Most 'Emergency' Transfers for Plastic Surgery Evaluation Are Unnecessary

Patients with hand or facial injuries seen in the emergency department (ED) are commonly transferred to a trauma center for "emergency" evaluation by a plastic surgeon. But nearly three-fourths of those transfers are unnecessary, reports a study in the June issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

"We found that less than one-third of patients required [emergency] transfer for evaluation by a plastic surgeon, and almost half did not receive an [acute] intervention following transfer," write Dr. Brian C. Drolet of Johns Hopkins, Baltimore, and colleagues. They discuss steps that might help to avoid the unnecessary costs, delays, and risks of these inappropriate hospital transfers.

No Need for Emergency Plastic Surgery Evaluation in Many Cases

The researchers evaluated the frequency and impact of emergency transfers to Rhode Island Hospital—the only level I trauma center in that state—for plastic surgery evaluation of hand and facial injuries. A review of more than 32,000 ED encounters between 2009 and 2013 identified nearly 1,200 patients sent for emergency evaluation of trauma to the hand or face.

Dr. Drolet and colleagues evaluated the necessity of each emergency transfer, based on the resources available at the original center and the treatment actually provided at the trauma center. Most patients were transferred from other hospital emergency departments—even though many of these hospitals had full-time on-call coverage for facial and hand surgery.

On independent review, nearly three-quarters of the transfers were considered unnecessary—the patients could have been treated at the original hospital, or sent home from the ED with a referral for follow-up by a plastic surgeon.

Only about ten percent of transferred patients were admitted to the plastic surgery service at Rhode Island Hospital and underwent non-emergency surgery. Overall, just 30 patients—2.5 percent of the total—required emergency surgery.

Hospital charges for patients with unnecessary transfers averaged about $5,400, for a total expense of nearly $4.6 million. Transfer was associated with delays in definitive care; on average, it was nearly seven hours before the patients were finally sent home or admitted to the hospital.

Nearly 60 percent of transferred patients did not have private health insurance. Patients with less- favorable insurance status (eg, public insurance) or no insurance were more likely to be unnecessarily transferred. This raises concern about possible "patient dumping"—transferring patients to other hospitals because of inability to pay or inconvenience to healthcare providers.

Many patients with hand or face trauma do need to be evaluated by plastic surgeons, who have special expertise in treatment and reconstruction of hand and facial injuries. However, there are no standardized guidelines for emergency transfer of patients with isolated hand or facial injuries.

This creates "a frustrating and expensive problem for patients and the healthcare system," Dr. Drolet and colleagues write. "Patients who are transferred unnecessarily experience a delay in definitive care," in addition to excess costs from transportation, duplicated tests, and so forth.

The study adds new evidence on the high rate of unnecessary hospital transfers for plastic surgery evaluation. The researchers highlight the need for steps to reduce unnecessary transfers—perhaps involving conversations between the transferring provider and the surgeon on call at the trauma center.

They also call for further studies to develop guidelines for appropriate emergency transfer—based on the resources available at the original hospital and the treatment provided at the receiving hospital. Dr. Drolet and coauthors conclude, "Ultimately, the entire community of plastic surgeons and our patients, as well the healthcare system, will benefit from improved care of patients in the emergency setting."

Plastic and Reconstructive Surgery® is published by Wolters Kluwer.

Click here to read "Unnecessary Emergency Transfers for Evaluation by a Plastic Surgeon: A Burden to Patients and the Health Care System.”

Article: "Unnecessary Emergency Transfers for Evaluation by a Plastic Surgeon: A Burden to Patients and the Health Care System.” (doi: 10.1097/PRS.0000000000002147)