Emergency Department Guidelines for Orthopedic Consultation in an Academic Trauma Center: Effect on ED Throughput and Consultation Utilization.

OBJECTIVES: Musculoskeletal injuries account for approximately 20% of presentations to emergency departments (ED) in the United States. While many patients can be treated exclusively by an emergency medicine (EM) clinician, others require consultation with an orthopedic surgeon. The objective of this quality improvement initiative was to develop and evaluate the effect of institutional orthopedic consultation guidelines on ED length of stay (LOS), the percentage of patients with fractures who receive an orthopedic consultation in the ED and orthopedic clinic referrals without an ED orthopedics consultation. METHODS: A multidisciplinary team of EM and orthopedic clinicians developed injury-based guidelines for ED patients defining when orthopedic consultation was required, when a phone consultation was required, and when EM clinicians should provide exclusive care. The guidelines were implemented at our institution on June 15, 2022. We performed a retrospective before-after study of all ED patients with orthopedic extremity or pelvis injuries between August 2021 and June 2023 and analyzed changes in ED metrics using multivariable difference-in-differences analysis and quantile regression. RESULTS: A total of 4013 patient visits with fractures of an extremity or the pelvis were included. After adjusting for covariates and temporal trends, ED LOS decreased by a median of 71 min (p < 0.001) after implementation of the guidelines in difference-in-differences analyses. After implementation of the guidelines, orthopedic consultation decreased by 5.5% (95% CI: -10.2, -0.8), and outpatient referrals to orthopedics without an in-person consultation in the ED increased by 11.2% (95% CI: 7.8, 14.5). CONCLUSION: Institutional guidelines for ED orthopedic consultations increased the number of patients managed exclusively by the EM service, decreased total consultations placed to the orthopedic service and decreased the ED LOS for patients at a large urban Level-1 trauma center.