Fig. 1 Incidence of injuries where transfer requests were considered inappropriate and could have been cared for by a general orthopaedic surgeon at a community hospital
Source: Pilla N, et al., “Emergency Pediatric Orthopaedic Transfer Criteria: A Pilot Study.”

AAOS Now

Published 3/25/2022
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Ariel DeMaio

Emergency Pediatric Orthopaedic Transfer Criteria Are Needed

Nearly two-thirds of emergency pediatric orthopaedic transfers are avoidable, according to results of a pilot study by researchers at a level 1 pediatric trauma center. The fact that a large proportion of pediatric orthopaedic cases could be treated in a smaller facility suggests the need for established transfer criteria in this setting, noted the authors, led by Nicholas Pilla, MD, an orthopaedic surgeon at the Penn State Health Milton S. Hershey Medical Center. Dr. Pilla shared the findings at the AAOS 2022 Annual Meeting.

To help define criteria for the transfer of orthopaedic pediatric patients from a smaller facility to a level 1 pediatric trauma center, Penn State Health researchers launched a pilot study in which they prospectively collected and retrospectively reviewed transfer requests for appropriateness. Criteria were based on American Academy of Pediatrics guidelines and the expert opinion of the study authors.

Fig. 1 Incidence of injuries where transfer requests were considered inappropriate and could have been cared for by a general orthopaedic surgeon at a community hospital
Source: Pilla N, et al., “Emergency Pediatric Orthopaedic Transfer Criteria: A Pilot Study.”
Fig. 2 Incidence of injuries where transfer request were considered appropriate, requiring immediate higher level of care or subspecialization later in clinic
Source: Pilla N, et al., “Emergency Pediatric Orthopaedic Transfer Criteria: A Pilot Study.”

The American Academy of Pediatrics criteria for an appropriate orthopaedic transfer included complex fractures/dislocations and bone or joint infections. The expert opinion criteria for an appropriate orthopaedic transfer included a patient requiring admission to the hospital or a patient needing surgery.

Dr. Pilla and coauthors noted that all centers requesting transfers were staffed by an on-call, board-certified general orthopaedic surgeon with the ability to care for pediatric orthopaedic injuries.

Per the pilot study protocol, a 10-question phone survey was conducted for every transfer request received by the level 1 trauma center to determine appropriateness of the request. During the pilot study, a total of 58 transfers were received from 26 hospitals. Transfer requests most often came from ED physicians (n = 25; 43 percent), followed by physician assistants (n = 11; 19 percent), orthopaedic attending physicians (n = 3; 5 percent), and orthopaedic residents (n = 3; 5 percent).

Approximately two-thirds (n = 37/58) did not meet transfer criteria and could have been managed by a general orthopaedic surgeon at the referring center, according to the study authors. Details about the injuries that were considered inappropriate and appropriate are presented in Fig. 1 and Fig. 2. Of the 58 transfers, 18 patients (31 percent) required hospital admission, and 17 patients (29 percent) were indicated for surgery.

Notably, the orthopaedic surgeon at the referring hospital examined the patient prior to transfer in only six instances (10 percent). Dr. Pilla and coauthors suggested that many of the inappropriate orthopaedic transfers could have been avoided if the referring orthopaedic surgeon had evaluated the patients and if the orthopaedic surgeons had called the trauma center personally to request transfer.

The study will be on display as Poster P0708 on Friday in Academy Hall from 7 a.m. to 5 p.m.

Dr. Pilla’s coauthors of “Emergency Pediatric Orthopaedic Transfer Criteria: A Pilot Study” are Gregory S. Mowrer; Scott M. Sorenson, MD; Douglas G. Armstrong, MD; and William L. Hennrikus, MD.

Ariel DeMaio is managing editor of AAOS Now.