Hand Surgery Transfers to Level 1 Center: Variables Affecting Transfer Method and Diagnostic Accuracy

BACKGROUND: We hypothesize that some costly patient transfers to a level 1 trauma center for hand specialist management may be unnecessary. This analysis evaluates transfer cost effectiveness and whether time of consult, transfer distance, diagnosis at time of transfer, and provider level influence diagnostic accuracy and transport method. METHODS: Two hundred and sixty-five patients transferred to a suburban level 1 trauma center for hand surgeon evaluation between 2014 and 2019 were evaluated for patient and injury characteristics, time of consult, transfer distance, provider level, transport method, treatment cost, and diagnostic accuracy. RESULTS: The average patient age was 36.2 years, and 80.3% were men. 21% of transfers had inaccurate pre-transfer diagnoses, and certain pre-transfer diagnoses correlated with an increased likelihood of inaccuracy, including flexor tenosynovitis and vascular injury. Patients with a language barrier had a greater likelihood of being transferred with an inaccurate diagnosis (P < 0.05). Compared with ground transport, air ambulance was associated with a higher cost of treatment ($225,679 versus $133,887, P < 0.00001). Of all transfers, 14 (5%) were discharged from the emergency department (ED) without a procedure, 9 (3%) were admitted for observation, 73 (27%) had an ED procedure before discharge, and 166 (62%) received operative management. CONCLUSIONS: Over 30% of transfers to a level 1 trauma center likely could have been managed at the transferring facility at a decreased cost. Certain diagnoses are associated with increased risk for diagnostic error and unnecessarily urgent transport. Providers can use this information to consider transfer patterns and to educate transferring providers.