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

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.

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.

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).

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.