Indirect Referral of Orthopaedic Patients to a Safety-Net Hospital

Objective. Patients seen in emergency departments (EDs) not requiring admission are typically discharged with appropriate follow-up. Sometimes hospitals indirectly refer, or redirect, patients to a different hospital's ED. Anecdotally, indirect referrals are commonly received in safety-net hospitals. This study characterizes the types of patients and hospitals affected and the cost of indirect referral in the orthopaedic trauma population. Methods. A retrospective cross-sectional chart review was conducted of 1,162 consecutive adult patients receiving orthopaedic care in an urban public hospital ED over a six-month period in 2011. Multivariable logistic regression analysis compared patients who were indirectly referred with those presenting primarily. Results. One in five (N=236) patients treated for orthopaedic injury was indirectly referred from neighboring hospitals with orthopaedists available; 209 (88.6%) of these patients were uninsured (OR 3.69; CI 1.85-7.34). Nonprofit hospitals initially treated 107 (64.1%) of these patients. Costs for largely uncompensated care at the public hospital were $1.77 million.