Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Background: Emergency physicians frequently transfer patients with spine pathology to tertiary- care centers, although research suggests many are discharged without requiring a procedure or specialized imaging. Such transfers consume resources and remove patients from their families and communities. Better understanding these transfers might help identify which patients can receive care without transfer. 

Methods: This was a retrospective cohort study of transfers for spine evaluation to an urban, tertiary-care, Level I trauma center from October 1, 2017–October 1, 2022. Transfers were defined as necessary if the patient a) went to the operating room (OR) within 12 hours of arrival, b) had a neurologic magnetic resonance image (MRI), c) was admitted to an intensive care unit from the emergency department (ED), or d) was admitted to either neurology or a surgical service (including neurosurgery and orthopedics, which share spine coverage in the study hospital). 

Results: The study included 1,918 transfers with a spine evaluation, of which 617 (32.2%) were deemed potentially avoidable. Just 3.3% of all transfers went to the OR within 12 hours of receiving ED arrival, 45.7% had a neurologic MRI at the receiving hospital, and 36.6% were admitted to a neurology or a surgical service. For all transfers, 17.7% were discharged directly from the ED, 16.8% were placed in observation and then discharged, 6.8% were placed in observation and then admitted, and 58.7% were admitted to inpatient from the ED. The average ED length of stay for necessary spine transfers was 15.4 hours vs 16.6 hours for potentially avoidable transfers (P = .07). Compared to the overall rate of necessary transfers (67.8%), patients with the following conditions had a decreased incidence of necessary transfers: cervical spine fractures (62% necessary, P = .008), lumbar spine/sacrum/coccyx fractures (53.5% necessary, P < .001), and disc disorders (51.4% necessary, P = .003). Patients diagnosed with cervical spinal cord lesions (91.7% necessary, P = .01) had an increased incidence of necessary transfers.

Conclusion: Nearly one-third of spine evaluation transfers were potentially avoidable. Patients transferred for spine evaluation experienced prolonged ED stays, creating challenges for both receiving hospitals and patients. Further research is needed to prospectively identify patients who do not require tertiary care and to study methods for managing them in community settings.