American Association for Hand Surgery

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Appropriateness of Transfer to a Tertiary Care Center for Operative Upper Extremity Trauma and Infection
Christopher J Goodenough, MD1, Eric J Maiorino, MD2, Paul J Deramo, MD1, Joseph K Moffitt, BS1, Zachary Tallackson, BS3 and Erik S Marques, MD4, (1)University of Texas Health Sciences Center at Houston, Houston, TX, (2)University of Texas Health Science Center Houston, Houston, TX, (3)University of Texas Health Science Center- Houston / McGovern Medical School, Houston, TX, (4)Division of Plastic and Reconstructive Surgery, University of Texas Health Science Center- Houston / McGovern Medical School, Houston, TX


Overutilization of healthcare resources has been cited as a leading cause of increasing healthcare expenditures in the US. Few studies have been published regarding the appropriateness of transfer to a tertiary care center for isolated upper extremity injuries and infections. The literature that exists primarily describes socioeconomic factors and insurance status. The purpose of this study is to assess the appropriateness of transfers to a tertiary care center in a cohort of patients with operative hand pathology.

Materials and Methods

We reviewed the records of 132 patients transferred to a tertiary care center between 2013 and 2018, all of whom required operative intervention. We analyzed demographic data, distance of transfer, mechanism and severity of injury, intervention received and follow up data. Patients were categorized by appropriateness of transfer into three categories, using published guidelines: pathology that does not require evaluation by an upper extremity surgeon, injuries that require non-emergent specialist follow up, and injuries that require emergent transfer for specialist care.


Of 132 patients who were transferred and required operative treatment, 106 (80%) patients were transferred for trauma, 25 (19%) for infection and 1 (1%) patient was transferred for a hemorrhagic tumor causing compartment syndrome. The median distance traveled for transfer was 22.7 (range 11, 124) miles. Overall, 73% of patients met criteria for transfer and 56% received emergent operative intervention. For non-emergent operations, the median time from arrival at the tertiary care facility to the operating room was 12.0 hours. Of the patients transferred for trauma, 79% met criteria for transfer for upper extremity specialist evaluation and 59% received emergent operative intervention. Only 56% of patients transferred for infection met criteria for transfer, and only 44% of transferred patients required emergent operative intervention.


Overall, the majority of patients transferred for trauma had significantly complex injuries, requiring acute management by an upper extremity surgeon. However, about half of patients transferred for infection were transferred unnecessarily and fewer than half required emergent operative intervention, resulting in unnecessarily long delays to definitive intervention and hospital stays. Widespread implementation of evidence based guidelines may reduce unnecessary transfers and improve healthcare resource utilization.

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