可避免性进行评分，包括他们对转诊是否可避免的总体印象（第2阶段）。每次转诊由2名护士独立评分，并使用kappa统计量评估评分者间信度。
kappa分数范围为-0.045至0.556。根据我们的标准去除一些条目后，12个最终条目构成了可避免转诊量表。为评估效度，我们将这个12条目量表与护士对转诊可避免性的总体判断进行了比较。对于被护士评为可避免的转诊，12条目量表得分显著高于被评为不可避免的转诊（平均分5.3对2.6，P<0.001）。
12条目可避免转诊量表提供了一种有效的方法，利用电子病历中的现有数据来识别和描述PAH。提高定量评估居民转诊可避免性的能力有助于疗养院开展质量改进举措，以便就地治疗居民病情的更急性变化。
