Emergency Hand Care: To Treat, Consult or Transfer: N/A - Not a clinical study

Abstract

Unnecessary inter-facility transfers for evaluation by a hand surgeon create significant human and economic burden for patients, providers, and the healthcare system. However, emergency hand care standards to guide treatment, consultation or transfer to a tertiary care center are lacking. Diagnosis-specific guidelines for emergency providers may improve both the quality and cost of care for upper extremity (UE) emergencies. We created a framework to group common UE emergency diagnoses based on ASSH standards and other published guidelines from the literature. Based on this framework, we designed a survey to evaluate the level of training – emergency medicine (EM), general orthopedic or plastic surgery, or hand fellowship – most appropriate to provide definitive, point-of-care service for each of the diagnostic groupings. As both educational leaders and key partners for developing consensus standards, EM and hand fellowship program directors (PDs) were chosen as the study population. We received 79 responses from hand fellowship PDs (89.7% return rate) and 151 responses from EM PDs (49.3% return rate). EM physicians were less likely than hand surgeons to report that specialized training was necessary to care for most of the diagnoses evaluated. (Table 1) Despite these differences, we identified consensus (>50% agreement with non-overlapping 99% confidence intervals) for the level of training that PDs felt was most appropriate to care for nearly all of the diagnosis groups in our framework. (Table 2) •This survey demonstrates variable levels of consensus (56.1% - 100%) between EM and hand surgery PDs regarding the level of training necessary to care for common urgent or emergent UE diagnoses. The program directors reported:○Emergency medicine physicians, with outpatient hand surgery follow up available, should provide point-of-care service for uncomplicated cellulitis, simple abscesses, paronychia or felon, simple lacerations without deep tissue involvement, non-displaced distal radius or ulna fractures, and reducible hand fractures.○General orthopedic or plastic surgery coverage should care for osteomyelitis, septic wrist, open fractures of the hand or wrist, and compartment syndrome.○Specialty hand coverage should be available for necrotizing infections, flexor tenosynovitis, crush injuries and complex lacerations, complicated dislocations, and high pressure injection injuries.•This diagnostic framework may improve triage in emergency hand care, specifically regarding the need for specialty consultation. Using these guidelines, unnecessary inter-facility transfers may avoided by identification of patients who do not require a provider with more specialized training, and therefore are not appropriate for transfer.View Large Image Figure ViewerDownload Hi-res image Download (PPT)