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Pediatric Orthopaedic Transfers to a Level I Trauma Center: After-Hours Burden and Resident Preparedness.

Jonathan J Light, Carrie Danziger, Christopher Woll, Clayton Maschhoff, Ashar Ata, Andrew Rosenbaum, Michael Waxman, Denis Pauze

Journal of the Pediatric Orthopaedic Society of North America · 2026-09-17 · Observational study

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Abstract

BACKGROUND: Level I pediatric trauma centers manage transferred orthopaedic injuries; however, interfacility transfer (IFT) patterns ​and educational implications for residents remain poorly characterized. METHODS: We performed a retrospective cohort study of pediatric ground/air emergency medical service transport IFTs to a level I pediatric trauma center for orthopaedic injuries from 2016 to 2021. Variables included demographics, International Classification of Diseases 10th Revision (ICD-10)-coded injuries, referring facility (emergency departments [EDs] and urgent care centers [UCCs]), arrival time/season, length of stay (LOS), and disposition. Continuous and categorical variables were compared using standard methods, with statistical significance set at ⍺ ​= ​0.05. ICD-10 codes were mapped to the American Academy of Orthopaedic Surgeons Resident Orthopaedic Core Knowledge (ROCK) contents to contextualize resident exposure. RESULTS: Of the 695 transfers included, the predominant injuries were femur fractures (24%), upper extremity injuries (23%), hip injuries (13%), and knee injuries (6%). Transfers peaked in summer (33.5%), although there was no significant seasonal variation in source distribution, and most arrivals occurred during evening hours (15:00-22:59; 62%), with fewer night (30.2%, n ​= ​210) and daytime (7.8%, n ​= ​54) arrivals. Evening transfers were more likely to originate from EDs (90.5%) than from other sources (P ​< ​.001), and most transfers originated from EDs (82%) rather than from UCCs (14%). Compared with UCC transfers, ED transfers were associated with longer LOS (39.9 vs ​27.5 ​hours; P ​= ​.04) and higher admission rates (63.3% vs ​35.7%). All 25 injury categories were mapped onto the ROCK framework. CONCLUSIONS: Pediatric orthopaedic transfers were most common during evening and overnight hours in summer, with ED transfers demonstrating higher acuity and longer LOS. These patterns highlight a substantial after-hours burden and support targeted evening and night staffing models, including resident "buddy" call (junior and senior residents), advanced practice provider coverage, pediatric-trained nursing, and the early integration of ROCK content into on-call education. KEY CONCEPTS: (1)Evenings and nights in a pediatric level I trauma center see a peak number of interfacility transfers/transfers from outside emergency departments (EDs), the majority of which are lower extremity fractures requiring overnight stabilization.(2)Fewer admissions of upper extremity fractures require closed reduction and casting, including knowledge of the successful parameters for sending out.(3)The American Academy of Orthopaedic Surgeons Resident Orthopaedic Core Knowledge curriculum includes sufficient depth and breadth regarding commonly encountered orthopaedic injuries in the ED and is therefore a valuable educational resource for training on-call residents. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

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Tags

Children · Interfacility & critical care transport · Time intervals

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