Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection

作     者：Mark Rose Carina Newton Benchaa Boualam Nancy Bogne Adam Ketchum Umang Shah Jordan Mitchell Safura Tanveer Tucker Lurie Walesia Robinson Rebecca Duncan Stephen Thom Quincy Khoi Tran 

作者机构：Department of Emergency Medicine University of Maryland School of Medicine University of Maryland at College Park University of Maryland School of Medicine Program of Trauma The R Adams Cowley Shock Trauma Center University of Maryland School of Medicine 

出 版 物：《World Journal of Emergency Medicine》 (世界急诊医学杂志（英文）)

年 卷 期：2019年第10卷第2期

页      面：94-100页

核心收录：

学科分类：10[医学] 

主　　题：Acute aortic dissection EMTALA Interhospital transfer Documentation Compliance 

摘      要：BACKGROUND: Acute aortic dissection(AoD) is a hypertensive emergency often requiring the transfer of patients to higher care hospitals; thus, clinical care documentation and compliance with the Emergency Medical Treatment and Active Labor Act(EMTALA) is crucial. The study assessed emergency providers(EP) documentation of clinical care and EMTALA compliance among interhospital transferred AoD ***: This retrospective study examined adult patients transferred directly from a referring emergency department(ED) to a quaternary academic center between January 1, 2011 and September 30, 2015. The primary outcome was the percentage of records with adequate documentation of clinical care(ADoCC). The secondary outcome was the percentage of records with adequate documentation of EMTALA compliance(ADoEMTALA). RESULTS: There were 563 electronically identified patients with 287 included in the final analysis. One hundred and five(36.6%) patients had ADoCC while 166(57.8%) patients had ADoEMTALA. Patients with inadequate documentation of EMTALA(IDoEMTALA) were associated with a higher likelihood of not meeting the American Heart Association(AHA) ED Departure SBP guideline(OR 1.8, 95% CI 1.03–3.2, P=0.04). Male gender, handwritten type of documentation, and transport by air were associated with an increased risk of inadequate documentation of clinical care(IDoCC), while receiving continuous infusion was associated with higher risk of ***: Documentation of clinical care and EMTALA compliance by Emergency Providers is poor. Inadequate EMTALA documentation was associated with a higher likelihood of patients not meeting the AHA ED Departure SBP guideline. Therefore, Emergency Providers should thoroughly document clinical care and EMTALA compliance among this critically ill group before transfer.