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

doi:10.5847/wjem.j.1920-8642.2019.02.005

Abstract

Abstract:

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 patients.
METHODS: 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 IDoEMTALA.
CONCLUSION: 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.

Key words: Acute aortic dissection, EMTALA, Interhospital transfer, Documentation, Compliance

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. Assessing adequacy of emergency provider documentation among interhospital transferred patients with acute aortic dissection[J]. World Journal of Emergency Medicine, 2019, 10(2): 94-100.

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References 26

1	Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Pra. Catheter Cardiovasc Interv. 2010; 76(2):E43-86.
2	Howard DP, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013; 127(20):2031-7.
3	Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283(7):897-903.
4	Dmowski AT, Carey MJ. Aortic dissection. Am J Emerg Med. 1999; 17(4):372-5. doi: 10.1016/s0735-6757(99)90090-6 pmid: 10452437
5	Nienaber CA, Powell JT. Management of acute aortic syndromes. Eur Heart J. 2012; 33(1):26-35.
6	Iwashyna TJ, Christie JD, Moody J, Kahn JM, Asch DA. The structure of critical care transfer networks. Med Care. 2009; 47(7):787-93.
7	Iwashyna TJ. The incomplete infrastructure for interhospital patient transfer. Crit Care Med. 2012; 40(8):2470-8.
8	Warren J, Fromm RE Jr, Orr RA, Rotello LC, Horst HM. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med. 2004; 32(1):256-62. doi: 10.1097/01.CCM.0000104917.39204.0A pmid: 14707589
9	Nevrekar V, Panda P, Wig N, Pandey R, Agarwal P, Biswas A. An interventional quality improvement study to assess the compliance to cardiopulmonary resuscitation documentation in an indian teaching hospital. Indian J Crit Care Med. 21(11):758-64.
10	Sturesson L, Falk AC, Castrén M, Niemi-Murola L, Lindström V. Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management. Scand J Pain. 2016; 13:32-5. pmid: 28850532
11	ACEP. Interfacility transportation of the critical care patient and its medical direction. Policy statement. Ann Emerg Med. 2006; 47(3):305.
12	Harl FNR, Saucke MC, Greenberg CC, Ingraham AM. Assessing written communication during interhospital transfers of emergency general surgery patients. J Surg Res. 2017; 214:86-92.
13	Usher MG, Fanning C, Wu D, Muglia C, Balonze K, Kim D, et al. Information handoff and outcomes of critically ill patients transferred between hospitals. J Crit Care. 2016; 36:240-5. pmid: 27591388
14	Alter S, Eskin B, Allegra J. Diagnosis of aortic dissection in emergency department patients is rare. West J Emerg Med. 2015; 16(5):629-31. pmid: 26587083
15	Kaji AH, Schriger D, Green S. Looking through the retrospectoscope: Reducing bias in emergency medicine chart review studies. Ann Emerg Med. 2014; 64(3):292-8.
16	Ipek E, Oktay AA, Krim SR. Hypertensive crisis: An update on clinical approach and management. Curr Opin Cardiol. 2017; 32(4):397-406. pmid: 28306673
17	Ruszala MW, Reimer AP, Hickman RL, Clochesy JM, Hustey FM. Use of arterial catheters in the management of acute aortic dissection. Air Med J. 2014; 33(6):326-30. doi: 10.1016/j.amj.2014.06.001
18	Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med. 2008; 3:17. doi: 10.1186/1751-0473-3-17 pmid: 19087314
19	Mickey RM. The impact of confounder selection criteria on effect estimation. Am J Epidemiol. 1989; 129(1):125-37. pmid: 2910056
20	Yu KT, Green RA. Critical aspects of emergency department documentation and communication. Emerg Med Clin North Am. 2009; 27(4):641-54, ix. pmid: 19932389
21	Elefteriades JA, Barrett PW, Kopf GS. Litigation in nontraumatic aortic diseases--a tempest in the malpractice maelstrom. Cardiology. 2008; 109(4):263-72. doi: 10.1159/000107790 pmid: 17873491
22	McCool WF, Guidera M, Griffinger E, Sacan D. Closed claims analysis of medical malpractice lawsuits involving midwives: lessons learned regarding safe practices and the avoidance of litigation. J Midwifery Women’s Heal. 2015; 60(4):437-44.
23	Terp S, Seabury SA, Arora S, Eads A, Lam CN, Menchine M. Enforcement of the Emergency Medical Treatment and Labor Act, 2005 to 2014. Ann Emerg Med. 2017; 69(2):155-162.e1.
24	Terp S, Wang B, Raffetto B, Seabury SA, Menchine M. Individual Physician Penalties Resulting From Violation of Emergency Medical Treatment and Labor Act: A Review of Office of the Inspector General Patient Dumping Settlements, 2002-2015. Acad Emerg Med. 2017; 24(4):442-6. pmid: 28109011
25	O’Connor AB, Zwemer FL, Hays DP, Feng C. Outcomes after intravenous opioids in emergency patients: A prospective cohort analysis. Acad Emerg Med. 2009; 16(6):477-87.
26	Usher MG, Fanning C, Wu D, Muglia C, Balonze K, Kim D, et al. Information handoff and outcomes of critically ill patients transferred between hospitals. J Crit Care. 2016; 36(16):240-5.

Variables	Results
Age, (years), mean (SD)	61 (14)
Gender
Female	104 (36.2)
Male	183 (63.8)
Hospital teaching status
Teaching	110 (38.3)
Non-teaching	177 (61.7)
Travel distance by ground
Mean (km), (SD)	48 (48)
<16	86 (30)
16.1-40	68 (24)
40.1-80	80 (28)
>80.1	53 (18)
Triage ESI
3-4	128 (45)
1-2	159 (55)
Type of documentation
Handwritten only	21 (7)
Mixed	109 (38)
Electronic only	157 (54)
Triage day of week ^a
Monday-Friday	210 (75)
Saturday-Sunday	71 (25)
Triage time of day ^a
Day (07:00-18:59)	174 (62)
Evening (19:00-06:59)	107 (38)
Triage SBP, mean (SD)	150 (42)
Triage HR, mean (SD)	78 (19)
Triage pain level ^b
0-3	58 (25)
4-6	58 (25)
7-10	118 (50)
Type of acute aortic dissection
Type A	135 (47)
Type B	105 (37)
Other	47 (16)
Mode of transport
Air	86 (30)
Ground	201 (70)
Mechanical ventilation
Yes	11 (4)
No	276 (96)
Receiving infusion medication
Yes	119 (41.5)
No	168 (58.5)
ED LOS (minute), median [IQR]	300 [205-415]
Departure SBP, mean (SD) ^c	139 (31)
Departure HR, mean (SD) ^d	77 (16)

Documentation component	Number of missing^a
Triage SBP	10 (3.5)
Triage HR	13 (4.5)
SBP at ED departure	38 (13)
HR at ED departure	46 (16)
≥ 2 assessments before diagnosis of AoD	81 (28)
≥ 2 assessments after diagnosis of AoD	50 (17)
Documentation of consultation with accepting physicians	95 (33)
Transfer consent signed by patient or family	42 (14)

Variables	SBP and HR according to AHA guidelines at ED departure
Variables	SBP≤120 (n=70)	SBP≥121 (n=217)	HR≤60 (n=27)	HR≥61 (n=260)
Documentation of clinical care^a
Adequate (n=105, 37%)	28 (27)	77 (73)	9 (9)	96 (91)
Inadequate (n=182, 63%)	42 (23)	140 (77)	18 (10)	164 (90)
Documentation complying with EMTALA compliance
Adequate (n=166, 58%)	48 (29)	118 (71)^b	15 (9)	151 (91)^c
Inadequate (n=121, 42%)	22 (18)	99 (82)^b	12 (10)	109 (90)^c
Documentation of both clinical care and EMTALA compliance^d
Adequate (n=67, 23%)	22 (33)	45 (67)	6 (9)	61 (91)
Inadequate (n=220, 77%)	48 (22)	172 (78)	21 (10)	199 (90)

Variables	OR	95% CI	P-value	Adj. OR	95% CI	Adj. P-value
Inadequate documentation of clinical care
Gender - male	1.89	1.15-3.11	0.012	2.2	1.3-3.7	0.005
Distance by ground (km)	0.82	0.66-1.03	0.085	0.9	0.7-1.2	0.5
Type of documentation - handwritten	1.77	1.10-2.46	0.008	1.9	1.3-2.9	0.002
Triage HR ≥101 beats/minute	0.54	0.28-1.03	0.06	0.5	0.3-1.0	0.053
Mode of transport - ground	0.45	0.27-0.75	0.002	0.4	0.2-0.8	0.008
Inadequate documentation of EMTALA compliance
Gender - male	1.5	0.94-2.5	0.09	0.5	0.3-3.3	0.07
Receiving infusion	1.9	1.20-3.0	0.009	1.9	1.2-3.2	0.007
Inadequate documentation of both clinical care and EMTALA compliance
Gender - male	2.2	1.30-3.9	0.005	2.1	1.2-3.8	0.01
Type of documentation - handwritten	1.8	1.20-2.8	0.005	1.9	1.2-3.0	0.004
Triage day - weekday	0.5	0.28-0.9	0.02	0.5	0.3-0.9	0.032
Triage HR ≥101 beats/minute	0.5	0.27-1.1	0.09	0.6	0.3-1.2	0.13