title: Inappropriate transfer of patients with orthopaedic injuries to a Level I trauma center: a prospective study.
abstract: OBJECTIVE
  The objective of this study was to analyze the appropriateness of transfer of patients with orthopaedic injuries to a Level I trauma center from surrounding Level II to IV centers.
  
  
  METHODS
  A prospective study was conducted over a 5-month period by collecting data on all orthopaedic patients being transferred to our facility. All transfer diagnoses were designated as appropriate or inappropriate. Patient demographics were calculated.
  
  
  METHODS
  The transfer of patients occurred from 23 Level II to IV hospitals to a Level I trauma center. These hospitals service 1 to 1.5 million people a year. PATIENTS/PARTICIPANTS MAIN OUTCOME MEASUREMENTS: All patients transferred with orthopaedic injuries were recorded. Patient variables such as transfer diagnosis, age, gender, insurance status, time of arrival, day of transfer, transferring and accepting physicians, previous imaging studies, and patient disposition were recorded. Outcome measurements included chi tests to determine variation in demographics based on insurance and appropriateness of transfer. Multivariate regression analysis was also performed to determine influence of individual patient variables on the main outcome variable: appropriateness of transfer.
  
  
  RESULTS
  Two hundred sixteen patients were transferred of which we considered 52% inappropriate. Sixty-eight percent of transfers occurred between 6:00 pm and 5:59 am and 60% of all transfers were over the weekend. Also, 69% of inappropriate transfers were discharged directly from the emergency department. Insurance was an independent factor affecting appropriateness of transfer. A larger percentage of inappropriate patients transferred were uninsured. The inappropriate patient who was transferred had more likelihood of being uninsured than insured. Moreover, there was a significantly higher percentage of inappropriate uninsured patients transferred after hours and over the weekend as compared with insured patients. More than 97% of inappropriate transfers were accepted by the emergency department physician without communication with the on-call orthopaedist at our facility.
  
  
  CONCLUSIONS
  There is a trend among community hospitals to transfer uninsured patients with benign orthopaedic injuries inappropriately to a Level I trauma center. This effect is magnified on weekends and at night. Strict regulation of the Emergency Labor Act and better communication between Level II to IV hospitals and Level I orthopaedic surgeons can decrease the inappropriate transfer of patients and reduce the burden on our healthcare system.
authors.affiliation: Department of Orthopaedics, Rhode Island Hospital, Providence, RI 02903, USA. nthakur79@gmail.com
authors.forename: Nikhil A
authors.initials: NA
authors.lastname: Thakur
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Plante
authors.forename: Stephen
authors.initials: S
authors.lastname: Kayiaros
authors.forename: Steven E
authors.initials: SE
authors.lastname: Reinert
authors.forename: Michael G
authors.initials: MG
authors.lastname: Ehrlich
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D050723:Fractures, Bone / Q000145:classification*; D006764:Hospitals, Community; D006801:Humans; D008297:Male; D008485:Medical Audit; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000145:classification* / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data*; D015995:Prevalence; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012237:Rhode Island / Q000453:epidemiology; D014193:Trauma Centers / Q000706:statistics & numerical data*; D055815:Young Adult