Orthopedics

Feature Article 

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center

Alex L. Gornitzky, BS; Andrew H. Milby, MD; Melissa A. Gunderson, BA; Benjamin Chang, MD; Robert B. Carrigan, MD

Abstract

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries. [Orthopedics. 2016; 39(2):e333–e339.]

Abstract

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries. [Orthopedics. 2016; 39(2):e333–e339.]

Efficient allocation of limited health care resources is necessary to maintain health care quality and maximize access to emergency services. Interfacility emergency transfer is a means of ensuring that patients with complex injuries obtain tertiary evaluation in a timely and seamless fashion; however, there are significant costs associated with its use. Transportation, interim management, and duplication of diagnostic studies may all contribute to the costs associated with emergent transfers. In addition, many such transfers do not ultimately require the tertiary services suspected at initial triage,1,2 with orthopedic diagnoses being the most common reason for transfer in patients discharged without intervention from either the emergency department (ED) or after less than 24 hours of inpatient hospitalization.3 Studies of hand transfers in adults have reported variable rates of nonemergent hand transfers between 16% and 75%. Furthermore, interfacility transfer added approximately 12 hours to the total treatment time and approximately 1.6 hours of additional ED time for those patients receiving hand consultation.4 Therefore, more accurate characterization of the factors driving the decision to transfer pediatric patients to a higher level of care may improve resource allocation and reduce health care expenditures.

Pediatric patients represent approximately 28% of ED patients per year, with more than 88% of these encounters occurring at general EDs with less than 25% annual pediatric patient volume.5 Accidental injuries are the most common reason for presentation of pediatric patients,5 with hand injuries representing nearly 2% of all visits to one pediatric tertiary referral center.4 The incidence of hand fractures alone in children is estimated to be between 24.2 and 624 per 100,000 per year.6–8 Severe injuries, such as traumatic amputations, may result in substantial and permanent functional and emotional impairment.9–11 Optimal outcomes require a multidisciplinary team of emergency physicians, hand surgeons, and anesthesiologists with expertise in the care of the pediatric trauma patient. As a result, many patients with such injuries who are initially triaged at regional hospitals subsequently undergo interfacility transfer for definitive evaluation and treatment. Many factors play a role in the decision to initiate transfer, including the capabilities of the referring institution and staff, parental preference, and the belief that transfer may maximize a patient's ultimate outcome. Other factors that may also influence this decision include insurance status, availability, and liability avoidance.

The current authors' experience at a tertiary referral center for pediatric trauma has included numerous anecdotal examples of patients who underwent interfacility transfer, often at considerable expense or inconvenience, but did not ultimately require admission or surgical intervention. By analyzing a series of patients undergoing interfacility transfer for hand injuries during a 2-year period, the authors sought to identify factors that may be associated with disproportionate rates of transfer within the pediatric population to better facilitate educational outreach and resource allocation.

Materials and Methods

The authors' institution is a pediatric Level I trauma center and academic tertiary referral center receiving a large volume of interfacility transfers. Institutional review board approval was obtained prior to commencement of this study. Electronic medical records were reviewed for a 2-year period to identify all patients transferred to the institution, as well as the subset of these patients transferred for evaluation or treatment of a traumatic injury to the hand or wrist. Data regarding age, sex, diagnosis, injury site, acuity, arrival time, insurance status, admission status, and procedures performed during the hospitalization were collected. A list of facilities referring at least 1 hand injury was generated, and these facilities were organized into 4 categories based on the following capabilities: (1) hand surgery and pediatric admission/anesthesia, (2) hand surgery but no pediatric admission/anesthesia, (3) pediatric admission/anesthesia but no hand surgery, and (4) neither hand surgery nor pediatric admission/anesthesia.

Descriptive statistics were generated for demographic variables. The list of referring facilities was used to identify all transfers originating from these facilities during the time period for comparison of the hand injury transfer rate to the category-specific transfer rates. The observed and expected hand injury transfer rates were compared using the chi-square test. The cohort of patients undergoing transfer for hand trauma was subsequently stratified by site of injury, time of transfer, admission status, need for surgical intervention, and insurance status. The distributions of patients in each of these subcategories were compared with the expected distributions from the overall cohort using the chi-square test. All statistical analyses were performed using PASW Statistics version 18.0 (SPSS Inc, Chicago, Illinois), with P values less than .05 considered significant.

Results

A total of 13,193 patients were transferred to the authors' institution during the 2-year study period. Of these, 169 patients were transferred for evaluation or management of an injury to the hand or wrist. Mean patient age was 8.4±5.1 years, with a greater proportion of males (69%) than females (31%; P<.001; Table 1). The most common diagnoses included fractures (43%), amputations (26%), lacerations (13%), and infections (11%). The majority (70%) of these transfers occurred via low-acuity ground transport (Table 2). No significant deviations from expected values occurred based on day of the week or time of the transfer. Hospital admission was required in 59 (35%) patients, of whom 51 (86%) underwent a surgical procedure within 24 hours of presentation. Of the remaining 110 (65%) patients who were discharged from the ED, 27 (25%) underwent elective surgical intervention within 2 weeks of discharge.


Demographics and Diagnoses of the Study Cohort

Table 1:

Demographics and Diagnoses of the Study Cohort


Transport Types, Timing, and Disposition

Table 2:

Transport Types, Timing, and Disposition

Hand injury transfers originated from a total of 48 surrounding hospitals, with 10,707 (81.2%) of the 13,193 total transfers originating from these institutions. Therefore, given 169 total transfers, hand injuries were responsible for 1.6% of patients transferred from these hospitals during the study period. Hand surgical coverage and pediatric admission/anesthesia capability were available at 16 hospitals, hand surgical coverage at 12, pediatric admission/anesthesia capability at 5, and neither hand surgical coverage nor pediatric admission/anesthesia capability at 15 (Table 3). Hospitals in these 4 categories were responsible for 41%, 18%, 11%, and 30% of all transfers, and 36%, 7%, 22%, and 36% of hand injury transfers, respectively. Based on an expected transfer rate proportional to the volume of overall transfers received in each category, there was a higher-than-expected rate of transfer from institutions with no pediatric admission/anesthesia capability, whether or not hand surgical coverage was present (P=.014).


Transfer Rates by Category for Institutions Referring Hand Injuries

Table 3:

Transfer Rates by Category for Institutions Referring Hand Injuries

Analysis of the cohort stratified by potentially influencing factors is shown in Table 4. The rates of hand transfer per institution type as shown in Table 3 were used as the expected values. Injury site, time of transfer, admission status, and need for surgical intervention were not influenced by the presence or absence of hand surgical coverage or pediatric admission capability (P>.05). In comparison with the volume-weighted predicted values, patients with Medicaid/self-pay were more likely to be transferred from hospitals without hand surgical coverage (29 observed vs 20 expected) than from hospitals with hand surgical coverage (17 observed vs 26 expected; P=.013). Conversely, the proportion of patients transferred was not affected by the pediatric admission capabilities of the transferring institution (P=.150).


Comparisons by Capabilities of Transferring Institution

Table 4:

Comparisons by Capabilities of Transferring Institution

Discussion

Emergent transfer of pediatric hand and wrist injuries presents an opportunity for streamlining health care resource use. Prior reports have found soft tissue injuries or lacerations to be the most common diagnoses prompting pediatric ED evaluation of hand or wrist injuries.4,12,13 The current authors observed a higher proportion of fractures (43%) and amputations (26%) in their series, a finding that is consistent with a higher overall injury acuity among patients undergoing emergent transfer. This may also suggest that ED physicians are more comfortable treating soft tissue injuries because a misdiagnosis rate of up to 8% may occur with pediatric hand fractures.14 Finally, with a mean age of 8.4 years, the relatively young age of the current study's cohort suggests that the threshold to pursue emergent transfer may be low for younger patients because pediatric hand injury rates peak in children older than 10 years,12 and recent studies have reported a mean age of 9.4 for children evaluated in the ED for hand injuries13 and a mean age of 10.9 for children referred to the pediatric hand clinic from the pediatric ED.8

In the current study, hand injuries represented a relatively small proportion (1.6%) of the total volume of patients transferred during the study period, with only 35% requiring admission following evaluation. However, of those admitted, 86% underwent a procedure within 24 hours (30% of total). The majority were discharged from the ED with outpatient follow-up and elective surgical intervention, if required. This is consistent with a series of 24,905 transfers by Li et al,3 who found that 24.7% of patients transferred to academic pediatric EDs were discharged directly from the ED, with a higher rate of discharge (48.5%) among patients with orthopedic diagnoses and only 25.4% requiring admission longer than 24 hours. In addition, these results are comparable with those in adults, who have described high rates of between 26% and 75% of hand transfers not requiring further hand surgical evaluation or intervention.15–18 Overall, the current results support the conclusion that a disproportionate number of pediatric hand transfers do not ultimately require acute hospitalization or intervention.

Although previous studies have explored factors influencing hand transfers in adults, none have done so in an exclusive pediatric population. Kuo et al19 reported that adults were more likely to be transferred for hand surgery evaluation from outside EDs if they were male, if it was the weekend, or if it was between 6:00 pm and midnight. Furthermore, although 81% arrived from EDs with partial or full hand surgery coverage, only 10.4% were evaluated by hand surgery prior to transfer.17,19 Studies have also implicated noncommercial insurance status as a reason for transfer,18–21 particularly among children22 or those with more severe injuries.23 More specifically, uninsured or underinsured patients have difficulty accessing outpatient hand surgical specialty care,24 which may also increase hand transfer rates to facilitate hand surgical evaluation. Finally, previous studies have suggested that young age increases risk of transfer,20,21 including among those transferred for hand surgical evaluation.16

Currently, the Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to evaluate and stabilize all patients who present seeking care but allows for interfacility transfer if the treating institution feels the medical benefits of transfer outweigh the risks.19,25 However, from a practical perspective, mutual decision making is often limited because tertiary care hospitals are frequently required to accept any transfer once it has been requested. As previously described, numerous demographic variables and patient characteristics have been proposed to influence this decision to transfer. In addition, malpractice liability concerns may also lower the threshold for transfer, particularly in non–tort reform states, such as Pennsylvania, and/or those regions where malpractice litigation is more frequent and payouts per capita are high. Although not directly related to patient transfers, studies in Pennsylvania have shown that recent litigation experiences and longer duration of practice are both independent predictors of increased defensive imaging practices, demonstrating that liability concerns may influence providers' decision making regarding musculoskeletal care.26 Given these multiple factors, it is reasonable to presume that a medical provider less comfortable with treating children may be more willing to initiate transfer to optimize the quality of care received while also minimizing his or her potential malpractice exposure.

The current authors hypothesized that the presence of hand surgical coverage and/or pediatric admission/anesthesia capability at the referring institution may influence the decision to pursue transfer. More hand injury transfers were observed originating from institutions without pediatric admission/anesthesia capability vs the volume-weighted expected value. This suggests that concerns regarding pediatric sedation or anesthesia may play a role in the decision to initiate transfer in these patients. Cimpello et al27 reviewed the analgesia and sedation practice patterns of pediatric and general emergency physicians and found a similar hesitation on the part of both groups to administer analgesic medications during encounters for extremity injuries in children. The authors noted that pediatric ED physicians were more likely to use sedatives and analgesics in combination for procedural sedation than were general ED physicians, although large proportions of patients in this and other series receive no analgesia whatsoever, even for reductions of severely displaced fractures.28 Given the well-characterized safety profile of pediatric procedural sedation and analgesia,29 even in a community ED setting,30 these findings may be a result of the variable exposure to and comfort with the use of these medications on the part of ED physicians.31 Therefore, transfers of pediatric patients for the purposes of procedural sedation or anesthesia alone may represent an underrecognized contribution to the overall cost burden of the practice of defensive medicine.

As seen in previous studies, a large proportion (58%) of patients was transferred from institutions with hand surgical coverage, with only 18% of those 58% going on to require admission.19 Similar to earlier studies, males represented a disproportionate number of hand transfers.19,21 Moreover, a greater number of hand injury patients with Medicaid or self-pay insurance status were observed to originate from institutions without hand surgical coverage vs the volume-weighted expected value. Nonetheless, insurance status did not appear to be a factor when referring institutions were stratified by pediatric admission capability. In addition, neither time of transfer nor day of the week influenced rates of transfer, as has been reported elsewhere.19 Progression to surgical intervention was also not affected by hand or pediatric coverage at referring institutions. Therefore, although difficult to definitively exclude, the authors' data do not support the hypothesis that patients requiring surgical intervention are transferred at increased rates.

Although the limited number of hand transfers seen during the study period precludes the formulation of firm treatment recommendations, several areas can be identified for further study in an effort to improve resource use. First, the value of educational outreach by physicians at tertiary referral centers cannot be overstated. The providers involved in all stages of a patient's evaluation and treatment are aligned in their desire to optimize outcomes; however, barriers to communication may result in risk-averse decision making by the referring party. As such, greater availability of phone consultation or telemedicine services may aid in the triage process.32 Obvious barriers to the implementation of such systems remain, including reimbursement and liability sharing across providers and institutions. Perhaps the most important and practical initiative on the part of tertiary centers treating a large volume of upper-extremity injuries is to ensure the availability of short-term outpatient appointments for patients who may require subacute surgical intervention. A closed feedback system that notifies referring providers when patients have been seen and evaluated in a timely fashion may help build trust among community ED physicians and reduce interfacility transfers in cases where there are concerns regarding access to care. Finally, in light of the current study's findings showing a greater number of transfers originating from institutions without pediatric admission/anesthesia capabilities, it is important to consider the balance between the financial and societal costs of interfacility transfer vs those of increasing pediatric and hand coverage at local hospitals. As such, alternative means of maximizing resource use, such as those methods described previously, may help to shift the point of care to a more cost-effective setting wherever possible.

This study has limitations. First, it was conducted at a single center in a densely populated urban area with a large number of referring hospitals of varying sizes and capabilities. Accordingly, the findings have the potential to be greatly affected by both increased travel time and lesser sub-specialization seen in rural areas. Second, the availability of detailed data on hand injury transfers alone, as opposed to the entire cohort, limits the forms of statistical analysis that could be performed, as well as the power of these comparisons. As such, even those findings that approach statistical significance cannot be deemed robustly significant after adjustment for multiple testing. Future directions will include a larger, more comprehensive data set to allow for examination of multiple potential variables influencing the decision to initiate transfer. Finally, limited data were available regarding referring institutions with multiple locations or decentralized specialty centers. However, best attempts were made to approximate the overall capabilities of each discrete referring hospital based on geographic proximity and knowledge of regional institutional affiliations.

Conclusion

The appropriate use of emergent interfacility transfers for pediatric patients with hand injuries may represent an opportunity for improved health care resource use. Children sustaining injuries to the hand or wrist make up a disproportionate number of patients undergoing transfer but not ultimately requiring admission or urgent surgical intervention. Particularly, the availability of pediatric admission/anesthesia capabilities at the referring institution may influence the decision to initiate transfer, although the presence or absence of hand surgical coverage does not. Improvements in interinstitutional provider communication and the consistent availability of short-term outpatient follow-up may help reduce rates of transfers for subacute conditions. Further study is warranted to better characterize the decision making behind initiation of emergent transfer for pediatric hand injuries and to identify factors that may improve quality, access, and cost-effectiveness.

References

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Demographics and Diagnoses of the Study Cohort

VariableNo. (%)a
Patients transferred with hand injuries169 (100)
Age, mean±SD, y8.4±5.1
Sexb
  Male116 (69)
  Female53 (31)
Diagnosis
  Fracture73 (43)
  Amputation44 (26)
  Laceration22 (13)
  Infection18 (11)
  Dislocation5 (3)
  Gunshot wound3 (2)
  Blast1 (1)
  Burn1 (1)
  Congenital1 (1)
  Vascular1 (1)
  Contusion0 (0)
Injury site
  Finger72 (42)
  Wrist68 (40)
  Hand26 (15)
  Arm4 (2)

Transport Types, Timing, and Disposition

VariableNo. (%)a
Overall169 (100)
Transport type
  ALS—hospital team not available7 (4)
  ALS—low acuity33 (20)
  BLS—low acuity61 (36)
  CHOP ground team11 (7)
  Critical care team—referring2 (1)
  Nonhospital ground27 (16)
  Nonhospital helicopter high acuity8 (5)
  Private vehicle—low acuity20 (12)
Day of the weekb
  Monday27 (16)
  Tuesday27 (16)
  Wednesday20 (12)
  Thursday19 (11)
  Friday17 (10)
  Saturday32 (19)
  Sunday27 (16)
Time of dayb
  06:00 to 18:0094 (56)
  18:00 to 06:0075 (44)
Admission status
  Admitted59 (35)
    Procedure within 24 h51 (86)
  Discharged110 (65)
    Procedure within 2 wk27 (25)
Surgical procedure required
  Yes78 (46)
  No91 (54)

Transfer Rates by Category for Institutions Referring Hand Injuries

VariableNo. (%)Pa

Observed TransfersExpected Transfers
Institutions
  Hands; no pediatric12 (25)
  Pediatric; no hands5 (10)
  Both16 (33)
  Neither15 (31)
Transfers
  Hands; no pediatric1880 (18)
  Pediatric; no hands1210 (11)
  Both4355 (41)
  Neither3262 (36)
Hand transfers (by category).073
  Hands; no pediatric37 (22)30 (18)
  Pediatric; no hands12 (7)19 (11)
  Both60 (36)69 (41)
  Neither60 (36)51 (30)
Hand transfers by pediatric coverage.014
  Yes72 (43)88 (52)
  No97 (57)81 (48)
Hand transfers by hand coverage.755
  Yes97 (57)99 (59)
  No72 (43)70 (41)

Comparisons by Capabilities of Transferring Institution

VariableOverallBy Hand CoverageBy Pediatric Coverage


No. (%)PaNo. (%)Pa


YesNoYesNo
Body side.926.769
  Arm4 (2)2 (1)2 (1)04 (2)
  Wrist68 (40)44 (26)24 (14)31 (18)37 (22)
  Hand26 (15)14 (8)12 (7)13 (8)13 (8)
  Finger71 (42)37 (22)34 (20)28 (17)43 (25)
Time of day.102.999
  06:00 to 18:0094 (56)46 (27)48 (28)40 (24)54 (32)
  18:00 to 06:0075 (44)51 (30)24 (14)32 (19)43 (25)
Admission status.662.472
  Admitted59 (35)30 (18)29 (17)30 (18)29 (17)
  Discharged110 (65)67 (40)43 (25)42 (25)68 (40)
Surgical intervention required.862.356
  Yes78 (46)42 (25)36 (21)39 (23)39 (23)
  No91 (54)55 (33)36 (21)33 (20)58 (34)
Insurance status.013.150
  Private insurance123 (73)80 (47)43 (25)59 (35)64 (38)
  Medicaid or uninsured46 (27)17 (10)29 (17)13 (8)33 (20)
Authors

The authors are from the Division of Orthopaedics (ALG, MAG, BC, RBC), The Children's Hospital of Philadelphia, and the Department of Orthopaedic Surgery (AHM), University of Pennsylvania, Philadelphia, Pennsylvania.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Robert B. Carrigan, MD, Division of Orthopaedics, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104 ( carriganr@email.chop.edu).

Received: May 15, 2015
Accepted: September 01, 2015

10.3928/01477447-20160222-06

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