Table 1.
Characteristics of Transfers that Occurred Within 48 Hours and 30 Days of SNF Admission vs. Transfers that Occurred 30 days or Longer After SNF Admission
| Characteristics | Number (%) with Specified Characteristic | p value1 | p value2 | ||
|---|---|---|---|---|---|
| Transferred within 48 hours of SNF admission (N =353) |
Transferred less than 30 days after SNF admission (N = 2,327) |
Transferred 30 days or longer after SNF admission (N = 2,331) |
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|
RISK FACTORS FOR HOSPITAL ADMISSION3 |
|||||
| Multiple comorbidities | 173 (49.0) | 1,222 (52.5) | 1,173 (50.3) | 0.646 | 0.134 |
| Polypharmacy | 121 (34.3) | 891 (38.3) | 1,000 (42.9) | 0.002 | 0.001 |
| CHF | 61 (17.3) | 459 (19.7) | 410 (17.6) | 0.887 | 0.061 |
| COPD | 46 (13.0) | 372 (16.0) | 348 (14.9) | 0.348 | 0.318 |
| Dementia | 21 (5.9) | 126 (5.4) | 251 (10.8) | 0.005 | < 0.001 |
| Fracture | 31 (8.8) | 192 (8.3) | 149 (6.4) | 0.094 | 0.015 |
| Cancer | 16 (4.5) | 147 (6.3) | 78 (3.3) | 0.258 | < 0.001 |
| Surgical complications | 20 (5.7) | 133 (5.7) | 79 (3.4) | 0.034 | < 0.001 |
| ESRD - on dialysis | 19 (5.4) | 97 (4.2) | 81 (3.5) | 0.078 | 0.217 |
| PRIOR HOSPITALIZATIONS | |||||
| In past 30 days | 274 (77.6) | 1840 (79.1) | 391 (16.8) | .000 | .000 |
| In past year, but not past 30 days | 23 (6.5) | 186 (8.0) | 1057 (45.3) | .000 | .000 |
| REASONS FOR TRANSFER3 | |||||
| Signs and Symptoms | |||||
| Abdominal pain | 14 (4.0) | 113 (4.9) | 94 (4.0) | 0.953 | 0.173 |
| Abnormal vital signs | 120 (34.0) | 814 (35.0) | 763 (32.7) | 0.638 | 0.105 |
| Altered mental status | 106 (30.0) | 622 (26.7) | 681 (29.2) | 0.754 | 0.059 |
| Behavioral symptoms | 58 (16.4) | 319 (13.7) | 387 (16.6) | 0.936 | 0.006 |
| Bleeding | 27 (7.6) | 169 (7.3) | 193 (8.3) | 0.687 | 0.195 |
| Chest pain | 16 (4.5) | 100 (4.3) | 81 (3.5) | 0.321 | 0.146 |
| Diarrhea | 5 (1.4) | 35 (1.5) | 24 (1.0) | 0.512 | 0.148 |
| Edema | 9 (2.5) | 75 (3.2) | 57 (2.4) | 0.906 | 0.110 |
| Fall | 16 (4.5) | 113 (4.9) | 267 (11.5) | < 0.001 | < 0.001 |
| Fever | 28 (7.9) | 253 (10.9) | 30 (13.1) | 0.006 | 0.020 |
| Decreased food and/or fluid intake | 33 (9.3) | 256 (11.0) | 283 (12.1) | 0.129 | 0.224 |
| Functional decline | 40 (11.3) | 307 (13.2) | 433 (18.6) | 0.001 | < 0.001 |
| Gastrostomy tube blockage/displacement | 7 (2.0) | 35 (1.5) | 41 (1.8) | 0.767 | 0.492 |
| Loss of consciousness | 7 (2.0) | 48 (2.1) | 43 (1.8) | 0.858 | 0.591 |
| Nausea/vomiting | 19 (5.4) | 146 (6.3) | 182 (7.8) | 0.107 | 0.041 |
| Pain (uncontrolled) | 60 (17.0) | 410 (17.6) | 461 (19.8) | 0.218 | 0.059 |
| Respiratory infection | 12 (3.4) | 82 (3.5) | 148 (6.3) | 0.029 | < 0.001 |
| Seizure | 7 (2.0) | 28 (1.2) | 23 (1.0) | 0.097 | 0.478 |
| Shortness of breath | 98 (27.8) | 594 (25.5) | 493 (21.1) | 0.005 | < 0.001 |
| Skin wound/pressure ulcer | 29 (8.2) | 183 (7.9) | 208 (8.9) | 0.662 | 0.192 |
| Unresponsiveness | 40 (11.3) | 242 (10.4) | 244 (10.5) | 0.623 | 0.940 |
| Urinary incontinence (new) | 4 (1.1) | 60 (2.6) | 98 (4.2) | 0.005 | 0.002 |
| Weight loss | 0 (0.0) | 5 (0.2) | 5 (0.2) | 0.384 | 0.998 |
|
Abnormal Test Results before Transfer3 |
|||||
| Anemia | 13 (3.7) | 237 (10.2) | 174 (7.5) | 0.009 | 0.001 |
| Electrocardiogram | 1 (0.3) | 21 (0.9) | 24 (1.0) | 0.174 | 0.657 |
| Hypoglycemia | 5 (1.4) | 32 (1.4) | 39 (1.7) | 0.723 | 0.407 |
| Hyperglycemia | 7 (2.0) | 82 (3.5) | 86 (3.7) | 0.102 | 0.762 |
| International Normalized Ratio (INR) - high | 1 (0.3) | 16 (0.7) | 6(0.3) | 0.929 | 0.032 |
| Kidney function abnormal | 5 (1.4) | 105 (4.5) | 102 (4.4) | 0.008 | 0.821 |
| Leukocytosis | 3 (0.8) | 38 (1.6) | 27 (1.2) | 0.607 | 0.167 |
| Pulse oximetry | 72 (20.4) | 402 (17.3) | 359 (15.4) | 0.017 | 0.084 |
| Urinalysis or urine culture | 5 (1.4) | 66 (2.8) | 118 (5.1) | 0.002 | < 0.001 |
| X-ray | 8 (2.3) | 122 (5.2) | 186 (8.0) | < 0.001 | < 0.001 |
| Other Factors3 | |||||
| Primary care clinician decision | 188 (53.3) | 1,158 (49.8) | 1,234 (52.9) | 0.911 | 0.030 |
| Resident and/or family insisted on transfer | 64 (18.1) | 398 (17.1) | 348 (14.9) | 0.120 | 0.043 |
| Advance directive not in place | 27 (7.6) | 159 (6.8) | 149 (6.4) | 0.374 | 0.545 |
| TIME OF DAY AND DAY OF WEEK4 | |||||
| Morning (7 am-noon) | 95 (31.1) | 601 (29.6) | 550 (26.7) | ||
| Afternoon (noon - 7 pm) | 118 (38.8) | 864 (42.6) | 885 (42.9) | 0.176 | 0.105 |
| Evening (7 pm - midnight) | 62 (20.4) | 352 (17.4) | 380 (18.4) | ||
| Night (midnight - 7 am) | 29 (9.5) | 210 (10.4) | 246 (11.9) | ||
| Weekday | 256 (72.5) | 1789 (76.8) | 1787 (76.7) | 0.089 | 0.943 |
| Weekend | 97 (27.5) | 541 (29.2) | 544 (23.3) | ||
| EVALUATION BEFORE TRANSFER4 | |||||
| On site (vs. telephone) medical evaluation before transfer |
70 (19.8) | 568 (24.4) | 487 (20.9) | 0.646 | 0.004 |
|
DIAGNOSTIC TESTS BEFORE TRANSFER3 |
|||||
| Blood tests | 29 (8.2) | 364 (15.6) | 337 (14.5) | 0.001 | 0.258 |
| EKG | 2 (0.6) | 32 (1.4) | 29 (1.2) | 0.267 | 0.694 |
| Urinalysis and/or culture | 5 (1.4) | 96 (4.1) | 170 (7.3) | < 0.001 | < 0.001 |
| Venous Doppler study | 1 (0.3) | 20 (0.9) | 16 (0.7) | 0.374 | 0.500 |
| X-ray | 15 (4.2) | 167 (7.2) | 276 (11.8) | < 0.001 | < 0.001 |
|
INTERVENTIONS BEFORE TRANSFER3 |
|||||
| New medication(s) | 43 (12.2) | 340 (14.6) | 397 (17.0) | 0.022 | 0.024 |
| Intravenous or subcutaneous fluids | 5 (1.4) | 88 (3.8) | 89 (3.8) | 0.022 | 0.948 |
| Increase oral fluid intake | 0 (0.0) | 4 (0.2) | 13 (0.6) | 0.160 | 0.029 |
| Oxygen | 80 (22.7) | 495 (21.3) | 475 (20.4) | 0.323 | 0.452 |
|
CLINICIAN AUTHORIZING TRANSFER4 |
|||||
| Primary care physician, nurse practitioner, or physician assistant |
259 (83.0) | 1787 (87.6) | 1813 (88.1) | 0.012 | 0.687 |
| Covering physician | 53 (17.0) | 252 (12.4) | 246 (11.9) | ||
| OUTCOME OF TRANSFER4 | |||||
| Emergency Department visit only with return to Skilled Nursing Facility |
51 (15.0) | 292 (13.3) | 471 (21.4) | 0.007 | <0.001 |
| Admitted as inpatient | 288 (85.0) | 1905 (86.7) | 1732 (78.6) | ||
| RATING OF PREVENTABILITY4 | |||||
| Potentially preventable | 76 (23.8) | 542 (25.1) | 467 (21.5) | 0.354 | 0.005 |
| Not preventable | 243 (76.2) | 1,617 (74.9) | 1,705 (78.5) | ||
|
OPPORTUNITIES FOR IMPROVEMENT3,5 |
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| Changes could have been detected earlier | 11 (14.5) | 114 (21.0) | 123 (26.3) | 0.026 | 0.047 |
| Communication could have been better | 9 (11.8) | 86 (15.9) | 95 (20.3) | 0.081 | 0.065 |
| Condition might have been managed in SNF with available sources |
19 (25.0) | 170 (31.4) | 192 (41.1) | 0.008 | 0.001 |
| Earlier discussion of preferences with resident/family |
14 (18.4) | 89 (16.4) | 77 (16.5) | 0.676 | 0.977 |
| ACP could have been in place earlier | 8 (10.5) | 62 (11.4) | 35 (7.5) | 0.364 | 0.034 |
| Resources not available to manage the change |
25 (32.9) | 144 (26.6) | 102 (21.8) | 0.035 | 0.081 |
p values calculated by chi square tests comparing characteristics of transfers that occurred within 48 hours of SNF admission to characteristics of transfers that occurred 30 days or longer after admission to the SNF. Values are highlighted that reached significance at the .05 level. Within categories of characteristics in which multiple comparisons were made, a Bonferroni correction was considered in evaluating the p values.
p values calculated by chi square tests comparing characteristics of transfers that occurred less than 30 days after SNF admission to characteristics of transfers that occurred 30 days or longer after admission to the SNF. Values are highlighted that reached significance at the .05 level. Within categories of characteristics in which multiple comparisons were made, a Bonferroni correction was considered in evaluating the p values.
N’s vary because more than one item could have been selected. Bonferroni correction was considered in evaluating these p values. For example in the category of Risk Factors for Hospital Admission, 9 comparisons were made. Thus a significant p value with the correction would be less than or equal to .05/9 = .0055.
Answers were mutually exclusive; N’s vary because not all items were answered on each QI tool. Bonferroni correction was not applied to these items.
N is only those rated as potentially preventable.