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Frequency and Impact of Inappropriate Emergent Transfer for Hand Surgical Consultation
Brian C. Drolet, MD1, Yifan Guo, MD1, Benjamin Z. Phillips, MD1, Vickram J. Tandon, B.A.2, Scott T. Schmidt, MD1.
1Rhode Island Hospital, Providence, RI, USA, 2Alpert Medical School of Brown University, Providence, RI, USA.
Approximately one in five Americans presents to an emergency department (ED) each year. With a total of 130 million visits in 2010, ED encounters made up 4% of all healthcare spending. Evaluation of hand and upper extremity diagnoses has been reported for up to 15% of ED visits. Previous studies have demonstrated that “hand surgery” evaluation is a common reason for patient transfers. We sought to identify the frequency and impact of “unnecessary” transfers for emergency evaluation by a hand surgeon.
Our level 1 trauma center maintains an electronic database of all inter-hospital transfers and direct referrals requests for ED evaluation. We reviewed over 30,000 consecutive ED referrals in this database between April 2009 and April 2013 and identified 805 transfers related to hand and upper extremity ‘emergency’ evaluation. We then performed a retrospective review of these patients’ charts. Three independent reviewers coded each referral as either appropriate or inappropriate based on a predetermined set of criteria. When coding discrepancies were noted, final classification was determined by consensus discussion. Other variables such as time in transfer, insurance status, and patient charges were also evaluated.
Most patients were transferred from a different ED (72%), and nearly all (99.7%) of these patients were transferred from a hospital with 24-hour general orthopedic coverage. The remaining patients were transferred either from urgent care (16%) or a private physician office (10%). Of all patients referred for ‘emergency’ hand evaluation, 194 (24%) were deemed appropriate. In fact, we found that 16% of patients received no hand surgery evaluation upon transfer, and another 22% were seen as a hand surgery consult but were discharged from the ED with no procedure or intervention (Table 1). The average transit time for these inappropriately transferred patients was 71 minutes and the average ED time was 336 minutes. Average hospital charges incurred were $5381 for a total expenditure of 3.3 million dollars. Patients without insurance were more likely to be transferred inappropriately than those with insurance (OR = 1.3, p<0.05).
This is the first empirical study reporting appropriateness of emergency referral for hand surgery consultation. Using a classification system based on intervention, diagnosis and several other variables, we found that a minority of patients required emergent transfer (i.e., were appropriately transferred). Nearly half of patients (49%) who were transferred did not require a hand surgeon for intervention or treatment (i.e., treated and discharged by the ER or admitted to a medical service). Likewise, a portion of the transferred patients (14%) had non-emergent diagnoses and could have been treated as outpatients with a referral to a hand surgeon. Based on patient time and financial expenses for these unnecessary evaluations, significant improvements could be made in both quality and cost of care by limiting inappropriate ED referrals.
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