Metrics Definition - Discharge Planning
Metrics Definition - Discharge Planning
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Discharge Planning Norm
Discharge Planning Norm
Connect Care provides decision and documentation supports that can help clinicians with discharge planning, while improving communication with healthcare providers picking up care after discharge. These tools comprise a "discharge planning package" that helps with:
Admission and Discharge capture of standardized structured data important to planning.
Anticipating and managing an Expected Discharge Date (EDD), Expected Discharge Disposition (DISP) and Medical Readiness for Discharge (MRD).
Declaring and sharing discharge readiness determinations from disciplines in the patient's care team.
Focusing attention on key considerations and decisions during multidisciplinary planning (RAPID Rounds) meetings.
Incorporating transition care plan elements into discharge communications with a standardized format and structure.
Calibrating follow-up arrangements to predictors for early re-admission (LACE Index).
Reviewing and updating alternate level of care statuses.
Appropriate and timely use of transition planning tools during inpatient encounters is among the Connect Care Meaningful Use Norms.
Discharge Planning Snapshot
Discharge Planning Snapshot
Discharge planning is among the "meaningful use norms" expected of inpatient health care teams. While MRD documentation is a prescriber responsibility, EDD and DISP documentation can be delegated within responsible inpatient health care teams. Compliance may be reflected by one or more measures tallied daily (03:00 AM) for all Connect Care inpatients as part of a discharge planning "snapshot" where the denominator is the number of days that a patient has been admitted and attached to the individual or group (unit, service, facility) of interest:
Discharge Planning Behaviours
Expected Date of Discharge - Not Set Days
A day is recorded (1) if the Expected Date of Discharge data field has no value (date is null or not set to "unknown")
Expected Discharge Disposition - Not Set Days
A day is recorded (1) if the Expected Discharge Disposition field has no value (null).
Medically Ready for Discharge - Not Set Days
A day is recorded (1) if the Medical Readiness for Discharge field has no value (null).
Conditional Discharge - Workflow Active Days
A day is recorded (1) if a conditional discharge order has been entered and is active or in pending (awaiting nursing action) status.
Level of Care Length of Stays
Encounter Days (LOS)
A day is recorded (1) if the patient status is "admitted" at the time of the snapshot. This is used to calculate a length of stay denominator that includes emergency inpatient (EIP) days but not emergency days.
Emergency Inpatient Days (EIP)
A day is recorded (1) if the level of care of the moment is "acute" or the patient is admitted, but the patient remains in an emergency department or affiliated holding unit . Used to calculate EIP length of stay.
Overcapacity Protocol Days (OCP)
A day is recorded (1) if the patient is admitted to hospital but is cared for on a stretcher in-between regular room beds or in a hallway or other space not considered a formal hospital bed. Used to calculate an OCP length of stay.
Critical Care Days
A day is recorded (1) if the level of care of the moment is "critical care". Used to calculate critical care (ICU, Burn Unit, Neuro ICU, Pediatric ICU, etc.)
Acute Level of Care Days
A day is recorded (1) if the level of care of the moment is "acute". Used to calculate an acute length of stay.
Intermediate Level of Care Days
A day is recorded (1) if the level of care of the moment is "intermediate". Used to calculate an intermediate (e.g., "iCare", step-down unit, step-up unit, etc. length of stay.
Medically Ready for Discharge Days
A day is recorded (1) if the medical readiness for discharge status is 1 ("ready"). Used to calculate a medically ready length of stay.
Alternate Level of Care Days
Alternate Level of Care - To Be Determined (TBD) Days
A day is recorded (1) if the level of care field is set to "ALC - TBD", which is the default for a newly assigned ALC status. Conversion to a formal ALC code is typically expected within 48 hours. Used to gauge frequency of patient's being in ALC-TBD status longer than expected.
Alternate Level of Care (ALC) Days
A day is recorded (1) if the level of care field is set to any ALC code (TBD or any Z code). Used to calculate an ALC length of stay.
Medically Ready for Discharge - Not Alternate Level of Care Days
A day is recorded (1) if the patient has been marked medically ready for discharge but has a level of care designation other than ALC (TBD or Z code). Used to reflect timeliness of ALC designations.
Alternate Level of Care - Not Medically Ready for Discharge Days
A day is recorded (1) if the patient has an ALC (TBD or Z code) level of care but has not been marked medically ready for discharge. Used to reflect appropriateness of ALC and MRD designations.
Attribution
Attending
Unique identifier for prescriber attached to the patient as the attending (most responsible) provider at the time of the snapshot.
Department
Unique identifier for the "department" (usually a hospital unit) attached to the patient at the time of the snapshot.
Team
Unique identifier for primary provider team (team attached to patient and also marked as the primary team) attached to the patient at the time of the snapshot. This attachment will not be accurate in facilities where primary provider team attachments are not maintained.
Service
Unique identifier for the admitting hospital service attached to patient at the time of the snapshot.
Discharge Planning Metrics
Discharge Planning Metrics
Expected Date of Discharge (EDD)
An inpatient's Expected Date of Discharge (EDD) (also referred to as "Estimated" or "Anticipated" discharge date) is the approximate day that the patient should be ready to transition to the next care setting, including community settings. The EDD may reflect awareness of an Expected Length of Stay (ELOS) for patients with the same admitting diagnosis, demographics, frailty and co-morbidity burden. The EDD is a date and the ELOS is an interval.
The EDD Management Metric is the proportion of hospital acute care inpatient encounters where the EDD is entered (including "unknown" selections) by the admitting hospital service within 24, 48 or 72 hours of the time of signing the admission order for the inpatient encounter; or within 48 or 72 hours of a completed discharge order. Meaningful Use Norms stipulate that an EDD should be entered at the time of entry of the inpatient admission order or as soon as possible after admission.
The EDD Not Set Metric is the proportion of inpatient days for which an expected date of discharge has not been set (is null and not marked "unknown") where the denominator is the patient encounter length of stay (as above in discharge snapshot) or of the total inpatient days attributed to a most responsible provider (attending), primary provider team, admitting hospital service, hospital unit or hospital facility (as above in discharge snapshot). Setting an EDD is among the meaningful use norms expected of all prescribers.
Crib-Sheet: Expected Discharge Date Not Set
Expected Discharge Disposition (DISP)
An inpatient's Expected Discharge Disposition (DISP) is the final destination type and/or health care supports for a patient when they complete an inpatient encounter and leave the associated facility. The DISP is estimated as soon as possible after admission and iteratively updated with any significant clinical developments during the hospital encounter.
The DISP Not Set Metric is the proportion of inpatient days for which an expected discharge disposition has not been set (is null) where the denominator is the patient encounter length of stay (as defined above in discharge snapshot) or of the total inpatient days attributed to a most responsible provider (attending), primary provider team, admitting hospital service, hospital unit or hospital facility (as above in discharge snapshot). Setting an EDD is among the meaningful use norms expected of all prescribers.
Crib-Sheet: Expected Discharge Date Not Set
Medical Readiness for Discharge (MRD)
An inpatient is considered "medically ready" for discharge (MRD) when the primary provider discipline (referred to as "medical" for simplicity) for an inpatient encounter has completed its clinical tasks and the patient is dischargeable from a "medical" perspective. The MRD should be entered for all inpatients by a most responsible provider (attending) or delegate, and then revised throughout an admission as clinical conditions change.
The MRD Management Metric is the proportion of hospital acute care inpatient encounters where the MRD is entered (ready or not ready) within 72 hours of admission or within 72 hours of the last entry or review (validation).
Crib-Sheet: Medical Readiness for Discharge Management
The MRD Not Set Metric is the proportion of inpatient days for which the MRD status has not been set (is null) where the denominator is the patient encounter length of stay (as defined above in discharge snapshot) or of the total inpatient days attributed to a most responsible provider (attending), primary provider team, admitting hospital service, hospital unit or hospital facility (as above in discharge snapshot). Setting an EDD is among the meaningful use norms expected of all prescribers.
Crib-Sheet: Medical Readiness for Discharge Management
The Medically Ready but not ALC Metric is the proportion of inpatient days for which the MRD status is set to Ready (1) but the patient is still in an acute level of care; where the denominator is the patient encounter length of stay (as defined above in discharge snapshot) or of the total inpatient days attributed to a most responsible provider (attending), primary provider team, admitting hospital service, hospital unit or hospital facility (as above in discharge snapshot). Setting an EDD is among the meaningful use norms expected of all prescribers.
Crib-Sheet: Medical Readiness for Discharge Management
The Conditional Discharge Metric is the proportion of inpatient days for which a conditional discharge order has been placed and is active or pending; where the denominator is the patient encounter length of stay (as defined above in discharge snapshot) or of the total inpatient days attributed to a most responsible provider (attending), primary provider team, admitting hospital service, hospital unit or hospital facility (as above in discharge snapshot). Setting an EDD is among the meaningful use norms expected of all prescribers.
Crib-Sheet: Medical Readiness for Discharge Management
Workflow
Workflow
Transition Planning Meaningful Use Norms and Workflows are described in the Connect Care Clinician Manual.
Expected Discharge Date (EDD)
Expected Discharge Date (EDD)
A first EDD entry can be entered in a variety of ways, including via an admission navigator, admission order, or admitting history & physical documentation. The same data can be reviewed and revised via admission and discharge navigators, sidebar popups, patient list popups, discharge planning popups and discharge orders.
The most recently revised EDD value is exposed for users in a variety of places within patient lists, reporting workbench reports and inpatient charts.
Expected Discharge Disposition (DISP)
Expected Discharge Disposition (DISP)
A first DISP entry can be entered in a variety of ways, including via an admission navigator, admission order, or admitting history & physical documentation. The same data can be reviewed and revised via admission and discharge navigators, sidebar popups, patient list popups, discharge planning popups and discharge orders.
Medical Readiness for Discharge (MRD)
Medical Readiness for Discharge (MRD)
Rapid Rounds patient lists and reports, as well as chart sidebar transition planning displays, provide access to interactive discharge readiness "Traffic Lights" that provide at-a-glance overviews of patient readiness from the perspective of health disciplines participating in discharge planning. The visual display further supports click-to-edit so that disciplines can quickly revise their readiness determinations.
Data
Data
Discharge Planning management is supported in Connect Care (Epic) with diverse data elements.
Handbook: Discharge Metrics Components (see Data)
Handbook: Discharge Planning Components (see Data)
Metrics
Metrics
Expected Discharge Date (EDD) Entry
Expected Discharge Date (EDD) Entry
Description
Percentage of admitted or discharged inpatients with an EDD entered by the admitting hospital service within 24 or 48 hours of the time of entry of the admission order or prior to the admission order time in the case of planned admissions (Surgery). The metrics are stratified into three sub-metrics:
EDD Entered
Unknown
Marked as Reviewed
When multiples values are entered, the most recent value is counted. Exception is “Marked as Reviewed” which is counted if it’s the only entry. If other values exist (either EDD Entered or Unknown), it is excluded from the numerator.
Denominator
Number of Patient Encounters where:
Inpatient (EPT 10110 = Inpatient) AND
Admitted OR Discharged (EPT 10115 = Admission OR Discharged) AND
Acute or ALC - TBD patient status (EPT 10135 = "Acute" or "ALC - TBD") AND
Has an admission effective instant (ADT 59 in preference to EPT 10986)
Numerator
Number of Patient Encounters from denominator where:
Absolute value of (First EDD entry instant [EPT 10446 first entry in array] MINUS Admission Order release instant LESS THAN OR EQUAL 48 Hours
Admission order release instant is defined as:
Order release instant (last order edit instant; ORD 750) WHERE Order Type (ORD 30) = Admission [47] AND Last Editing Action (ORD 760) = Released [6]
EDD Entry Instant is updated whenever an EDD is entered or updated, or when the EDD "Mark as Reviewed" button is selected.
Calculation
Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point
Grouping (Denominator Subsets)
Provider
Patients attached to selected provider as the Admitting Attending (EPT 18867)
Hospital Service (specialty)
Patients attached to selected Hospital Admitting Service: ADT 70 - CATEGORY - (e.g., General Internal Medicine [106])
Hospital Unit
Patients attached to selected Hospital Admitting Unit: ADT 50 - CATEGORY - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])
Excluding ADT Unit Type Emergency (DEP 7050) and Hospital Outpatient Departments (DEP 6100)
Hospital Facility
Patients attached to selected Hospital Facility: EPT 18883 - CATEGORY - (e.g., EDM WMC University of Alberta Hospital [101094])
Analytics Definitions
EDD Not Set
EDD Not Set
Description
Percentage of inpatient days for which an expected discharge date has NOT been set, based on daily discharge metrics snapshot (03:00 AM).
Denominator
Number of Patient Encounters where:
Inpatient (EPT 10110 = Inpatient) AND
Expected Discharge Date (EPT 18855; EPT 10308 for "unknown") available.
Numerator
Number of Patient Days where EPT 18855 AND EPT 10308 is non-null
Calculation
Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point
Grouping (Denominator Subsets)
Attending
Patients attached to the selected provider as the most responsible provider.
Service
Patients attached to selected Hospital Specialty Service: EPT 18886 - CATEGORY - (e.g., General Internal Medicine [106])
Unit
Patients attached to selected Hospital Admitting Unit: ADT 50 - CATEGORY - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])
Excluding ADT Unit Type Emergency (DEP 7050) and Hospital Outpatient Departments (DEP 6100)
Facility
Patients attached to selected Hospital Facility: EPT 18883 - CATEGORY - (e.g., EDM WMC University of Alberta Hospital [101094])
Analytics Definitions
Expected Discharge Disposition (DISP) Not Set
Expected Discharge Disposition (DISP) Not Set
Description
Percentage of inpatient days for which a DISP has NOT been set, based on daily discharge metrics snapshot (03:00 AM).
Denominator
Number of Patient Encounters where:
Inpatient (EPT 10110 = Inpatient) AND
Expected Discharge Disposition (EPT 11090) available.
Numerator
Number of Patient Days where EPT 11090 is non-null
Calculation
Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point
Grouping (Denominator Subsets)
Attending
Patients attached to the selected provider as the most responsible provider.
Service
Patients attached to selected Hospital Specialty Service: EPT 18886 - CATEGORY - (e.g., General Internal Medicine [106])
Unit
Patients attached to selected Hospital Admitting Unit: ADT 50 - CATEGORY - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])
Excluding ADT Unit Type Emergency (DEP 7050) and Hospital Outpatient Departments (DEP 6100)
Facility
Patients attached to selected Hospital Facility: EPT 18883 - CATEGORY - (e.g., EDM WMC University of Alberta Hospital [101094])
Analytics Definitions
Crib-Sheet: Expected Discharge Disposition Review
Medical Readiness for Discharge (MRD) Entry
Medical Readiness for Discharge (MRD) Entry
Description
Percentage of admitted or discharged inpatients with a MRD entered by the admitting hospital service within 72 hours of the time of entry of the admission order or prior to the admission order time in the case of planned admissions (Surgery).
When multiples values are entered, the most recent value is counted.
Denominator
Number of Patient Encounters where:
Inpatient (EPT 10110 = Inpatient) AND
Admitted OR Discharged (EPT 10115 = Admission OR Discharged) AND
Has an admission effective instant (ADT 59 in preference to EPT 10986)
Numerator
Number of Patient Encounters from denominator where:
Absolute value of (First MRD entry instant [EPT 10110 first entry in array] MINUS Admission Order release instant LESS THAN OR EQUAL 48 Hours
Admission order release instant is defined as:
Order release instant (last order edit instant; ORD 750) WHERE Order Type (ORD 30) = Admission [47] AND Last Editing Action (ORD 760) = Released [6]
MRD Entry Instant is updated whenever an MRD is entered or updated, or when the MRD "Mark as Reviewed" button is selected.
Calculation
Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point
Grouping (Denominator Subsets)
Provider
Patients attached to selected provider as the Admitting Attending (EPT 18867)
Hospital Service (specialty)
Patients attached to selected Hospital Admitting Service: ADT 70 - CATEGORY - (e.g., General Internal Medicine [106])
Hospital Unit
Patients attached to selected Hospital Admitting Unit: ADT 50 - CATEGORY - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])
Excluding ADT Unit Type Emergency (DEP 7050) and Hospital Outpatient Departments (DEP 6100)
Hospital Facility
Patients attached to selected Hospital Facility: EPT 18883 - CATEGORY - (e.g., EDM WMC University of Alberta Hospital [101094])
Analytics Definitions
Crib-Sheet: Medical Readiness for Discharge
MRD Not Set
MRD Not Set
Description
Percentage of inpatient days for which a MRD has NOT been set, based on daily discharge metrics snapshot (03:00 AM).
Denominator
Number of Patient Encounters where:
Inpatient (EPT 10110 = Inpatient) AND
Medical Readiness for Discharge (EPT 11423) available.
Numerator
Number of Patient Days where EPT 11423 is non-null
Calculation
Numerator DIVIDED INTO Denominator expressed as PERCENTAGE rounded up to nearest integer percentage point
Grouping (Denominator Subsets)
Attending
Patients attached to the selected provider as the most responsible provider.
Service
Patients attached to selected Hospital Specialty Service: EPT 18886 - CATEGORY - (e.g., General Internal Medicine [106])
Unit
Patients attached to selected Hospital Admitting Unit: ADT 50 - CATEGORY - inpatient unit/ward (e.g., EDM UAH WMC 5D4 GIM [101094229])
Excluding ADT Unit Type Emergency (DEP 7050) and Hospital Outpatient Departments (DEP 6100)
Facility
Patients attached to selected Hospital Facility: EPT 18883 - CATEGORY - (e.g., EDM WMC University of Alberta Hospital [101094])
Analytics Definitions
Crib-Sheet: Medical Readiness for Discharge
Limitations
Limitations
Attributable Change
Attributable Change
Discharge Planning Metrics will most closely reflect meaningful use norm compliance when the responsible hospital service has trained, organized and supported its staff in recommended workflows. If discharge planning occurs, but Connect Care tools are not used, or some alternate toolkit is used within or outside Connect Care, then changes to discharge processes and outcomes will not be attributable to standard discharge management tool use.
Discharge Metrics do not capture information about the use of related information tools (e.g., EDD Comments, Discharge Milestones, Discharge Delays, Discharge Checklists and Flowsheets) that may be as or more important to efficient inpatient flows.
Discharge Metrics do not reflect whether information is communicated to patients and families, and how this might impact discharge readiness.
Validity
Validity
The current Connect Care configuration assumes that discharge expectations are estimated and manually entered by providers, reflecting their best understanding of when discharge can occur. Discharge metric snapshots are performed every morning at 03:00 and so may not reflect important changes at other times in a hospital day.
Timeliness
Timeliness
Discharge Metrics are currently calculated for admitted or discharged patients (discharged patients only for EDD Review metrics), are retrospective (or delayed by several hours for admitted patients), and so do not necessarily help with current hospital service inpatient flow or discharge planning. The metric can help teams set goals for behavior (meaningful use) and process changes but cannot be used for real-time observation of behavior change.
Discharge Metric Snapshot data accurately represents the state of key discharge planning measures, as well as in-the-moment attribution to attending provider, primary provider team, hospital service, ward and facility.
User Interface Variation
User Interface Variation
A variety of user interfaces and tools are available for entering and changing discharge estimattions in Connect Care. Those that are part of Epic Foundation have little to no embedded help or decision supports. Newer Connect Care tools draw more attention to what is clinically meaningful for discharge planning.
Practice Variation
Practice Variation
Confusion about appropriate use of the "unknown" button in some EDD user interfaces has led to null EDD values for most inpatients in many settings. There is currently difference of opinion, and so inconsistent meaning of EDD data, about how dates should be estimated, whether intervals should be used and when it is appropriate to click the "unknown" button.
Reports
Reports
Radar Dashboards
Radar Dashboards
Reporting Workbench
Reporting Workbench
Slicer-Dicer
Slicer-Dicer
Components
Components
Planning is supported in Connect Care (Epic) with a wide range of documentation, listing and reporting components that are used in many workflows.
Resources
Resources
Expected Discharge Date
Expected Discharge Date
Expected Length of Stay Estimations
Analytics Definitions
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