Isolated Orthopedic Transfers to Bellevue Medical Center Requiring Joint Replacement

Purpose:

·         To Identify which patients can appropriately be transferred to Bellevue Medical Center (BMC) who have sustained an isolated fractures requiring total or partial joint replacement

Background/definitions:

·         Lack of OR availability at Nebraska Medicine main campus for partial or total joint replacement in trauma patients has put a strain on the system and delayed definitive surgical treatment for these patients. 

Guideline Inclusion Criteria:

• Isolated traumatic fracture patients only needing partial or total joint replacement for their injury as opposed to ORIF of the hip fracture alone.
• Deemed appropriate for transfer to Bellevue Medical Center by the Trauma Service.

Guideline Exclusion Criteria:

• Poly-trauma patients with fractures requiring total or partial joint replacement.
• Deemed inappropriate for transfer to Bellevue Medical Center by the Trauma Team or Orthopedic Surgery Team.

Diagnostic Evaluation:

• Routine trauma lab work.
• Body region  X-ray and/or CT scan
• Pan scan CT as indicated by mechanism or provider discretion
• Trauma Team consultation to make sure trauma work up is complete and no other injuries are present.
• Orthopedic Surgery consultation to make sure patient needs total or partial joint replacement (as opposed to non-operative management or routine ORIF of the fracture) and is appropriate for transfer to expidite surgical repair. 

Practice Recommendations for Management:

• Patients transferred in from an outside institution will be directed to Nebraska Medicine ED (ER→ER).  Trauma Team will do the initial trauma evaluation and work-up in the emergency department.
  • • If a fracture is identified along with other injuries, Orthopedic Surgery will be consulted as well as other consulting services as needed
      • • Patient will be admitted to Nebraska Medical Center (NMC) by the Trauma Service for further trauma management as deemed appropriate.  
    • If an isolated fracture is identified, Orthopedic Surgery will be consulted for their recommendations

1. If patient requires fixation via a partial or total joint replacement, is deemed appropriate for transfer to Bellevue Medical Center (BMC) by the Trauma Service, and has an accepting physician, the patient will then be transferred to BMC from the NMC ED for further isolated fracture management.  BMC hospitalist is the accepting primary service for BMC transfer and ensures appropriate medical resources are in place for patient to be cared for at BMC. (Example- If patient has a hip fracture but is ESRD on dialysis, patient stays at NMC)
   1. •  Transfer to BMC will be arranged by the Orthopedic Surgery resident by contacting the PPU (aka BMC bed desk, 402-559-2337) and requesting transfer to the BMC hospitalist service.
      • PPU informs Ortho resident of approximate inpatient BMC bed wait time.
      • If there is an inpatient bed wait time at BMC, patient is sent to BMC Pre-Op as long as a same day BMC OR time can be assigned.  If BMC OR time cannot be assigned the same day, patient is prioritized to BMC inpatient bed with all BMC ED admissions, the purpose of this prioritization is to transfer patient out of NMC ED expeditiously.
      • No admission orders are placed to admit the patient to NMC.  While the patient awaits transfer to BMC in the NMC ED, Trauma service continues to care for the patient.
2. If Orthopedic Surgery resident determines patient would be more expeditiously cared for at main campus due to BMC bed wait
   1. • Trauma service is contacted again and admits the patient.
      • Trauma or Ortho provider contacts HM surgical co-mgmt service for pre-op evaluation and medical co-mgmt.
3. If prolonged inpatient bed wait at both BMC and NMC campuses, On-Call Trauma attending and On-Call Orthopedic attending (& if needed BMC hospitalists for medical needs) determine whether it is best to transfer to BMC versus admit to NMC.  PPU can help coordinate the conference call on the rare chance that all 3 physicians are needed to determine best location.  Once location is determined, follow steps outlined above in A. to transfer to BMC or B. if admitting to NMC.

• The trauma tertiary survey will be completed by Orthopedic resident at BMC 24 hours after initial injury and documented as preferred by Trauma Service.
  • • If injuries discovered on tertiary appropriate consultations will be initiated by BMC Orthopedics team, including BMC service consults or remote NMC consultation.
• If the patient requires fracture fixation via routine ORIF, the patient will be admitted to the Trauma Service at Nebraska Medicine and follow the standard Nebraska Medicine Enhanced Recovery after Surgery (NERAS) pathway that has been established for isolated fracture patients.
  • • If the patient does not require fixation, the patient will be admitted to the Trauma Service at Nebraska Medicine and follow the standard NERAS pathway that has been established for isolated fracture patients.
• If patient primarily presents to Nebraska Medicine, patient will be activated based on criteria and both the Emergency Medicine and Trauma Team will respond appropriately and the trauma work-up will be conducted as per usual.
  • • If a fracture is identified along with other injuries, Orthopedic Surgery will be consulted as well as other consulting services as needed
      • • Patient will be admitted to Nebraska Medicine by the Trauma Service for further trauma management as deemed appropriate.   
    • If an isolated fracture is identified, Orthopedic Surgery will be consulted for their recommendations
      • • If patient requires fixation via a partial or total joint replacement, is deemed appropriate for transfer to BMC by the Trauma Service, and has an accepting physician, the patient will then be transferred to BMC from the ED for further isolated hip fracture management.
          • • Transfer to BMC will be arranged by the Orthopedic resident.
            • The trauma tertiary survey will be completed by Orthopedic resident at BMC 24 hours after initial injury.
              • • If injuries discovered on tertiary appropriate consultations will be initiated by BMC admitting team, including BMC service consults or remote NMC consultation.
        • If the patient requires fracture fixation via routine ORIF, the patient will be admitted to the Trauma Service at Nebraska Medicine and follow the standard NERAS pathway that has been established for isolated fracture patients.
        • If the patient does not require fracture fixation, the patient will be admitted to the Trauma Service at Nebraska Medicine and follow the standard NERAS pathway that has been established for isolated fracture patients.

• If the patient does not meet activation criteria, Emergency Medicine will perform the initial evaluation.
  • • ***If a fracture is identified, Trauma should be consulted for additional trauma evaluation***
    • If a fracture is identified along with other injuries, Orthopedic Surgery will be consulted as well as other consulting services as needed
      • • Patient will be admitted to Nebraska Medicine by the Trauma Service for further trauma management as deemed appropriate.  
    • If an isolated fracture is identified, Orthopedic Surgery will be consulted for their recommendations
      • • If patient requires fracture fixation via a partial or total joint replacement, is deemed appropriate for transfer to BMC by the Trauma Service, and has an accepting physician, the patient will then be transferred to BMC from the ED for further isolated fracture management.
          • • Transfer to BMC will be arranged by the Orthopedic resident.
            • The trauma tertiary survey will be completed by Orthopedic resident at BMC 24 hours after initial injury.
              • • If injuries discovered on tertiary appropriate consultations will be initiated by BMC admitting team, including BMC service consults or remote NMC consultation.
        • If the patient requires fracture fixation via routine ORIF, the patient will be admitted to the Trauma Service at Nebraska Medicine and follow the standard NERAS pathway that has been established for isolated fracture patients.
        • If the patient does not require fracture fixation, the patient will be admitted to the Trauma Service at Nebraska Medicine and follow the standard NERAS pathway that has been established for isolated fracture patients.

Follow-up Care:

• If the patient is a poly-trauma patient, discharge and follow-up recommendations will be provided by all consulting services as needed and PT/OT.
  • • All attempts will be made to discharge patient to appropriate location based on patient/family preferences, PT/OT recommendations, and discretion of the Trauma Service
• If the patient is an isolated fracture patient admitted to Nebraska Medicine, discharge and follow-up recommendations will be provided by Orthopedic Surgery and PT/OT.
  • • All attempts will be made to discharge patient to appropriate location based on patient/family preferences, Orthopedic Surgery and PT/OT recommendations, and discretion of the Trauma Service.
• If the patient is an isolated fracture patient transferred to BMC, discharge and follow-up recommendations will be at the discretion of the teams managing the patient at BMC

Outcome Measures and Guideline Adherence: 

• All patients transferred to BMC will be reviewed by the PI team at Nebraska Medicine. 
  • • If the patient is admitted to a non-surgical service @ BMC, and if there is no identified opportunity for improvement, the following may be closed in primary review:
      • • ISS<9
    • As part of secondary review, the Trauma Medical Director must review any that meet any of the following criteria:
      • • ISS>9
        • Cases with an opportunity for improvement identified at primary review
    • Patients that get transferred to BMC and for some reason transferred back to Nebraska Medicine, will undergo a tertiary review by the Trauma PI team and by all providers involved.
    • Emerging trends will signal a need to review this pathway and modify as necessary

Key Contributors:

·         Zachary Bauman, DO, MHA

Last updated:

·         1/16/2023

References:

·         American College of Surgeons 2022 Trauma Standards