Julia Morphet1, Debra L Griffiths2, Kelli Innes3, Kimberley Crawford2, Sally Crow2, Allison Williams2. 1. School of Nursing & Midwifery, Monash University, Peninsula Campus, McMahons Road, Frankston, Australia. Electronic address: Julia.morphet@monash.edu. 2. School of Nursing & Midwifery, Monash University, Peninsula Campus, McMahons Road, Frankston, Australia. 3. School of Nursing & Midwifery, Monash University, Berwick Campus, Clyde Road, Berwick, Australia.
Abstract
BACKGROUND: Increasing numbers of residents are transferred from aged care facilities to emergency departments. Frequently, residents arrive with inadequate documentation regarding their presenting complaint or medical history, making it difficult for emergency department staff to make decisions about care. METHODS: A retrospective review of emergency department records was undertaken for residents transferred from residential aged care facilities to two emergency departments in Melbourne, Victoria in 2012. RESULTS: 2880 resident transfers were included in the sample, of which 408 transfers were randomly selected for documentation review. Clinically important documentation was frequently absent including: the reason for transfer to the ED (n=197, 48.2%); baseline cognitive function (n=244, 59.7%); and vital signs at time of complaint (n=285, 69.9%). When the reason for transfer was absent, residents with an altered conscious state had more investigations and spent longer in the emergency department than when the reason for transfer was recorded. CONCLUSION: Inadequate documentation negatively impacted the resident's journey through the emergency department. There is evidence that inadequate documentation contributes to poor patient outcomes. To minimise the gaps in the transfer documentation regular staff development and quality assurance programs may be required in residential aged care facilities.
BACKGROUND: Increasing numbers of residents are transferred from aged care facilities to emergency departments. Frequently, residents arrive with inadequate documentation regarding their presenting complaint or medical history, making it difficult for emergency department staff to make decisions about care. METHODS: A retrospective review of emergency department records was undertaken for residents transferred from residential aged care facilities to two emergency departments in Melbourne, Victoria in 2012. RESULTS: 2880 resident transfers were included in the sample, of which 408 transfers were randomly selected for documentation review. Clinically important documentation was frequently absent including: the reason for transfer to the ED (n=197, 48.2%); baseline cognitive function (n=244, 59.7%); and vital signs at time of complaint (n=285, 69.9%). When the reason for transfer was absent, residents with an altered conscious state had more investigations and spent longer in the emergency department than when the reason for transfer was recorded. CONCLUSION: Inadequate documentation negatively impacted the resident's journey through the emergency department. There is evidence that inadequate documentation contributes to poor patient outcomes. To minimise the gaps in the transfer documentation regular staff development and quality assurance programs may be required in residential aged care facilities.
Authors: Cameron J Gettel; Roland C Merchant; Yanan Li; Sara Long; Austin Tam; Sarah J Marks; Elizabeth M Goldberg Journal: J Am Med Dir Assoc Date: 2018-10-29 Impact factor: 4.669
Authors: Kaitlyn Tate; Patrick McLane; Colin Reid; Brian H Rowe; Garnet Cummings; Carole A Estabrooks; Greta Cummings Journal: BMJ Open Qual Date: 2022-03