NR 542 Week 7 Collection Design Brief Example

Collection Design Brief: Three Questions Added to the ICU Transfer Order to Capture Why Early Transfers Happen, With No Preselected Answers, Plain Definitions, a Thirty-Second Burden and a Pilot Before Anyone Relies on Them

Student Name

College of Nursing, Chamberlain University

NR 542: Managing Data and Information

Instructor Name

Month Day, Year

Collection Design Brief: Three Questions Added to the ICU Transfer Order to Capture Why Early Transfers Happen, With No Preselected Answers, Plain Definitions, a Thirty-Second Burden and a Pilot Before Anyone Relies on Them

The Figure Nobody Has Written Down

The analysis of early intensive care transfers found that about 3% of emergency department admissions to hospital medicine move to intensive care within 24 hours of reaching a medical floor, that the rate is higher at night and that a sizable minority of transferred patients already had worrying warning scores in the emergency department. The hospital medicine director's real question, whether those patients should have gone to intensive care in the first place, could not be answered from existing fields. Nobody records why an early transfer happened, or whether intensive care was considered at the time of admission. The hardest figure to produce is the one nobody has ever written down, and by now the existing fields have been fully interrogated. This brief designs the capture itself.

What Needs to Be Captured

Three pieces of information would let the hospital distinguish transfers that reflect unpredictable deterioration from those that might reflect initial placement. First, the main reason for the transfer, in clinical categories. Second, whether the patient's condition at transfer was a change from their condition at admission, or a continuation of it. Third, whether intensive care placement was discussed with the intensive care team before the patient left the emergency department. None of these is currently recorded in a structured field.

Where and When to Capture It

The information will be captured on the intensive care transfer order, completed by the physician or advanced practice provider requesting the transfer, but only when the transfer occurs within 48 hours of floor arrival. The order is chosen because it is already completed for every transfer, by the person who knows the answer, at the moment the answer is freshest. The 48-hour window is wider than the report's 24 hours so that transfers just outside the window can be compared. A rule in the record will display the three questions only when this condition is met, so that most transfer orders are unaffected.

The rule that shows the questions only for early transfers depends on the same floor-arrival time the report uses. If that time is recorded late, as the audit found occasionally happens at night, a transfer at hour 47 might not trigger the questions when it should. The pilot will count transfer orders that should have shown the questions but did not, so that this dependency is tested rather than assumed.

The Three Questions

Question 1. Main reason for transfer. Required, single choice: respiratory failure or increasing oxygen needs; hypotension or shock; altered mental status; cardiac arrhythmia or ischemia; bleeding; metabolic emergency; other, specify. The categories were drawn from the transferred patients' diagnoses in the analysis and reviewed with two intensivists.

Question 2. Change from admission. Required, single choice: new problem not present at admission; worsening of the admitting problem; admitting problem unchanged but requiring more monitoring than the floor provides. Each choice has a one-line definition visible on hover.

Question 3. ICU discussed before floor admission. Required, single choice: yes, and floor placement agreed; yes, and ICU recommended but no bed available; no; unknown.

No question has a preselected answer. The data quality audit found that a preselected admission source had been left unchanged in 5.5% of encounters, and a default here would produce the same kind of error in a field whose whole purpose is to capture judgment. The "unknown" option in question 3 is deliberate, because a transferring provider may not know what was discussed on a previous shift, and a forced guess is worse than an honest unknown.

Burden

The three questions take about 30 seconds and appear on roughly 15 orders a month. That is a small burden, but it is not nothing, and studies of how clinical systems misfire have shown that extra mandatory fields add work and prompt clinicians to enter whatever lets them proceed (Ash et al., 2004). The design limits burden by appearing only for early transfers, using short choices rather than free text and requiring no more than three answers. It will be reviewed if providers report that it delays urgent transfers.

Data Quality Built In

The design includes checks from the start. Answers will be compared monthly with the transfer note for a sample of five orders, to test whether the structured answer agrees with what the provider wrote. The "other" category will be reviewed quarterly, and any recurring free-text reason will be added as a category. A framework for assessing record data quality for secondary use recommends defining each element's meaning, allowed values and expected completeness before data are collected (Kahn et al., 2016). Those definitions are written here and stored with the reporting plan. A review of data quality methods lists completeness and correctness among the core dimensions (Weiskopf & Weng, 2013); the monthly comparison measures both.

Pilot and Use

The questions will be piloted for three months on the two medical units with the most early transfers. At the end of the pilot, the informatics team will report completion rates, agreement with notes and provider feedback. Only if completion exceeds 90% and agreement exceeds 80% will the data be used in reports. Until then, the report of early transfers will continue without them.

If the pilot succeeds, the new fields will let the hospital medicine director see, for example, how many early transfers involved a new problem compared with a worsening admitting problem, and how often intensive care was recommended but no bed was available. The last category matters: if early transfers often follow an intensive care recommendation that could not be met because of capacity, the problem is beds, not judgment, and the response is different.

The design has been reviewed by the hospital medicine director, two intensivists and the emergency department's medical director, each of whom had a stake in how the questions are worded. The intensivists asked for the "no bed available" option; the emergency department asked that question 3 not imply blame for placement decisions made under pressure. The final wording tries to respect both.

If the pilot fails its thresholds, the questions will be revised with the providers who used them before any second attempt.

References

Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11(2), 104-112. https://doi.org/10.1197/jamia.M1471

Kahn, M. G., Callahan, T. J., Barnard, J., Bauck, A. E., Brown, J., Davidson, B. N., Estiri, H., Goerg, C., Holve, E., Johnson, S. G., Liaw, S.-T., Hamilton-Lopez, M., Meeker, D., Ong, T. C., Ryan, P., Shang, N., Weiskopf, N. G., Weng, C., Zozus, M. N., & Schilling, L. (2016). A harmonized data quality assessment terminology and framework for the secondary use of electronic health record data. eGEMs, 4(1), Article 18. https://doi.org/10.13063/2327-9214.1244

Weiskopf, N. G., & Weng, C. (2013). Methods and dimensions of electronic health record data quality assessment: Enabling reuse for clinical research. Journal of the American Medical Informatics Association, 20(1), 144-151. https://doi.org/10.1136/amiajnl-2011-000681