Study questions appropriateness of ED transfers

By: Maureen Leahy

By Maureen Leahy

More than half of the patients transferred from surrounding hospitals to a Level I trauma center could have been treated locally, and nearly 60 percent of the patients transferred were uninsured, said the authors of a study presented yesterday.

These results may indicate a trend—magnified on weekends and at night—among emergency department (ED) physicians and hospitals to transfer uninsured patients with nonemergency orthopaedic injuries to a Level I trauma center. Inappropriate orthopaedic patient transfers can result in the delayed delivery of appropriate patient care, further overcrowding in the ED, and increased health-care expenditures.

The purpose of the study was to analyze the legitimacy of patient transfers to a Level I trauma center from surrounding Level II–Level IV hospitals, explained Nikhil A. Thakur, MD, study author.

Study design
Data were collected prospectively over a 5-month period on 216 orthopaedic patients (65 percent male; 40 percent pediatric [17 years old or younger]) who were transferred to a Level I trauma center from 23 surrounding Level II–Level IV hospitals. The reason for transfer was documented for each patient, along with patient demographics, insurance status, day and time of transfer, transferring and accepting physicians, previous imaging studies, and patient disposition.

Three senior-level, fellowship-trained orthopaedic surgeons designated the transfers as appropriate or inappropriate based only on the diagnosis in the transfer information (Table 1). Inappropriate transfers were defined as patients who could have been managed by board-certified, residency-trained general orthopaedists in community hospitals.

The study showed that more than half (52 percent) of the patients were inappropriately transferred, including 53 percent of the pediatric patients. Additionally, 59 percent of the 128 transfers that occurred over the weekend were deemed inappropriate.

Moreover, 97 percent of all transfers were made by the ED physician, and a similar number were accepted by the ED physician, without con­tact­ing the orthopaedic surgeon on call.

“This demonstrates a breakdown in the communication system, where the orthopaedic surgeon is not being involved directly in the care of an orthopaedic patient prior to transfer,” said Dr. Thakur. “It also suggests that better communication with the orthopaedist on call could have prevented some of the inappropriate transfers and thus further distress to the patient.”

Other patient variables, including insurance, were analyzed independently to determine their effect on the legitimacy of patient transfers. More than half of all patients transferred were uninsured, and an inappropriate transfer was twice as likely to be uninsured than insured. After-hours and weekend data showed that 75 percent of all patients transferred between 6 p.m. and 6 a.m. were uninsured, and 67 percent of inappropriate transfers arriving over the weekend were uninsured.

Patient gender, arrival time at the ED, and day of transfer were not associated with the legitimacy of transfer.

Overall, 54 percent of all transfers were admitted. Of patients discharged from the ED after evaluation, 77 (69 percent) were inappropriate transfers.

Majority of injuries don’t warrant transfer
The study data suggest a trend among ED physicians and com­munity hospitals to transfer uninsured patients with nonemergency orthopaedic injuries to a Level I trauma center. These physicians and hospitals also appear reluctant to treat patients after hours or to contact the orthopaedic surgeon on call and request that he or she confer with the orthopaedist at the Level I trauma center prior to the transfer.

“A substantial number of orthopaedic injuries in our study were isolated and not of sufficient severity to warrant a transfer,” said Dr. Thakur. “Although we

were unable to acquire information on orthopaedic patients being treated at each transferring hospital, this analysis suggests an overutilization of our regional trauma center. It may also represent an unwillingness of outside hospitals and physicians to manage even the most basic aspects of orthopaedic trauma.

“We suggest that stricter enforcement of the Emergency Medical Treatment and Active Labor Act (EMTALA) is warranted to ensure appropriate delivery of health care to patients,” he concluded. “These steps will further assist in decreasing the burden on EDs and help reduce the financial expenditure and health cost.”

Dr. Thakur’s co-authors of “Inappropriate Transfer of Patients with Orthopaedic Injuries to a Level I Trauma Center” include Matthew J. Plante, MD; Steven E. Reinert, MD; and Michael G. Ehrlich, MD. None of the authors reported any conflicts related to this manuscript. A link to the abstract of their study can be found in the online version of this article, available at

Maureen Leahy is assistant managing editor for AAOS Now. She can be reached at