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Disproportionate Availability Between Emergency and Elective Hand Coverage: A National Trend?

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      Abstract

      Background: Traumatic hand injuries represent approximately 20% of emergency department visits; yet, access to emergency care remains inadequate. Recent surveys from several states report a wider availability of hand specialists providing elective care than emergency care. The authors aim to examine this phenomenon in the state of New Jersey and whether there is a national trend toward disproportionate availability between emergency and elective hand coverage. Methods: A survey was conducted of all New Jersey hospitals, excepting university hospitals, in August 2014. To assess the availability of hand surgery coverage, the following questions were asked: (1) Does your hospital provide elective hand surgery? and (2) Is there a hand specialist/surgeon on call always, sometimes, or never? Results: A total of 58 hospitals were called, with a 67.2% response rate ( n = 39). The majority (87.2%) of hospitals offered elective hand surgery, whereas only 64.1% provided immediate 24/7 hand coverage. Only 38.5% of hospitals located in the same county as a level I trauma center provided 24/7 emergency hand care, whereas 76.9% of hospitals in counties without any level I trauma center did ( P < .05). Cities with a higher poverty level were less likely to provide emergency coverage than cities with a lower poverty level (47.4% vs 80.0%; P < .05). Conclusions: There is a discrepancy between emergency and elective hand care in New Jersey. Similar findings across the nation suggest a concerning trend of limited access to emergency hand health care. Alternative systems that can appropriately triage and treat patients are warranted.

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      Most cited references 24

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      National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary.

      This report presents the most current (2005) nationally representative data on visits to hospital emergency departments (ED) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1995 through 2005 are also presented. Data are from the 2005 National Hospital Ambulatory Medical Care Survey (NHAMCS), the longest continuously running nationally representative survey of hospital ED and outpatient department (OPD) utilization. The NHAMCS collects data on visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. During 2005, an estimated 115.3 million visits were made to hospital EDs, about 39.6 visits per 100 persons. This represents on average roughly 30,000 visits per ED in 2005, a 31 percent increase over 1995 (23,000). Visit rates have shown an increasing trend since 1995 for persons 22-49 years of age, 50-64 years of age, and 65 years of age and over. In 2005, about 0.5 million (0.4 percent) of visits were made by homeless individuals. Nearly 18 million patients arrived by ambulance (15.5 percent). At 1.9 percent of visits, the patient had been discharged from the hospital within the previous 7 days. Abdominal pain, chest pain, fever, and cough were the leading patient complaints, accounting for nearly one-fifth of all visits. Abdominal pain was the leading illness-related diagnosis at ED visits. There were an estimated 41.9 million injury-related visits or 14.4 visits per 100 persons. Diagnostic and screening services were provided at 71.1 percent of visits, and procedures were performed at 47.3 percent of visits. Medications were either given in the ED or prescribed at discharge at 76.7 percent of visits, resulting in 204.9 million drug mentions. On average, patients spent 56.3 minutes waiting to see a physician, and 3.3 hours for the full duration of their ED visit. About 12 percent of ED visits resulted in hospital admission. The average total length of stay for those admitted was 5.2 days, and the leading principal hospital discharge diagnosis was nonischemic heart disease.
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        Frequent overcrowding in U.S. emergency departments.

        To describe the definition, extent, and factors associated with overcrowding in emergency departments (EDs) in the United States as perceived by ED directors. Surveys were mailed to a random sample of EDs in all 50 states. Questions included ED census, frequency, impact, and determination of overcrowding. Respondents were asked to rank perceived causes using a five-point Likert scale. Of 836 directors surveyed, 575 (69%) responded, and 525 (91%) reported overcrowding as a problem. Common definitions of overcrowding (>70%) included: patients in hallways, all ED beds occupied, full waiting rooms >6 hours/day, and acutely ill patients who wait >60 minutes to see a physician. Overcrowding situations were similar in academic EDs (94%) and private hospital EDs (91%). Emergency departments serving populations < or =250,000 had less severe overcrowding (87%) than EDs serving larger areas (96%). Overcrowding occurred most often several times per week (53%), but 39% of EDs reported daily overcrowding. On a 1-5 scale (+/-SD), causes of overcrowding included high patient acuity (4.3 +/- 0.9), hospital bed shortage (4.2 +/- 1.1), high ED patient volume (3.8 +/- 1.2), radiology and lab delays (3.3 +/- 1.2), and insufficient ED space (3.3 +/- 1.3). Thirty-three percent reported that a few patients had actual poor outcomes as a result of overcrowding. Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings. Its causes are complex and multifactorial.
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          Are patients being transferred to level-I trauma centers for reasons other than medical necessity?

          In the United States, the Emergency Medical Treatment and Active Labor Act defines broad guidelines regarding interhospital transfer of patients who have sought care in the emergency department. However, patient transfers for nonmedical reasons are still considered a common practice. The purpose of this study was to evaluate the possible risk factors for hospital transfer in a population of patients unlikely to require transfer to a level-I center for medical reasons. A retrospective case-control national database study was performed with use of data from the National Trauma Data Bank (version 4.3). The study group consisted of patients with low Injury Severity Scores (< or =9) who were transferred to a level-I trauma center from another hospital. The controls were patients with low Injury Severity Scores who were treated at any hospital that was lower than a level-I trauma center and were not transferred. Hypothesized risk factors for hospital transfer were the age, gender, race, and insurance status of the patient; the time of day the transfer was received; and the number and type of comorbidities. The total sample included 97,393 patients, 21% of whom were transferred to a level-I trauma center. The odds ratios adjusted for all risk factors indicated that transfer rates were higher for male patients compared with female patients (adjusted odds ratio = 1.46), children compared with seniors (3.54), blacks compared with whites (1.28), evening or night transfers compared with morning or afternoon transfers (2.25), patients with Medicaid compared with those with other types of insurance (2.02), and for those with one or more comorbidities compared with those with no comorbidity (2.79). These results suggest the need for prospective studies to further investigate the relationships between hospital transfer and medical and nonmedical factors.
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            Author and article information

            Affiliations
            Division of Plastic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark
            Author notes
            Journal
            Eplasty
            Eplasty
            ePlasty
            Eplasty
            Open Science Company, LLC
            1937-5719
            2016
            9 September 2016
            : 16
            5021704
            28
            Copyright © 2016 The Author(s)

            This is an open-access article whereby the authors retain copyright of the work. The article is distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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