Hand and Microvascular Replantation Call Availability Study: A National Real-Time Survey of Level-I and Level-II Trauma Centers
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: The regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status. We queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared. 5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06). These data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated.0Comments 0Citations
- "Surgery subspecialist availability can be problematic even at level 1 and 2 centers, let alone more regional referring institutions. For example, hand and microvascular call is inconsistent at level 1 and 2 trauma centers and one study in Cook County found that neurosurgical services had decreased across the board except at academic medical centers, as of 2008 [32, 33] . Given the significantly increased proportion of subspecialty surgical discharges, it appears at least one impetus for transfer was decreased subspecialty availability at referring hospitals and subsequent need for transfer for injuries requiring subspecialist surgical 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.0Comments 3Citations
- [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.0Comments 5Citations