Many hospitals lack specialists for hand, face emergencies

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In an emergency involving face or hand trauma, barely one in four hospitals can muster a specialist surgeon, a recent U.S. study suggests.

In a survey of hospitals in New York State, excluding those in New York City, researchers found that only 27% had hand surgeons available or on call for emergency hand procedures and 29% had plastic surgeons available for facial emergencies.

“Although more people have insurance now, it doesn’t guarantee access, especially in areas with geographic barriers,” said senior study author Dr. Ashit Patel, the chief of plastic surgery at Albany Medical College.

In his practice in Albany, for example, patients are often drawn from 20 counties in New York, as well as Connecticut, Massachusetts, Vermont and Canada, Patel noted.

“Nearly every small town has a small hospital, and these hospitals deliver elective care, but there’s not anyone available 24/7 for emergencies,” he told Reuters Health in a phone interview.

Some 40 million injuries are treated in U.S. emergency departments annually, the study authors write online October 1 in the Annals of Plastic Surgery, and facial and hand traumas make up more than 20% of these injuries.

If they are not treated by a specialist surgeon, or if treatment is delayed in order to transfer a patient to a facility where a specialist is available, these injuries can have poorer outcomes and ultimately higher costs, the study team writes.

To see how often New York patients do have access to these specialists in emergency situations, Patel and colleagues surveyed 52 hospitals throughout the state. They asked about available elective hand surgeries – which are scheduled in advance – such as carpal tunnel release, finger fracture reduction and microsurgery, and elective facial procedures like deviated septum surgery, eyelid surgery and nose surgery.

They also asked whether surgeons who had at least done fellowship-level training in these specialties were available on site or on call for emergency cases.

The researchers found that access to these surgeons in New York State is fairly good for elective procedures: 88% of the hospitals surveyed offered specialist hand surgeries and 79% offered facial surgery.

Increasing the number of specialists who are on call for emergencies could decrease the need for transfer of minor traumas, which would reduce trauma center costs and reduce burden on hub hospitals, the study authors conclude.

“There is benefit in regionalization of care for complex trauma, and there is always going to be a role for this type of concentration of patients with devastating injuries,” said Dr. Megan Patterson, a professor of orthopedic surgery at the University of North Carolina at Chapel Hill School of Medicine, who wasn’t involved in the study.

“It’s the care of the less complex injuries that could be improved upon,” she told Reuters Health by email. “It’s not just that the patient is transferred . . . but they will then be required to come back for follow-up visits, which can be a significant burden to the patient and their families.”

Telemedicine approaches such as phone consultations, digital X-ray review and email connection to a specialist could help manage patients, she said.

“Access is only going to continue to be more challenging as reimbursement rates drop and smaller rural hospitals close,” Patterson said.

“Medicaid patients who live (on) up to 138% of the poverty line don’t have the resources to travel distances for the right care,” Patel said. “They’re choosing between feeding their children and paying for gas.”

Talking to state legislators about the data is key, too, Patel said. He’s spoken with members of both parties and found similar studies in states such as Tennessee and New Jersey that show a discrepancy in specialist access for trauma.

“It’s impractical to say that the one specialist should be on call all day, every day, so we have to look at how insurance and Medicaid can change,” he added.

“Many residents in these smaller communities may not realize how narrow their insurance networks are,” Patel noted. “Buyer beware about the insurance you have. Do your homework.”