Recommendation Document:

Standard Data Elements Suggested for Inclusion on Hospital Inter-facility Transfer Forms and Face Sheets to Facilitate Large-scale Emergency Patient Evacuation

Purpose: This document provides a list of standard data elements that hospitals are encouraged to include on existing inter-facility transfer forms and patient face sheets, in order to ensure that transfer forms and patient face sheets can be effectively used during large-scale evacuations of healthcare facilities. This list was compiled by the Patient Movement Workgroup (see description below). It is the workgroup’s belief that the inclusion of these elements by hospitals throughout the NYC region will facilitate appropriate staging, transfer and triage of patients during emergency events which require or result in large-scale patient evacuation from one hospital to another.

Patient Movement Workgroup: Launched in February 2015, the Patient Movement Workgroup (PMW) is jointly led by the NYC Department of Health and Mental Hygiene (DOHMH) and the Greater New York Hospital Association (GNYHA). Bringing together emergency managers, clinicians, health IT specialists, transfer center leadership and others from more than ten hospitals and health systems, as well as government agencies and medical transport organizations, the PMW has worked to tackle several related challenges experienced during Hurricanes Irene (2011) and Sandy (2012) which hampered patient evacuation.

Problem(s) of Interest: During Hurricanes Sandy and Irene, basic clinical and demographic information was not always available to the clinicians and staff responsible for staging at the sending hospital, facilitating appropriate transport, and triage at the receiving hospital. Regardless of clinical conversations that may occur between providers at both hospital, it is imperative that staff involved with patient care throughout the evacuation and transport process, which can take several hours, possess basic clinical and demographic information in order to appropriately care for the patient during this transition period. Furthermore, having a set of standard data elements used across institutions will ensure that regardless of the origin or destination of the patient, at a regional level clinicians know what information they can expect when receiving a patient.

A Potential Solution: While some jurisdictions have developed a stand-alone patient evacuation form for such purposes, it was the opinion of the PMW members that use of day-to-day systems and documents would result in higher adherence during a stressful situation and therefore would result in better outcomes. The PMW considered several potential sources of clinical and demographic information.The group determined that the use of inter-facility transfer forms and patient face sheets held the greatest promise. These two documents are ubiquitous at hospitals across the region, and in the case of inter-facility transfer forms, their day-to-day purpose closely mimics the purpose such forms would have in a patient evacuation scenario.

The PMW collected and examined nearly a dozen examples of suchforms, assessing the frequency with which various elements were used and weighing the importance of these elements for safe patient staging, transport and triage during an evacuation scenario. This process resulted in the development of the list of recommended standard data elements detailed below.

Recommended Standard Data Elements: Inter-facility Transfer Form

Demographic Information /
  • Name
  • Date of Birth
  • Medical Record Number/NYS DOH eFinds Number
  • Height/Weight/Sex
  • Preferred Language

Transport-related Information /
  • Patient Mobility Level (Ambulatory, Wheelchair, Non-ambulatory)
  • If an ambulance required, ALS or BLS
  • Bariatric
  • IV Medication requirements during transport
  • ECMO or IABP (requires transport team)
  • Oxygen Requirements (eg. BiPAP, CPAP)
  • Ventilator Settings
  • Settings/Sizes of lifesaving equipment (eg. trach)
  • Behavioral Concerns/Safety Risks
  • Fall Risk/Restraints
  • Hospital Bed Numberat sending and, if known, at receiving facility
  • Nurse or physician contact Information at sending and receiving facility
  • Date and time of departure and arrival with signature lines

Clinical Information /
  • Primary Diagnosis
  • Secondary Diagnosis
  • Relevant Comorbidities
  • Most Recent Vitals
  • Current Medications including pain management medications
  • Timing and dosage of medications
  • Allergies
  • Isolation Status/Presence of Infectious Disease
  • IV Access
  • DNR/Advanced Directive/Healthcare Proxy
  • Transplant List Status
  • Progress Notes Section

Patient Information /
  • Mental Status
  • Personal Assistive Devices transferred with patient such as glasses or hearing aid
  • Diet information
  • Bariatric
  • Presence of pressure ulcers
  • Seizure precautions
  • Drug research protocol

Recommended Standard Data Elements: Patient Face Sheet

  • Name
  • Medical Record Number/NYS DOH eFinds Number
  • Social Security Number
  • Sex
  • Date of Birth
  • Address
  • Emergency Contact Information/Next of Kin
  • Primary Care Physician Name and Number
  • Parent/Guardian Information for Minors
  • Insurance Information
  • Guarantor Information
  • ADL
  • Room and Bed Number
  • Primary Diagnosis

Suggested Internal Process: As an outcome of the PMW, DOHMH and GNYHA urge all hospitals in the NYC region to compare the list of recommended data elements provided above to their current inter-facility transfer forms and patient face sheets, and determine which elements are already included and which are not. In order to successfully advocate for the addition of these elements to your hospital’s standard documents, you should consider two elements:

  1. Educate key staff within your hospital regarding the need to integrate these data elements. While each institution is different, these staff may include: emergency managers, nursing leadership, transfer center staff, and EMS/transport leadership.
  2. Understand the process by which changes to forms occurs in your hospital.

Working in collaboration with key staff in your hospital, following your institution’s standard process, and tying your efforts to this larger regional initiative, you will likely be able to integrate many of these elements into your existing documents.

Creating Complimentary EMR Reports: Either in parallel, or at the conclusion of the paper form revision process, we suggest working with your facility’s Health Information Technology staff to create standard EMR reports that can automatically populate the required variables on the inter-facility transfer form and patient face sheet. The creation of such reports has the potential to increase speed and accuracy during an emergency event as well as during routine inter-facility transfers.

How DOHMH and GNYHA Can Assist: We have created the attached Process Change Workflow to assist you in tracking your internal efforts. We are also committed to tracking progress on this initiative at a system level. To this end, we plan to contact all member institutions during late 2015 to understand which standard data elements are currently included on their inter-facility transfer forms and patient face sheets. Approximately one year later, in late 2016, we will follow up again to determine which missing elements have been successfully adopted and offer assistance as needed.

Additional Clinical Documentation: Depending upon the particular circumstances of the emergency patient evacuation, hospitals should consider sending additional clinical documentation with each patient. Below we have provided a list developed by the PMW in order from highest to lowest priority. As part of its emergency plan development and review process, hospitals should consider if and how they could produce the documents below. At the time of an emergency event requiring patient evacuation, Incident Command leadership should determine what documentation from the list should be produced for each patient as part of the preparation and staging process.

  • Medical Chart including:
  • Most recent set of complete medical Orders
  • Medication Administration Sheets
  • History and Physicals
  • Operative/Consultation Reports
  • Most recent set of labs
  • Radiology/EKG
  • Blood and Blood Product Transfusion Records
  • Doctor/RN Transfer notes
  • DNR
  • Healthcare Proxy
  • Advance Directives
  • Critical Care Equipment Settings for Critical Patients
  • Restraints Order

If you have questions about the Patient Movement Workgroup, this recommendation document or the suggested internal process set forth, please contact Jenna Mandel-Ricci ()

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