Shortfalls in residents' transfer documentation: challenges for emergency department staff

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.

Keywords: Documentation; Emergency department; Information gaps; Patient transfer; Residential aged care facility.