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J Am Med Dir Assoc. 2019 Aug;20(8):935-941.e3. doi: 10.1016/j.jamda.2018.09.008. Epub 2018 Oct 29.

The Impact of Incomplete Nursing Home Transfer Documentation on Emergency Department Care.

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Department of Emergency Medicine, Brown University, Providence, RI. Electronic address:
Department of Emergency Medicine, Brigham & Women's Hospital, Harvard University, Boston, MA.
School of Public Health, Brown University, Providence, RI.
Warren Alpert Medical School of Brown University, Providence, RI.
Department of Emergency Medicine, Brown University, Providence, RI.



Emergency department (ED) clinicians rely on the accuracy of written communication when assessing needs of nursing home (NH) residents. This study aimed to review the completeness of NH transfer documentation according to expected core components, as guided by the INTERACT 4.0 quality improvement tool. We also describe the association between patient or facility characteristics and transfer documentation completeness, as well as establish whether information gaps in NH-ED transfer documentation were associated with hospital admission.


Retrospective study using 2 abstractors blinded to the study aims.


474 records from NH residents transferred to the 3 EDs of Rhode Island's largest health care system from September 2015 to September 2016.


NH-ED transfer documentation completeness was reviewed according to the expected core items of transfer documentation, guided by the INTERACT 4.0 quality improvement tool. We used multivariable linear regression with random effects to assess factors associated with NH-ED transfer documentation completion and logistic regression with random effects to assess the relation between information gaps and hospital admission.


Of the 474 NH-ED transfer visits, mean patient age was 76 years; 43% were male, 14% were nonwhite, and 34% had dementia. NH-ED transfer documents were present for 97% of visits, and an average 11.9 of 15 INTERACT core items were complete. Usual mental status and reason for transfer were absent for 75% of patients, whereas functional status was absent for 80%. The multivariable model showed that a higher Charlson Comorbidity Index score (coefficient 0.08, standard error 0.04, P = .03) was associated with more complete documentation. More complete documentation was associated with greater likelihood of hospital admission (adjusted odds ratio = 1.09, 95% confidence interval = 1.01-1.18).


Usual mental and functional status and the reason for transfer are often missing in NH-ED transfer documents and should be incorporated into standardized transfer forms.


Transfer documentation; dementia; emergency department; nursing home

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