Tyranny of distance and rural prehospital care: Is there potential for a national rural responder network?

A novel COVID-19 program, delivering vaccines throughout rural and remote Australia

Background

The Royal Flying Doctor Service of Australia (RFDS) established a unique SARS-CoV-2 vaccination program for vaccinating Australians that live in rural and remote areas. This paper describes the preparation and response phases of the RFDS response.

Methods

This study includes vaccinations conducted by the RFDS from 01 January 2021 until 31 December 2021 when vaccines were mandatory for work and social activities. Prior to each clinic, we conducted community consultation to determine site requirements, patient characteristics, expected vaccination numbers, and community transmission rates.

Findings

Ninety-five organizations requested support. The majority (n = 60; 63.2%) came from Aboriginal Community Controlled Health Organizations. Following consultation, 360 communities were approved for support. Actual vaccinations exceeded expectations (n = 70,827 vs. 49,407), with a concordance correlation coefficient of 0.88 (95% CI, 0.83, 0.93). Areas that reported healthcare workforce shortages during the preparation phase had the highest population proportion difference between expected and actual vaccinations. Areas that reported high vaccine hesitancy during the preparation phase had fewer than expected vaccines. There was a noticeable increase in vaccination rates in line with community outbreaks and positive polymerase chain reaction cases [r (41) = 0.35, p = 0.021]. Engagement with community leaders prior to clinic deployment was essential to provide a tailored response based on community expectations.

GP decisions to participate in emergencies: a randomised vignette study

Background

GPs use their judgement on whether to participate in emergencies; however, little is known about how GPs make their decisions on emergency participation.

Aim

To test whether GPs' participation in emergencies is associated with cause of symptoms, distance to the patient, other patients waiting, and out-of-hours (OOH) clinic characteristics.

Design & setting

An online survey was sent to all GPs in Norway (n = 4701).

Method

GPs were randomised to vignettes describing a patient with acute shortness of breath and asked whether they would participate in a callout. The vignettes varied with respect to cause of symptoms (trauma versus illness), distance to the patient (15 minutes versus 45 minutes), and other patients waiting at the OOH clinic (crowding versus no crowding). The survey included questions about OOH clinic characteristics.

Results

Of the 1013 GPs (22%) who responded, 76% reported that they would participate. The proportion was higher in trauma (83% versus 69%, χ² 24.8, P<0.001), short distances (80% versus 71%, χ² 9.5, P=0.002), and no crowding (81% versus 70% χ² 14.6, P<0.001). Participation was associated with availability of a manned-response vehicle (adjusted odds ratio [OR] 2.06, 95% confidence interval [CI] = 1.25 to 3.41), and team training at the OOH clinic once a year (OR = 1.78, 95% CI = 1.12 to 2.82) or more than once a year (OR = 3.78, 95% CI = 1.64 to 8.68).

Conclusion

GPs were less likely to participate in emergencies when the incident was not owing to trauma, was far away, and when other patients were waiting. A manned-response vehicle and regular team training were associated with increased participation.

Emergency trauma care in rural and remote settings: Challenges and patient outcomes

INTRODUCTION

Trauma is a global public health concern, with higher mortality rates acknowledged in rural and remote populations. Research to understand this phenomenon and to improve patient outcomes is therefore vital. Trauma systems have been developed to provide specialty care to patients in an attempt to improve mortality rates. However, not all trauma systems are created equally as distance and remoteness has a significant impact on the capabilities of the larger trauma systems that service vast geographical distances. The primary objective of this integrative literature review was to examine the challenges associated with providing emergency trauma care to rural and remote populations and the associated patient outcomes. The secondary objective was to explore strategies to improve trauma patient outcomes.

METHODS

An integrative review approach was used to inform the methods of this study. A systematic search of databases including CINAHL, Medline, EmBase, Proquest, Scopus, and Science Direct was undertaken. Other search methods included hand searching journal references.

RESULTS

2157 articles were identified for screening and 87 additional papers were located by hand searching. Of these, 49 were included in this review. Current evidence reveals that rural and remote populations face unique challenges in the provision of emergency trauma care such as large distances, delays transferring patients to definitive care, limited resources in rural settings, specific contextual challenges, population specific risk factors, weather and seasonal factors and the availability and skill of trained trauma care providers. Consequently, rural and remote populations often experience higher mortality rates in comparison to urban populations although this may be different for specific mechanisms of injury or population subsets. While an increased risk of death was associated with an increase in remoteness, research also found it costs substantially less to provide care to rural patients in their rural environment than their urban counterparts. Other factors found to influence mortality rates were severity of injury and differences in characteristics between rural and urban populations. Trauma systems vary around the world and must address local issues that may be affected by distance, geography, seasonal population variations, specific population risk factors, trauma network operationalisation, referral and retrieval and involvement of hospitals and services which have no trauma designation.

CONCLUSIONS

The challenges acknowledged for rural and remote trauma patients may be lessened and mortality rates improved by implementing strategies such as telemedicine, trauma training and the expansion of trauma systems that are responsive to local needs and resources. Additional research to determine which of these challenges has the most significant impact on health outcomes for rural patients is required in an effort to reduce existing discrepancies. Emphasis on embracing and expanding inclusive planning for complex trauma systems, as well as strategies aimed at understanding the issues rural and remote clinicians face, will also assist to achieve this.

Aeromedical retrievals in Queensland: A five-year review

OBJECTIVE

Aeromedical services are an essential part of the healthcare system. Centralised coordination of aeromedical retrieval tasking offers benefits for safety, timeliness and efficiency in service delivery. The aim of the present study is to review aeromedical retrievals in Queensland exploring patient demographics, temporal patterns and usage characteristics.

METHODS

This is a retrospective cases series for the period 1 January 2010 to 31 December 2014 incorporating data from Retrieval Services Queensland and Queensland Newborn Emergency Transport Service. Ethics approval was obtained (JCU-HREC H6137 and Public Health Act #RD005673). Descriptive analysis of the de-identified data was undertaken included patient demographics, referral and receiving locations, retrieval platform and acuity of transport request.

RESULTS

There were 73 042 aeromedical retrievals undertaken during the period, with an average of 40 cases per day (range 16-89). The majority (95%) of retrievals were for Queensland residents. Overall 23.1% of cases were cardiology-related and 12.7% were injury-related. Older adults aged 75-84 years had the highest rate of retrievals relative to the population with a crude rate of 942.4 per 100 000 per annum. Overall 14.9% of cases were Priority 1, which represents the tasking with the highest acuity but majority were Priority 4 (41.6%). One third (37.6%) of all patients were from inner regional locations.

CONCLUSIONS

Potential investments in health service planning may alleviate the burden on aeromedical services, particularly related to cardiology services in inner and outer regional Queensland. Aeromedical services are pivotal in enabling all sick and injured residents' access to the highest quality of care regardless of the remoteness of their residence.

Motivation of emergency medical services volunteers: a study of organized Good Samaritans

BACKGROUND

Early professional care in emergencies is beneficial in general and its utility has been proven in many studies, particularly in regard to out-of-hospital cardiopulmonary arrest. A person in distress can expect help from two sources: bystanders, including family members, community members, and complete strangers; and professionals, including emergency medical services, first responders, firefighters, and police officers. Emergency Medical Services try to achieve faster first response times through various approaches. Recent technological and social developments have enabled a new form of Emergency Medical Services volunteering, called Organized Good Samaritans, which represents a new layer between occasional volunteers and time-donation volunteers. Organized Good Samaritans are people with a medical background, particularly off-duty medical professionals who are willing and able to provide first aid in emergencies in their vicinity.

METHODS

A qualitative formalization of technology-enabled Organized Good Samaritans is presented. One thousand eight hundred Israeli National Emergency Medical Services volunteers were surveyed using Clary and Snyder's Volunteer Functions Inventory instrument. Demographics, professional backgrounds, and volunteering functions of Time-Donation Volunteers and Organized Good Samaritans are compared.

RESULTS

Significant differences between Organized Good Samaritans and Time Donation Volunteers were found. Demographically, Organized Good Samaritans are older and the percentage of males is higher. Professionally, the percentage of physicians and nurses among Organized Good Samaritans is higher. Motivation measures find that the motivation of Organized Good Samaritans is higher and the order of importance of the volunteering functions differs.

CONCLUSION

A clearly identifiable and differently motivated class of emergency services volunteers has emerged. An appropriate information technology infrastructure enables Emergency Medical Services organizations to integrate Organized Good Samaritans into core business processes to shorten response times to emergencies. Organized Good Samaritans provide a volunteering opportunity for highly skilled people unable to be Time-Donation Volunteers. Our findings provide an empirical basis for further research on Organized Good Samaritans integration into Emergency Medical Services operations. Emergency Medical Services administrators can use these findings to establish an Organized Good Samaritans infrastructure and adjust recruitment and retention. This study is limited to one national Emergency Medical Services organization in Israel. Cultural differences can impact results in other countries. Organized Good Samaritans effectiveness should also be studied in terms of response times and medical outcomes.

A Geospatial Analysis of Distances to Hospitals that Admit Pediatric Asthma Patients

Objective: Pediatric care is now concentrated in urban specialty centers ("regionalization"), even for common conditions such as asthma. At the same time, rural emergency medical services (EMS) faces challenges related to adequate workforce staffing and financing. This statewide study describes how regionalization of pediatric inpatient care for asthma exacerbations affects EMS operations, particularly for rural agencies. Methods: This is a statewide cross-sectional study of EMS encounters for pediatric asthma in patients aged 2-18 years from 2011 to 2016 using Florida's EMS Tracking and Reporting System (EMSTARS) database. EMSTARS encounters were deterministically linked to Florida's Agency for Healthcare Administration (AHCA) database. We categorized AHCA hospital facilities that received included patients by whether they did or did not admit pediatric asthma patients during the study period ("admitting facility"). We used geospatial analysis to map the EMS agency's home county and the admitting facilities addresses. For each county in Florida, we calculated the average estimated EMS travel distance to the nearest admitting facility using a dasymetric mapping approach. Results: The study included a total of 11,226 EMS pediatric asthma encounters, of which 11,153 (99%) matched to an EMS home county. AHCA data was available for 3,812 (34%) patients. Most counties with distances to admitting facilities less than or equal to 15 miles were urban (31 of 39). For distances of 31-45 miles to an admitting facility, 7 of 8 of counties were rural, and for distances greater than 46 miles, all 4 counties were rural. Conclusions: In this statewide study in Florida, we found long average estimated EMS travel distances to admitting facilities for Florida's pediatric population in rural counties for pediatric asthma exacerbations. Those long distances have great implications for rural EMS operations, including pediatric destination decisions, transport times, and availability for others who call 9-1-1. Further research on bypass and secondary transport rates, and outcomes for asthma and other pediatric conditions are required to further characterize pediatric regionalization's impact on rural EMS.

Leveraging Data Quality to Better Prepare for Process Mining: An Approach Illustrated Through Analysing Road Trauma Pre-Hospital Retrieval and Transport Processes in Queensland

While noting the importance of data quality, existing process mining methodologies (i) do not provide details on how to assess the quality of event data (ii) do not consider how the identification of data quality issues can be exploited in the planning, data extraction and log building phases of any process mining analysis, (iii) do not highlight potential impacts of poor quality data on different types of process analyses. As our key contribution, we develop a process-centric, data quality-driven approach to preparing for a process mining analysis which can be applied to any existing process mining methodology. Our approach, adapted from elements of the well known CRISP-DM data mining methodology, includes conceptual data modeling, quality assessment at both attribute and event level, and trial discovery and conformance to develop understanding of system processes and data properties to inform data extraction. We illustrate our approach in a case study involving the Queensland Ambulance Service (QAS) and Retrieval Services Queensland (RSQ). We describe the detailed preparation for a process mining analysis of retrieval and transport processes (ground and aero-medical) for road-trauma patients in Queensland. Sample datasets obtained from QAS and RSQ are utilised to show how quality metrics, data models and exploratory process mining analyses can be used to (i) identify data quality issues, (ii) anticipate and explain certain observable features in process mining analyses, (iii) distinguish between systemic and occasional quality issues, and (iv) reason about the mechanisms by which identified quality issues may have arisen in the event log. We contend that this knowledge can be used to guide the data extraction and pre-processing stages of a process mining case study to properly align the data with the case study research questions.

Emergency Medical Services Bypass of the Closest Facility for Pediatric Patients

Objectives: Pediatric specialty care is increasingly regionalized. It is unknown how regionalization affects emergency medical services (EMS) providers' destination decisions for non-trauma pediatric patients. We sought to characterize the rates of bypass of the closest facility, and destination facilities' levels of pediatric care in three diverse EMS agencies. Methods: This is a one-year retrospective study of non-trauma pediatric patients less than 18 years of age transported by three EMS agencies (Baltimore City, Prince George's County, and Queen Anne's County) in 2016. A priori, a bypass was defined as transport to a facility more than 2 km farther than the distance to the closest facility. We calculated rates of bypass and categorized destination and closest facilities by their pediatric service availability using publicly available information. EMS transport distance and time were also compared for bypass and closest facility patients. Results: The three EMS agencies in 2016 transported a total of 12,258 non-trauma pediatric patients, of whom 11,945 (97%) were successfully geocoded. Overall 43% (n = 5,087) of patients bypassed the nearest facility, of which 87% (n = 4,439) were transported to a facility with higher-level pediatric care than the closest facility. Both bypass rates and destination facility pediatric levels differed between agencies. Bypasses had significantly longer transport times and distances as compared to closest facility transports (p < 0.001). For non-trauma pediatric bypasses alone, an additional 41,494 kilometers traveled, and 979 hours of EMS transport time was attributable to bypassing the closest facility. Conclusions: This study reveals a high rate of pediatric bypass for non-trauma patients in three diverse EMS agencies. Bypass results in increased EMS resource utilization through longer transport time and distance. For non-trauma pediatric patients for whom there is little destination guidance, further work is required to determine bypass' effects on patient outcomes.

Review article: Managing medical emergencies in rural Australia: A systematic review of the training needs

The aim of the study was to determine the training needs of doctors managing emergencies in rural and remote Australia. A systematic review of Australian articles was performed using MEDLINE (OVID) and INFORMIT online databases from 1990 to 2016. The search terms included 'Rural Health', 'Emergency Medicine', 'Emergency Medical Services', 'Education, Medical, Continuing' and 'Family Practice'. Only peer-reviewed articles, available in full-text that focussed on the training needs of rural doctors were reviewed. Data was extracted using pre-defined fields such as date of data collection, number of participants, characteristics of participants, location and study findings. A total of eight studies published from 1998 to 2006 were found to be suitable for inclusion in the analysis. Six studies cited the results of self-reported questionnaires and surveys, one used a telephone questionnaire on a hypothetical patient and one utilised a theoretical examination. The studies found a significant proportion of participants wanted more emergency training. Junior rural doctors were found to have deficiencies in knowledge about stroke. Emergency skills doctors wanted more training including: emergency ultrasound, paediatric/neonatal procedures and cricothyroidotomy. However, many of the studies were performed by training providers that may benefit from deficient results. Given that the data was over 10 years old and that advances have been made in knowledge, training opportunities and technology, the implications for current training needs of rural doctors in Australia could not be accurately assessed. Thus there is a need for further research to identify current training needs.