Paediatric aeromedical retrievals in the 'Top End' of the Northern Territory

The availability and delivery of culturally responsive Australian Aboriginal infant resuscitation education programmes: a structured literature review

AIM

To critically appraise the literature to determine availability and identify the cultural responsiveness of infant resuscitation education for Aboriginal and Torres Strait Islander populations.

BACKGROUND

Despite overall reductions in infant mortality in the last two decades, Aboriginal people have some of the highest rates of infant mortality of any developed nation. One of the key factors that has attributed to improvements in infant mortality rates is parent and carer education around risk factors and actions of first responders. Identifying gaps in the current basic first-aid initiatives available to Aboriginal communities may contribute to developing resources to contribute to reductions in Aboriginal neonatal mortality rates.

METHOD

The review used key terms and Boolean operators across an 11-month time frame searching for research articles utilising the databases of CINAHL, Scopus, Ovid Emcare, Informit, Pubmed and Proquest. After review, 39 articles met the inclusion criteria, 25 articles were discarded due to irrelevant material and 14 articles were included in the structured literature review. The search process was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Articles were assessed for validity and inclusion using the Critical Appraisal Skills Program checklist.

RESULTS

Research literature relating to First Nation community-based CPR and first-aid education programmes in Canada, USA, India, UK and Europe, Asia and Africa were identified; however, none pertaining specifically to CPR and first-aid education in Australian Aboriginal communities were found.

DISCUSSION

Despite the lack of research evidence relating to infant cardiopulmonary resuscitation (CPR) education for Australian Aboriginal populations, the reviewed studies noted the importance of culturally responsive education designed in collaboration with First Nation peoples, using novel ways of teaching CPR, that align with the language, culture and needs of the communities it is intended for.

CONCLUSION

Further research is required to create a framework for the delivery of culturally responsive infant resuscitation education for Australian Aboriginal parents and communities.

Pregnancy-related aeromedical retrievals in rural and remote Australia: national evidence from the Royal Flying Doctor Service

BACKGROUND

Inequalities in the availability of maternity health services in rural Australia have been documented, but not the impact on aeromedical retrievals. This study aims to examine the prevalence of pregnancy-related aeromedical retrievals, the most common conditions (overall and in specific age groups), and their distribution according to operation area and demographic characteristics.

METHODS

Cross-sectional study using administrative data from the Royal Flying Doctors Service (RFDS) including all pregnant women aged 15-49 years retrieved by the RFDS between 2015 and 2019. All pregnancy-related aeromedical retrievals were classified according to the International Classification of Diseases, Tenth Revision (ICD-10, chapter XV). The distribution of pregnancy-related conditions was presented overall and stratified by age group (i.e. < 20 years, 20-34 years and 35+ years). Retrieval and receiving sites were geographically mapped with Tableau mapping software® based on postcode numbers of origin and destination.

RESULTS

A total of 4653 pregnancy-related retrievals were identified (mean age 27.8 ± 6.1 years), representing 3.1% of all RFDS transfers between 2015 and 18 and 3.5% in 2018-19 (p-value 0.01). The highest proportion of pregnancy-related retrievals (4.8%) occurred in Western operation. There was an apparent increase in pregnancy-related retrievals in South Australia and the Northern Territory (Central Operation) in 2018-19. Preterm labour/delivery was responsible for 36.4% of all retrievals (40.7% among women aged 15-19 years) and premature rupture of membranes for 14.9% (19.4% among women aged 35-49 years). Inter-hospital transfers represented 87.9% of all retrievals, with most patients relocated from rural and remote regions to urban hospitals; most retrievals occurred during the day, with a median distance of 300 km. Adolescents and Aboriginal and Torres Strait Islander were overrepresented in the sample (four and eight times higher than their metropolitan counterparts, respectively).

CONCLUSIONS

The proportion of pregnancy-related aeromedical retrievals varies geographically across Australia. Overall, one-third of retrievals were related to preterm/delivery complications, especially among adolescents. Most retrievals performed by the RFDS are susceptible to public health strategies aimed at improving antenatal care and preventing unintended pregnancies among adolescents and Aboriginal and Torres Strait Islander women. Greater capacity to manage pregnancy conditions in rural hospitals could reduce the requirement for aeromedical inter-hospital transfers.

Impact of point-of-care testing for white blood cell count on triage of patients with infection in the remote Northern Territory of Australia

In Australia's Northern Territory (NT), acute infections are highly prevalent within Indigenous remote communities and difficulties in diagnosing the aetiology of infection are exacerbated by limited access to diagnostic tests. The objective of this study was to investigate the clinical effectiveness of point-of-care (POC) testing for total and 5-part differential white blood cell (WBC DIFF) counts for the triage of patients with possible acute infection. The HemoCue WBC DIFF POC device was introduced into 13 remote health clinics over a 6 month period. A retrospective clinical audit of patient cases meeting the selection criteria for three acute infections (sepsis, respiratory infection and appendicitis) were examined by four registrars in duplicate; one with POC test results available and the other with POC test results removed to determine if WBC DIFF results changed or assisted in patient triage. The number of changed outcomes provided a preliminary cost-benefit analysis. Sixty (23%) patient cases met the selection criteria for the clinical effectiveness analysis. POC test results changed the triage decision for 24 (41%) patients, of which 20 (34%) led to the prevention of an unnecessary medical retrieval and four (7%) indicated the patient had an acute infection which required a medical retrieval. POC test results assisted decision making for a further 13 (22%) patients. Cost savings related to avoiding unnecessary medical retrievals were estimated to be AU$481,440. Extrapolated NT-wide cost savings are projected to be AU$5.33 million per annum. POC testing for WBC DIFF counts aided clinical decision making for triaging patients with three common acute infections.

Is Nifedipine as a Tocolytic Effective in Facilitating In Utero Transfer?

OBJECTIVE

Previous studies have reported that air medical transfer of women in preterm labor can be safely accomplished, without preterm birth occurring; in fact, many women were later discharged without preterm birth occurring. The purpose of this study was to determine if nifedipine, when used as a tocolytic, is effective at facilitating in utero transfer of women in preterm labor in the Top End of the Northern Territory of Australia.

METHODS

This was a retrospective descriptive study over a 3-year period of all women transported in preterm labor between 23 + 6 to 36 + 6 weeks' gestation of pregnancy (N = 325).

RESULTS

The average gestation period was 32 + 2 weeks. The mean retrieval time was 6 hours. The mean time of birth from referral was 33 hours. A number of women gave birth to a preterm newborn in a remote health center (17%). There were 3 in-flight preterm births, and 49% of women were discharged without a preterm birth occurring. All women transported by air medical retrieval were admitted to the tertiary hospital for at least 24 hours.

CONCLUSION

In this study, nifedipine was used successfully to facilitate in utero transfer in many cases. Nearly half of the women referred were discharged without preterm birth occurring. Findings compare favorably with other published studies.

Mid-level providers and emergency care: let's not lose the force

The progressive rise of ED visits globally, and insufficient numbers of emergency physicians, has resulted in the use of mid-level providers as adjuncts for the provision of emergency care, especially in the US and Canada. Military medics, midwives, aeromedical paramedics, EMT-Ps, flight nurses, forensic nurses, sexual assault nurse examiner nurses--are some examples of well-established mid-level provider professionals who achieve their clinical credentials through accredited training programmes and formal certification. In emergency medicine, however, mid-level providers are trained for general care, and typically acquire emergency medicine skills through on-the-job experience. There are very few training programmes for NPs and PAs in emergency care. The manpower gap for physicians in general, and emergency physicians specifically, will not be eliminated in the reasonable future. Mid-level providers--ENTs, paramedics, NPs, PAs--are an excellent addition to the emergency medicine workforce. However, the specialty of emergency medicine developed because specific and focused training was needed for physicians to practice safe and qualify emergency care. This same principle applies to mid-level providers. Emergency Medicine needs to develop a vision and a plan to train emergency medicine specialist NPs and PAs, and explore other innovations to expand our emergency care workforce.