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Repeat Emergency Room Visits for Hand and Upper Extremity Injuries
Vishnu C. Potini, MD1; Walter Bratchenko, MS1; Glen C. Jacob, MD2; Linda Chen, MS1; Virak Tan, MD1
1University of Medicine and Dentistry of New Jersey- New Jersey Medical School, Newark, NJ; 2West Virginia University, Morgantown, WV

Introduction: Concerns regarding access to care and over-utilization of resources has led to scrutiny of inappropriate patient referral to university-based hospital emergency departments (ED). We observed that many of the hand and upper extremity patients who present to our university hospital ED had been seen at another ED for the same complaint. We hypothesize that 1) a majority of these patients did not require urgent or emergent care, 2) most utilized the ED as outpatient clinics, and 3) there's a disproportionate number of un- or under-insured patients.
Materials and Methods: We retrospectively reviewed all hand and upper extremity-related ED visits during a 9-year period. Patients who walked-in to our emergency department after documented evaluation by an outside ED within 30 days, for the same complaint, were included in this review. Direct transferred patients were also included. Demographics, diagnosis, referral instructions from the initial institution, date and time of ED visit, treatment received, and insurance status were recorded. Clinical urgency of diagnosis was quantified on an ordinal scale.
Results: 401 patients met the inclusion criteria for the study. 92% were treated by a junior-level orthopaedic resident and discharged from the ED. Of the studied population, 60% were uninsured, 31% had Medicaid, and 9% had commercial insurance, compared to our state's distribution of 16%, 8%, and 76%, respectively (p<0.05). Patients who were directly transferred had more severe injuries (p<.01) and were more likely to need admission for operative treatment(p<.001) compared to ED walk-in patients. Of the 355 ED walk-in patients, 318(90%) presented on weekdays and 301(85%) arrived between 6a-6p. Upon discharge from the outside ED, 170 patients were instructed to follow-up with an "orthopaedist", 180 to follow-up specifically at our institution, and 5 presented because no diagnosis was made initially. For transfer patients, 37% arrived during the daytime and 35% on weekdays, p<.001. For patients with urgent/emergent diagnoses, an average of 2 days (range, 0-14; SD, 3) elapsed after initial evaluation by the outside ED. For patients with non-urgent/semi-elective diagnoses, an average of 5 days (range, 0-29; SD, 6) elapsed, p<0.001.
Conclusions: Most hand and upper extremity patients seen in our emergency department after presenting to another ED did not have a condition that warranted urgent or emergent evaluation and treatment. Additionally a vast majority of these patients presented during regular business hours, when outpatient offices are open. With limited resources, it is imperative that appropriate treatment and follow-up plan from the initial institution be in place so that patients do not have to re-visit another ED for the same problem.


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