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

Background Level I pediatric trauma centers manage transferred orthopaedic injuries; however, inter-facility transfer (IFT) patterns, and educational implications for residents remain poorly characterized. Methods We performed a retrospective cohort study of pediatric ground/air EMS transport IFTs to a Level I pediatric trauma center for orthopaedic injuries from 2016 to 2021. Variables included demographics, 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 AAOS 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. Nighttime transfers were more likely to originate from EDs (90.5%) than from other sources ( P =0.005), and most transfers originated from EDs (82%) rather than UCCs (14%). Compared with UCC transfers, ED transfers were associated with longer LOS (39.9 vs. 27.5 hours; P =0.04) 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. Level of Evidence III; retrospective cohort study. Key Concepts 1. Evenings and nights in a pediatric Level I trauma center see a peak number of IFTs/transfers from outside 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 AAOS ROCK curriculum includes sufficient depth and breadth regarding commonly encountered orthopaedic injuries in the emergency department and is therefore a valuable educational resource for training on-call residents.