The importance of complete transfer documentation between EDs is integral to the smooth transition of care; however, as demonstrated in this study, transmission of key information is inadequate. Provider note and radiology report are viewed by physicians as the most important to aid in the transition of care; however, these are most frequently missing in the transfer documentation. The improved transition of care with appropriate documentation of medical results reduces hospital costs by avoiding redundant testing and likely helps reduce medical error [11].
Our results are similar to previous studies of hospital discharge paperwork [1, 2], as well as nursing home and ECF-to-ED transfers [4,5,6,7,8]. Lack of documentation has been found to increase time in ED and investigative studies in patients with altered mental status [8]. Additionally, ED length of stay (LOS) has been shown to be increased by investigative studies [12, 13] and physician hand-off [14]. For every five additional lab tests ordered, the median ED LOS increases by 10 min [12]. Moreover, lab turnaround times affect time to disposition, with every 30-min interval of lab turnaround time leading to 17 min additional LOS [12]. Compared with no testing, admitted patients with any test performed in the ED had a 49.5-min increase in LOS [13]. While our study did not look directly at LOS of transferred patients, it stands to reason that lack of complete transfer documentation may lead to repeat testing and therefore longer LOS. Furthermore, 4.4% of transferred cases did not include the radiology imaging, which may not only impact LOS but also may lead to repeat radiologic studies and unnecessary radiation exposure.
Given the similarities of findings between our study, ECF-to-ED transfers, and discharged patients to ECFs and PCPs, the question remains how best to improve the transmission of critical information during the transition of care. Gandara et al. organized wholesale changes in the umbrella corporation governing the five major hospitals in its study [1]. These included improvements to the computer-based discharge summaries to include prompts or auto-importation for required documentation, creation of discharge templates, peer review, and feedback, as well as mandated training for clinicians on proper discharge summaries [1]. While all of these methods may not be feasible in an ED setting, information technology (IT) should be at the forefront.
A standardized role of healthcare IT and electronic medical records (EMR) in hand-offs within the hospital would markedly improve safety and decrease the loss of information at patient hand-off [9]. Linking of EMRs between transferring facilities could decrease the amount of lost data. During our study period, two of the transferring facilities shared EMRs with the medical center. While 24% of cases were transferred from these institutions, EMR was available in only 13%. This may have been related to a technical delay in uploading into the EMR to be used by the accepting team or delayed linking of the patient’s information within the computer system. Both of these issues could be addressed by the IT department. Likewise, the adoption of a cloud-based radiology imaging program would ensure that all imaging is available.
While it may not be feasible for an accepting facility to routinely provide feedback to the transferring facility on the quality and completeness of the transfer documentation, as implemented in Gandara et al.’s study, it is possible to create a standardized transfer checklist to be filled out by the transferring institution in order to ensure all information available is transmitted. The use of a standardized ECF-to-ED transfer sheet containing 11 essential data elements increased the amount of data provided to the ED [5]. Although it was included in only one third of transfers, it resulted in successful documentation in nearly all cases [5]. Another study developed forms for nursing home transfers, which ED staff found to be helpful in 98% of cases and more time-efficient [7]. The main critique from physicians was that the form was not always completed [7]. A standardized ED-to-ED transfer form, proposed in Fig. 2, ensuring both the provider note and radiology reports are included could improve the transfer documentation packet received by accepting facilities, thereby decreasing the time to disposition and overall LOS.
Limitations
Our study is limited by both its small sample size and single study site. This was a convenience sample study design during which residents voluntarily filled out a survey. Multiple subjects may not have been included due to resident preference. There is no fully accurate way to determine the exact number of transfers that occurred during the 2-month study period. Inter-rater reliability was not measured between residents filling out the surveys, and it is possible that results were biased by specific individuals completing or not completing surveys. Finally, the utility score is based on a subjective decision that may not be standardized among respondents.