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Our objectives were to determine the frequency of patient transfers to a tertiary care emergency department (Tertiary ED) due to a lack of radiology services in rural hospital EDs (Rural EDs), and examine the community and patient attributes that are associated with these transfers.This was a retrospective chart review of patients transferred to a Tertiary ED from Rural EDs. Transfers excluded from the study included pediatric patients (age < 18 years old) and patients transferred for trauma surgeon evaluation. Only those patients who were transferred for radiology services were included in the final analysis.Over a 12-month period, 1445 patients were transferred to the Tertiary ED with 73.8% (n = 1066) of this population being transferred from a Rural ED. Excluding 381 trauma and pediatric patients, 64.3% (n = 685) of patients were transferred from a Rural ED and were included in the study. Of these 685 transfers, 24.5% (n = 168) were determined to be due primarily to a lack of a radiology service.Lack of radiology services in Rural EDs leads to numerous patient transfers to the Tertiary ED each year. A disproportionate number of these transfer patients are African American. These transfers place additional financial and social burdens on patients and their families. This study discusses these findings and alternative diagnostic options (ie, telemedicine and ultrasound video transfer) to address the lack of radiology services available in Rural EDs. The use of these alternate diagnostic options will likely reduce the number of patient transfers to Tertiary EDs.