Implementation of a 3-Tier Priority System for Emergency Department Patients' Follow-up in Orthopaedic Surgery

Abstract

Introduction: Increasing demand for emergency department (ED) services and strained specialty-care access requires referral precision and was the impetus for a collaborative redesign of referrals between the Department of Emergency Medicine and Department of Orthopaedic Surgery.

Methods: Guided by root cause analysis of delays in post-emergency department (ED) specialty follow-up in our academic health system, the intervention targeted the finding that all ED referrals were marked "urgent" without differentiation by acuity of orthopedic issues. After implementation, referrals were triaged into three tiers-immediate, urgent, and routine-with stipulated follow-up timeframes. We evaluated differences in completion of scheduling and realized visits, across five calendar months (July-November) pre- and post-implementation (2021 vs 2022). Logistic regression assessed the relationship between patient demographics and outcomes. We report medians and interquartile ranges.

Results: Compared to the 393 urgent referrals to the Department of Orthopaedic Surgery pre-implementation, there were 463 total referrals post-implementation as follows: 11/463 (2.4%) marked as immediate; 123/463 (26.6%) urgent; and 329/463 (71.1%) routine. Similar proportions successfully scheduled pre- and post-implementation (41.5% vs 45.1%; P = .28). On average, immediate referrals completed scheduling within 1.0 (0.0 - 1.0) day and were seen in 4.0 (2.0 - 8.0) days, urgent referrals completed scheduling within 2.0 (1.0 - 4.0) and 7.0 (5.0 - 15.0) days, and routine within 3.0 (1.0 - 6.0) and 12.0 (6.0 - 19.5) days. Race/ethnicity and insurance were related to odds of successful scheduling; Black patients had lower odds than all other groups (odds ratio [OR] 0.3 - 0.4). All insurance categories had higher odds of successful scheduling relative to Medicaid out-of-network (OR 3.5 - 7.2).

Conclusion: A three-tier ED-to-orthopedics referral triage system was quickly adopted and differentiated referrals by urgency but did not impact time to follow-up or loss to follow-up. Structural inequities in access to follow-up care remain.

Figure 1

Root cause analysis of emergency department to orthopedic referrals.

Figure 2

Screenshot of the view of the emergency department-to-the-Department of Orthopaedic Surgery referral priority options within the electronic health record. ED, emergency department.

Figure 3

Number (%) of referrals from the emergency department encounter to Orthopaedic Surgery for follow-up, and number (%) of referrals with completed scheduling and follow-up visit attendance. All referrals were marked as urgent pre-implementation, whereas referrals could be marked as routine, urgent, or immediate with defined follow-up timelines post-implementation. There were no significant differences in proportion of referrals with completed scheduling (*P = .28; chi square), a recorded reason for referral not being scheduled (**P = .13; Monte Carlo estimate of the Fisher exact test), and follow-up visit attendance (***P = .82; Fisher exact test). EM, emergency medicine.

Figure 4

Number of Emergency Department (ED) to Orthopaedic Surgery referrals placed every two weeks (bi-weekly) and emergency department clinicians’ use of referral priorities before (pre) and after (post) implementation of a 3-tiered referral priority system. The number of Emergency Department to Orthopaedic Surgery referrals is provided above each bar. The percentage of referrals that are Routine, Urgent, and Immediate are provided within the green, orange, and blue portion of the bars, respectively.

Figure 5

A: Days from referral from the emergency department (ED) to completion of scheduling for Orthopaedic Surgery follow-up encounter pre- and post-implementation of a three-tiered referral priority system. Number of referrals is provided above each data point. B: Days from referral from the ED to seen in clinic for Orthopaedic Surgery follow-up encounter pre- and post-implementation of a three-tiered referral priority system. Number of referrals is provided above each data point. ED, emergency department.