Direct admission versus transfer to a tertiary hospital for definitive management of lower extremity injuries: Systematic review and meta-analysis.

BACKGROUND

Delays in definitive management for traumatic lower extremity injuries may result in morbidity. We compared patients with lower extremity injuries directly admitted to a tertiary hospital for definitive care with patients transferred to that hospital following initial treatment elsewhere.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were searched. Participants sustained lower extremity injuries, definitively treated at a tertiary hospital. Interventions were direct admission to a tertiary hospital for definitive care and patients transferred to that hospital for definitive care after initial management at another location. PRISMA, Cochrane, and grading of recommendations assessment, development and evaluation certainty-evidence guidelines were implemented.

RESULTS

Nineteen studies published from 1991 to 2020 compared 3,367 patients directly admitted with 1,046 patients transferred to a hospital for definitive management of lower extremity injuries. Direct admission to a tertiary center, compared with transfer, decreased time to first definitive surgical procedure (standard mean difference, -0.36; 95% confidence interval [CI], -0.57 to -0.16; p = 0.0006; participants, 788; studies, 6; I2 = 34%; high-certainty evidence) and wound infections (risk ratio [RR], 0.38; 95% CI, 0.19-0.77; p = 0.007; participants, 475; studies, 7; I2 = 27%; high-certainty evidence). Risks for diabetic patients (RR, 0.87; 95%CI, 0.77-0.98; p = 0.03; participants, 2,973; studies, 4; I2 = 0%; moderate-certainty evidence), total number of surgeries (standard mean difference, -0.69; 95% CI, -1.02 to -0.36; p < 0.0001; participants, 259; studies, 4; I2 = 35%; moderate-certainty evidence), osteomyelitis (RR, 0.47; 95% CI, 0.28-0.80; p = 0.006; participants, 212; studies, 2; I2 = 0%; moderate-certainty evidence), and total complications (RR, 0.47; 95% CI, 0.32-0.67; p < 0.0001; participants, 729; studies, 5; I2 = 32%; moderate-certainty evidence) are likely lower for direct admits compared with transfers. Direct admission may reduce risks for systemic infections (RR, 0.08; 95% CI, 0.01-0.51; p = 0.007; participants, 198; studies, 2; I2 = 0%; low-certainty evidence), venous thromboembolism (RR, 0.09; 95% CI, 0.01-0.73; p = 0.02; participants, 94; studies, 1; low-certainty evidence), and postoperative bleeding (RR, 0.74; 95% CI, 0.59-0.93; p = 0.01; participants, 2,725; studies, 3; I2 = 0%; low-certainty evidence), compared with transfer.

CONCLUSION

Earlier admission to a definitive tertiary center avoids morbidity associated with transfer delays.

LEVEL OF EVIDENCE

Systematic Review/meta-analysis, level III.