This chapter presents conclusions and best practices for BAC testing and reporting. It is based on information from all study sources: law review, data analyses, ten State visits, reports or other information from additional States, and the steering committee. It is organized into three sections. The first two, Who Is Tested and How Test Results Are Transmitted to FARS, build on the information presented in Chapters III and IV, respectively. The third, Management, affects every aspect of the issue.

No one model BAC testing and reporting system applies to all States. Each State has its own structure for the organizations involved in BAC testing and reporting: medical examiners or coroners, law enforcement, testing facilities, and traffic records. Each State has its own laws and procedures that affect testing and reporting. This means that laws, policies, or practices that work well in one State may not be effective or even possible in another State. This chapter presents best practices in two forms: as general principles that each State can apply within its own structure, and as examples from the study States that other States may wish to adopt or adapt.

Who Is Tested

Fatally Injured Drivers

Coroners or medical examiners typically have the responsibility for testing driver fatalities as part of their duties in investigating deaths not due to natural causes. As discussed in Chapter III, 27 States have laws requiring all fatally injured drivers to be tested. Ten States authorize, but do not require testing. Thirteen States and the District of Columbia have no law affecting testing. Chapter III also observed that BAC testing rates varied widely among the States in each of these three groups and that none of the three groups had testing rates markedly different from the others (Table 5).

Of the ten study States, six require testing -- California, Louisiana, Minnesota, Nebraska, Oregon, and Utah; and four have no law affecting testing -- Delaware, Iowa, Maine, and North Carolina.

Mandatory testing law requirements are not always understood or followed consistently throughout a State: sometimes different persons involved in the BAC testing and reporting process have quite different interpretations of their State’s laws. The presence of a law by itself does not assure high testing rates.

State medical examiners in many States or jurisdictions have adopted the practice of conducting a BAC test on every traffic fatality, sometimes also on non-traffic fatalities not due to natural causes, so that the medical examiner’s report can assess whether alcohol may have affected the death. Delaware, Iowa, Maine, and North Carolina all have such practices, though in some States not all county medical examiners or coroners
observe them. A mandatory testing law will of course support this practice. Table 10 summarizes the testing rates, laws, and medical examiner practices in the study States.

Table 10. BAC Testing for Fatally Injured Drivers
Study States, FARS 2002

Each of the ten study States had a mandatory testing law or medical examiner practice of testing all traffic fatalities. The two States with less than 80 percent known BACs had not implemented the law or practice in all areas of the State.

Fatally injured drivers who are not tested in high-testing States, even States with mandatory testing laws or practices, fall into several main classes. A small number cannot reasonably be tested because they die in crashes in which the driver cannot be identified or are crushed or burned so severely that a blood draw is not possible. Some die in crashes in rural locations where medical examiners or coroners may not be notified promptly. Others may be in areas where medical examiners or coroners do not have the equipment, training, or initiative to test. Still others are so “obviously” sober that medical examiners or coroners see no need to test. These latter two classes can be addressed through well-understood medical examiner practices and adequate equipment for testing. Finally, some are taken to a treatment facility and die some time after the crash. These are discussed subsequently.

Conclusions:

• Mandatory testing laws for fatally injured drivers produce high testing rates only if the laws are understood and followed consistently. Mandatory testing laws by themselves do not assure high testing rates.
  
  
• The medical examiner or coroner practice of testing all driver fatalities, as part of a complete report on the cause of death, will produce high testing rates if understood and followed consistently.

Best Practices:

• Establish and follow a medical examiner and coroner practice of testing all driver fatalities.
  
  
• In States with mandatory testing laws, inform all coroners and medical examiners of the law’s requirements and assure that these requirements are satisfied.
  
  
• Provide medical examiners and coroners with appropriate training and equipment for testing. Training may be provided through distance learning so need not be expensive or inconvenient.

Surviving Drivers

Law enforcement typically has the responsibility for obtaining a BAC test from surviving drivers under the circumstances authorized by State law. As discussed in Chapter III, five States require or permit all surviving drivers to be tested. Four States require or permit testing if the driver was responsible for the crash or violated a traffic law. Testing in the remaining States follows the probable cause standards of any DWI investigation. Thirty of these States and the District of Columbia have some law to assist in obtaining a test from drivers in fatal crashes who are under investigation for DWI, though these laws may not be commonly used or applied. Nine States have criminalized test refusal in any DWI investigation. Again, Chapter III observed that test rates varied considerably within each of these groups and that States in each group have achieved high testing rates.

Maine and Nebraska, among the study States, require all surviving drivers to be tested. Minnesota authorizes all surviving drivers to be tested under its vehicular homicide law and can force a test. Delaware, Louisiana, Maine, and Oregon also can force a test if law enforcement has established probable cause for a DWI violation. Test refusal is a criminal offense in Minnesota and Nebraska. In California, forced tests have been upheld in case law rather than by statute. The remaining three States -- Iowa, North Carolina, and Utah -- have no special provision for requesting or forcing a BAC test.

Law enforcement in some States without a mandatory testing law uses two practices to encourage BAC testing for surviving drivers. First, some law enforcement jurisdictions in Delaware, Louisiana, Oregon, and Utah request voluntary tests from all surviving drivers not suspected of DWI, as well as requesting tests of the remaining drivers under standard DWI procedures. They report very high compliance. Second, Delaware and Louisiana have established dedicated teams to investigate many fatalities. In several other States, the State law enforcement agency investigates a large proportion of traffic fatalities. The special teams and many State law enforcement officers are highly trained and understand the importance of BAC evidence, so have high testing rates for those drivers for whom tests are permitted by the State’s laws. Table 11 summarizes the testing rates, laws, and law enforcement practices in the study States.

Table 11. BAC Testing for Surviving Drivers
Study States, FARS 2002

Some States have adopted standard procedures to assist officers in acquiring BAC tests. Minnesota has a Motor Vehicle Implied Consent Advisory that the investigating law enforcement officer reads to a driver. It informs the driver that a test can be forced under Minnesota’s vehicular homicide law and is remarkably effective in encouraging cooperation. Louisiana has a Voluntary Submission Form that explains the reasons for the test request. Other States, including Louisiana and Maine, assist testing by providing investigating law enforcement officers with blood test equipment for use when needed by those authorized to draw blood.

Each of the five study States that tested over 50 percent of surviving drivers had either a mandatory testing law or requested voluntary tests as a standard practice. The remaining two States that requested voluntary tests tested 41 and 45 percent of surviving drivers, respectively.
.
California and Iowa have excellent law enforcement systems, no law that requires or encourages testing, and no widespread practice of requesting voluntary tests. They tested 25 percent and 35 percent of surviving drivers, respectively. They probably define the maximum testing rate that can be obtained without a mandatory testing law for all involved drivers or a widespread practice of requesting voluntary tests.

As with fatally injured drivers, testing rates for surviving drivers may be lower in rural areas, where law enforcement may not be able to respond quickly to the crash, may
not be experienced or trained in investigating fatal crashes, or may have long travel times from the crash scene to breath test equipment.

Conclusions:

• Mandatory testing laws for surviving drivers produce high testing rates; however, only five States have these laws.
  
  
• Voluntary testing programs can produce testing rates of 50 percent or more.
  
  
• Without either a mandatory testing law or a voluntary testing program, test rates are unlikely to exceed 35 percent and may be considerably lower.
  
  
• Testing rates may be lower in rural areas due to long response and travel times or lack of experience by investigating officers.
  
  
• Law enforcement should have standard procedures for carrying out the State’s testing requirements, backed up with appropriate training and equipment.

Best practices:

• In States with no mandatory testing law, establish and implement voluntary testing for all surviving drivers in fatal crashes.
  
  
• Establish standard procedures to request and administer tests. Back these up with appropriate training and equipment for all law enforcement personnel or others who may be called upon to administer tests. Training may be provided at roll-call or through distance learning methods as well as in formal class settings.
  

Drivers Taken to Hospitals or Emergency Departments

Drivers taken to hospitals or emergency departments present special challenges. If the driver subsequently dies, medical examiner or coroner personnel must go to the hospital and either draw blood, acquire a portion of the blood sample drawn upon admission, or access hospital records to obtain the BAC. In most study States, medical examiners reported good cooperation from hospitals. Oregon encourages cooperation with a law that authorizes medical examiners to access medical records and blood drawn for clinical purposes.

If the driver survives, law enforcement must go to the hospital to seek a test as appropriate: a mandatory test if required by the State, a DWI investigation test if probable cause has been established, or a voluntary test. Most study States routinely dispatch a law enforcement officer to the hospital in these circumstances. Cooperation between law enforcement and hospitals is critical. Again, Oregon law assists this process by authorizing medical personnel to notify law enforcement if the driver’s BAC level
exceeds Oregon’s per se level of 0.08 and by providing legal immunity for medical personnel who draw blood at the request of law enforcement.

As discussed in Chapter III, insurance laws in some States, including North Carolina and Texas, inhibit hospitals from drawing blood for clinical purposes. These laws substantially reduce BAC testing rates in these States.

Conclusions:

• Officials seeking blood samples or test results -- law enforcement, medical examiners, and coroners -- need good communications and relationships with medical facilities.
  
  
• Insurance laws should not deny payment to treat intoxicated persons.

Best practices:

• Establish and maintain good relationships and communications with medical facilities. Provide information about applicable laws.
  
  
• Eliminate provisions from State laws or insurance codes that allow insurers to deny payment for the treatment of intoxicated persons.
  
  
• Consider the use of contract phlebotomists or other authorized persons where there are difficulties in obtaining cooperation of medical personnel to draw blood.
  

How Test Results Are Transmitted to FARS

As Table 9 shows, in nine States over 10 percent of the fatally injured drivers were tested but the test results were not reported to FARS. Seven States had at least 10 percent unreported test results for surviving drivers. Several States appear on both lists.

Missing test results suggest problems in managing the data flow from test to FARS. States differ in their systems for processing and reporting test results. As with the discussion of who is tested, the following discussion of the reporting process attempts to document general principles that have been effective and to present examples of good practices in the study States.

FARS analysts in most study States obtain most BAC test information from the law enforcement agency that investigated the crash. The test information may be on the State’s crash report or on a separate report that accompanies the crash report. The process begins when the State’s FARS analyst is notified of a traffic fatality. Law enforcement in most study States notifies the FARS analyst by telephone, fax, or teletype as soon as they learn of a fatality. Many States use additional notification methods.

• California uses a weekly Persons Killed Report from the Highway Patrol, a monthly report from most county coroners, and regular copies of all death certificates (though death certificates may not be complete for six to nine months after a fatality).
  
  
• Delaware State Police have a Fatal Accident Investigation/Reconstruction (FAIR) team in each county that investigates most traffic fatalities. The FAIR teams notify FARS when they respond to a crash.
  
  
• Some States, including Iowa, Louisiana, and Maine, also scan newspaper stories of traffic crashes. This method works well in States with a small number of newspapers that between them cover the entire State.

Once FARS learns of a traffic fatality, FARS waits for a crash report on the crash and for BAC testing information for each driver and nonoccupant: whether the person was tested, and, if so, the test result. Often BAC test results are delayed substantially due to backups in a testing laboratory or to legal issues in crashes where criminal action is contemplated. When BAC results are delayed, law enforcement typically submits an incomplete crash report to FARS and follows up with an amended crash report or other report when the BAC results are received. These delays make more work for law enforcement, who must submit an additional report to FARS well after the original report has been sent. Sometimes law enforcement forgets to forward the BAC reports to FARS, so that FARS must check back periodically with law enforcement for the information.

Some States have developed alternate ways to obtain BAC test information if needed.

• Iowa obtains blood test results directly from the State testing laboratory, which conducts 50 to 60 percent of all tests from drivers in fatal crashes.
  
  
• Minnesota FARS has developed a special “fatality report” form for BAC data on each fatal crash, since Minnesota’s crash report does not include BAC test results.
  
  
• Nebraska has a unique system. The county attorney in each county is responsible for reporting the BAC result of each driver, fatally injured or surviving, in each fatal crash. (Nebraska law requires all drivers in fatal crashes to be tested.) Each county attorney sends BAC test results directly to FARS.
  
  
• Medical examiners in Oregon similarly report test results for fatally injured drivers directly to FARS.

FARS analysts in all study States have developed methods to track BAC test results and to follow up when necessary with the persons responsible for submitting these test results to FARS. Some examples:

• California FARS will call law enforcement agencies or coroners to obtain missing BAC test results.
  
  
• Maine and Utah FARS send letters to law enforcement requesting test results. Maine FARS also sends a quarterly spreadsheet of all fatally injured drivers and pedestrians to the State medical examiner’s office. The medical examiner’s office checks the spreadsheet against their records and add any missing data.
  
  
• Minnesota FARS faxes a form to the law enforcement agency if a crash report is received without BAC test data.
  
  
• Minnesota’s Office of Traffic Safety conducts an end-of-year check of all drivers in fatal crashes who may have had a BAC test, but for whom no test result has been recorded on FARS. The list is checked against the files of the State testing laboratory and, if necessary, with the individual law enforcement officer or medical examiner who would have been responsible for a test.
  
  
• Nebraska FARS will follow up with county attorneys periodically when necessary.
  
  
• North Carolina FARS receives a monthly report from the State medical examiner.
  
  
• Oregon has a “traffic fatalities tracking” crash data file with a “BAC received” field, from which it produces a monthly missing BAC report.

Study States raised several common problems in addition to delays in receiving BAC test results from testing laboratories.

• Staffing shortages at any point in the system can reduce testing and reporting rates, since BAC testing and reporting is not the top priority for many law enforcement officers, medical examiners, or coroners responsible for a fatal crash. In particular, staffing changes in one State’s FARS office reduced reported BAC results by 50 percent for one year.
  
  
• Reporting procedures in some States are not well institutionalized, but depend on personal relationships. These relationships must be re-established after every staffing change.
  
  
• Victims from crashes occurring near a State border may be transported to a hospital in an adjoining State for treatment. This adds another layer of complexity to establishing cooperation between law enforcement, medical examiners, coroners, and medical staff.
  
  
• The State’s FARS analysts are ultimately responsible for the completeness of the FARS data, but FARS has no direct authority over the persons responsible for supplying the data.

Conclusions:

• There is no single system for processing and reporting test results. Each State’s system must work within the confines and opportunities of the State’s structure.
  
  
• Effective systems employ many or all of the following best practices.

Best practices:

• Use a well-defined reporting process, with clear responsibilities. Institutionalize the process so it does not rely on personal relationships. Consider creating a flowchart to outline the process and responsibilities and checklists for FARS analysts, law enforcement, coroners, medical examiners, and other key participants.
  
  
• Establish a standard method for notifying FARS promptly of each fatal crash; use alternate sources as a backup.
  
  
• Track each involved driver from the FARS office until BAC data are received; follow up regularly with the persons responsible for reporting the data.
  
  
• When appropriate, establish methods to obtain BAC data directly from testing laboratories, coroner or medical examiner databases, or State breath test databases as well as through crash reports.
  
  
• Use electronic data transfer methods when possible to reduce data transmission delays and errors.
  
  
• Examine the FARS data periodically to check for missing BAC data; follow up if necessary.
  
  
• Establish and maintain good communication and relations among all organizations and staff involved in the process. It is especially important for law enforcement, medical examiners, and coroners to communicate well with hospitals and emergency departments and for the FARS office to communicate well with every involved organization.
  
  
• Establish good communications and working relationships with counterparts in adjoining States to obtain reports from crashes occurring in these States.

How the Process Is Managed

The BAC testing and reporting process presents management challenges. Law enforcement, medical examiners and coroners, State laboratories, hospitals and emergency departments, Highway Safety Offices, and motor vehicle departments all have critical roles, but are housed in different State agencies. States with high testing and reporting rates have established good working relations and communications among these organizations at both staff and management levels. High-reporting States also have made acquiring BAC data a high priority for all organizations involved in the process.

Some States cited funding and resources as barriers to higher testing and reporting rates. Law enforcement can be reluctant to seek tests on drivers where there is no suspicion of alcohol because of the time that must be taken from their other duties. Some jurisdictions, especially smaller towns and counties, are reluctant to send blood to a laboratory for testing if the jurisdiction must pay for the tests.

Several States encourage blood samples to be sent to the State laboratory for testing and pay all laboratory costs from the State budget. Maine uses Section 402 highway safety funds to pay the costs of drawing blood and analyzing blood samples.

An inexpensive suggestion that may increase testing and reporting rates is to relax FARS standards for BAC test evidence. Many investigating law enforcement officers use PBT (Preliminary Breath Test) equipment routinely. The PBT may not meet evidentiary standards in some States, but will provide a BAC reading that is acceptable for FARS. PBTs can be used easily and quickly to obtain voluntary tests from surviving drivers who are not suspected of being impaired. Similarly, clinical BAC results from medical facilities are not included in California autopsy reports because they are not considered to meet forensic standards, but they should be perfectly acceptable for FARS.

Conclusions:

• Managing the BAC testing and reporting process is a continuing challenge.
  
  
• In addition to the specific suggestions outlined in the previous section, good management requires that all participating organizations give BAC testing and reporting a high priority and that adequate resources and funding be provided.

Best practices:

• Establish BAC testing and reporting as a high priority for all State-level organizations involved in testing and reporting.
  
  
• Fund BAC testing at the State level as much as possible
  
  
• Accept PBT and other non-evidentiary BAC evidence in FARS for drivers where evidentiary BAC tests are not available or appropriate.
  
  
• To be most effective, State BAC testing and reporting operations need a focal point or champion -- a dedicated individual who will ensure that data collection steps are well documented, that staff are well trained, that interagency agreements are formalized and communications maintained, that necessary follow-up work is encouraged, that resources are available, that problems are resolved quickly, and that overall performance is monitored.
  
  
• Maintain adequate staff levels in all organizations involved in the process, especially the FARS office.

State BAC Testing and Reporting Forums

States have used BAC testing and reporting forums as a method to bring all participants together to understand the testing and reporting process, clarify roles, and uncover and solve problems. Other States have included BAC testing and reporting as one topic in a more general impaired driving forum. NHTSA encourages States with BAC testing and reporting issues to hold these forums and for a time accepted a forum as satisfying Basic Grant Criterion #7 for Section 410 impaired driving grants if the forum was:

“...attended by law enforcement officials, prosecutors, hospital officials, medical examiners, coroners, physicians, and judges; and must address the medical, ethical, and legal impediments to increasing the percentage of BAC testing among drivers involved in fatal motor vehicle crashes.”

Table 12 lists the fifteen States that held a forum devoted entirely to BAC issues from 1999 through 2003. Forum reports are available from the State Highway Safety Offices when noted. Appendix G contains the agenda from South Carolina’s 2003 forum.

Table 12. State BAC Testing and Reporting Forums, 1999 - 2003

Table 13 summarizes BAC testing and reporting rate changes following their forums for the 12 States that held forums between 1999 and 2001. In the table, the year of each State’s forum is shaded. Indiana, North Carolina, Ohio, and South Carolina improved some or all of their testing and reporting rates markedly after their forums. Florida, Maryland, and Missouri may have seen slight improvements. The forums in Alabama, the District of Columbia, New Mexico, Pennsylvania, and Virginia appear to have produced little change.

Conclusions:

• BAC testing and reporting forums can be a useful method to identify problems and suggest improvements.

Best practices:

• If appropriate, use a State BAC testing forum to clarify the testing and reporting process, discover problems, and suggest solutions.

Regional FARS Meetings

NHTSA’s Region VI conducts an annual meeting of the FARS coordinators from the Region’s States to share issues, solutions, strategies, and ideas. NHTSA covers travel expenses for participants. Other Regions may wish to consider similar meetings if there are problems common to several States in the Region or if some States can suggest strategies to deal with issues from other States.

Table 13. BAC Testing and Reporting Changes after BAC Forums (click here to view Table 13)