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Patients Transferred for Upper Extremity Amputation: Do All Level I Trauma Centers Participate?
Shantum Misra, BA1, Suzanne C. Wilkens, MD2; Neal C. Chen, MD3; Kyle R Eberlin, MD3
1George Washington University School of Medicine and Health Sciences, Washington, DC; 2Harvard University, Boston, MA; 3Massachusetts General Hospital, Cambridge, MA

Introduction: Level I trauma centers are required to provide hand surgery and microsurgery capability 24 hours a day. We hypothesize that patients are transferred to our center for management of upper extremity amputations despite the availability of approved, closer level I facilities.

Materials & Methods: Medical records were reviewed from October 2010 to June 2015 to evaluate patients transferred to our level I institution for upper extremity amputation. Patients who presented with an ICD-9 code demonstrating amputation of an upper extremity were included. Patient demographics, type and presence of medical insurance, injured extremity, dominant extremity, number of extremity amputations, trauma designation of transferring facility, and zip code of transferring facility were recorded. Patients from 6 states were transferred to our facility and distances from each patient's transferring facility to all 13 level I trauma centers in these 6 states was computed by compiling straight-line distances from the zip code of the transferring facility to the zip code of each level I trauma center.

Results: Out of 261 patients with eligible ICD-9 codes transferred, 250 (91.2% male, 8.8% female) had available data. Of these, patients were transferred from hospitals in 6 surrounding states: Massachusetts (163), Maine (31), Vermont (7), New Hampshire (21), Rhode Island (27), and Connecticut (1). For 112 patients our hospital was the nearest level I trauma center, however for the remaining 138 patients other trauma facilities were located closer to the referring hospital and were bypassed to get to our hospital. Among these 138 patients, an unpaired student t-test showed that the mean distance of the transferring facility to the nearest level I trauma center (mean= 30 miles; SD= 27 miles) was significantly different from the mean distance of the transferring hospital to our facility as a more distant level I trauma center (72 miles; SD= 60 miles) (P< 0.001). An average of 4 (range 1 10) level I trauma centers were bypassed before patients arrived at our center.

Conclusion: 55% of patients transferred for upper extremity amputation from 6 surrounding states had a level I trauma center closer to their injury than our institution. Patients with upper extremity amputations are referred to our regional center despite the proximity of closer level I trauma centers. This suggests that regional microsurgical expertise is recognized and may be independent of ACS trauma accreditation.

Distance of transport from transferring facility (A); Trauma designation of transferring facility (B, n= 74)

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