AAOS Now

Published 3/1/2003

New report issued on orthopaedic ED care

AOA Institute calls for community-based solutions

The American Orthopaedic Association’s (AOA) Orthopaedic Institute of Medicine (OIOM) recently released the results of an in-depth study into the challenges surrounding emergency department (ED) coverage. The report also provides possible solutions and recommendations for addressing this crisis, as well as actual case studies.

Survey sets the stage
Providing emergency care on an on-call basis has become unattractive to many specialists in critical disciplines such as orthopaedics. According to a survey of AAOS members conducted by the OIOM in 2008, more than 70 percent of respondents take call because hospital bylaws mandate that they participate. About half of respondents considered call a personal responsibility to the community, and about 40 percent considered call a professional obligation.

More than half of respondents received no financial compensation for taking ED call. When asked what they might consider “adequate” pay for a 24-hour on-call session, more than three out of four respondents opted for $1,000 to $2,000.

Nearly 70 percent of respondents viewed orthopaedic ED coverage in their communities as problematic. Of those participating in call, 90 percent reported that problems surrounding call coverage affected both them and their practices.

The three most significant barriers to ED call coverage, as identified by the survey, were disruption of the surgeon’s lifestyle and family life, inadequate compensation from the hospital for call coverage, and disruptions to the surgeon’s elective orthopaedic practice.

Recommendations
As part of the report, the OIOM Task Force included a total of 29 recommendations in the following 8 specific areas: delivery of emergency care, physician leadership, education and core competencies, hospital resources for orthopaedic emergency care, collaboration with other organizations, reimbursement for services (orthopaedists and hospitals), tort reform, and third-party payors as community participants in generating solutions.

The following recommendations are among those proposed by the report:

  • Hospitals [should] provide the readily available resources (diagnostic testing and imaging services, available inpatient beds, operating room (OR) guaranteed time and trained personnel) that are needed to administer appropriate care to patients with urgent musculoskeletal conditions.
  • Hospitals should collaborate with local orthopaedic surgeons to develop an effective and viable orthopaedic emergency department call system and to establish meaningful transfer agreements between institutions to ensure the best care for the patient and eliminate inappropriate referrals.
  • Communities of hospitals and orthopaedic surgeons [should] work together to find an appropriate method to provide compensation (either monetary or in-kind) for orthopaedic surgeons covering on-call responsibilities.
  • Insurers, legislators, hospital organizations, and physician organizations [should] step up efforts to propose, discuss, and enact meaningful tort reform at the federal level.
  • The ABOS and orthopaedic training programs [should] assess the feasibility of developing a training program for an acute care orthopaedist.

Case studies provide real-life examples
The report includes several case studies that illustrate both the problems and possible solutions. In one situation, for example, orthopaedists in a level I trauma center felt that ED call was interfering with their ability to develop subspecialty practices and were becoming more dissatisfied. By developing a trauma service and a trauma OR, the institution was able to release orthopaedic surgeons who did not enjoy trauma care from taking call and enable them to do more elective cases. This change resulted in a positive learning environment for residents; more importantly, it improved patient access to quality care.

In another case, a large private hospital established a collaborative relationship with local community hospitals. The larger hospital is associated with a community-based multispecialty group that includes orthopaedic traumatologists. The arrangement clearly delineates the types of cases to be transferred and provides telemedicine consultation by the traumatologist for each hospital.

Establishing a hospital-owned orthopaedic practice was the solution for a level II trauma center that initially relied on community orthopaedists to cover call. The hospital-owned group operates largely as a private practice, except that the hospital provides minimum salary guarantees and retains any earnings from the practice. The solution satisfies the community orthopaedists, in spite of the competition from the hospital-owned group for insured patients.

Table 1: Recommendations of the OIOM Task Force on ED Call Coverage

Delivery of emergency department (ED) care

    1. Communities should ensure all patients have access to readily available orthopaedic surgical consultation in the ED.

    2. Hospitals should streamline processes so that emergency patients are prioritized to receive inpatient diagnostic procedures and treatment promptly.

    3. Communities should create community-wide teams to evaluate musculoskeletal emergency care.

    4. Hospitals should provide the readily available resources that are needed to administer appropriate care to patients with urgent musculoskeletal conditions. At minimum, this should include the provision of prompt diagnostic testing and imaging services, the availability of hospital inpatient beds, and the guarantee of appropriate operating room (OR) time and adequately trained OR personnel. All such resources should be dedicated to providing care to urgent patients without disrupting or displacing the elective schedule.

Physician Leadership

    1. All orthopaedic surgeons should have a professional obligation to ensure that there is a system in their community whereby all patients have access to timely and appropriate high-quality emergency musculoskeletal care.

    2. The orthopaedic professional organizations should have a responsibility to establish professional guidelines to ensure that emergency musculoskeletal care is available to all patients requiring it.

    3. The orthopaedic community must work collaboratively and constructively with hospitals and other stakeholders to ensure that, in each community, all patients receive timely and appropriate care for urgent musculoskeletal conditions.

Education and Core Competencies

    1. The ABOS and the Accreditation Council for Graduate Medical Education’s Residency Review Committee should define core competencies for the care of urgent and emergent musculoskeletal conditions; delineate specific conditions that can be definitively managed; and propose methods for maintaining these core competencies. As part of this process, these organizations should consider the role of the community orthopaedic surgeon’s practical experience.

    2. The OIOM should support continuing data-driven efforts to better define minimal criteria for general musculoskeletal emergency care and community care of transfers.

    3. Continued evaluation of the community emergency musculoskeletal needs must be done to best define the core competencies and case mix. This evaluation will develop a basis for transfer criteria that will allow the appropriate management of the orthopaedic emergency department patient.

    4. The ABOS and orthopaedic training programs should assess the feasibility of developing a training program for an acute care orthopaedist.

Hospital Resources for Orthopaedic Emergency Care

    1. Hospitals should follow the recommendations of the American College of Surgeons (ACS) and Orthopaedic Trauma Association (OTA) to provide the necessary resources for the orthopaedist to provide surgical and nonsurgical care to their emergency patients.

    2. Hospitals should provide dedicated daily operating room time for the management of musculoskeletal emergency cases.

    3. Hospitals should make available the necessary surgical equipment and implants for the orthopaedist to provide appropriate care.

    4. Hospitals should provide qualified staff to assist in performing urgent musculoskeletal surgical cases.

    5. Hospitals should collaborate with local orthopaedic surgeons to develop an effective and viable orthopaedic emergency department call system.

    6. Hospitals and orthopaedic surgeons should work together to establish meaningful transfer agreements between institutions to ensure the best care for the patient and eliminate inappropriate referrals.

    7. Orthopaedic surgeons should meet the expectations for patient care outlined in the recommendations of the ACS, AAOS, and OTA.

Collaboration with other organizations

    1. The AOA should consider establishing a resource center for the orthopaedists to use to help in resolving this crisis.

    2. The AOA should work with other organizations, such as the American Hospital Association, AAOS, ACS, ABOS, and orthopaedic specialty societies, at state and congressional levels, to increase awareness and produce results that will further support community-based solutions to this crisis.

Reimbursement

    1. U.S. hospitals and leadership of professional organizations for orthopaedic surgery should collaboratively advocate for appropriate reimbursement for emergency musculoskeletal care for both orthopaedic surgeons and hospitals.

    2. Communities of hospitals and orthopaedic surgeons should work together to find an appropriate method to provide compensation (either monetary or in-kind) for orthopaedic surgeons covering on-call responsibilities.

    3. Advocacy efforts should continue for the development of some form of compensation (state and/or federal) for the care of patients sustaining catastrophic injury or illness.

    4. Physicians should understand, in advance, the scheme for state-level reimbursement for indigent care (if one exists) because this currently varies from state to state.

    5. Consideration should be given to modifying tax laws and other regulations that would allow physicians and hospitals to gain tax credits for the provision of urgent care.

Tort reform

    1. The orthopaedic community should continue to work with other affected specialties and state orthopaedic and medical associations to achieve tort reform at the state level.

    2. Insurers, legislators, hospital organizations, and physician organizations should step up efforts to propose, discuss, and enact meaningful tort reform at the federal level.

Third-party Payors

    1. Local hospitals should assess their need for high-quality emergency department coverage by specialty area. If there is a lack of such care secondary to financial problems, they should approach third-party payors to negotiate a cooperative solution to remedy this problem.

    2. Local physicians should involve themselves in this process so as to provide unbiased opinions and support for new reimbursement schemes.