INTRODUCTION

The American Orthopaedic Association recognizes the significant crisis that exists in the provision of Emergency Department (ED) orthopaedic coverage. The American College of Emergency Physicians reported that three-quarters of ED medical directors have inadequate on-call specialist coverage.

1 In another survey, 42% of ED administrators felt that the lack of specialty coverage in the ED posed a significant risk to patients.

2 Providing emergency care on an on-call basis has become unattractive to many specialists in critical disciplines such as orthopaedics.

3 Many factors have contributed to this ED crisis in the field of orthopaedics ranging from lifestyle choices to financial and liability issues. Solutions must be tailor-made by the community-based group of stakeholders to meet the needs of patients with urgent musculoskeletal conditions by optimizing the resources of individual communities. To uphold its commitment to patient access to high quality care and to serve in a leadership capacity for the profession, the American Orthopaedic Association established a Task Force in 2008 under the aegis of its Orthopaedic Institute of Medicine to review the scope of this crisis, identify barriers impacting orthopaedic coverage in EDs across the US, and propose solutions that can be adopted at the community level.

GOALS AND OBJECTIVES

The goal of the Task Force was to engage the orthopaedic community in putting forth new strategies to ensure that all patients who require emergent orthopaedic care have access to high quality service in the ED.

METHODS

The Orthopaedic Institute of Medicine Council Task Force on ED Call Coverage examined the peer-reviewed literature and consulted with experts in government, health care administration, and clinical orthopaedic practice. To characterize and quantify the problem of ED coverage among practicing orthopaedists, the Orthopaedic Institute of Medicine surveyed the membership of the American Academy of Orthopaedic Surgeons in May and June of 2008. The survey was designed to clarify the characteristics of the barriers to ED coverage, both real and perceived, such as call frequency and intensity, reimbursement, support, and required skill (Appendix E).

RESULTS

Barriers to Patient Access to Quality Orthopaedic Emergency Care
Based on survey results, peer-reviewed literature, expert opinion, and Task Force consensus, the following barriers to ED call coverage emerged: lifestyle/time away from family; poor reimbursement; increased liability risk; medical practice issues (e.g., disruption of elective practice, lack of inpatient practice); lack of comfort with skills needed for ED cases; and inadequacies of hospital emergency care resources. Solutions to these barriers impact social, professional, and financial aspects of our current system and require change at many levels. Recommendations from the Task Force address these barriers with potential solutions and emphasize that most solutions must be individualized at the local level.

RECOMMENDATIONS

Orthopaedic surgeons are ultimately the most qualified, capable, and cost-effective providers of musculoskeletal care. To help resolve the looming crisis in orthopaedic ED call coverage, the Orthopaedic Institute of Medicine Council recommends that in each community in the US, orthopaedic surgeons partner with hospitals and other stakeholders to discuss the issues, identify specific problems and local resources, and implement a solution that will ensure access for all patients to appropriate high quality emergency care for most musculoskeletal conditions. The solution in each community will be unique and determined by the identified issues that must be overcome in that community’s medical environment. Modifications are also needed at the state, regional, and national levels to assist in removing barriers that are presently challenging access to emergency musculoskeletal care in many communities.

1. Delivery of Emergency Care
The Orthopaedic Institute of Medicine recommends that communities ensure all patients have access to readily available orthopaedic surgical consultation to the ED by creating community-wide teams to evaluate emergency musculoskeletal care, assess needs for local services, and recommend and champion the solutions.

2. Physician Leadership
The Orthopaedic Institute of Medicine recommends that all orthopaedic surgeons acknowledge a professional obligation to ensure that there is a system in their community whereby all patients have access to timely and appropriate emergency musculoskeletal care. Orthopaedic professional organizations can support this goal by establishing professional guidelines specific to patient access to emergency musculoskeletal care.

3. Education and Core Competencies
The Orthopaedic Institute of Medicine recommends that the American Board of Orthopaedic Surgery and the Residency Review Committee (a subcommittee of the Accreditation Council for Graduate Medical Education) define core competences for the care of urgent and emergent musculoskeletal conditions; delineate specific conditions that can be definitively managed; and propose methods for maintaining these core competencies. These organizations should continue to define minimal criteria for musculoskeletal emergency care and community care of transfers. Dialogue with orthopaedic training programs regarding the training of an acute care orthopaedist should occur.

4. Hospital Resources for Orthopaedic Emergency Care
The Orthopaedic Institute of Medicine recommends that hospitals provide dedicated daily operating room time for the management of musculoskeletal emergency cases (including the necessary equipment, devices, and qualified staff) and collaborate with local orthopaedic surgeons to develop an effective ED call system and meaningful transfer agreements between local and regional institutions to provide the best care for the patient and eliminate inappropriate referrals.

5. Collaboration with Other Organizations
The American Orthopaedic Association should work with other organizations such as the American Hospital Association, the American College of Emergency Physicians, the American Academy of Orthopaedic Surgeons, the American College of Surgeons, the American Board of Orthopaedic Surgery, and orthopaedic specialty societies, at congressional and state levels, in an attempt to increase awareness and produce results that will provide further support for community-based solutions to this crisis.

6. Reimbursement for Services: Orthopaedists and Hospitals
The Orthopaedic Institute of Medicine recommends that hospitals and the leadership of professional organizations for orthopaedic surgery jointly advocate for appropriate reimbursement for emergency musculoskeletal care for both orthopaedic surgeons and hospitals. Communities of hospitals and orthopaedic surgeons should develop an appropriate method to provide compensation (either monetary or in-kind) for orthopaedic surgeons covering ED on-call responsibilities.

7. Tort Reform
The Orthopaedic Institute of Medicine recommends that the orthopaedic community partner with other affected specialties and state orthopaedic and medical associations to achieve state-level tort reform. Insurers, legislators, hospital organizations, and physician organizations can assist by increasing efforts to propose, discuss, and enact meaningful tort reform at the federal level.

8. Third-party Payers as Community Participants in Generating Solutions
The Orthopaedic Institute of Medicine recommends that local hospitals assess their need for quality emergency coverage by specialty area. If there is lack of such care secondary to financial problems, hospitals and other physician groups could approach third-party payers to negotiate a cooperative solution to remedy this problem. Involving local physicians in this process provides unbiased opinions and support for new reimbursement schemes.

CALL TO ACTION

The Orthopaedic Institute of Medicine Council presents the following call to action related to the looming crisis in orthopaedic ED call coverage:

In each community in the US, orthopaedic surgeons, in partnership with hospitals and other stakeholders, should discuss, identify, and implement a solution to this issue. The goal is to provide local access to emergency care for most musculoskeletal conditions for all patients in that community. The solutions will be based on the unique resources and obstacles identified within in each community. To support these local initiatives, national organizations such as the American Orthopaedic Association, the American Academy of Orthopaedic Surgeons, the American Board of Orthopaedic Surgery, the Accreditation Council for Graduate Medical Education, and orthopaedic specialty societies should continue to support activities and legislation at state, regional, and national levels to assist in removing barriers presently challenging access to emergency musculoskeletal care in many communities.

REFERENCES

1.American College of Emergency Physicians’ (ACEP) Emergency Medicine Foundation. On-Call Specialist Coverage in U.S. Emergency Departments: ACEP Survey of Emergency Department Directors, April 2006. ACEP web site. Accessed from http://www.acep.org/pressroom/ on October 1, 2008.

2.The Schumacher Group: 2005 Hospital Emergency Department Administration Survey. Cited in the American Academy of Orthopaedic Surgeons (AAOS). Position Statement 1172: On-Call Coverage and Emergency Care Services in Orthopaedics, September 2006. AAOS web site. Accessed from http://www.aaos.org/about/papers/position/1172.asp on October 12, 2008.

3.Institute of Medicine Emergency, Board on Health Care Services. Committee on the Future of Emergency Care in the United States Health System. Medical Services at the Crossroad. Washington, DC. The National Academies Press, 2007.