Over 1 in 10 trauma referrals to EDs in Singapore unnecessary

Stephen Padilla
11 Nov 2020
Believe it or not ER stories

A Singapore study has shown that more than one in 10 trauma referrals to the emergency department (ED) are not needed, as these patients have been discharged from the ED with no therapeutic procedure being performed.

“It is important to avoid such referrals, as they put a strain on the receiving ED and would lead to substantial costs for patients and the healthcare system,” the researchers said.

A retrospective chart review was conducted between 1 January and 31 December 2016 to determine the proportion of unnecessary trauma referrals and describe the characteristics of this patient population. The researchers collected data on demographics, diagnosis, and clinical course at the ED in standardized forms. Trauma referrals were considered unnecessary if the patient was discharged from the ED without a therapeutic procedure performed.

A total of 121 trauma referrals were included in the review. Ninety-four patients (77.7 percent) were male, and the mean age was 39.0±18.3 years. Of the referrals, 78 (64.5 percent) were from the EDs in the same healthcare cluster. [Proc Singapore Healthc 2020;29:163-166]

Fifteen trauma referrals (12.3 percent) were unnecessary. Of these, nine patients had sustained burns or suffered from smoke inhalation. These needless referrals had a length of stay of 197±96.2 minutes. Of note, a significant association was found between unnecessary referrals and the referring ED outside the healthcare cluster (odds ratio, 4.42, 95 percent confidence interval, 1.40–13.97; p=0.007).

In the US, the proportion of unnecessary referral was higher at 36 percent, which could be explained by the inclusion of EDs and hospitals from both urban and rural settings, in which significant variations in capabilities and resources to assess and manage trauma patients exist. [JAMA Surg 2017;152:11-18]

“This variation in clinical setting was less significant in our study, as we included EDs of restructured hospitals in Singapore which were all part of tertiary hospitals supported by clinical specialties,” the researchers said.

In addition, most physicians are not aware of the economics and costs involved in interhospital referrals, according to a study by Honigman and colleagues. [West J Emerg Med 2013;14:609-616]

“Therefore, a possible intervention could be to promote awareness amongst referring physicians of the downstream financial costs to patients, departments, hospitals, and the healthcare system, as well as inconvenience to patients and their caregivers,” the researchers said.

Telemedicine can also be explored to reduce the number of needless referrals. Use of real-time video conference consult with the receiving hospital’s specialists can provide a remote review of focused physical examination.

Previous studies support telemedicine use in different types of trauma, such as burn and hand injuries, thus reducing unnecessary referrals, length of stays, and the costs of interhospital referrals. [J Trauma 2008;64:92-97; J Trauma 2009;67:358-365; J Telemed Telecare 2017;23:321-327]

“Further prospective studies are needed in collaboration with other hospitals to elucidate the underlying reasons for these unnecessary referrals so that targeted solutions can be put in place to reduce them,” the researchers said.

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