Emergency Orthopaedic Care
This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.
Emergency orthopaedic care includes acute trauma care and urgent general orthopaedic care delivered in hospital emergency rooms. Access to emergency orthopaedic care in the United States is problematic and may get worse. At present, there is variable access to orthopaedic emergency care in many communities in the United States.
Since this access problem varies from community to community, one solution which is applicable to all locales remains elusive.
Factors contributing to the emergency orthopaedic care access problem include:
- An increasing patient population seeking emergency orthopaedic care1
- A shortage of physicians available to take emergency orthopaedic call in certain parts of the country2
- Unique difficulties in pediatric orthopaedic coverage.3
- Government health care programs that do not provide adequate coverage for emergency care
- Inadequate hospital facilities and insufficient resources to support emergency care services4
- A decrease in the number of hospital emergency departments5
- Decreasing professional reimbursement and increasing professional practice costs6
- An increasing volume of uninsured patients, uncompensated care, underinsured patients7
- A challenging medical liability environment8
- Changing practice patterns with increased orthopaedic subspecialization
- An anticipated orthopaedic manpower shortage9
Recognizing this emergency orthopaedic care crisis, the American Academy of Orthopaedic Surgeons (AAOS) believes that orthopaedists, working in conjunction with all stakeholders, including other physicians, hospitals, and government policymakers, have a responsibility to address the problems in access to emergency orthopaedic care. Accomplishing this objective is in the best interests of patient care.
Local Emergency Care
Most injuries occur near a patient’s home. It is inconvenient and costly to transfer injured patients out of their local community for emergency orthopaedic care; however, polytrauma patients should be transferred to specialized trauma centers, which provide specialized, multidisciplinary emergency care for trauma patients. At present, from time to time, trauma centers become overburdened with transfers of patients for routine urgent orthopaedic care which can lead to impairment of the trauma center’s ability to care for legitimate acute trauma victims.
The AAOS believes emergency orthopaedic care should be provided in the patient’s local community whenever possible, recognizing that acute trauma care may necessitate transfers to polytrauma centers.
The Responsibility of the Orthopaedic Community
Orthopaedic surgeons are the most qualified physicians to provide acute musculoskeletal trauma care and urgent general orthopaedic care. Access to these services is a critical factor in the emergency orthopaedic care issue. Reasons for variability in access to acute trauma care and urgent general orthopaedic care include:
- The availability of orthopaedic surgeons for emergency room call
- The willingness of hospitals to provide facilities and resources for emergency orthopaedic care
- The development of hospital business models to negotiate call arrangements with on-call physicians
- Public policies and health plan coverage to pay for the costs of treating uninsured and underinsured patients in the emergency room.
The AAOS recognizes modern orthopaedics depend on subspecialized orthopaedists for the highest quality orthopaedic care. Therefore, it is difficult to expect an orthopaedic surgeon who has provided subspecialty care for a significant period of time, to provide general orthopaedic trauma care outside his/her subspecialty.
The AAOS believes board-eligible and board-certified orthopaedic surgeons possess comprehensive orthopaedic clinical competency and are qualified to provide emergency orthopaedic care. The AAOS does not believe all orthopaedic surgeons should be required to provide emergency orthopaedic care in all circumstances.
The AAOS believes orthopaedic surgeons have a responsibility to take a leadership role in working with their hospitals to ensure that emergency patients with musculoskeletal problems receive timely and appropriate care in their local communities.
Leadership responsibility for emergency orthopaedic care requires collaboration with hospitals, communities, health plans, other physicians, and patients to develop an emergency orthopaedic care system that addresses the needs of the patients, the community, the hospitals, and the physicians.
The AAOS believes orthopaedic surgeons in a local community have a responsibility, utilizing mutually agreed upon incentives with their hospitals, to provide a call system for emergency orthopaedic care in their local community.
The Role of Other Stakeholders
The Responsibilities of Hospitals
Hospitals must provide facilities and resources to allow orthopaedic surgeons to provide safe, high quality emergency orthopaedic care. Specifically, hospitals should provide adequate facilities, equipment, devices, and well-trained ancillary personnel, as well as guaranteed operating room time to manage emergency cases the night of admission or the following day. Of paramount importance is that these provisions are made regardless of patients’ insurance status or ability to pay.
Hospitals should also share the financial burdens that orthopaedists and other physicians now bear alone when they take call and provide emergency services. These financial burdens include:
- Opportunity costs associated with not being able to provide care for elective patients on the day of call and the day after call because of obligations associated with providing emergency orthopaedic care;
- Extra costs that physicians absorb when they treat uninsured and underinsured emergency patients, including additional liability risks, and
- Loss of sleep and other disruptions to personal and professional routines from being on-call and providing emergency orthopaedic care.
Providing adequate funding and support service has been shown to encourage orthopaedic surgeons to provide emergency orthopaedic care in their communities. Hospitals are obligated to assume an appropriate portion of these costs given the federally mandated responsibility for provision of emergency services. Given decreases in physician reimbursement, from both federal and private payers, assumption of the costs for provision of emergency services by physicians is not reasonable or sustainable.
The Joint Responsibilities of Orthopaedists and Hospitals
Hospitals have a federally mandated responsibility to provide care to emergency patients. Hospitals and orthopaedic surgeons have a joint responsibility to ensure that orthopaedic patients receive timely and appropriate emergency orthopaedic care. Hospitals and orthopaedic surgeons have a joint responsibility to: develop call schedules based on the local community’s emergency care needs and local orthopaedic workforce issues (age of orthopaedists, years of emergency service, on-call frequency, and sub-specialization); developing protocols for transferring patients to other facilities based on objective clinical criteria and the ability of the orthopaedist to provide high quality care; and executing defined agreements with receiving centers for acceptance of the transfer of patients for whom musculoskeletal emergency services cannot be provided at the initial receiving center.
Hospitals and their orthopaedic staff should jointly decide what is a maximum frequency for orthopaedic call realizing that at times, a particular hospital emergency department may not have orthopaedic coverage.
Coverage for the emergency room should be based on mutually agreed incentives and not mandates to take call.
The Responsibilities of Government
Government must take greater responsibility for helping physicians and hospitals meet society’s expectations for delivering emergency orthopaedic care regardless of ability to pay.
- Medicaid reimbursement must be sufficient to ensure adequate emergency orthopaedic access to care for Medicaid beneficiaries.
- Federal, state, and local governments must support fair and reasonable compensation for trauma and emergency services and create new sources to finance emergency orthopaedic care for underinsured patients.
- Best practice models for delivering emergency orthopaedic care should be identified and promoted.
- Impediments to access to emergency orthopaedic care, including an actual or perceived increase in liability exposure must be addressed. Federal and state medical liability reform must be enacted to restore and preserve access to care for patients who require emergency orthopaedic care throughout the U.S.
Reimbursement and medical liability are significant contributing factors in the emergency orthopaedic care access problem, and they should be addressed by hospitals, communities, health plans, other physicians, and patients.
In return for developing emergency orthopaedic care services, the AAOS believes orthopaedic surgeons should be fairly compensated for the knowledge, skills, work, expertise, and management of risks which they deliver to their community.
Support for orthopaedic surgeons who provide emergency coverage may include, but not be limited to, access to the hospital emergency room, utilization of hospital operating rooms and staff, assistance from hospital mid-level professionals, payment for specific professional services (clinical and administrative), and payment for time.
General Principles to Address the Emergency Care Crisis
The AAOS believes orthopaedic surgeons can stimulate change to improve the emergency orthopaedic care access problem. However, orthopaedic surgeons cannot accomplish this alone. The AAOS believes all stakeholders including orthopaedic surgeons, the government, hospitals, policymakers and payers must work together to improve access to emergency orthopaedic care in the United States.
1Emergency Department Visits Remain at Record High Levels. American College of Emergency Physicians Press Release, June 23, 2006. http://www.acep.org/pressroom.aspx?id=25644 . The National Report Card on the State of Emergency Medicine; Evaluating the Environment of Emergency Care Systems State by State. American College of Emergency Physicians, January 2006.
2 Crucial Minutes Go By without ER On-Call Specialists. Boston Globe, December 23, 2007. On-Call Specialists at Emergency Rooms Harder to Keep. Washington Post, December 21, 2007.
3Emergency Care for Children; Growing Pains. Institute of Medicine, June 14, 2006. http://www.iom.edu/?id=48897
4Hospital Emergency Surge Capacity; Not Ready for the “Predictable Surprise. A Majority Staff Report; House Oversight and Government Reform Committee. U.S. House of Representatives, May 2008. http://oversight.house.gov/documents/20080505101837.pdf . Emergency Medical Services at the Crossroad. Institute of Medicine, June 14, 2006. http://www.iom.edu/?id=48898
5Hospital-Based Emergency Care; At the Breaking Point. Institute of Medicine, June 14, 2006.
6Physician Alignment Strategies; Choose the Right on Call Compensation Model for Your Hospital. Health Leaders Media Webcast, June 17, 2008.
7Study: Nearly half of all ER Physician Care Goes Uncompensated. Orlando Business Journal, December 27, 2005. http://www.bizjournals.com/orlando/stories/2005/12/26/daily1.html
8To address the medical liability crisis, the AAOS was the founder and current chair of Doctors for Medical Liability Reform. www.ProtectPatientsNow.org.
9To address this issue, the AAOS Board of Directors created an Orthopaedic Work Force Project Team.
September 2006 American Association of Orthopaedic Surgeons. Revised December 2008.
This material may not be modified without the express written permission of the American Association of Orthopaedic Surgeons.
Position Statement 1172
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