Misra Shantum, Wilkens Suzanne C, Chen Neal C, Eberlin Kyle R
George Washington University School of Medicine and Health Sciences, Washington, DC.
Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
J Hand Surg Am. 2017 Dec;42(12):987-995. doi: 10.1016/j.jhsa.2017.08.006. Epub 2017 Sep 21.
Level-I trauma centers are required to provide hand and microsurgery capability at all times. We examined transfers to our center to better understand distant patient referrals and, indirectly, study referrals in our region.
Records were reviewed from 2010 to 2015 to evaluate patients transferred to our level-I institution for upper extremity amputation. Patients were referred from 6 states to our institution over this period. We measured the straight-line distance from each patient's transferring facility to our facility and compared this distance with the straight-line distances from the zip code of the transferring facility to the zip code of each level-I trauma center.
We had data for 250 transferred patients (91% male, 9% female). For 110 patients (44%), our hospital was the nearest level-I trauma center; however, for the remaining 140 patients (56%), other level-I trauma facilities were located closer to the referring hospital. Among these 140 patients, the mean distance of the referring facility to the nearest level-I trauma center (30 miles; SD, 27) was significantly different from the mean distance of the referring facility to our facility (71 miles; SD, 60). A median of 4 (range, 1-10) level-I trauma centers were bypassed before patients arrived at our center. Medicaid and "self-pay" patients were more likely to be transferred to our facility.
Fifty-six percent of patients transferred to our hospital for upper extremity amputation had a level-I trauma center closer to their injury. Patients with upper extremity amputation are referred to our regional center despite the proximity of closer level-I trauma centers. This suggests that regional microsurgery expertise does not correlate with level-I trauma designation, and establishment of designated microsurgery centers and formal referral guidelines may be beneficial for management of these difficult injuries.
We believe that this study further supports the need for formal designation of regional centers of expertise for microsurgical hand trauma.
一级创伤中心必须随时具备手部和显微外科手术能力。我们对转诊至我院的患者进行了调查，以更好地了解远距离患者转诊情况，并间接研究本地区的转诊情况。
回顾2010年至2015年期间的记录，评估转诊至我院接受上肢截肢手术的患者。在此期间，患者来自6个州。我们测量了每位患者转诊机构到我院的直线距离，并将此距离与转诊机构邮政编码到各一级创伤中心邮政编码的直线距离进行比较。
我们有250例转诊患者的数据（男性91%，女性9%）。对于110例患者（44%），我院是最近的一级创伤中心；然而，对于其余140例患者（56%），其他一级创伤机构距离转诊医院更近。在这140例患者中，转诊机构到最近一级创伤中心的平均距离（30英里；标准差27）与转诊机构到我院的平均距离（71英里；标准差60）有显著差异。患者到达我院之前，平均绕过了4个（范围1 - 10个）一级创伤中心。医疗补助患者和“自费”患者更有可能被转诊至我院。
转诊至我院接受上肢截肢手术的患者中有56%附近有更近的一级创伤中心。尽管附近有更近的一级创伤中心，但上肢截肢患者仍被转诊至我们的区域中心。这表明区域显微外科专业知识与一级创伤指定无关，设立指定的显微外科中心和正式的转诊指南可能有助于处理这些复杂损伤。
我们认为这项研究进一步支持了正式指定手部显微创伤区域专业中心的必要性。
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