Reply: Unnecessary Interfacility Transfers for Craniomaxillofacial Trauma

Abstract

Sir: We appreciate the auhors’ review of our recent study.1 The question of whether a referring provider is able to diagnose a patient’s traumatic injuries is an important one. We did not address this because it was not the goal of this study. The goal of this study was to identify the problem of secondary overtriage of facial trauma patients. The second phase of our study has been designed to evaluate national perceptions of this problem and whether the craniomaxillofacial surgical community felt there was a need for transfer guidelines. Indeed, the results of this multidisciplinary survey demonstrated that roughly 50 percent of facial trauma surgeons agreed that most emergency transfers for isolated facial trauma at their institutions were unnecessary. Eighty-seven percent of respondents thought that transfer guidelines could help decrease unnecessary transfers, and data regarding which specific injury patterns should be transferred were also collected.2 With regard to the availability of on-call facial traumatologists, the data presented by the authors’ team appear to be regional. Unfortunately, studies have shown that a large percentage of referral centers implicated in secondary overtriage of facial trauma patients have full-time facial trauma coverage.3 This was also the case in our cohort. The long-term goal of our project is not to leave the diagnosis of facial injuries to the nontrauma practitioner; in fact, it is the opposite. Our goal is to educate those practitioners and provide them with tools to diagnose injuries of lesser acuity that may not require emergency systems activation. Education is essential in this effort. The first phase is to define the problem; the second, to quantify the need; and the third, to provide a solution. The third phase of our project, which is underway, uses an assembled panel of expert craniomaxillofacial traumatologists in the fields of ear, nose, and throat; oromaxillofacial; and plastic surgery. We aim to construct transfer guidelines similar to those put forth by the American Burn Association for referral to a regional burn center. The guidelines will be written for use by all providers, including those with little facial trauma experience. Using data collected from our second study2 and consensus collected in our third stage (using the modified Delphi method), our guidelines will define exactly which facial skeletal and soft-tissue injuries should be transferred. We agree that a patient with an unclear diagnosis should be transferred to a higher level of care. It is well documented that isolated facial trauma is implicated in secondary overtriage,2–6 and we, alongside facial trauma providers from different specialties across the nation, believe that there is room to improve the management of these patients. Our goal remains to refine the transfer process for facial trauma patients while minimizing the potential untoward consequence of secondary undertriage. Unfortunately, a small percentage of secondary undertriage is a necessary tradeoff for a reduction in substantial secondary overtriage, and a proper balance of undertriage and overtriage is paramount. Such a large percentage of unnecessary transfers carry far worse ramifications to the patient and the health care system than does the rare undertriage event. We thank the authors for their thoughtful commentary. DISCLOSURE The authors have no relevant financial disclosures related to the content of this communication.