Lack of CT scanner in a rural emergency department increases inter-facility transfers: a pilot study
Bergeron et al. BMC Res Notes
Lack of CT scanner in a rural emergency department increases inter-facility transfers: a pilot study
Catherine Bergeron 0 2
Richard Fleet 0 1 2
Fatoumata Korika Tounkara 0 2
Isabelle Lavallée‑Bourget 0 2
Catherine Turgeon‑Pelchat 0 2
0 Chaire de recherche en médecine d'urgence de l'Université Laval, CHAU Hôtel‐ Dieu de Lévis , 143 Rue Wolfe, Lévis, QC G6V 3Z1 , Canada
1 Department of Family Medicine and Emergency Medicine, Université Laval , 1050, Avenue de la Médecine, Québec City, QC G1V 0A6 , Canada
2 Chaire de recherche en médecine d'urgence de l'Université Laval, CHAU Hôtel‐Dieu de Lévis , 143 Rue Wolfe, Lévis, QC G6V 3Z1 , Canada
Objective: Rural emergency departments (EDs) are an important gateway to care for the 20% of Canadians who reside in rural areas. Less than 15% of Canadian rural EDs have access to a computed tomography (CT) scanner. We hypothesized that a significant proportion of inter‑ facility transfers from rural hospitals without CT scanners are for CT imaging. Our objective was to assess inter‑ facility transfers for CT imaging in a rural ED without a CT scanner. Results: We selected a rural ED that offers 24/7 medical care with admission beds but no CT scanner. Descriptive statistics were collected from 2010 to 2015 on total ED visits and inter‑ facility transfers. Data was accessible through hospital and government databases. Between 2010 and 2014, there were respectively 13,531, 13,524, 13,827, 12,883, and 12,942 ED visits, with an average of 444 inter‑ facility transfers. An average of 33% (148/444) of inter‑ facility transfers were to a rural referral centre with a CT scan, with 84% being for CT scan. Inter‑ facility transfers incur costs and potential delays in patient diagnosis and management, yet current databases could not capture transfer times. Acquiring a CT scan may represent a reasonable opportunity for the selected rural hospital considering the number of required transfers.
Emergency department; Rural; Computed tomography; Inter‑ facility transfer
Quebec is Canada’s second largest province, with 20% of
its population living in rural areas [
]. Rural patients
cope with a curtailed physician-population ratio ,
longer pre-hospital emergency care response times [
and greater travel distances [
] than urban patients.
Rural patients and practitioners also live and work in
the context of limited access to specialists [
resources including, diagnostic imaging tools [
Computed tomography (CT) scans are commonly
used for the diagnosis of many surgical and
time-sensitive emergency conditions such as stroke, head trauma
and pulmonary embolism [
]. Most urban
emergency departments (EDs) in Canada have access to 24/7
in-hospital CT scanners, along with more than 90% of
all US hospitals [
]. The use of CT scans in EDs has
increased 330% between 1996 and 2007, and
approximately 25% of all CT scans performed in the US are now
requested by the ED [
In Canada, rural EDs outside the province of Quebec
have poor access to CT scans; 15% of Canadian rural EDs
have access to a CT scanner, compared to 77% in Quebec
]. This finding has generated debate on a national
]. While scanners may sometimes be overused,
lack of a local CT scanner may impose considerable
burden on the physician decision-making process in rural
settings where inter-facility transfers must to be weighed
in regards to the risks of transport over great distances,
delayed diagnosis, treatment and costs.
In a Canadian study conducted 18 years ago, up to 14%
of inter-facility transfers from five rural hospitals to
referral centres were solely for CT scans [
]. Another report
suggested that rural EDs are responsible for up to 60% of
patient transfers to tertiary centres, transfers that could
have been avoided if the rural EDs had radiology services
]. Similarly, an American group reported that patients
undergoing CT scans at the hospital to which they were
initially admitted were less likely to be transferred [
Although Canada’s Health Act has a clause promising
the right to access health care [
], there is no specific
guideline concerning standards for access to CT scans
]. According to a thorough review of the literature,
few recent studies have examined inter-facility transfers
for CT scans (“Annex 1”), particularly in rural Canada,
where CT imaging is limited. This pilot project aimed to
assess inter-facility transfer requirements for CT imaging
in a rural ED without local access to a CT scanner.
This pilot project is derived from a previous study [
The original study protocol was approved by the CSSS
Alphonse–Desjardins Research Ethics Committee
(Project MP-HDL-1213-011). In this earlier study, we
collected data on all of Quebec’s rural EDs (N = 26). We
found that only 6 out of 26 (23%) rural EDs did not have
access to a 24/7 CT scanner. For the purposes of the
current pilot study, we selected one of these six rural EDs for
convenience reasons (relative proximity to research team
and previous enthusiastic participation in pilot stages
of studies). We henceforth refer to this hospital as the
“selected rural ED”.
We contacted the selected rural hospital’s medical
archivists to obtain data on ED visits and transfer details
from 1 April 2010 to 31 March 2015. Using the local ED
triage software program, StatUrgence, we collected the
following data: total number of ED visits, total number of
patient transfers, receiving hospital names, and their
distances from the selected rural ED (“Annex 2”). Distances
between hospitals were measured using Google Maps
Additional data was collected concerning
inter-facility transfers from the selected rural ED to another rural
referral hospital. This hospital, 50.9 km distant, was
similar to the selected rural ED except that it had a CT
scanner. Transfers to this facility were therefore likely for the
purpose of a CT scan, while transfers to the more distant
urban, academic hospitals were more likely for severe
cases requiring specialized imaging and consultants. We
henceforth refer to this rural hospital as the “rural
referral centre”. We collected data on transfers between these
two rural hospitals between 1 April 2010 and 31 March
2015. Only transfer requests from the ED were
considered; thus, CT imaging requests from admission beds,
local clinics, family doctors or specialists outside the ED
were excluded. Both urgent and elective transfers were
eligible, regardless of the means of transportation. The
local archivist compiled the electronic medical records
for all patients transferred to the rural referral centre
during our study period in StatUrgence which provided the
date of transfer and the escort needed for each transfer.
Two medical students (CB, IL-B.) independently
reviewed transfer patients’ corresponding medical
records in MédiRad, the rural referral centre’s
radiology software, to determine which patients were
transferred for a CT scan. They searched the software to verify
whether patients underwent CT scan imaging on their
transfer date, and if so, double-checked if the origin of
the scan request corresponded with the selected rural
ED. If it did not, it was concluded that the transfer was
not for a CT scan. For patients transferred for a CT scan,
we searched for four main variables in MédiRad: age, sex,
type of scan, and the interval between the request and
the scan. To calculate the interval, we subtracted the time
the scan was ordered in the ED from the time the scan
was conducted as noted in the radiologist’s reports. We
only calculated the delay for urgent scan requests in the
selected ED; we excluded elective scans.
The primary outcome of our study was the preliminary
results of the inter-facility transfers for a CT scan in a
Quebec rural ED without a CT scanner to another
similar rural hospital with a scanner.
Inter‑facility transfers for a CT scan
Characteristics of the population served by the selected
ED and facilities available to them are described in
Over a 5-year period, the selected ED received an
average of 13,341 ED consultations per year, 444 (3%) of
which were transferred to other facilities. One-third of
these transfers (148, or 33.2%) were to the rural
referral centre. Of patients transferred to this referral centre,
125 (84%) were transferred to perform a CT scan, i.e.
28% (n = 125/444) of all transfers from the selected ED
(Table 2). Of these 125 transfers, 3.4% required a nurse
escort. Finally, as a yearly average, 330 (74%) of the
transfers from the selected rural ED were by ambulance,
with approximately 93 (63%) transfers to the rural
referral hospital for a CT scan.
Inter‑facility transfers for CT scans
The selected ED transferred 3.3% of its patients, a higher
percentage than the approximately 2% cited in literature
9, 27, 28
]. One third of all transfers went to the rural
referral centre, and 84% of these transfers were in fact
for CT scans. Thus, at least 28% of all the ED’s
inter-facility transfers were exclusively required for CT imaging,
which is twice as much as the proportion reported in the
]. Since this proportion is based on transfers
to only one rural referral centre (that is the “designated”
CT imaging center for the region) and only from the ED
(not from admitted patients or local clinics) this may be
an underestimation of overall transfers for CT scans.
Inter-facility transfers are costly and can delay the
diagnosis and management of time-sensitive emergency
conditions. The selected rural ED is 50.9 km away from the
rural referral hospital, and in the opposite direction of
the nearest Level 1 trauma center (91.8 km away). Travel
is accomplished in mountainous country road
conditions that are often hazardous, particularly in winter. In
this region, a single ambulance transfer takes 3 h round
trip and costs $722 including paramedic care [
Thus our rural ED’s estimated average of 93
ambulance transfers for a CT scan cost the healthcare system
approximately $68,000 per year, not including healthcare
professionals’ or staff time during transfer or direct and
indirect costs accrued by the patient. Inter-facility
transport costs for CT imaging must be weighed against the
costs necessary to purchase and maintain a local scanner
(upwards of $730,000 for purchase and $160,000/year
In addition to reducing inter-facility transports, it has
been shown that rural CT scans both narrow the gap
between urban and rural levels of health care as well as
promote general patient and local care because of the
faster access to diagnoses, higher confidence in
diagnoses, quicker treatments, better management of referrals
to specialists, and lower waiting times for CT scans for
rural patients [
]. Walkerton is a good example of the
beneficial impacts of access to a CT scanner in a rural
setting: this pilot project had such conclusive results that
the study was ended early and Walkerton decided to keep
the scanner [
This pilot study also indicates that conducting a larger
study is meaningful and feasible. Data on
inter-facility transfer requirements for CT imaging is important
and this was easily and reliably obtained using current
databases. We had access to all essential transfer
information, except for the time intervals between the CT
requests and the actual CT imaging. Only 2.5% of all
patient records mentioned the time at which the scan
was ordered in the ED, so we could not expect
significant findings on delays. This hinders our capacity to
estimate potential delays in diagnosis and treatment.
Quebec’s rural hospitals have limited electronic
]. Inter-facility data and imaging time-frames
are critical for resource planning and should be included
in future iterations of electronic databases. Without
these changes, only prospective and more costly study
where each inter-facility transfer for CT is tracked from
time requested to image interpretation and physician
assessment would help us assess the impact of not
having access to a local CT scanner.
• We believe this is the first Canadian study in the last
15 years to evaluate inter-facility transfers from a
rural ED without a CT scan [
• Considering our findings that less than 15% of rural
EDs in Canada have no in-hospital access to CT
scans, and faced with great transfer costs, similar
provincewide or nationwide studies are warranted [
A considerable proportion of inter-facility transfers were
required for CT imaging in a small rural hospital ED.
Inter-facility transfers incur costs and potential delays
in patient diagnosis and management, yet current
databases could not capture transfer times and final
diagnoses. Further improvement of databases is required.
Finally, acquiring a CT scan may represent a reasonable
solution for the selected rural hospital considering the
number of required transfers. Other studies are justified
to help stakeholders decide on the purchase of a CT in
• This pilot study was conducted in a single site out of
the 6/26 potential rural hospitals in Quebec without
access to a CT scanner. Our findings may not be
generalizable to these 5 other EDs, where ED volumes
and distances to CT may be different.
• The retrospective design may have limited thorough
data review in charts. For example, we did not have
access to data concerning reasons for transfer nor the
time intervals from requests and the imaging
interpretation. Moreover, the retrospective nature of the
data makes it impossible to prove that the patients
were solely transferred for a CT scan; it is
plausible that some patients may have been transferred
for another reason than for a CT, and received a
scan afterward in the referral hospital. Whatsoever,
if the patients had not been transferred, they could
not have received this particular investigation in the
selected rural ED.
EDs: rural emergency departments; CT: computed tomography.
RF, CB, CTP, FKT, IL‑B actively contributed to the creation of the study design.
RF, CB and IL‑B participated in the data collection and analysis. RF, CB, CTP, FKT,
IL‑B participated in the writing and reviewing of the manuscript and take full
responsibility for the content therein. All authors read and approved the final
We wish to thank the rural emergency staff and the medical archivists of
the selected ED for participating in this study. We also thank Luc Lapointe,
MA, and Rebecca Francois, BA, for their help with editing and formatting the
The authors declare that they have no competing interests.
Availability of data and materials
The datasets analysed during the current study are not publicly available due
to ethical considerations.
Consent for publication
Ethics approval and consent to participate
The original study protocol was approved by the CSSS Alphonse–Desjardins
Research Ethics Committee (Project MP‑HDL ‑1213‑011).
The research project was supported by the Fonds de recherche du Québec—
Santé (FRQS) and the Chaire de recherche en médecine d’urgence—Uni‑
versité Laval—Hôtel‑Dieu de Lévis. These funding organisms allowed us to
independently design the study, collect, analyse and interpret the data and to
write the manuscript.
See Fig. 1.
All articles were reviewed on the basis of the title and
abstract. We retained 11 relevant articles. We defined
as relevant articles that were about emergency rural CT
scans: accessibility, inter-facility transfers, quality of care,
difference with urban trends, etc. There were no
restrictions on origin or language of publication. However, we
rejected articles about telemedicine in rural areas, rural
stroke systems and very specific diseases. We also
discarded articles more than 20 years old since CT scan use
in rural areas evolved considerably over this period. Of
the 11 relevant articles, only two concerned inter-facility
“Tomography, X-Ray Computed”[Mesh] OR “CT”[tiab]
OR “scan”[tiab] OR “CT scanners”[tiab] OR
“Computed Tomography”[tiab]) OR “CT scanner”[tiab] OR
“CTscan”[tiab] OR “CT scanning”[tiab].
“Emergency services”[TIAB] OR “emergency
service” [TIAB] OR “emergency departments” [TIAB] OR
“emergency department”[TIAB] OR “emergency medical
services”[mesh] OR “emergency medical service” [tiab]
OR “Emergency Service, Hospital”[mesh].
“Rural health services” [mesh] OR “rural health
service” [tiab] OR rural population [mesh] OR “remote area”
[TIAB] OR “remote areas”[TIAB] OR “rural healthcare”
[TIAB] OR “Rural Health”[mesh] OR “medically
underserved area” [mesh] OR “medically underserved areas”
[tiab] OR “rural emergency department”[tiab] OR “rural
emergency departments”[tiab] OR “rural emergency
‘computed tomography scanner’/exp OR ‘CT’:ti,ab
OR ‘scan’:ti,ab OR ‘CT scanners’:ti,ab OR
‘Computed Tomography’:ti,ab OR ‘CT scanner’:ti,ab OR
‘CTscan’:ti,ab OR ‘CT scanning’:ti,ab.
‘emergency medical services education’/exp OR
‘emergency health service’/exp OR ‘emergency services’:ti,ab
OR ‘emergency service’:ti,ab OR ‘emergency
departments’:ti,ab OR ‘emergency department’:ti,ab OR
‘emergency medical service’:ti,ab.
‘rural health care’/exp OR ‘rural population’/exp OR
‘health care planning’/exp OR ‘rural health service’:ti,ab
OR ‘remote area’:ti,ab OR ‘remote areas’:ti,ab OR ‘rural
healthcare’:ti,ab OR ‘medically underserved areas’:ti,ab
OR ‘rural emergency department’:ti,ab OR ‘rural
emergency departments’:ti,ab OR ‘rural emergency
(CT OR scan OR CT scanners OR Computed
Tomography OR CT scanner OR CTscan OR CT scanning):ti,ab,tb
OR (Tomography, X-Ray Computed):kw.
(Emergency services OR emergency service OR
emergency departments OR emergency department OR
emergency medical service):ti,ab,tb OR (emergency medical
services OR Emergency Service, Hospital):kw.
(Rural health service OR remote area OR remote areas
OR rural healthcare OR medically underserved areas
OR rural emergency department OR rural emergency
departments OR rural emergency care):ti,ab,tb OR (Rural
health services OR rural population OR Rural Health OR
medically underserved area):kw.
Total ED patient transfers
Referral centres (and distances)
Primary care rural hospital with CT scan (50.9 km) Urban teaching hospital (91.8 km)
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