Abstract
Background:
Inconsistent availability of subspecialty hand and microvascular emergency call services could influence patient outcomes and the efficiency of a system dependent on limited resources and timely intervention because declining reimbursements, increased medicolegal risk, lack of confidence in microsurgical skills, and the disruption of elective schedules present a deterrent to call panel participation. This study assessed the availability of hand and microvascular replantation surgery call services at all level-I and level-II trauma centers in the United States.
Methods:
Between May and December 2010, all level-I (N = 137) and level-II (N = 153) trauma centers across the U.S. were contacted by telephone. Phone contact was unannounced; responders were invited to participate in our institutional review board-approved anonymous survey regarding hand and microvascular replantation emergency coverage specific to their hospital.
Results:
Level-I trauma centers: 117 (85%) of 137 participated, and sixty-four (55%) of these had immediate access for hand surgery and microvascular replantation services. Six hospitals provided services for fifteen to thirty-one days per month, and three hospitals supported services for one to fifteen days per month. Ten hospitals indicated inconsistent coverage, which was difficult to estimate, and thirty-four hospitals reported no coverage. Level-II trauma centers: 132 (86%) of 153 participated, and thirty-eight (29%) of these had immediate access for hand surgery and microvascular replantation services. Seven hospitals provided services for fifteen to thirty-one days per month, and three hospitals provided coverage for one to fifteen days per month. Eighty-four hospitals reported no specific coverage protocol.
Conclusions:
Inconsistency in the definition and coverage of emergency hand and microvascular replantation services was identified at level-I and level-II trauma centers across the U.S. Many hospitals indicated the presence of subspecialty hand surgery coverage; however, the determination of microvascular replantation resources was not available consistently. The results of our study strengthen previous conclusions about the need for a more defined and coordinated system of emergency microvascular replantation surgery services in order to improve the efficiency of a limited resource and, ultimately, improve patient care.
Inconsistency in the definition and coverage of hand surgery and microvascular replantation call services at level-I trauma centers across the United States has been identified1-5. A task force recently was established by the American Society for Surgery of the Hand (ASSH) to explore this challenging issue. Current guidelines for level-I accreditation by the American College of Surgeons (ACS) stipulate that “hand surgery…capabilities are present at Level I trauma centers.”6,7 However, the policy does not specify a requirement for microvascular replantation services, and there is little consensus as to whether this technical skill must be provided as a component of hand surgery call coverage.
In 2007, a survey of the ASSH membership reported that incomplete participation in hand surgery and microvascular replantation call panels was a result of several factors, including busy elective schedules, declining reimbursements, inadequate confidence in performing the replantation, and poor clinical results4. The survey was completed by 561 of the 1238 members of the ASSH at that time, representing a 45% participation rate. Almost 30% of respondents did not take emergency hand call, and 44% did not perform replantation surgery or revascularization procedures. Of those who did perform replantations, 196 (62%) of 316 did less than five replantations per year. Many surgeons in level-I trauma centers believed that there was a need for additional local or regional call coverage, such as from level-II and community centers, to decrease the call burden often assumed by level-I or academic trauma centers4.
While this survey-based study demonstrated the potential difficulty of establishing consistent hand surgery call coverage, particularly microvascular replantation services, within a region or within an individual hospital call panel, the scope of the problem has not been confirmed. There may be an inherent bias associated with self-reporting one’s participation on a surgical call panel: survey participants may overestimate their caseload or may provide coverage for more than one institution while on call. Therefore, previous assessments of hand surgery and replantation call participation may overestimate participation in the on-call system.
Based on the relatively low participation rate in the ASSH survey and a lack of documentation regarding the consistency of hand surgery and/or microvascular replantation call coverage both within a trauma system and within individual institutions, we designed a study to evaluate the real-time availability of hand surgery and microvascular replantation call coverage at all ACS-accredited level-I and level-II trauma centers with use of a phone survey to communicate directly with the emergency room physician or charge nurse. We believed that this methodology would improve the study participation rate and reduce a perceived self-reporting bias by the hand surgeon, therefore permitting a more accurate assessment of hand surgery and microvascular replantation call coverage in regional trauma centers across the U.S.
Between May and December 2010, the emergency room attending physician or charge nurse of all ACS-accredited level-I (N = 137) and level-II (N = 153) trauma centers across the U.S. were contacted by telephone by the study authors. Centers were identified through the ACS trauma systems database.8 Phone contact was unannounced; responders were invited to participate in our institutional review board-approved anonymous survey regarding hand and microvascular replantation emergency coverage specific to their hospital. A standardized script (Telephone Survey Script; see Appendix) was reviewed with the responder, which included queries regarding the availability of a hand and microvascular replantation surgeon at that moment and regarding the number of days and nights covered during the course of the month. Up to three phone calls with personal contact were made to a hospital before it was deemed “unwilling to participate.”
Source of Funding
There was no external source of funding for this study.
All 290 ACS-verified level-I and level-II trauma centers in the U.S. were contacted by the study authors; 249 (86%) were willing to participate. When considering both level-I and level-II centers, hand surgery and microvascular replantation call coverage (twenty-four hours/day, seven days/week) was provided by ninety-three (37%) of 249 institutions.
ACS Level-I Trauma Centers
All 137 ACS-verified level-I trauma centers in the U.S. were contacted. Twenty of these institutions were unwilling to participate, generally because of time limitations of the responding emergency department physician or because of institutional or personal preference regarding participation in surveys and/or phone studies. Therefore, 117 (85%) of 137 centers participated and formed the basis for the level-I trauma center data. At the time of institutional contact, sixty-four (55%) level-I trauma centers definitively had a surgeon on call who would accept a patient for the appropriate indications of hand or finger replantation. Ten emergency room physicians were unsure if they had a surgeon willing to accept such a transfer at the time of contact: in some cases, the responder noted that there was a hand surgeon on call, but he or she was unsure if patients with an isolated injury involving single or multiple digit amputations would be accepted for consideration of replantation. In some institutions, replantations were accepted intermittently: acceptance was determined by the hand surgeon who was on call at the time. One physician asserted that the center would accept isolated finger amputations for replantation, but a more proximal level replantation candidate would not be accepted.
Fifty-five institutions had full-time (twenty-four hours/day, seven days/week) coverage available for hand surgery and replantation. Four level-I centers had coverage 50% of the time, and two institutions had coverage for nineteen of thirty days per month. One institution had coverage for ten of thirty days monthly, and two institutions limited their coverage to two or three days per month. Two institutions were willing to accept replantations on a case-by-case basis.
Overall, in this sampling of participating level-I institutions, 47% (fifty-five of 117) provide continuous microsurgical replantation services, and 56% (sixty-six of 117) offer such services at some point defined by a monthly schedule.
ACS Level-II Trauma Centers
All 153 ACS-certified level-II trauma centers in the U.S. were contacted. Twenty-one centers refused to participate because of time limitations of the responding physician or because of personal or institutional preference not to participate in the study. When the emergency room physician was the responder, there was 100% participation. In all, 132 (86%) of 153 centers participated and formed the basis for the level-II trauma center data. At the time of institutional contact, forty-seven (36%) level-II trauma centers definitively had a surgeon on call who would accept a patient requiring a digital replantation. Six emergency room physicians did not know at the time of the survey and/or did not have ready access to determine whether the institution had a surgeon willing to accept such a transfer.
Thirty-eight (29%) of the level-II institutions had full-time (twenty-four hours/day, seven days/week) coverage available for replantation, although in one case there was a single hand surgeon available for microvascular replantation services who would cover at all times except during his vacation. One institution claimed to have coverage “most of the time” but could not provide a defined call schedule. Another center indicated that it had full-time hand surgery call coverage, but replantation coverage was surgeon-dependent. One institution could perform replantation 80% of the time, while two others had coverage for 50% of every month. Two institutions reported coverage for twenty of thirty days per month; one of these could provide replantation services but usually sent them to another institution. Also, this center claimed to be a level-I trauma center despite being listed by the ACS as a level-II institution. One center had coverage for ten of thirty days per month, while another provided microvascular replantation coverage on fewer than five days of the month. One institution had a hand surgeon that selectively took call and performed finger replantation on a case-by-case basis. Several institutions reiterated that they had hand surgery call coverage; however, they were not aware if replantation candidates would be accepted for transfer to their facility and noted that replantation candidates typically were diverted to another hospital. For level-II centers, 36% had hand surgery and microvascular replantation call coverage at least at some point during the month, while only 29% had definitive and continuous coverage.
Inconsistent availability of subspecialty hand and microvascular replantation emergency call services has the potential to influence patient outcomes and the efficiency of a system that is dependent on limited resources and timely intervention because declining reimbursements, increased medicolegal risk, lack of confidence in microsurgical skills, and the disruption of elective schedules present a deterrent to call panel participation4. Hand surgery trauma call encompasses a wide spectrum of responsibility, often involving osseous injury distal to and including the carpus as well as soft-tissue injury distal to the elbow, and is considered in conjunction with the emergency responsibilities of the general orthopaedic, plastic surgery, and vascular surgery services. Often, these determinations of call responsibility are made locally at the hospital administration and department levels, although typically they are created to comply with the ACS Committee on Trauma (COT) guidelines, particularly for level-I and level-II trauma centers6,7. Recently, several studies have evaluated the availability of emergency call coverage for hand surgery and have identified the decreasing numbers of hand surgeons who provide concurrent microvascular replantation coverage for the treatment of digital or upper limb amputations1,2,4,5. A recent survey of the ASSH membership in 2007, unfortunately limited by a 45% participation rate, reported that 29% of respondents do not take emergency hand surgery call and 40% do not provide microvascular replantation services4. While a decrease in the number of surgeons and/or institutions that provide emergency call services does not correlate necessarily to a worsening of patient outcomes, it does support the role of a coordinated system of care that defines the expectations of hand and/or microsurgical replantation call coverage and considers the designation of “Centers of Excellence.” Such a system could minimize the risk of adverse outcomes that might be associated with a delay in care from prolonged patient acceptance and transfer times9.
In their ASSH survey, Payatakes et al. found that 74% of surgeons perceived a decrease in replantations performed over the past decade, and 79% believed that microvascular replantation was performed predominantly at ACS level-I trauma centers4. They noted that of those respondents (56%) who performed microvascular replantation, 62% performed less than three replantation procedures per year. In a study of the national database from the Agency for Health Care Policy and Research, Chung et al. reported that of the 906 hospitals sampled, only 136 performed finger replantation. Importantly, of those 136, 60% performed only one procedure, and only 2% performed ten or more cases2. Several conditions may have supported a diminished volume of replantation candidates, including more stringent indications for surgical replantation, patient preference to limit surgical treatment to revision amputation because of employment and social pressures to return to activity more quickly, and improved occupational safety mechanisms that have resulted in fewer amputation injuries in the workplace2. The number of digital replantations performed annually declined in the state of Florida between 1997 and 2007, where 6% of the hospitals performed 68% of its replantation procedures5. This same study observed an increasing proportion of patients who were admitted and treated outside their county of residence for both revision amputations and replantations, suggesting a relatively high rate of patient transfer during triage. Several authors have asserted that much of the replantation capacity in the U.S. is underserved by level-I trauma centers and that there is a need to increase local and regional coverage of microvascular replantation to lessen the burden on these institutions1-5. However, based on the small number of replantations performed by a majority of individual surgeons in the study by Chung et al.2, the centralization or regionalization of resources to manage these complex injuries should be considered in light of the reported association between increased surgical volume and improved patient outcomes10.
Our finding that only 36% of ACS level-II trauma centers had coverage for microvascular replantation supports previous observations reported in the literature. Chung et al. described diminishing coverage at level-II centers, citing decreasing reimbursement as a cause2. Chen and Narayan documented an 80% decrease in the number of replantations being performed at secondary centers from 1992 to 2002, noting that 11% of the replantations were being performed at level-II centers, whereas ten years prior, slightly more than 50% of replantations occurred at level-II centers11. While our current study did not quantify the number of digital replantations performed at level-I or level-II trauma centers, it examined the availability of level-I and level-II centers to provide microvascular replantation services.
Patients with acute amputations who are triaged without an evaluation by a surgeon familiar with the indications for replantation may experience less than optimal outcomes for several reasons. In the absence of technical expertise for replantation and because of the inherent bias of the surgeon, a revision amputation may be the only option presented to a patient despite the potential for microsurgical replantation. In addition, transfer to a higher level of care for definitive management has been demonstrated to add hours to a complex procedure where tissue ischemia time influences ultimate outcome. Ozer et al. reported a mean time of transport of 5.15 hours (range, one to twenty-four hours) for patients transferred for possible digital replantation9, and Menchine and Baraff reported that 40% or more of orthopaedic or plastic surgery transfers to a higher level of care took over three hours12. Also, inadequate evaluation, triage, and patient education can increase the cost of medical care with the inappropriate use of expensive medical transportation, such as air transport, when transferring a patient to a higher level of care9. Therefore, in the absence of resources capable of providing definitive treatment, a system providing appropriate triage and experienced care in replantation may improve ultimate outcomes10.
Our study presents a unique trauma system survey whereby the survey participants were members of the emergency room staff and representatives of the trauma centers, not the subspecialty surgeons themselves. This methodology may have reduced a perceived self-reporting bias and improved survey participation. Our study participation rate exceeded previous surveys of hand surgery call systems and the average participation rate of approximately 55% to 60% observed in many surveys done by mail that have been reported in the medical literature4,13. Also, the survey was administered in part as a “real-time” survey so that the respondents were not adversely influenced by recall bias. Importantly, our findings confirmed a lack of consistent hand and microvascular replantation call coverage at both level-I and level-II trauma centers across the U.S.; only 55% of level-I and 36% of level-II participating centers had resources available at all times to support microvascular digital replantation surgery. This inconsistency was noted not only within a region, but also within an institution’s call panel. Many institutions provided intermittent microvascular replantation call coverage whereby the center’s availability was guided by the number of qualified hand surgeons covering the hand surgery call schedule, by the preference of the individual surgeon taking call, and by a case-by-case review. There was a trend of uncertainty, although not tested for significance, as to whether hand surgery call included microvascular replantation surgery. This reflects the ambiguity in the current ACS guidelines for level-I accreditation, which stipulates that the requirement for “hand surgery…capabilities are present” but does not specify such a requirement for microvascular or replantation coverage6. Current guidelines for level-II trauma designation do not include specific recommendations for hand surgery resources. Based on this lack of consensus, recently approved changes in the ACS COT guidelines have attempted to clarify hand surgery call policy to make “microvascular capability for revascularization and replantation available at level-I centers 24/7/365 or have a transfer agreement in place to another institution.”14
The limitations of our study are similar to studies that use a survey to gather information: some respondents may not be adequately informed to justify their participation or may be overprotective of the hospital’s triage status, thereby giving false information to the surveyor. Additionally, the introduction of our study by the surveyor, with use of the phrase “the growing national concern regarding a lack of availability for emergency hand replantation and microsurgery call” might bias the response of a study participant. The timing of the telephone calls to specific emergency department staffing or shifts was not standardized, which could represent an uncontrolled covariable because the availability of services might be influenced by the day of the week and/or the time of day. We attempted to minimize the impact of this potential influence by requesting information about the on-call availability over the course of a calendar month. If the trauma center did have a hand surgery call roster, it was unclear on several occasions as to whether this represented microvascular replantation call coverage; in many instances, clarification of this distinction was required. We recognize that the number of trauma centers providing emergency microvascular replantation services will be overestimated, as it is not uncommon for one hand surgeon to be providing emergency call coverage for more than one hospital at a time; this replication of service may impact a region’s actual capacity to provide such services. Despite multiple telephone calls during different staffing shifts, we were unable to achieve a 100% participation rate; however, we did achieve an 86% participation rate. This participation rate is an improvement compared with similar studies assessing subspecialty emergency call4 and compared with rates of participation in similar surveys reported in the medical literature13. While it cannot be completely excluded, our methodology minimized the risk of nonresponder bias influencing the study results since the queried participants were not reporting data directly related to their practice.
In conclusion, the results of our study strengthen previous conclusions regarding the need for a more defined and coordinated system of emergency microvascular replantation surgery services to improve the efficiency of a limited resource and, ultimately, improve patient care.
Telephone Survey Script
“Hello, my name is Dr. [blinded] and I am a hand surgeon at [blinded] and a member of the American Society for Surgery of the Hand. We are conducting an anonymous and very brief study to assess the growing national concern regarding a lack of availability for emergency hand replantation and microsurgery call. The results of this nationwide study will provide a better understanding of our current call model and potentially provide useful information regarding the improvement of regional hand trauma systems. No physician names or hospital names will be recorded by this study.”
“Would you be willing to answer one or two simple questions regarding the status of your hand surgery on-call availability?”
____ Yes ____ No
If no and the subject is not willing to participate in the survey:
“Thank you for your time. Goodbye.”
If yes:
“Does your hospital have a hand surgery call schedule?”
____ Yes ____ No
“How many days in the current month is your hospital covered/not covered for hand surgery call (if known)? Please review your call schedule if available.”
____ covered ____ not covered
# days/month coverage ____
“Could you tell me if your trauma center has a hand surgeon on call and willing to accept a hand or finger replantation at this moment?”
____ Yes ____ No
“How many days in the current month is your hospital covered/not covered for hand microsurgical replantation (if known)? Please review your call schedule if available.”
____ covered ____ not covered
# days/month coverage ____
At survey completion:
“Thank you, again, for your cooperation with our study and for your time in answering my questions.”
Note: The authors thank Dr. L. Scott Levin for his time and effort in providing information pertinent to our study regarding the current ACS COT position statement on microvascular replantation call services and trauma level designation.
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.