Ethical Considerations in the Interhospital Transfer of Patients

The regionalization of trauma care has resulted in improvement of patient outcomes by triaging complex injuries to tertiary and quaternary hospitals with more resources, greater availability of subspecialty care, and higher case volumes. Undertriage of complex patients is associated with poor patient outcomes and mortality. Conversely, overtriage, defined as the overestimation of injury severity and unnecessary transfer to a higher level of medical care, risks overburdening higher trauma tier hospitals, can create a bottleneck effect of scarce resources and personnel, and may impede access for other critically ill patients. The increasing burden is borne by these trauma centers, which is more concerning, given the current trend of fewer practicing hand surgeons taking hand call. The medical decision to transfer a patient from a local hospital to a higher-tier hospital is a complex, shared decision between providers, and this is generally subject to time constraints with limited information regarding the patient's injuries. Furthermore, previous research has demonstrated that nonmedical factors often considerably influence the decision to transfer, including insurance status, Black race, and presentation to a local emergency department during night or weekend hours. This article discusses a number of ethical concerns that arise in the consideration of interhospital transfers of hand surgery patients and implications for practicing hand surgeons on both the referring and receiving sides. The main focuses of the article include the following: (1) the regionalization of hand trauma care; (2) the harms of undertriage; (3) the practical problems with overtriage; (4) viewing through the lens of principalism; and (5) recommendations for the path forward.