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Frequency and costs of laboratory and radiograph repetition in trauma patients undergoing interfacility transfer
Frequency and Costs of Laboratory and Radiograph Repetition in Trauma Patients Undergoing Interfacility Transfer STEPHEN H. THOMAS, MD, MPH*I JANET ORF, RN MS* CHAD PETERSON*I AND SUZANNE K. WEDEL, MD*::I: Receiving trauma centers often duplicate laboratory and radiograph testing performed by referring institutions. Our objective was to quantify frequency and costs of this practice. In this prospective study of 104 consecutive interfacility-transported adult trauma patients flown by an emergency medical service to an urban level I center, flight crew noted which labs and radiographs were done at referring hospitals, which tests were sent with patients, and which were repeated on trauma center arrival. Overall, results from 246 of 283 (86.9%) laboratory tests and 241 of 249 (96.8%) radiographs done at referring hospitals were sent with patients. Repetition of laboratory tests at the receiving hospital was frequent regardless of whether initial results were sent (P = .6 by X2), and radiograph repetition was unrelated to whether sent films were originals or copies (P = .2 by X2). For these 104 patients, the receiving hospital charged $66,463 for repetition of work-up done at referring facilities. (Am J Emerg ied 2000;16:156-158. Copyright © 2000 by W.B, $aunders Company)
The current environment of focus on rising healthcare costs compels examination of any facet of patient care representing an area of potential efficiency improvement and cost reduction. One such arena is the trauma laboratory and radiography work-up in patients undergoing evaluation at a referring hospital and then undergoing repeat workup at a receiving trauma center. Although some prior reports have addressed benefits of reducing redundant laboratory analysis in a general emergency department (ED) population, 1 and others have stressed the need for judicious laboratory and radiographic evaluation of injured patients,2 there has been less attention to the specific practice of redundant trauma work-ups at referring and receiving hospitals. Because trauma care is often resource-intensive, the population of injured patients is a particularly attractive target on which to direct cost-reduction analysis. Although some laboratory and radiograph repetition is clearly appropriate, duplication of testing, if found to be frequent, would appear to be an area of potential efficiency improvement and cost reduction. In any attempt to fully investigate the issue of appropriate laboratory and radiograFrom the *Boston MedFlight Critical Care Transport Service, the ~rDepartment of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, and the ~cDepartment of Surgery, Boston University School of Medicine, Boston, MA. Address reprint requests to Stephen H. Thomas, MD, Department of Emergency Medicine, Massachusetts General Hospital--Clinics Building #115, 55 Fruit Street, Boston MA 02114. Presented in part at the National Association of EMS Physicians Annual Meeting, Marco Island FL, January 7-9, 1999. Key Words: Trauma workup, laboratory repetition, radiograph repetition. Copyright © 2000 by W.B. Saunders Company 0755-6757/00/1802-0009510.00/0 156
phy work-up at referring and receiving hospitals, a logical first step is to define the overall frequency of repetition of these aspects of the trauma work-up. If such repetition were found to be frequent then subsequent analysis would be indicated to focus on the more difficult, but ultimately "bottom-line," issue of which redundant laboratory and radiograph tests could safely be eliminated. Therefore, the goal of this study was to begin to address laboratory and radiograph repetition in trauma patients by defining the frequency and costs of such repetition in a prospective series of injured patients. METHODS
The study was conducted between January 6, 1996 and August 4, 1997. Eligible patients were adult (at least 14 years of age) blunt trauma patients undergoing interfacility helicopter transport from any referring hospital ED to the Massachusetts General Hospital, an urban academic level I trauma center ED with annual census 70,000. All patients in the study were transported by Boston MedFlight Critical Care Transport Service, which uses two helicopters and a nurse-paramedic crew to transport approximately 1,400 patients annually. For this study, all data were collected as a consecutive series of transports of eligible patients on which one of the authors (J.O.) served as a flight nurse. Therefore, the study was conducted on a convenience sample of patients undergoing transport. On arrival at referring hospitals, flight crew noted all radiographs, both plain and computed tomography (CT) films, which had been done at the referring center. Also, the crew recorded which of the following laboratory testing was done at referring hospitals: complete blood count, standard (sodium, potassium, chloride, glucose, creatinine, bicarbonate) and extended (standard plus calcium, magnesium, phosphorus) electrolyte panels, prothrombin time and partial thromboplastin time, toxicology screens, creatine phosphokinase, liver functions, urinalysis, and pregnancy tests. Crew also recorded which radiograph and laboratory test results were sent with patients to the Massachusetts General Hospital. Also, for plain radiographs it was noted whether originals or copies were forwarded. Subsequently, study personnel reviewed hospital medical records and computer records and noted which tests were performed within 1 hour of arrival at the Massachusetts General Hospital. The study was conducted with approval from the Massachusetts General Hospital Institutional Review Board. For determination of financial impact of laboratory and radiograph repetition, data were available from the receiving
THOMAS ETAL [] LABORATORY AND RADIOGRAPH REPEAT
trauma center only. Data for both laboratory and radiograph tests represents actual charges, rather than costs, as this was the only information that could be obtained. Initial analysis was descriptive, entailing delineation of frequency and costs of test repetition. Chi-squared (c~ = .05) and risk ratio analysis was used for categorical data (eg, whether plain radiography repetition was related to original versus copy status of sent films). All statistical analysis was performed with Intercooled STATA 6.0 for Windows 95 (STATA Corporation, College Station, TX).
RESULTS During the study period, a total of 104 adult blunt trauma patients were enrolled. In this group, referring hospitals performed a total of 249 plain and CT radiographs and 283 laboratory tests. Almost all (241 of 249, 96.8%) radiographs, and most laboratory tests (195 of 283, 68.9%) done at referring hospitals were forwarded to the trauma center. Compared with laboratory tests, radiographs were 1.4 times (95% confidence interval, 1.29-l.52) more likely to be forwarded to the receiving hospital (P value by X2, <.0001). Because nearly all radiographs performed at referring institutions were in fact sent to the receiving trauma center as either originals or copies, analysis of radiograph repetition focused on a possible association between trauma center radiograph repetition and whether the referring hospital sent plain radiographs as originals or copies. Of the 241 radiographs forwarded to receiving trauma centers, 215 (89.2%) were plain radiographs and the remainder were CT films for which original/copy status was not applicable. The proportion of forwarded plain radiographs which were original films was 64.7% (139 radiographs). Original versus copy status of forwarded plain radiographs was not associated (P value by X2, .19) with trauma center radiograph repetition; compared with original films, copies of plain radiographs were 1.2 times more likely to be repeated but this difference was not significant (95% confidence interval, .92-1.6). Although CT scans represented a small portion (30 of 249 radiographs, 12.0%) of films done at referring hospitals, 43.3% (13 of 30) of patients undergoing CT at referring hospitals had repeat CT scans at the Massachusetts General Hospital. Of the 283 laboratory tests done at referring hospitals, 246 (86.9%) were repeated on trauma center arrival; in 171 (69.5%) of the 246 repeated labs, results from initial (referring institution) tests had been sent. Unsent labs were those which were ordered by the referring hospital, but for which no results were sent with patients. For the 283 laboratory tests done at referring hospitals, receiving hospital test repetition was unassociated (P value by X2, .57) with whether referring hospitals sent (87.7% repeat rate) or did not send (85.2% repeat rate) results from initial tests; repetition of forwarded laboratory tests was an insignificant 1.03 times (95% confidence interval, 0.93 to 1.14) more likely than repetition of labs which had not been forwarded. For this group of 104 patients, the receiving hospital charged $49,843 for repetition of radiographs which had been done at referring facilities. Duplicate laboratory testing done at the receiving institution in patients who had had the same laboratory tests at the referring hospital, accounted for
157
$16,620 in trauma center charges. Repeat laboratory and radiographs, therefore, resulted in charges of $66,463 ($639 per patient) at the receiving trauma center.
DISCUSSION The idea of reducing repetitive laboratory testing through improved availability of previous results is not new to the emergency medicine literature, having been discussed by Stair in the context of the efficiency and cost advantages of computerized medical records. ~ In addition, investigators emphasizing provision of appropriate and cost-effective trauma care have cast doubt on the utility of many laboratory and radiographic tests "routinely" ordered on trauma patients. Specifically, experts have questioned the universal ordering of electrolytes, complete blood count, amylase, urinalysis, and toxicological screens. 2-5 Similar literature exists for the "routine" performance of trauma radiography. 2,6,7The concepts of increasing prior test result availability and judicious employment of trauma laboratory and radiograph testing can be simultaneously used by examining trauma work-up repetitions occurring in patients undergoing interfacility transfer. The most important point to include in this discussion is that the study attempts to address only the frequency and cost of work-up repetition. There is no intent, either explicit or implied, to determine to what degree the repetition is clinically indicated or otherwise appropriate. Of course, this is a shortcoming of the study if one's intent is to apply these results directly to patient care; such an application is not intended. Rather, the importance of the results is to show that workup repetition is frequent and costly, thereby highlighting a new area for future investigation. Injured patients ultimately requiring trauma center transfer may not appear to warrant trauma center care on presentation at community hospitals; these patients may legitimately undergo some testing that appears in retrospect to have been "unnecessary" or unrelated to the decision to transfer the patient. On the other hand, patients may have had findings on a referral hospital CT scan which warrant transfer to a trauma center, where repeat CT is necessary to evaluate interval change. The very nature of helicoptertransported patients is that they tend to have relatively high injury acuity. This higher injury acuity may account for reasonable repetition of some testing to more closely follow these critical patients. In fact, because helicopter-transported patients are usually more acutely injured than patients arriving at trauma centers by ground transport, the study has limited external validity to the entire population of injured patients undergoing interfacility transport. However preliminary the results may be, they are in some ways compelling. First, the very high number of radiographs forwarded with patients are a credit to referring hospitals. Although some of this excellent showing may be a Hawthorne effect from having the flight crew participating in the study, the fact that nearly 97% of radiographs were forwarded with patients speaks well for referring hospitals. Less optimal was the fact that over a third of plain radiographs forwarded were copies. In our experience, it is not unusual to have uninterpretable "copies" forwarded with trauma patients. However, our results (with relatively
158
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 2 • March 2000
narrow confidence intervals around the risk ratio) do not support the conclusion that trauma center physicians were impelled to order repeat radiographs because of the fact that forwarded films were copies. The issue of radiograph copies brings up the major shortcoming of this study, and the necessary focus of follow-up studies: the question of why there was work-up repetition. We did not attempt to ask referring hospital physicians why laboratory and radiograph testing was done, and also did not ask physicians at receiving hospitals why tests were repeated; the logistics of this were beyond the scope of this preliminary investigation but will certainly be a major part of subsequent studies. Given anecdotal experience with referring hospitals' forwarding unreadable copies of nonindicated extremity films, and also with trauma center physicians ordering repeat laboratory or radiography-without even looking at information sent from referring hospitals--based solely on protocol, we Suspect that further study of the rationale for performing trauma laboratory and radiograph testing will likely shed light on avenues for improved efficiency of care at both referring and receiving hospitals. Regarding laboratory testing, there are many justifiable reasons for repeating laboratory tests, ranging from rechecking for interval changes to establishing "baseline" laboratory data at the admitting hospital. However, it was noteworthy that there was no relationship between whether labs were sent from referring hospitals and whether they were repeated at the receiving hospital. Given recent focus 2-5 on reducing routine laboratory analysis in trauma patients, this may be an area where costs can be easily reduced without risk to patients. There are two issues relevant to data collection that warrant comment. First, the patient population studied was a cohort transported by a helicopter emergency medical service (EMS). We chose to study helicopter-transported patients because of the logistics of patient enrollment and the ability to obtain a consecutive series. However, although acuity and outcome information for our patients is unavailable (other than the fact that all were admitted to the trauma service) this group is likely to have been of higher injury
acuity than trauma patients transported by ground EMS. Because a more acute patient population could be expected to incur more laboratory and radiography work-up than a less injured group, the study's external validity to ground transported patients may be limited. Because the goal of the project was merely to identify whether repetitive work-up was frequent, this limitation does not negate our results. Indeed, even if the results from these patients could be extrapolated only to helicopter-transported interfacility trauma patients, the potential cost savings warrant further investigation. In summary, we present preliminary data which suggests that there is frequent repetition of laboratories and radiographs in trauma patients undergoing inteffacility transfer; there may be room for improved efficiency in the area of redundant trauma work-ups at referring and receiving institutions. We conclude that further study is warranted to address laboratory and radiography repetition in these patients, and that future efforts should focus on understanding: (1) why physicians at referring and receiving institutions order laboratory and radiograph testing, (2) why repetition is so frequent, and (3) whether some testing at referring or receiving hospitals can safely be eliminated.
REFERENCES 1. Stair TO: Reduction of redundant laboratory orders by access to computerized patient records. J Emerg Med 1998; 16:895-897 2. Melio FR: Priorities in the multiple trauma patient. Emerg Med Clin North Amer 1998;16:29-43 3. Namias N, McKenney MG, Martin LC: Utility of admission chemistry and coagulation profiles in trauma patients: A reappraisal of traditional practice. J Trauma Injury Infect Crit Care 1996;41:21-25 4. Mure A, Josloff R, Rothberg J, et al: Serum amylase determination and blunt abdominal trauma. Am Surg 1991 ;57:210-213 5. Tortella BJ, Lavery R, Rekant M: Utility of routine admission serum chemistry panels in adult trauma patients. Acad Emerg Med 1995;2:190-194 6. Terregino C, Ross S, Lipinski M, et al: Selective indications for thoracic and lumbar radiography in blunt trauma. Ann Emerg Med 1995;26:126-129 7. Yugueros P, Sarmiento JM, Garcia AF, et al: Unnecessary use of pelvic X-ray in blunt trauma. J Trauma Injury Infect Crit Care 1995;39:722-725
The current environment of focus on rising healthcare costs compels examination of any facet of patient care representing an area of potential efficiency improvement and cost reduction. One such arena is the trauma laboratory and radiography work-up in patients undergoing evaluation at a referring hospital and then undergoing repeat workup at a receiving trauma center. Although some prior reports have addressed benefits of reducing redundant laboratory analysis in a general emergency department (ED) population, 1 and others have stressed the need for judicious laboratory and radiographic evaluation of injured patients,2 there has been less attention to the specific practice of redundant trauma work-ups at referring and receiving hospitals. Because trauma care is often resource-intensive, the population of injured patients is a particularly attractive target on which to direct cost-reduction analysis. Although some laboratory and radiograph repetition is clearly appropriate, duplication of testing, if found to be frequent, would appear to be an area of potential efficiency improvement and cost reduction. In any attempt to fully investigate the issue of appropriate laboratory and radiograFrom the *Boston MedFlight Critical Care Transport Service, the ~rDepartment of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, and the ~cDepartment of Surgery, Boston University School of Medicine, Boston, MA. Address reprint requests to Stephen H. Thomas, MD, Department of Emergency Medicine, Massachusetts General Hospital--Clinics Building #115, 55 Fruit Street, Boston MA 02114. Presented in part at the National Association of EMS Physicians Annual Meeting, Marco Island FL, January 7-9, 1999. Key Words: Trauma workup, laboratory repetition, radiograph repetition. Copyright © 2000 by W.B. Saunders Company 0755-6757/00/1802-0009510.00/0 156
phy work-up at referring and receiving hospitals, a logical first step is to define the overall frequency of repetition of these aspects of the trauma work-up. If such repetition were found to be frequent then subsequent analysis would be indicated to focus on the more difficult, but ultimately "bottom-line," issue of which redundant laboratory and radiograph tests could safely be eliminated. Therefore, the goal of this study was to begin to address laboratory and radiograph repetition in trauma patients by defining the frequency and costs of such repetition in a prospective series of injured patients. METHODS
The study was conducted between January 6, 1996 and August 4, 1997. Eligible patients were adult (at least 14 years of age) blunt trauma patients undergoing interfacility helicopter transport from any referring hospital ED to the Massachusetts General Hospital, an urban academic level I trauma center ED with annual census 70,000. All patients in the study were transported by Boston MedFlight Critical Care Transport Service, which uses two helicopters and a nurse-paramedic crew to transport approximately 1,400 patients annually. For this study, all data were collected as a consecutive series of transports of eligible patients on which one of the authors (J.O.) served as a flight nurse. Therefore, the study was conducted on a convenience sample of patients undergoing transport. On arrival at referring hospitals, flight crew noted all radiographs, both plain and computed tomography (CT) films, which had been done at the referring center. Also, the crew recorded which of the following laboratory testing was done at referring hospitals: complete blood count, standard (sodium, potassium, chloride, glucose, creatinine, bicarbonate) and extended (standard plus calcium, magnesium, phosphorus) electrolyte panels, prothrombin time and partial thromboplastin time, toxicology screens, creatine phosphokinase, liver functions, urinalysis, and pregnancy tests. Crew also recorded which radiograph and laboratory test results were sent with patients to the Massachusetts General Hospital. Also, for plain radiographs it was noted whether originals or copies were forwarded. Subsequently, study personnel reviewed hospital medical records and computer records and noted which tests were performed within 1 hour of arrival at the Massachusetts General Hospital. The study was conducted with approval from the Massachusetts General Hospital Institutional Review Board. For determination of financial impact of laboratory and radiograph repetition, data were available from the receiving
THOMAS ETAL [] LABORATORY AND RADIOGRAPH REPEAT
trauma center only. Data for both laboratory and radiograph tests represents actual charges, rather than costs, as this was the only information that could be obtained. Initial analysis was descriptive, entailing delineation of frequency and costs of test repetition. Chi-squared (c~ = .05) and risk ratio analysis was used for categorical data (eg, whether plain radiography repetition was related to original versus copy status of sent films). All statistical analysis was performed with Intercooled STATA 6.0 for Windows 95 (STATA Corporation, College Station, TX).
RESULTS During the study period, a total of 104 adult blunt trauma patients were enrolled. In this group, referring hospitals performed a total of 249 plain and CT radiographs and 283 laboratory tests. Almost all (241 of 249, 96.8%) radiographs, and most laboratory tests (195 of 283, 68.9%) done at referring hospitals were forwarded to the trauma center. Compared with laboratory tests, radiographs were 1.4 times (95% confidence interval, 1.29-l.52) more likely to be forwarded to the receiving hospital (P value by X2, <.0001). Because nearly all radiographs performed at referring institutions were in fact sent to the receiving trauma center as either originals or copies, analysis of radiograph repetition focused on a possible association between trauma center radiograph repetition and whether the referring hospital sent plain radiographs as originals or copies. Of the 241 radiographs forwarded to receiving trauma centers, 215 (89.2%) were plain radiographs and the remainder were CT films for which original/copy status was not applicable. The proportion of forwarded plain radiographs which were original films was 64.7% (139 radiographs). Original versus copy status of forwarded plain radiographs was not associated (P value by X2, .19) with trauma center radiograph repetition; compared with original films, copies of plain radiographs were 1.2 times more likely to be repeated but this difference was not significant (95% confidence interval, .92-1.6). Although CT scans represented a small portion (30 of 249 radiographs, 12.0%) of films done at referring hospitals, 43.3% (13 of 30) of patients undergoing CT at referring hospitals had repeat CT scans at the Massachusetts General Hospital. Of the 283 laboratory tests done at referring hospitals, 246 (86.9%) were repeated on trauma center arrival; in 171 (69.5%) of the 246 repeated labs, results from initial (referring institution) tests had been sent. Unsent labs were those which were ordered by the referring hospital, but for which no results were sent with patients. For the 283 laboratory tests done at referring hospitals, receiving hospital test repetition was unassociated (P value by X2, .57) with whether referring hospitals sent (87.7% repeat rate) or did not send (85.2% repeat rate) results from initial tests; repetition of forwarded laboratory tests was an insignificant 1.03 times (95% confidence interval, 0.93 to 1.14) more likely than repetition of labs which had not been forwarded. For this group of 104 patients, the receiving hospital charged $49,843 for repetition of radiographs which had been done at referring facilities. Duplicate laboratory testing done at the receiving institution in patients who had had the same laboratory tests at the referring hospital, accounted for
157
$16,620 in trauma center charges. Repeat laboratory and radiographs, therefore, resulted in charges of $66,463 ($639 per patient) at the receiving trauma center.
DISCUSSION The idea of reducing repetitive laboratory testing through improved availability of previous results is not new to the emergency medicine literature, having been discussed by Stair in the context of the efficiency and cost advantages of computerized medical records. ~ In addition, investigators emphasizing provision of appropriate and cost-effective trauma care have cast doubt on the utility of many laboratory and radiographic tests "routinely" ordered on trauma patients. Specifically, experts have questioned the universal ordering of electrolytes, complete blood count, amylase, urinalysis, and toxicological screens. 2-5 Similar literature exists for the "routine" performance of trauma radiography. 2,6,7The concepts of increasing prior test result availability and judicious employment of trauma laboratory and radiograph testing can be simultaneously used by examining trauma work-up repetitions occurring in patients undergoing interfacility transfer. The most important point to include in this discussion is that the study attempts to address only the frequency and cost of work-up repetition. There is no intent, either explicit or implied, to determine to what degree the repetition is clinically indicated or otherwise appropriate. Of course, this is a shortcoming of the study if one's intent is to apply these results directly to patient care; such an application is not intended. Rather, the importance of the results is to show that workup repetition is frequent and costly, thereby highlighting a new area for future investigation. Injured patients ultimately requiring trauma center transfer may not appear to warrant trauma center care on presentation at community hospitals; these patients may legitimately undergo some testing that appears in retrospect to have been "unnecessary" or unrelated to the decision to transfer the patient. On the other hand, patients may have had findings on a referral hospital CT scan which warrant transfer to a trauma center, where repeat CT is necessary to evaluate interval change. The very nature of helicoptertransported patients is that they tend to have relatively high injury acuity. This higher injury acuity may account for reasonable repetition of some testing to more closely follow these critical patients. In fact, because helicopter-transported patients are usually more acutely injured than patients arriving at trauma centers by ground transport, the study has limited external validity to the entire population of injured patients undergoing interfacility transport. However preliminary the results may be, they are in some ways compelling. First, the very high number of radiographs forwarded with patients are a credit to referring hospitals. Although some of this excellent showing may be a Hawthorne effect from having the flight crew participating in the study, the fact that nearly 97% of radiographs were forwarded with patients speaks well for referring hospitals. Less optimal was the fact that over a third of plain radiographs forwarded were copies. In our experience, it is not unusual to have uninterpretable "copies" forwarded with trauma patients. However, our results (with relatively
158
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 2 • March 2000
narrow confidence intervals around the risk ratio) do not support the conclusion that trauma center physicians were impelled to order repeat radiographs because of the fact that forwarded films were copies. The issue of radiograph copies brings up the major shortcoming of this study, and the necessary focus of follow-up studies: the question of why there was work-up repetition. We did not attempt to ask referring hospital physicians why laboratory and radiograph testing was done, and also did not ask physicians at receiving hospitals why tests were repeated; the logistics of this were beyond the scope of this preliminary investigation but will certainly be a major part of subsequent studies. Given anecdotal experience with referring hospitals' forwarding unreadable copies of nonindicated extremity films, and also with trauma center physicians ordering repeat laboratory or radiography-without even looking at information sent from referring hospitals--based solely on protocol, we Suspect that further study of the rationale for performing trauma laboratory and radiograph testing will likely shed light on avenues for improved efficiency of care at both referring and receiving hospitals. Regarding laboratory testing, there are many justifiable reasons for repeating laboratory tests, ranging from rechecking for interval changes to establishing "baseline" laboratory data at the admitting hospital. However, it was noteworthy that there was no relationship between whether labs were sent from referring hospitals and whether they were repeated at the receiving hospital. Given recent focus 2-5 on reducing routine laboratory analysis in trauma patients, this may be an area where costs can be easily reduced without risk to patients. There are two issues relevant to data collection that warrant comment. First, the patient population studied was a cohort transported by a helicopter emergency medical service (EMS). We chose to study helicopter-transported patients because of the logistics of patient enrollment and the ability to obtain a consecutive series. However, although acuity and outcome information for our patients is unavailable (other than the fact that all were admitted to the trauma service) this group is likely to have been of higher injury
acuity than trauma patients transported by ground EMS. Because a more acute patient population could be expected to incur more laboratory and radiography work-up than a less injured group, the study's external validity to ground transported patients may be limited. Because the goal of the project was merely to identify whether repetitive work-up was frequent, this limitation does not negate our results. Indeed, even if the results from these patients could be extrapolated only to helicopter-transported interfacility trauma patients, the potential cost savings warrant further investigation. In summary, we present preliminary data which suggests that there is frequent repetition of laboratories and radiographs in trauma patients undergoing inteffacility transfer; there may be room for improved efficiency in the area of redundant trauma work-ups at referring and receiving institutions. We conclude that further study is warranted to address laboratory and radiography repetition in these patients, and that future efforts should focus on understanding: (1) why physicians at referring and receiving institutions order laboratory and radiograph testing, (2) why repetition is so frequent, and (3) whether some testing at referring or receiving hospitals can safely be eliminated.
REFERENCES 1. Stair TO: Reduction of redundant laboratory orders by access to computerized patient records. J Emerg Med 1998; 16:895-897 2. Melio FR: Priorities in the multiple trauma patient. Emerg Med Clin North Amer 1998;16:29-43 3. Namias N, McKenney MG, Martin LC: Utility of admission chemistry and coagulation profiles in trauma patients: A reappraisal of traditional practice. J Trauma Injury Infect Crit Care 1996;41:21-25 4. Mure A, Josloff R, Rothberg J, et al: Serum amylase determination and blunt abdominal trauma. Am Surg 1991 ;57:210-213 5. Tortella BJ, Lavery R, Rekant M: Utility of routine admission serum chemistry panels in adult trauma patients. Acad Emerg Med 1995;2:190-194 6. Terregino C, Ross S, Lipinski M, et al: Selective indications for thoracic and lumbar radiography in blunt trauma. Ann Emerg Med 1995;26:126-129 7. Yugueros P, Sarmiento JM, Garcia AF, et al: Unnecessary use of pelvic X-ray in blunt trauma. J Trauma Injury Infect Crit Care 1995;39:722-725