Hand Surgery Transfers to a Level 1 Center: Variables Affecting Transfer Method and Diagnostic Accuracy
Rachel Pedreira, MD1; Jill Putnam, MD2; Paige Fox, MD, PhD3
1Stanford Hospital and Clinics, Stanford, CA; 2Stanford University, Stanford, CA; 3Stanford University, Palo Alto, CA
We hypothesize that many costly patient transfers to a level 1 trauma center for higher level of care and hand specialist management may be unnecessary. This analysis evaluates transfer cost effectiveness and whether time of consult, transfer distance, and provider level influence diagnostic accuracy and transport method.
265 consecutive patients transferred to a suburban level 1 trauma center between 2014 and 2019 were evaluated for patient and injury characteristics, time of consult, transfer distance, provider level, transport method, cost of medical treatment, accuracy of pre-transfer diagnosis, and type of patient management.
The average patient age was 36.2 years old and 80.3% were male. As expected, longer interfacility distance and certain diagnoses were associated with increased utilization of air transport (p < 0.05). Mean air transfer distance was 166 miles, versus 63 miles for ground transport. Twenty one percent of transfers had inaccurate pre-transfer diagnoses (pre-transfer diagnosis did not match final diagnosis by hand specialist), and certain pre-transfer diagnoses correlated with an increased likelihood of inaccuracy, including flexor tenosynovitis and vascular injury requiring repair. Patients with a language barrier had a greater likelihood of being transferred with an inaccurate diagnosis (p < 0.05). Compared to ground transport, air ambulance was associated with a higher cost of medical treatment ($225,679 versus $133,887, p < 0.00001). Of all transfers, 14 (5%) were discharged from the emergency department (ED) without a procedure, 9 (3%) were admitted for observation, 73 (27%) had an ED procedure before discharge, and 166 (62%) received formal operative management.
Over 30% of transfers to a level 1 trauma center likely could have been managed at the transferring facility at lower cost due to decreased expenditure of healthcare resources. Certain diagnoses are associated with increased risk for diagnostic error and unnecessarily urgent transport. Providers at accepting facilities can use this information to consider transfer patterns and to educate transferring providers. Transferring providers can use this information to assure a language barrier does not contribute to unnecessary, costly patient transfer.
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