Inconsistent availability of subspecialty hand and microvascular emergency call services could influence patient outcomes and the efficiency of a system dependent on limited resources and timely intervention because declining reimbursements, increased medicolegal risk, lack of confidence in microsurgical skills, and the disruption of elective schedules present a deterrent to call panel participation. This study assessed the availability of hand and microvascular replantation surgery call services at all level-I and level-II trauma centers in the United States.
Between May and December 2010, all level-I (N = 137) and level-II (N = 153) trauma centers across the U.S. were contacted by telephone. Phone contact was unannounced; responders were invited to participate in our institutional review board-approved anonymous survey regarding hand and microvascular replantation emergency coverage specific to their hospital.
Level-I trauma centers: 117 (85%) of 137 participated, and sixty-four (55%) of these had immediate access for hand surgery and microvascular replantation services. Six hospitals provided services for fifteen to thirty-one days per month, and three hospitals supported services for one to fifteen days per month. Ten hospitals indicated inconsistent coverage, which was difficult to estimate, and thirty-four hospitals reported no coverage. Level-II trauma centers: 132 (86%) of 153 participated, and thirty-eight (29%) of these had immediate access for hand surgery and microvascular replantation services. Seven hospitals provided services for fifteen to thirty-one days per month, and three hospitals provided coverage for one to fifteen days per month. Eighty-four hospitals reported no specific coverage protocol.
Inconsistency in the definition and coverage of emergency hand and microvascular replantation services was identified at level-I and level-II trauma centers across the U.S. Many hospitals indicated the presence of subspecialty hand surgery coverage; however, the determination of microvascular replantation resources was not available consistently. The results of our study strengthen previous conclusions about the need for a more defined and coordinated system of emergency microvascular replantation surgery services in order to improve the efficiency of a limited resource and, ultimately, improve patient care.
[Show abstract][Hide abstract] ABSTRACT: Appropriate use of microsurgical techniques in the emergency management of injured hands increases the salvage rate of complex upper limb injuries. Over time, the indications for replantation, both major and minor, have expanded and techniques refined to get better functional outcomes. The wide choice of free flaps available has made primary reconstruction possible to obtain a good functional and aesthetic outcome. The benefits microsurgery offers in the emergent management of the injured hand are now firmly established. The challenge is to create and maintain centers which can provide around-the-clock, high quality microsurgery services. The issues of adequate training opportunities, obtaining adequate work load to maintain high skill levels, attracting talent into the field are the challenges faced in maintaining high levels of service. In the developing countries, in addition to these issues, increasing the awareness of the potential of microsurgical services among the medical personal and the public has to be addressed.
Current Reviews in Musculoskeletal Medicine 01/2014; 7(1). DOI:10.1007/s12178-013-9197-4
[Show abstract][Hide abstract] ABSTRACT: The transfer of patients with hand injuries involves a commitment of substantial resources, emphasizing the importance of understanding factors that may influence referral patterns. Anecdotal experience suggests that the likelihood of transfer increases during nights and weekends. This study aimed to analyze patterns of hand trauma transfers to Duke University Medical Center with respect to timing and patient insurance status.
The authors performed a retrospective chart review and analysis of 1147 consecutive patient transfers from 2005 to 2010 at a single level 1 university trauma center. Data categories included timing of transfer, patient demographics, insurance status, diagnosis, and procedures performed. Statistical analysis was performed using SAS software (SAS Institute Inc., Cary, N.C.).
Of the patient sample, 39.8 percent was female, 30 percent were African American, and 57.3 percent were white. Contrary to our expectations, transfers were more likely during the day (p = 0.0001). Likewise, patients were more likely to present on weekdays than on weekends (p = .001). Although uninsured patients were not disproportionately represented overall, they were more frequently transferred at night (p = 0.0001), despite having the same complexity of injuries as privately insured patients. Conversely, patients with private insurance were less likely to be transferred at night (p = 0.0001).
Similar to studies in other surgical specialties, this analysis demonstrates significant associations between insurance status and hand injury transfer patterns. The current climate, including declining numbers of surgeons willing to provide emergency hand care, diminishing reimbursements, and an expanding uninsured patient population, threatens to exacerbate these concerning trends in trauma patient management.
Plastic and Reconstructive Surgery 04/2014; 133(4):842-8. DOI:10.1097/PRS.0000000000000017 · 2.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose
To characterize patients with hand or wrist injuries presenting to our university-based emergency department (ED) after a previous evaluation by an outside ED. We hypothesized that a majority of these patients did not require emergent care, most arrived during working hours, and a disproportionate number were uninsured.
We retrospectively reviewed 3,047 orthopedic hand consults from 2002 to 2010. Patients were included if our ED was the patient's second ED evaluation within 30 days for the same complaint. Demographics, diagnosis, referral instructions from the initial institution, date and time of ED visit, treatment received, and insurance status were recorded. Clinical urgency was quantified on an ordinal scale.
A total of 325 patients met the inclusion criteria. The most common diagnoses were distal radius and metacarpal fractures. There were 266 (82%) patients with nonurgent diagnoses. A junior-level orthopedic resident treated and discharged 97% of patients from the ED. Sixty-two percent of the patients were uninsured, 32% had Medicaid, and 6% had commercial insurance or Medicare. There was a disproportionate percentage of uninsured and Medicaid patients compared with the payer mix of our state, orthopedic department, and ED. Ninety percent of patients presented on weekdays, and 84% arrived between 6 am and 6 pm.
Most patients who met our inclusion criteria presented to our ED during regular business hours. Most were uninsured and did not have a condition that warranted urgent or emergent evaluation and treatment. With limited resources, it is important that an appropriate follow-up plan from the initial ED be in place so that patients do not have to present to a second ED for the same problem.
Type of study/level of evidence
The Journal of hand surgery 04/2014; 39(4). DOI:10.1016/j.jhsa.2014.01.019 · 1.67 Impact Factor
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