Published 2/1/2009
Mary Ann Porucznik; Lindsay Law

AAOS takes position on ED orthopaedic care

Ensuring access to emergency orthopaedic care in the United States continues to challenge communities, hospitals, orthopaedic surgeons, and patients. At its December 2008 meeting, the AAOS Board of Directors approved a new position statement on Emergency Orthopaedic Care.

A national problem, with local solutions
Although several factors contribute to the crisis in providing emergency orthopaedic care on a national basis, access to such care varies from community to community, making a single solution “elusive.” But in recognizing this emergency orthopaedic care crisis, “the 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,” according to the statement.

Because most injuries occur near a patient’s home, “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 statement goes on to outline the responsibilities of the orthopaedic community, hospitals, and government in addressing the crisis.

The orthopaedic community’s responsibility
As the most qualified physicians to provide acute musculoskeletal trauma care and urgent general orthopaedic care, orthopaedic surgeons play a key role in providing emergency orthopaedic care. The position statement recognizes this, stating: “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.

Many orthopaedists, however, focus their services in a specialty, and are reluctant to provide general trauma care outside that specialty. Although the position statement recognizes that “board-eligible and board-certified orthopaedic surgeons possess comprehensive orthopaedic clinical competency and are qualified to provide emergency orthopaedic care,” it goes on to state that “the AAOS does not believe all orthopaedic surgeons should be required to provide emergency orthopaedic care in all circumstances…

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 hospital’s responsibilities
The position statement calls on hospitals to “provide facilities and resources to allow orthopaedic surgeons to provide safe, high quality emergency orthopaedic care.” It specifies that 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 should be made available regardless of the patient’s insurance status or ability to pay.

  • The statement also calls on hospitals to share the following financial burdens that orthopaedists and other physicians now bear alone when they take call and provide emergency services:
  • 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
  • loss of sleep and other disruptions to personal and professional routines from being on-call and providing emergency orthopaedic care

The position statement notes that “Given decreases in physician reimbursement, from both federal and private payors, assumption of the costs for provision of emergency services by physicians is not reasonable or sustainable.

Shared responsibilities
The statement notes that hospitals and orthopaedic surgeons have the following joint responsibilities:

  • 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)
  • to develop protocols for transferring patients to other facilities based on objective clinical criteria and the ability of the orthopaedist to provide high quality care
  • to execute 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

In particular, the statement notes that “coverage for the emergency room should be based on mutually agreed incentives and not mandates to take call.”

Government’s responsibilities
The statement calls on government to take greater responsibility for helping physicians and hospitals meet society’s expectations for delivering emergency orthopaedic care regardless of the patient’s ability to pay, and proposes the following steps:

  • 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 United States.

Other considerations
Noting that reimbursement and medical liability are significant contributing factors in the emergency orthopaedic care access problem, the statement reads, “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.”

In conclusion, “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 payors must work together to improve access to emergency orthopaedic care in the United States.”

Mary Ann Porucznik is managing editor of AAOS Now. Lindsay Law is communications manager for the AAOS office of government relations.

Look for it online
The position statement on “Emergency Orthopaedic Care” replaces the previous statement regarding “On-call Coverage and Emergency Care Services in Orthopaedics,” which was adopted in 2006. The new statement was initially drafted by a Board Project Team chaired by William L. Healy, MD. The draft was presented to the Board at its June 2008 meeting and referred to the Council on Advocacy, under the leadership of David A. Halsey, MD, for further refinement. The final statement was drafted with input from the Board of Councilors, the Board of Specialty Societies, several state societies, and the membership and leadership of the Orthopaedic Trauma Association and the Pediatric Orthopaedic Society of North America.

The 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. Read the complete statement on the AAOS Web site