Impact of an anesthesiology rotation on subsequent endotracheal intubation success.

BACKGROUND: Endotracheal intubation (ETI) is an essential skill that emergency medicine residents learn throughout their training. OBJECTIVE: To evaluate the effect of implementing a postgraduate year (PGY)-1 anesthesiology rotation on ETI success in the emergency department during PGY-2. METHODS: Residents in the study group completed a 4-week PGY-1 anesthesiology rotation. During the first 6 months of PGY-2, we compared ETI performance of the study group with a control group who did not experience a PGY-1 anesthesiology rotation. Data recorded included date, level of training, first- and second-attempt success, rescue devices used, major adverse events, and intubation scenario. A Pearson χ(2) test was used to compare first-attempt success, overall success (≤2 attempts), and adverse events rates between the 2 groups. RESULTS: Overall success rate for the study groups was 95.7% (111 of 116), compared with 94.5% (137 of 145) for the controls (P  =  66). First-attempt success for the study group was 78.4% (91 of 116), compared with 83.4% (121 of 145) for the control group; this was not statistically significant (P  = .30). Observed major and minor adverse events were similar: 19.0% for the study group (22 of 116) versus 24.8% (36 of 145) for the control group (P  = .26). CONCLUSIONS: The addition of an anesthesiology rotation to the PGY-1 curriculum did not have a significant effect on ETI success or the rate of adverse events during the first 6 months of PGY-2. First-attempt overall success and adverse events of our PGY-2 study group were consistent with previously published studies.

The Morphology Index: predictive value of malignancy among clinicians at various levels of training.

OBJECTIVE: To determine whether clinicians at various levels of training can reproduce and apply the Morphology Index when compared to Ueland's Morphology Index data, and to determine intra-observer variability when applied by observers at various levels of training. METHODS: One hundred four transvaginal ultrasound images of adnexal masses obtained at Indiana University between 1991 and 2003 were identified which had correlating surgical pathology. The images were scored by four investigators at four different levels of training. Scoring was based upon the revised University of Kentucky Morphology Index by Ueland. Each mass received 0-5 points for its structure, and 0-5 points for tumor volume. Each total score was then correlated with the surgical pathology. Sensitivity, specificity, positive predictive value and negative predictive value for each investigator were determined. All images were reviewed independently by each investigator; each was blinded to scores given by the other investigators and to final pathology. RESULTS: Nine malignant and 95 benign masses were noted on final pathology. Ranges for statistical values were: positive predictive value (PPV) 15-18%, negative predictive value (NPV) 93-98%, sensitivity 44-89%, and specificity 52-76%. CONCLUSION: The Morphology Index is a consistent and reliable tool for predicting benign disease demonstrating a high negative predictive value with little intra-observer variability. However, when predicting malignancy, the results showed more intra-observer variability and a positive predictive value half of that previously reported. This study confirms the clinical utility of the Morphology Index when utilized for its NPV and demonstrates its widespread application even among clinicians with minimal ultrasound training.

Measuring the glomerular filtration rate in obese individuals without overt kidney disease.

BACKGROUND: Identifying methods to accurately measure the glomerular filtration rate (GFR) in obese individuals without kidney overt kidney disease is necessary to understanding the pathophysiology and natural history of obesity-related kidney disease. METHODS: Using a cross-sectional design, iohexol clearance and disposition was measured, an optimal sampling schedule was identified, and the reliability of GFR-estimating methods was described in 29 obese individuals with normal serum creatinine levels. Iohexol disposition was measured using population pharmacokinetics. The agreement with GFR-estimating equations was assessed by intraclass coefficients. RESULTS: Mean age was 44 ± 10 years, body mass index 45 ± 10, creatinine 0.7 ± 0.2 mg/dl (62 ± 18 µmol/l) , and cystatin C 0.83 ± 0.18 mg/dl (8.3 ± 1.8 mg/l). Iohexol disposition fit a two-compartment model and 5 sampling windows were identified over a 4-hour period to optimize model accuracy and minimize blood draws. Precision was not compromised with this sampling design. Neither creatinine nor cystatin C were linearly correlated with the measured GFR though cystatin C was independent of body composition. Agreement was fair to poor between the measured GFR and GFR-estimating equations. CONCLUSION: This study offers a rigorous method to study obesity-related kidney disease and improve upon suboptimal GFR-estimating methods.

Quantification of three-dimensional orthodontic force systems of T-loop archwires.

OBJECTIVE: To demonstrate the three-dimensional (3D) orthodontic force systems of three commercial closing T-loop archwires using a new method and to quantify the force systems of the T-loop archwires. MATERIALS AND METHODS: An orthodontic force tester (OFT) and a custom-made dentoform were developed to measure force systems. The system simulated the clinical environment for an orthodontic patient requiring space closure, which included measurement of three force components along, and three moment components about, three clinically defined axes on two target teeth. The archwires were attached to the dentoform and were activated following a standard clinical procedure. The resulting force system was measured using the OFT. RESULTS: The force systems of the T-loops on the teeth were 3D. Activation in one direction resulted in force and moment components in other directions (side effects). The six force and moment components as well as the moment-to-force ratios in the clinically defined coordinate system were quantified. CONCLUSIONS: The commercial archwires do not provide force systems for pure translation. Quantification of the force system is critical for the selection and design of optimal orthodontic appliances.

Clinical outcomes of 0.018-inch and 0.022-inch bracket slot using the ABO objective grading system.

OBJECTIVE: To determine if there is a significant difference in the clinical outcomes of cases treated with 0.018-inch brackets vs 0.022-inch brackets according to the American Board of Orthodontics (ABO) Objective Grading System (OGS). MATERIALS AND METHODS: Treatment time and the ABO-OGS standards in alignment/rotations, marginal ridges, buccolingual inclination, overjet, occlusal relationships, occlusal contacts, interproximal contacts, and root angulations were used to compare clinical outcomes between a series of 828 consecutively completed orthodontic cases (2005-2008) treated in a university graduate orthodontic clinic with 0.018-inch- and 0.022-inch-slot brackets. RESULTS: A two-sample t-test showed a significantly shorter treatment time and lower ABO-OGS score in four categories (alignment/rotations, marginal ridges, overjet, and root angulations), as well as lower total ABO-OGS total score, with the 0.018-inch brackets. The ANCOVA-adjusting for covariants of discrepancy index, age, gender, and treatment time-showed that the 0.018-inch brackets scored significantly lower than the 0.022-inch brackets in both the alignment/rotations category and total ABO-OGS score. CONCLUSIONS: There were statistically, but not clinically, significant differences in treatment times and in total ABO-OGS scores in favor of 0.018-inch brackets as compared with the 0.022-inch brackets in a university graduate orthodontic clinic (2005-2008).

Effect of advanced access scheduling on processes and intermediate outcomes of diabetes care and utilization.

BACKGROUND: The impact of open access (OA) scheduling on chronic disease care and outcomes has not been studied. OBJECTIVE: To assess the effect of OA implementation at 1 year on: (1) diabetes care processes (testing for A1c, LDL, and urine microalbumin), (2) intermediate outcomes of diabetes care (SBP, A1c, and LDL level), and (3) health-care utilization (ED visits, hospitalization, and outpatient visits). METHODS: We used a retrospective cohort study design to compare process and outcomes for 4,060 continuously enrolled adult patients with diabetes from six OA clinics and six control clinics. Using a generalized linear model framework, data were modeled with linear regression for continuous, logistic regression for dichotomous, and Poisson regression for utilization outcomes. RESULTS: Patients in the OA clinics were older, with a higher percentage being African American (51% vs 34%) and on insulin. In multivariate analyses, for A1c testing, the odds ratio for African-American patients in OA clinics was 0.47 (CI: 0.29-0.77), compared to non-African Americans [OR 0.27 (CI: 0.21-0.36)]. For urine microablumin, the odds ratio for non-African Americans in OA clinics was 0.37 (CI: 0.17-0.81). At 1 year, in adjusted analyses, patients in OA clinics had significantly higher SBP (mean 6.4 mmHg, 95% CI 5.4 - 7.5). There were no differences by clinic type in any of the three health-care utilization outcomes. CONCLUSION: OA scheduling was associated with worse processes of care and SBP at 1 year. OA clinic scheduling should be examined more critically in larger systems of care, multiple health-care settings, and/or in a randomized controlled trial.

Literature review and meta-analysis of topical carbonic anhydrase inhibitors and ocular blood flow.

The purpose of this literature review and meta-analysis was to determine what, if any, effects topical carbonic anhydrase inhibitors have on ocular hemodynamics in humans. A literature review and meta-analysis was conducted to investigate the effects of topical carbonic anhydrase inhibitors on ocular blood flow. Thirty-five articles were evaluated according to the inclusion criteria with 13 manuscripts meeting requirements for statistical analysis. Each study's effect size, defined as the change in blood flow measures after treatment with topical carbonic anhydrase inhibitors, was estimated using the weighted mean difference. Based on this meta-analysis, we conclude that topical carbonic anhydrase inhibitors increase ocular blood flow velocities in the retinal circulation, central retinal and short posterior ciliary arteries, but not in the ophthalmic artery.

Reduced 10-year risk of coronary heart disease in patients who participated in a community-based diabetes prevention program: the DEPLOY pilot study.

OBJECTIVE: We evaluated whether participation in a community-based group diabetes prevention program might lead to relative changes in composite 10-year coronary heart disease (CHD) risk for overweight adults with abnormal glucose metabolism. RESEARCH DESIGN AND METHODS: We used the UK Prospective Diabetes Study engine to estimate CHD risk for group-lifestyle and brief counseling (control) groups. Between-group risk changes after 4 and 12 months were compared using ANCOVA. RESULTS: Baseline 10-year risk was similar between treatment groups (P = 0.667). At 4 and 12 months, the intervention group experienced significant decreases in 10-year risk from baseline (-3.28%, P < 0.001; and -2.23%, P = 0.037) compared with control subjects (-0.78%, P = 0.339; and +1.88%, P = 0.073). Between-group differences were statistically significant and increased from the 4- to 12-month visits. CONCLUSIONS: Community-based delivery of the Diabetes Prevention Program lifestyle intervention could be a promising strategy to prevent both CHD and type 2 diabetes in adults with pre-diabetes.

Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study.

BACKGROUND: The Diabetes Prevention Program (DPP) found that an intensive lifestyle intervention can reduce the development of diabetes by more than half in adults with prediabetes, but there is little information about the feasibility of offering such an intervention in community settings. This study evaluated the delivery of a group-based DPP lifestyle intervention in partnership with the YMCA. METHODS: This pilot cluster-randomized trial was designed to compare group-based DPP lifestyle intervention delivery by the YMCA to brief counseling alone (control) in adults who attended a diabetes risk-screening event at one of two semi-urban YMCA facilities and who had a BMI>or=24 kg/m2, >or=2 diabetes risk factors, and a random capillary blood glucose of 110-199 mg/dL. Multivariate regression was used to compare between-group differences in changes in body weight, blood pressures, HbA1c, total cholesterol, and HDL-cholesterol after 6 and 12 months. RESULTS: Among 92 participants, controls were more often women (61% vs 50%) and of nonwhite race (29% vs 7%). After 6 months, body weight decreased by 6.0% (95% CI=4.7, 7.3) in intervention participants and 2.0% (95% CI=0.6, 3.3) in controls (p<0.001; difference between groups). Intervention participants also had greater changes in total cholesterol (-22 mg/dL vs +6 mg/dL controls; p<0.001). These differences were sustained after 12 months, and adjustment for differences in race and gender did not alter these findings. With only two matched YMCA sites, it was not possible to adjust for potential clustering by site. CONCLUSIONS: The YMCA may be a promising channel for wide-scale dissemination of a low-cost approach to lifestyle diabetes prevention.

A comparison of observed versus documented physician assessment and treatment of pain: the physician record does not reflect the reality.

STUDY OBJECTIVE: The Joint Commission requires "appropriate assessment" of patients presenting with painful conditions. Compliance is usually assessed through retrospective chart analysis. We investigate the discrepancy between observed physician pain assessment and that subsequently documented in the medical record. METHODS: This was an observational study using a trained investigator watching bedside interactions of emergency physicians. Using a priori definitions, the investigator recorded whether the patient volunteered the presence of pain, physician inquiry about pain, attempts to quantify the pain, treatment offered/rendered, and any assessment of the response to therapy. An independent investigator subsequently assessed the patient's chart for documentation of pain assessment, therapy rendered, and response to treatment. Children younger than 5 years and patients with major trauma, altered mental status, or nontraumatic chest pain were excluded. The institutional review board approved the protocol, the physicians agreed to participate in an "ergonomic study" without knowing the exact nature of data collection, and patients released their records. RESULTS: The investigator observed 209 patient encounters. Physicians acknowledged the patients' pain 98.1% of the time but documented its presence in 91.7%. Physicians attempted to quantify the patient's pain in 61.5% of encounters but documented that attempt in only 38.9%. Treatment was offered in 79.9% and recorded in 31.7% of charts. When treatment was offered, the patient's response to the therapy was recorded only 28% of the time. CONCLUSION: Physicians almost always assess and treat patient pain but infrequently record those efforts. The patient's chart is a poor surrogate marker for pain assessment and care by emergency physicians and may not be suitable for use as a compliance assessment tool. Research methodology using retrospective chart analysis may be affected by this phenomenon, suggesting the potential for underestimation of patient pain assessment and treatment by emergency physicians.

Emergency department procedural sedation with propofol: is it safe?

Propofol is a sedative agent gaining popularity for Emergency Department Procedural Sedation (EDPS). However, some institutions across the country continue to restrict the use of propofol secondary to safety concerns. The purpose of our study was to evaluate the complication rate of EDPS with propofol. We conducted a prospective, observational, multi-center study of EDPS patients aged > or = 18 years, consenting to procedural sedation with propofol. Eighty-two patients from two Level I trauma centers were enrolled between August 1, 2002 and January 31, 2003. Transient hypoxemia was the only noted sedation complication. Nine patients (11%) had brief hypoxemia. The combined average hypoxemia time was 1.2 min (SD 0.4), and in all instances responded to simple airway maneuvers or increased oxygen concentration. No patient required advanced airway maneuvers such as intubation or even positive pressure ventilation. EDPS with propofol seems to be safe in our population.

An assessment of the association of bispectral index with 2 clinical sedation scales for monitoring depth of procedural sedation.

OBJECTIVE: We conducted a study to assess the correlation of bispectral index (BIS) to 2 clinical sedation scales. METHODS: This was a prospective, observational study. The BIS number was recorded at baseline and every 30 seconds. One investigator separately monitored the patients for depth of sedation using the Observer's Assessment of Alertness/Sedation and the Continuum of Depth of Sedation scales. RESULTS: During the 6-month period, 75 patients were enrolled. The Spearman correlation between the BIS and the Observer's Assessment of Alertness/Sedation was 0.59 (95% confidence interval [CI], 0.44-0.74). The Spearman correlation between the BIS and the Continuum of Depth of Sedation was 0.53 (95% CI, 0.36-0.70). The mean minimum BIS for patients without a complication was 70 (SD, 15.9) compared with 68 (SD, 12.9) for patients with a complication (difference = 2; 95% CI, -7-11). CONCLUSIONS: Our study demonstrated moderate correlation between BIS and the 2 clinical sedation scales. The correlation is not strong enough to be used reliably in a clinical setting. The mean minimum BIS scores were not significantly different for those with sedation complications vs those without complications.

Care management of poststroke depression: a randomized, controlled trial.

BACKGROUND AND PURPOSE: Poststroke depression is a prevalent and disabling disorder, yet evidence regarding the effectiveness of treating poststroke depression is inconclusive. Our objective was to determine the effectiveness of the Activate-Initiate-Monitor care management program for the treatment of poststroke depression. METHODS: We conducted a prospective, randomized, outcome-blinded trial in 188 ischemic stroke survivors identified at the time of admission to one of 4 Indianapolis hospitals. Depression screening and enrollment occurred between 1 and 2 months poststroke. The Activate-Initiate-Monitor intervention was a care management program that included Activation of the patient to recognize depression symptoms and accept treatment, Initiation of an antidepressant medication, and Monitoring and adjusting treatment. Usual care subjects received nondepression-related education and were prescribed antidepressants at the discretion of their provider. The primary outcome measure was depression response, defined as a Hamilton Depression Inventory score <8 (remission) or a decrease from baseline of at least 50% at 12 weeks. RESULTS: Intervention and usual care groups did not differ on any key baseline measures. Both depression response (51% versus 30%, P=0.005) and remission (39% versus 23%, P=0.01) were more likely in the Activate-Initiate-Monitor intervention than in the usual care group. This difference in depression scores was present by 6 weeks and persisted through the 12-week assessment. Serious adverse events did not differ between the 2 groups. CONCLUSIONS: The Activate-Initiate-Monitor care management model is significantly more effective than usual care in improving depression outcomes in patients with poststroke depression.

A more explicit grading scale decreases grade inflation in a clinical clerkship.

OBJECTIVES: The medical education literature contains few publications about the phenomenon of grade inflation. The authors' clinical clerkship grading scale suffered from apparent inflation relative to the recommended university distribution. The investigators hypothesized that a simple change of the shift grading cards, using explicit criteria, would decrease this grade inflation and aid to redistribute the shift evaluations. METHODS: This was a before-and-after study examining medical student shift evaluation grades. Evaluators and students were blinded to the purpose of the card change and were unaware that a study was being conducted. Beginning June 1, 2005, the authors altered the shift evaluation cards from the previous four choices of honors, high pass, pass, or fail to five choices of upper 5%, upper 25%, expected, below expected, or far below expected, and explicit grading criteria were provided. No other interventions to alter the grade distribution occurred. Data were collected on all evaluations from June 1, 2004, to March 31, 2005 (before change), and compared with data on all evaluations from June 1, 2005, to March 31, 2006 (after change). RESULTS: A total of 3,349 evaluations were analyzed: 1,612 before the card change and 1,737 after the change. The grade distribution before the card change was as follows: honors, 22.6%; high pass, 49.0%; pass, 28.4%; and fail, 0%. This compared with the following ratings after the card change: upper 5%, 9.8%; upper 25%, 41.2%; expected, 46.2%; below expected, 2.8%; and far below expected, 0% (p < 0.001). CONCLUSIONS: A simple change in shift evaluation cards to include more explicit grading criteria resulted in a significant change in grade distribution and greatly decreased grade inflation.

Treating postprandial hyperglycemia does not appear to delay progression of early type 2 diabetes: the Early Diabetes Intervention Program.

OBJECTIVE: Postprandial hyperglycemia characterizes early type 2 diabetes. We investigated whether ameliorating postprandial hyperglycemia with acarbose would prevent or delay progression of diabetes, defined as progression to frank fasting hyperglycemia, in subjects with early diabetes (fasting plasma glucose [FPG] <140 mg/dl and 2-h plasma glucose > or =200 mg/dl). RESEARCH DESIGN AND METHODS: Two hundred nineteen subjects with early diabetes were randomly assigned to 100 mg acarbose t.i.d. or identical placebo and followed for 5 years or until they reached the primary outcome (two consecutive quarterly FPG measurements of > or =140 mg/dl). Secondary outcomes included measures of glycemia (meal tolerance tests, HbA(1c), annual oral glucose tolerance tests [OGTTs]), measures of insulin resistance (homeostasis model assessment [HOMA] of insulin resistance and insulin sensitivity index from hyperglycemic clamps), and secondary measures of beta-cell function (HOMA-beta, early- and late-phase insulin secretion, and proinsulin-to-insulin ratio). RESULTS: Acarbose significantly reduced postprandial hyperglycemia. However, there was no difference in the cumulative rate of frank fasting hyperglycemia (29% with acarbose and 34% with placebo; P = 0.65 for survival analysis). There were no significant differences between groups in OGTT values, measures of insulin resistance, or secondary measures of beta-cell function. In a post hoc analysis of subjects with initial FPG <126 mg/dl, acarbose reduced the rate of development of FPG > or =126 mg/dl (27 vs. 50%; P = 0.04). CONCLUSIONS: Ameliorating postprandial hyperglycemia did not appear to delay progression of early type 2 diabetes. Factors other than postprandial hyperglycemia may be greater determinants of progression of diabetes. Alternatively, once FPG exceeds 126 mg/dl, beta-cell failure may no longer be remediable.

How valid are family proxy assessments of stroke patients' health-related quality of life?

BACKGROUND AND PURPOSE: Proxy respondents are often needed to report outcomes in stroke survivors, but they typically systematically rate impairments worse than patients themselves. The magnitude of this difference, the degree of agreement between patients and proxies, and the factors influencing agreement are not well known. METHODS: We compared patient and family proxy health-related quality of life (HRQL) responses in 225 patient-proxy pairs enrolled in a clinical trial for poststroke depression. We used paired t-tests and the intraclass correlation (ICC) statistic to evaluate the agreement between patient and proxy domain scores and the overall Stroke-specific Quality of Life (SS-QOL) score. We used multivariate linear regression to model patient- and proxy-reported SS-QOL scores. RESULTS: Patients were older (63 versus 55 years) and less often female (48% versus 74%) than proxies. Proxies rated all domains of SS-SQOL slightly worse than patients. The Mood, Energy, and Thinking domains had the greatest disparity with mean patient-proxy differences of 0.45, 0.37, and 0.37 points, respectively. The ICC for each domain ranged from 0.30 (role function) to 0.59 (physical function). Proxy overall SS-QOL score was also lower (worse) than patient score (3.7 versus 3.4, P<0.001) with ICC of 0.41. Agreement was higher among patient-proxy pairs with higher patient depression scores and with lower proxy report of caregiving burden. CONCLUSIONS: Proxies systematically report more dysfunction in multiple aspects of HRQL than stroke patients themselves. Agreement between patient and proxy HRQL domain scores is modest at best and is affected by patient depression and proxy perception of burden. These differences may be large enough to impact the outcome assessment in stroke clinical trials.

Activity of newer triazoles against Histoplasma capsulatum from patients with AIDS who failed fluconazole.

OBJECTIVES: To determine the activity of newer triazoles against strains of Histoplasma capsulatum resistant to fluconazole. METHODS: Susceptibility testing was performed on 17 paired pre- and post-treatment H. capsulatum isolates from patients with AIDS who failed fluconazole. RESULTS: The median MICs of fluconazole, voriconazole, and posaconazole and ravuconazole for the pre-treatment isolates were 1 mg/L, 0.015 mg/L and <0.007 mg/L, respectively. A 4-fold or greater increase in the MIC of fluconazole and voriconazole was observed in 12 and 7 of the post-treatment isolates, respectively; the median fold increases in MIC were 8 and 2.1, respectively. No MIC increases were observed for posaconazole and ravuconazole. One pair of isolates exhibiting reduced susceptibility was examined in more detail. A single amino acid substitution (at tyrosine 136) was identified in the active site of the CYP51 protein from the post-treatment isolate, which is presumed to be responsible for reduced susceptibility to voriconazole and fluconazole, analogous to recent observations in Candida albicans. CONCLUSIONS: These findings support careful monitoring for relapse in patients receiving voriconazole treatment for histoplasmosis, particularly in those who were previously treated with fluconazole.

An analysis of maximum vehicle G forces and brain injury in motorsports crashes.

PURPOSE: Traumatic brain injury from automobile crashes is a major source of trauma deaths. The investigation of crashes to understand factors of occupant injuries is an established practice. Our objective was to evaluate the association between vehicle G forces (G) sustained on impact and brain injury in motor sports crashes. METHODS: We analyzed data regarding Indy Racing League (IRL) car crashes from 1996 to 2003 and compared the likelihood of head injury in those drivers who were in a vehicle that sustained an impact of > or =50 G versus those with a lesser impact. The mean maximal G for those with head injury was compared with those without head injury. RESULTS: We analyzed 374 crashes. A driver in a crash with an impact of > or =50 G developed a head injury 16.0% (30/188) versus 1.6% (3/186) in those of <50 G (P < 0.001). The mean peak G for those with head injury was 79.6 (SD 28.5) versus 50.6 (SD 28.0) in those with no head injury (P < 0.001). CONCLUSION: Findings were that IRL car crashes with peak vehicle G > or = 50 were associated with the development of traumatic brain injuries.

An extended care facility-to-emergency department transfer form improves communication.

OBJECTIVES: Previous studies have established that essential information is inconsistently provided during the transfer of extended care facility (ECF) patients to the emergency department (ED). The authors tested the hypothesis that a one-page, standard ECF-to-ED transfer form would change the rate of successful documentation of ECF patient information. METHODS: The design was a pre- and postintervention investigation. The setting was the Methodist Hospital ED, an urban teaching facility in Indianapolis, Indiana. The population included consecutive patients transferred from ECFs to the ED. The intervention consisted of the introduction of a one-page, standard ECF-to-ED transfer form that listed 11 data elements that are critical for patient care. The completed form was to be sent with patients transferred to the ED. Successful documentation was defined as the recording of at least nine of 11 data elements. RESULTS: In the preintervention period, the ED received 130 transfers from 41 ECFs. Sixty-five of 130 transfers were from ten ECFs, which were the targets of the intervention. In the postintervention period, 72 consecutive transfers from ten ECFs were studied. Postintervention, the proportion of transfers with successful documentation was 77.8% (56 of 72), an increase of 19.3% (95% CI = 4.0% to 34.7%) over the preintervention period. In 31.9% (23 of 72) of postintervention ED transfers, the transfer form was transported with the patient. Successful documentation was achieved in 22 (95.6%) of these 23 transfers. CONCLUSIONS: Use of a one-page, standard ECF-to-ED transfer form increased the amount of essential data provided to the ED.