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

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.

Factors associated with refractory pain in emergency patients admitted to emergency general surgery

BACKGROUND: Oligoanalgesia in emergency departments (EDs) is multifactorial. A previousstudy reported that emergency providers did not adequately manage patients with severe paindespite objective findings for surgical pathologies. Our study aims to investigate clinical andlaboratory factors, in addition to providers’ interventions, that might have been associated witholigoanalgesia in a group of ED patients with moderate and severe pains due to surgical pathologies.METHODS: We conducted a retrospective study of adult patients who were transferred directlyfrom referring EDs to the emergency general surgery (EGS) service at a quaternary academic centerbetween January 2014 and December 2016. Patients who were intubated, did not have adequaterecords, or had mild pain were excluded. The primary outcome was refractory pain, which wasdefi ned as pain reduction <2 units on the 0–10 pain scale between triage and ED departure.RESULTS: We analyzed 200 patients, and 58 (29%) had refractory pain. Patients with refractory painhad signifi cantly higher disease severity, serum lactate (3.4±2.0 mg/dL vs. 1.4±0.9 mg/dL, P=0.001), and lessfrequent pain medication administration (median [interquartile range], 3 [3–5] vs. 4 [3–7], P=0.001), whencompared to patients with no refractory pain. Multivariable logistic regression showed that the number of painmedication administration (odds ratio [OR] 0.80, 95% confi dence interval [95% CI] 0.68–0.98) and ED serumlactate levels (OR 3.80, 95% CI 2.10–6.80) were signifi cantly associated with the likelihood of refractory pain.CONCLUSIONS: In ED patients transferring to EGS service, elevated serum lactate levelswere associated with a higher likelihood of refractory pain.