Assessment of Telemedicine and Phone Consultation Effects on Rate of Hand Transfers to Trauma Centers and Specialty Services Referrals

Introduction

Injuries involving the wrist, hand, and fingers are the most frequently injured body parts, accounting for 11.6% of all injury-related emergency department (ED) visits nationally. ¹ Unfortunately, 50% of EDs nationally report inadequate orthopedic coverage, and 80% report inadequate hand surgeon access.^2,3 Of the counties in Arkansas, 41% of the population live in a rural county and have reduced access to specialty care. ⁴ Many patients with traumatic hand injuries in Arkansas reach 1 of the 2 centrally located level 1 trauma centers only to be discharged from the ED with outpatient hand surgery follow-up. Previous studies have revealed similar trends with only 48% of hand trauma transfers requiring attending hand surgeon evaluation within 24 hours and only 39% requiring surgery within 24 hours, and at least 53% of transfers did not require emergent transfer to a level 1 trauma center.^5,6 Transfer of patients that could be managed locally or simply with outpatient follow-up unduly burdens patients, hospitals, and resources.

Telemedicine is one way to combat access inequality to health care and to decrease cost. ⁷ Due to the frequency of upper extremity injuries and lack of access to orthopedic or hand surgeons locally, telemedicine has been suggested nationally to increase access to subspecialty hand trauma care and to reduce the cost to patients and hospitals.^5,8 The Arkansas Hand Trauma Telemedicine Program (AHTTP) was created in 2014 in collaboration with the University of Arkansas for Medical Sciences Center for Distance Health and the Arkansas Trauma Communications Center (ATCC). This program provides around-the-clock real-time phone, video, and diagnostic imaging access to an on-call fellowship-trained hand surgeon available to all local EDs throughout the entire state. The first year of the program increased transferred patients’ admission from 47.8% in 2012 to 2013 (pre-AHTTP) to 68.2% in 2014 to 2015 (post-AHTTP) with a significance of P = .02 and decreased patient transfer costs of those discharged directly from the ED by 17.1% in the same time period, with a significance of P = .001. ⁹ On assessment of our first year data, we saw trends that suggested phone-only and live video both significantly decreased transfer rates. This article further investigates the significance of phone-only and live video hand trauma consultation on transfer rates and type of transfer (general orthopaedic surgeon or hand specialist).

Materials and Methods

Results

Live Video and Phone Effects on Rates of Transfer

In the first year of the program, 35% of the cases did not have telemedicine available for a variety of reasons. In these cases, the local provider was able to access the on-call hand surgeon by phone.

There were 298 telemedicine consultations performed using the AHTTP in 2014 with 195 (65%) using live video and 103 (35%) using phone-only consultation with all consults having access to digital imaging studies for review. Consults that used live video resulted in 91 patients (47%) transferred and 104 patients (53%) managed locally; for cases that used phone consults, 43 (42%) were transferred and 60 (58%) were managed locally (Figure 1). The use of live video when compared with phone consultation did not significantly affect the decision to transfer (P = .42).

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Figure 1.

Comparison of local management and transfers of hand traumas that used phone or live video consults. Transfers were not significantly affected by modality of consult (P = .42).

Live Video and Phone Effects on Type of Transfer

Ninety-one live video cases and 43 phone cases were transferred for specialty care. The types of transfer referrals for video consultation are 39 cases (43%) to orthopedics and 52 cases (57%) to hand surgery; for phone-only consultations, 23 cases (55%) were transferred to orthopedics and 20 (45%) to hand surgery (Figure 2). The use of video when compared with phone consultation did not significantly affect the type of transfer (P = .25).

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Figure 2.

Comparison of type of transfers, orthopedic or hand surgeon, that used live video or phone consultation: Transfer type was not significantly affected by the type of consultation: live video or phone with a P = .25.

Discussion

To provide quality care, we must increase access to specialty services and deliver care efficiently and cost-effectively. Implementation of quality care has multiple roadblocks including proximity of injured patients to appropriate care, available providers of specialty care, transportation availability, cost of care, and effective early determination of needs. Telemedicine is one way to increase the quality of the care delivered. The AHTTP addressed roadblocks to care by having fellowship-trained hand surgeons available for round-the-clock evaluation. This program more effectively determined the patients’ needs, leading to decreased patient transfers and decreased transportation cost for the patients. ¹⁰

In 2014, not all consultations were conducted with live video feeds. Phone-only consultations were performed due to technical issues with connectivity by the local or remote site, the surgeon being scrubbed into a case, and iPads not being fully charged. In addition, sometimes, it is clear to the on-call hand surgeon by the description of the injury that immediate transfer is necessary (i.e., multiple dysvascular digits or dysvascular limb, mangled extremity) or that simple outpatient follow-up is warranted (i.e., closed undisplaced finger or hand fracture). In these instances, phone-only consultation is felt to be accurate and more efficient. These observed trends led us to assess the differences in consultation modalities. Live video and phone-only consultation data showed no significant difference in either form of consultation regarding rates of transfer and type of transfer. When reviewing consultations, we concluded that the factors that led to more accurate transfers were the fellowship-trained hand surgeon consultation and the surgeon having access to the diagnostic imaging. Phone consultations may have been beneficial because the poles of the injury spectrum can be easily identified by a hand surgeon after simply reviewing imaging studies.

Live video and phone consultation increased patients’ access to specialty care and decreased cost to patients and hospitals. ¹⁰ The greatest contributing factor to correct assessment was consultation with fellowship-trained hand surgeon who had access to diagnostic images. This was highlighted by the fact that live video and phone rates were not significantly different in transfer rate or type of transfer. Limitations to this study include the effect of injury severity as it relates to the on-call surgeon choosing phone-only or live video consultation for evaluation of a case has not been assessed, and the data are limited to the Arkansas database.

In our previous work, we have documented the direct benefit of the establishment of this program in our state. During 2013 (pretelemedicine), there were 263 hand traumas identified. In all, 191 (73%) injuries required transfer to a higher level of care, while 72 (23%) were managed locally. In the first year of the telemedicine program (2014), a total of 331 hand injuries were identified. A total of 298 (90%) resulted in telemedicine consultation with 65% (195) using video encounters. After telemedicine consultation, local management was recommended for 164 injuries (55%), while transfer was recommended for 134 (45%). Using telemedicine, there was a significant decrease in the percentage of transfer for hand injuries (P < .001). ⁹

Also in our previous work, we have documented the direct decrease in cost both financially and in use of overall emergency care resources for patients with hands injuries. The number of patients who were discharged home directly from the ED at our tertiary care institution which receives more than 90% of the total hand injury transfers were assessed. Prior to the institution of AHTTP, 44 patients (47.8%) were discharged home after arriving at our ED, and the remaining 48 (52.2%) were admitted or underwent urgent surgical treatment. This is compared with post-AHTTP where only 35 patients (31.8%) were discharged directly home, and 75 patients (68.2%) were admitted or underwent surgical treatment, resulting in a significant difference (P = .02). Furthermore, 48% of presystem patients and 30% of postsystem patients were discharged directly from the ED to home/self-care, 13% of presystem and 21% of postsystem patients were admitted to the floor, and 29% of presystem and 40% of postsystem patients were taken to the operating room for surgical treatment. These data demonstrate a decrease in unnecessary emergent hand transfers with the implementation of the AHTTP system. The costs of transportation were also analyzed based on whether the patient was admitted or discharged home post-ED prior to and after the implementation of AHTTP. The approximate cost of transport for patients who were discharged home directly from the ED was 38.5% ($47 233) of the total transportation costs for the 2012 to 2013 period (pre-AHTTP) and was 21.4% ($34 017) of the costs for the 2014 to 2015 period (post-AHTTP), which is a significant difference (P < .0001). ¹⁰

Telemedicine is increasing health care access globally, but adoption of telemedicine is hindered by cost, availability of information technology (IT), and adapting to changes in telemedicine platforms. ¹¹ Regarding infrastructure cost, our data elucidate that 24-hour access to consultation with a fellowship-trained hand surgeon, whether by phone or live video, leads to fewer unnecessary transfers. Regions without telemedicine or secure IT infrastructure or those establishing telemedicine programs could improve access to care and reduce cost by establishing 24-hour on-call surgical phone consultation programs with secure access to diagnostic imaging allowing fellowship-trained hand surgeons to help better triage and determine disposition of patients with traumatic hand injuries. These programs could be stand-alone programs or the beginning of the establishment of a telemedicine program. In a 2016 review of hand trauma in the United States, it was concluded that the largest barrier to adequate specialty care of hand trauma was access or consultation with a fellowship-trained hand surgeon. ¹² With our novel establishment of the AHTTP, its proven effectiveness at assessing patients, reducing unnecessary transfer, and our new data that show that phone and live video consultations led to effective patient care, we conclude that round-the-clock access to hand surgeon consultation is the biggest component of delivering quality care. In addition, exploring options for telemedicine evaluation and care of other hand problems and injuries in outpatient care settings other than the ED where there is no availability of fellowship-trained hand surgeons but there are established general care providers to work with would be beneficial.