AAOS Bulletin - October, 2006

Orthopaedic Trauma Association

On-Call Position Statement

As part of its stated mission, the Orthopaedic Trauma Association (OTA) is committed to excellence in the treatment of patients with musculoskeletal injuries. Recent reports indicate that emergency departments and hospitals are experiencing difficulty finding specialty surgeons, including orthopaedic surgeons, to provide on-call services.

The OTA believes that board certified/eligible orthopaedic surgeons are the most appropriate providers of acute musculoskeletal care. A loss of the availability of this resource in emergency departments will negatively impact the quality of musculoskeletal trauma care delivered in the United States.

This access problem is exacerbated by several factors:

  • Many hospitals do not apply sufficient resources to allow quality care delivery to the trauma patients. Working within such a compromised system provides disincentive to surgeons who attempt to provide such care. In the context of overall rising cost and decreasing reimbursement, the financial burdens associated with provision of on-call services have become difficult for orthopaedic practices to bear. Many uninsured and underinsured patients now use emergency departments as a primary source of health care leaving those covering these facilities with a disproportionate burden of providing uncompensated service.
  • There is a perceived increase in liability associated with the treatment of higher risk problems such as severe trauma, which is predisposed toward poorer outcome. This has influenced orthopaedic surgeons to avoid such activity.

The combined effect of these factors as well as others has resulted in decreasing access to orthopaedic surgeons for patients with musculoskeletal injuries. Analysis of these issues suggests that such access is likely to further decrease in the future without changes in the emergency health care environment.

The OTA believes that the following principles are paramount in the development of a solution to this developing health care crisis:

  1. Orthopaedic surgeons are the best trained caregivers to evaluate and treat patients with significant musculoskeletal injuries.
  2. Orthopaedic surgeons, hospitals and legislators share a duty to the community in which they serve to provide timely services to patients with musculoskeletal injury.
  3. Musculoskeletal trauma care from a qualified orthopaedic surgeon should be available to individuals with significant injuries 24 hours per day and 7 days per week within their communities. If these responsibilities cannot be met, appropriate need-based transfer policies should be established.
  4. Access to specialized high-level care from orthopaedic trauma specialists should be available on a primary or referral basis for those patients with severe injuries to the musculoskeletal system that cannot be adequately managed by a non-trauma specialist orthopaedic
  5. surgeon.
  6. Board certified orthopaedic surgeons have been trained in basic musculoskeletal trauma care and should maintain the skills needed to provide basic musculoskeletal trauma care services (i.e. splinting, fasciotomies, debridement of open wounds and basic internal and external fixation application.)

In support of these principles, we support adoption of the following specific guidelines with regard to provision of emergency musculoskeletal trauma services:

  1. Emergency care for injuries to the musculoskeletal system should be provided by a properly trained orthopaedic surgeon prepared to consider both the acute as well as the long-term reconstructive and rehabilitative needs associated with musculoskeletal injury.
  2. Meaningful liability reform is necessary to reduce physicians’ risk associated with the delivery of emergent care and prevent attendant insurance costs from driving orthopaedic surgeons away from providing necessary emergency musculoskeletal care.
  3. The financial burden for provision of emergency musculoskeletal services on-call should be borne jointly by hospitals, the public and physicians. The challenges associated with disruption in medical practice and lifestyle are borne by the physicians alone. Therefore, orthopaedic surgeons must be compensated for their on-call services. Payment for such services should reflect the work and liability risk associated with these services.
  4. Hospitals need to provide adequate resources both in terms of personnel and facilities to ensure that provision of emergency musculoskeletal trauma care can be accomplished in a safe and timely fashion regardless of the time of the day at which that care is needed. Non-emergent conditions requiring surgery should be addressed during regular working hours when regular staffing and ancillary help are available. Emergency conditions should be addressed surgically within a medically appropriate timeframe. The responsibility for determination of the distinction between urgent and emergent conditions must rest with the treating orthopaedic surgeon, as he or she is best capable of combining information about the individual patient’s condition, the treatment options for that condition and the available evidence in the medical literature.
  5. Hospitals without continuous availability of musculoskeletal trauma specialists should develop transfer agreements with centers where such specialists practice to allow for the appropriate transfer of patients with musculoskeletal injuries whose complexity exceeds the capability of the initial treating institution. Such transfers should always be based on complexity of injury and the best interest of the injured patient’s musculoskeletal condition. Such transfers should never be based on an injured patient’s ability (or lack thereof) to pay for such services. Transfers other than those prearranged by standing hospital agreements should be communicated from the consulting orthopaedic surgeon to the receiving orthopaedic surgeon after an appropriate evaluation (history and physical exam) by the referring physician.
  6. All board certified orthopaedic surgeons should make themselves available to their hospital’s on-call list during the active years of their practice at that institution. In providing emergency department coverage, hospitals should not impose an undue burden on orthopaedic surgeons offering such coverage. Hospitals and orthopaedic staff should negotiate an appropriate amount of on-call coverage that is not burdensome to either party.
  7. Hospital systems MUST provide necessary facilities, equipment, and ancillary services necessary to provide emergent care to those with musculoskeletal injury. A general scheme of these elements may be seen in the OTA optimum resource guidelines, which are the minimum standard.
  8. The OTA calls on the American Academy of Orthopaedic Surgeons (AAOS), the American Board of Orthopaedic Surgeons (ABOS), the American Orthopaedic Association (AOA), and all specialty societies to work toward mechanisms to assure the sufficient participation of their membership on call lists at their institutions including evidence of such participation as a qualification for membership and certification.
  9. AAOS and the ABOS must monitor the orthopaedic workforce to insure availability and distribution of orthopaedic surgeons to meet the needs of the nation’s emergency departments.

Adopted: December 2, 2005

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