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A total of 25 organizations in six States were interviewed about their use of a patient risk assessment rating tool. Of the 25 organizations interviewed, two thirds (17) described using a two-, three-, four-, or five-level categorization system to rank patients, usually at the time of admission. The 17 entities that reported using a formal system were all home health and/or hospice agencies. Four other home health and/or hospice agencies reported that they do not use a patient classification system because they are small and know all their patients' needs; staff at these agencies can quickly identify those who are at risk (e.g., patients who require oxygen or continuous IV infusion) and see no need for a formal system with graded levels.
None of the four other community service providers (non-home health/hospice agencies) use a formal risk assessment tool, although they could describe their clients who are at highest risk (e.g., patients who have little or no support in the home, require high flow use of oxygen, or have restricted mobility).
Use of Formal Patient Classification Systems
The formal classification systems described by the home health agencies (HHAs) typically use a numeric or color coded ranking, with descriptions of the types of patients that fit in each level. These systems vary in terms of the number of levels, the basis for the level characterization, and the order ranking of risk (highest risk to lowest or vice versa). The majority of patient categorization systems have three levels.
The basis for the categorizations varies; some focus on the time frame in which each patient must be seen (e.g., patient needs to be seen in 24 hours, 48 hours), while some vary based on medical care needs, using examples of medical diagnoses or care conditions to determine risk level. Others are based on the amount of support an individual has available (e.g., caregiver in the home), and one is based in part on the individual's own ability to respond to a disaster situation. Several patient categorization tools are based on some combination of the above criteria. Table 2 summarizes the basis for each level characterization in the systems reviewed.
Table 2. Basis for Level Characterization in Patient Classification Systems Reviewed
|Type of System
||Time Frame (1)
||Time Frame (3)
Care Needs (6)
Combination of Care Needs and Support (3)
Combination of Care Needs and Time Frame (1)
||Combination of Care Needs and Time Frame (1)
No information available (1)
||Combination of Care Needs, Support, and Response to Disaster (1)
Source: Abt Associates, 2009.
In most systems, the first or number "1" level represents the patients who are most at risk. One system was the reverse, with a higher numeric level ("Level 3") indicating greater risk. Standardization in this regard—where "Level 1" indicates greatest risk—would reduce the potential for confusion
Process for Collecting and Updating Patient Information
The HHAs reported using a mix of paper and electronic systems. Larger HHAs tended to use electronic medical record systems, while smaller HHAs tended to use paper systems or none at all.
The HHAs reported that their intake assessment protocols include questions about patient risk classification. The risk classification item is completed on admission to the HHA and updated at recertification (every 60 days) or when the patient's medical condition worsens. Several reported updating seasonally and/or annually. A few HHAs reported faxing the medical risk information to the city government for emergency management planning purposes or communicating information on medical supply reserves (e.g., number of oxygen tanks kept on site, how long the generator will last in the event of a power failure) to the local fire department.
Experiences Using the Patient Classification System in an Emergency Situation
Several of the HHAs described their experiences using their patient classification system in anticipation of severe storms. Each used an electronic system and was able to print a list of patients who were considered highest priority. Many of the respondents explained that there were far too many patients on the high priority list to possibly visit them all quickly. This seems to indicate that either the categorization tool did not accomplish its goal of triaging patients effectively or that HHAs have more high-priority patients than they can serve during disasters.
The HHAs were asked to estimate the percentage of their patients who would be classified as highest risk should home care or other community-based services be interrupted by a disaster. Two HHAs estimated that 1 percent of their average daily census would fit into the highest risk category and require hospital care; two other HHAs estimated that 21 to 25 percent of their census would be in this highest risk category. These HHAs cautioned that the census varies from one month to the next. In general, these highest risk patients were described as follows:
- Bed-bound and without a caregiver, unable to get food or fluids, or immobilized or paralyzed.
- Ventilator dependent.
- Oxygen dependent.
- IV infusion dependent.
- In need of highly technical equipment (e.g., wound vacuum-assisted closure device, chest tube drainage system).
- Dependent on a skilled service (e.g., respiratory therapy).
- Medication dependent and unable to self-administer.
- Dialysis dependent;
- Patients with severe dementia or Alzheimer's disease.
- Patients with severe mental illness; or
- In need of daily wound care.
When HHA nurses were asked to describe how they used their patient classification systems in preparation for storms in which services could be disrupted, they described taking their lists of at risk patients and reviewing cases individually to further identify the most critical patients. Based on information from medical records, nursing notes, or personal knowledge of the patients, they could then determine in an ad hoc manner which patients could be seen before the storm arrived, which could be checked on by a family member or neighbor, and which might need transport to a hospital by the local fire/police department. Patients who could not be visited in person during or immediately after the storm were contacted by telephone to determine whether they had enough medication/food/water/power and if there was a family member available to help. In the worst situations, the HHAs informed local fire departments that a patient needed to be seen but the visiting nurse could not reach them. In these cases, ambulances were sent to bring the patients to hospitals.
None of the HHAs had experienced an emergency that arrived without advance warning; their experiences were all storm-related, with sufficient lead time to sort through their patient lists and prioritize visits. In a sudden disaster (e.g., earthquake) none of this would be possible; moreover, the clinicians with personal knowledge of patient needs might not be available.
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