Table 1.

Grading scale for transfers

Grade	Definition	Clarification
1	Completely inappropriate—care should have been provided by referring ED without further consultation	Something that should be within the scope of a physician working in a community ED (emergency medicine physician)
2	Appropriate for referral but on an outpatient basis	Something that needs outpatient follow-up by a specialist, but not necessarily that night
3	Needed urgent treatment, but should have been provided by referring ED’s consultant coverage	Something within the scope of community hand, general ortho, or plastic surgery consultant coverage for a ED (if that ER reports having that coverage)
4	Appropriate for transfer but patient refused elevated level of care	Patient did not want the treatment recommended by our orthopedist/hand/plastic surgeon, but instead went with the treatment that could have been provided by the referring consultant
5	Appropriate	Patient required urgent treatment by a specialist not available at the referring facility