• Phoebe Kuo, Tristan L Hartzell, Kyle R Eberlin, Diana Miao, David Zurakowski, Jonathan M Winograd, and Charles S Day.
• Department of Orthopedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215. E-mail address for C.S. Day: cday1@bidmc.harvard.edu.
• J Bone Joint Surg Am. 2014 Mar 19; 96 (6): e48.

BackgroundAs emergency departments (EDs) become increasingly overwhelmed and specialist coverage in some EDs decreases, patients may be transferred to tertiary or quaternary facilities for specialized care to decrease patient load at transferring facilities. Our objective was to determine whether facilities that transferred patients for hand surgery had hand surgery coverage and to evaluate any nonmedical factors that might have been associated with transfer.MethodsA retrospective review was conducted for 1167 visits of hand and wrist patients seen in the EDs of two urban level-I trauma centers. The hand surgery capacity of referring facilities was determined by phone calls to the EDs. Univariate and multivariable analyses were conducted to identify nonmedical factors that could potentially affect the decision to transfer.ResultsA total of 155 (13.3%) of 1167 patients arrived from other facilities for specialized hand care. These patients were significantly more likely to be male (p = 0.02), have noncommercial insurance (p = 0.04), require an interpreter (p = 0.01), and arrive between 6:00 p.m. and midnight (p = 0.03). In a multivariable analysis, sex and insurance status were significantly associated with transfer (p < 0.05). The subset of ninety-five patients who were transferred from other EDs was significantly more likely to be male (p < 0.01) and arrive on weekends (p < 0.01) or between 6:00 p.m. and midnight (p < 0.01). Of these patients, seventy-seven (81%) were transferred from an ED that reported partial or full hand surgery coverage. However, only eight (10.4%) received a hand surgery evaluation prior to transfer.ConclusionsThe low percentage of patients receiving hand surgery evaluations prior to transfer suggests that referring hospitals are not using their own hand surgeon resources. Nonmedical factors, including noncommercial insurance and off-hour time of initial arrival, may be associated with the decision to transfer patients.Clinical RelevanceIdentifying nonmedical factors associated with patient transfers and referrals can enlighten efforts to improve the quality and appropriate use of transfers for specialty care.

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