Interfacility Transfer Guidelines for Isolated Facial Trauma: A Multi-disciplinary Expert Consensus.

Abstract

Background: The objective of this study was to develop guidelines for the transfer of patients with isolated craniomaxillofacial trauma. Methods: A national, multidisciplinary expert panel was assembled from leadership in national organizations and contributors to published literature on facial reconstruction. The final panel consisted of five plastic surgeons, four otolaryngologist–head and neck surgeons, and four oral and maxillofacial surgeons. The expert panelists’ opinions on transfer guidelines were collected using the modified Delphi process. Consensus was predefined as 90 percent or greater agreement per statement. Results: After four Delphi consensus building rounds, 13 transfer guidelines were established, including statements on fractures of the frontal sinus, orbit, midface, and mandible, as well as soft-tissue injuries. Twelve guidelines reached consensus. Conclusions: The decision to transfer a patient with craniomaxillofacial trauma to another facility is complex and multifactorial. While a percentage of overtriage is acceptable to promote safe disposition of trauma patients, unnecessarily high rates of secondary overtriage divert emergency medical services, increase costs, delay care, overload tertiary trauma centers, and result in tertiary hospital staff providing primary emergency coverage for referring hospitals. These craniomaxillofacial transfer guidelines were designed to serve as a tool to improve and streamline the care of facial trauma patients. Such efforts may decrease the additional health care expenditures associated with secondary overtriage while decompressing emergency medical systems and tertiary emergency departments.

Interfacility Transfer Guidelines for Patients With Isolated Facial Trauma—From Problem to Solution

“…Other patients who require transfer for specialty care include those with injury to the facial nerve, eyelid and lacrimal system, globe, and parotid duct. 1 Facial injuries are an inescapable occurrence, affecting individuals of all ages. They occur across all geographic locations, irrespective of patients' race, sex, or socioeconomic status.…”

“…These guidelines were designed to identify and direct interfacility transfer of patients with specific facial injuries, focusing on isolated craniomaxillofacial trauma in both adult and pediatric patients. 1 The guidelines are built on the foundation of identifying severe facial injuries associated with multisystem trauma that require an immediate transfer and evaluation by a facial traumatologist. Such injuries include uncontrollable hemorrhage, fractures with a large loss of overlying tissue, compromised airway, ballistic trauma, panfacial injuries, and traumas with critical intraocular hypertension or loss of vision.…”

“…Secondary overtriage occurs when this interfacility transfer is deemed unnecessary for a myriad of reasons. However, it has been shown that secondary overtriage is increasing and is common among patients with facial injuries . A 2019 study of more than 1 million patients with facial trauma concluded that isolated facial fractures were frequently managed nonoperatively yet transferred at a disproportionately higher rate.…”

“…Guidelines were first proposed in a 2022 study published in Plastic and Reconstructive Surgery. A panel of 13 facial trauma experts in plastic and reconstructive surgery, otolaryngology–head and neck surgery, and oral and maxillofacial surgery collaborated to develop guidelines using the modified Delphi process. These guidelines were designed to identify and direct interfacility transfer of patients with specific facial injuries, focusing on isolated craniomaxillofacial trauma in both adult and pediatric patients .…”

“… A panel of 13 facial trauma experts in plastic and reconstructive surgery, otolaryngology–head and neck surgery, and oral and maxillofacial surgery collaborated to develop guidelines using the modified Delphi process. These guidelines were designed to identify and direct interfacility transfer of patients with specific facial injuries, focusing on isolated craniomaxillofacial trauma in both adult and pediatric patients . The guidelines are built on the foundation of identifying severe facial injuries associated with multisystem trauma that require an immediate transfer and evaluation by a facial traumatologist.…”