title: Unnecessary Emergency Transfers for Evaluation by a Plastic Surgeon: A Burden to Patients and the Health Care System.
abstract: BACKGROUND
  Plastic surgeons are frequently consulted for hand and facial injuries, and patients are often transferred to trauma centers for evaluation of these problems. The authors sought to identify the frequency and impact of "unnecessary" transfers for emergency evaluation by a plastic surgeon at a Level I trauma center.
  
  
  METHODS
  The authors reviewed more than 32,000 consecutive emergency department encounters at their institution between April of 2009 and April of 2013 and found 1181 patients transferred for evaluation by plastic surgery. Using a retrospective chart review, necessity of transfer was determined based on the intervention performed at the authors' institution and the availability of resources at the transferring site.
  
  
  RESULTS
  Of all the patients referred for "emergency" evaluation, 860 (74.1 percent) were unnecessary. Transfers for hand-related issues were more likely to be coded as unnecessary compared with referrals for facial trauma and infection (76 percent versus 66 percent; p < 0.001). The average time from referral to discharge from the emergency department was 412 minutes. The expense for these unnecessary transfers exceeded $4.6 million.
  
  
  CONCLUSIONS
  This is the first intervention-based study evaluating the impact of unnecessary transfer for evaluation of hand and facial emergencies. Using a framework based on objective outcomes, the authors found that fewer than one-third of patients required emergent transfer for evaluation by a plastic surgeon, and almost half did not receive an intervention following transfer. Based on patient time and financial expenses for these unnecessary evaluations, improvements could be made in both quality and cost of care by limiting inappropriate emergency department referrals.
authors.affiliation: Baltimore, Md.; and Providence and Wakefield, R.I.|From the Department of Plastic Surgery, Johns Hopkins Medicine; the Departments of Plastic Surgery and Orthopaedic Surgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University; and South County Orthopedics.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Drolet
authors.affiliation: Baltimore, Md.; and Providence and Wakefield, R.I.|From the Department of Plastic Surgery, Johns Hopkins Medicine; the Departments of Plastic Surgery and Orthopaedic Surgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University; and South County Orthopedics.
authors.forename: Vickram J
authors.initials: VJ
authors.lastname: Tandon
authors.affiliation: Baltimore, Md.; and Providence and Wakefield, R.I.|From the Department of Plastic Surgery, Johns Hopkins Medicine; the Departments of Plastic Surgery and Orthopaedic Surgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University; and South County Orthopedics.
authors.forename: Austin Y
authors.initials: AY
authors.lastname: Ha
authors.affiliation: Baltimore, Md.; and Providence and Wakefield, R.I.|From the Department of Plastic Surgery, Johns Hopkins Medicine; the Departments of Plastic Surgery and Orthopaedic Surgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University; and South County Orthopedics.
authors.forename: Yifan
authors.initials: Y
authors.lastname: Guo
authors.affiliation: Baltimore, Md.; and Providence and Wakefield, R.I.|From the Department of Plastic Surgery, Johns Hopkins Medicine; the Departments of Plastic Surgery and Orthopaedic Surgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University; and South County Orthopedics.
authors.forename: Benjamin Z
authors.initials: BZ
authors.lastname: Phillips
authors.affiliation: Baltimore, Md.; and Providence and Wakefield, R.I.|From the Department of Plastic Surgery, Johns Hopkins Medicine; the Departments of Plastic Surgery and Orthopaedic Surgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University; and South County Orthopedics.
authors.forename: Edward
authors.initials: E
authors.lastname: Akelman
authors.affiliation: Baltimore, Md.; and Providence and Wakefield, R.I.|From the Department of Plastic Surgery, Johns Hopkins Medicine; the Departments of Plastic Surgery and Orthopaedic Surgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University; and South County Orthopedics.
authors.forename: Scott T
authors.initials: ST
authors.lastname: Schmidt
mesh_terms: D039602:After-Hours Care / Q000191:economics; D015331:Cohort Studies; D017281:Cost of Illness; D004632:Emergency Medical Services / Q000191:economics*; D005151:Facial Injuries / Q000191:economics* / Q000601:surgery*; D006230:Hand Injuries / Q000191:economics* / Q000601:surgery*; D017722:Hospital Charges; D006801:Humans; D019458:Insurance Coverage / Q000191:economics; D010360:Patient Transfer / Q000191:economics*; D012017:Referral and Consultation / Q000191:economics*; D012189:Retrospective Studies; D012237:Rhode Island; D013518:Surgery, Plastic / Q000191:economics*; D014193:Trauma Centers / Q000191:economics*; D019564:Unnecessary Procedures / Q000191:economics*