Resources for managing trauma in rural New South Wales, Australia

Rural emergency departments: A systematic review to develop a resource typology relevant to developed countries

OBJECTIVE

Despite low patient numbers, rural emergency departments have a similar diversity of case presentations as urban tertiary hospitals, with the need to manage high-acuity cases with limited resources. There are no consistent descriptions of the resources available to rural emergency departments internationally, limiting the capacity to compare clinical protocols and standards of care across similarly resourced units. This review aimed to describe the range of human, physical and specialist resources described in rural emergency departments in developed countries and propose a typology for use internationally.

DESIGN AND SETTING

A systematic literature search was performed for journal articles between 2000 and 2019 describing the staffing, access to radiology and laboratory investigations, and hospital inpatient specialists.

RESULTS

Considerable diversity in defining rurality and in resource access was found within and between Australia, New Zealand, Canada and USA.

DISCUSSION

A typology was developed to account for (a) emergency department staff on-floor, (b) emergency department staff on-call, (c) physical resources and (d) access to a specialist surgical service. This provides a valuable tool for relevant stakeholders to effectively communicate rural emergency department resources within a country and internationally.

CONCLUSION

The proposed five-tiered typology draws together international literature regarding rural emergency department services. Although further research is required to test this tool, the formation of this common language allows a base for effective communication between governments, training providers and policy-makers who are seeking to improve health systems and health outcomes.

The challenges of developing a trauma system for Indigenous people

Trauma systems have been shown to provide the best trauma care for injured patients. A trauma system developed for Indigenous people should take into account many factors including geographical remoteness and cultural diversity. Indigenous people suffer from a significant intentional and non-intentional burden of injury, often greater than non-Indigenous populations, and a public health approach in dealing with trauma can be adopted. This includes transport issues, prevention and control of intentional violence, cultural sensitization of health providers, community emergency responses, community rehabilitation and improving resilience. The ultimate aim is to decrease the trauma burden through a trauma system with which indigenous people can fully identify.

Trauma education of junior hospital doctors at a major Australian trauma service

BACKGROUND

Junior hospital doctors are often involved in the early management of major trauma. The present study assesses the access to trauma education and clinical trauma exposure and skills of junior doctors at a major trauma service.

METHODS

A semi-structured questionnaire was distributed to all resident medical officers (pre-registrar level) at a major trauma service. The questionnaire explored the quantity of exposure to major trauma, access to trauma education, self-perceived confidence and experience in basic trauma resuscitative procedures and future career aspirations.

RESULTS

A 70% response rate was achieved; 11% were Basic Surgical Trainees. Mean length of time post-graduation was 2.5 years. Fourteen per cent of respondents had completed the Advanced Trauma Life Support (ATLS) course; another 14% were on the waiting list for the ATLS course. Sixty-four per cent of respondents had attended fewer than five adult major trauma resuscitations in their entire career; 80% had never witnessed a major paediatric trauma resuscitation. Personal confidence in inserting a chest drain, management of cervical spine and airway was reported by 20%, 36% and 63% of respondents, respectively. The majority of respondents had never performed any of these procedures. Basic Surgical Trainees did not feel more confident in performing these procedures. Two-thirds (58%) of respondents nominated a future career aspiration which would potentially require involvement in the early management of major trauma.

CONCLUSIONS

Despite working in a major trauma service, the studied cohort of resident medical officers, including Basic Surgical Trainees, have minimal exposure to major trauma, restricted access to trauma education and limited self-perceived confidence and experience in basic trauma resuscitative procedures.

RURAL NEUROTRAUMA IN AUSTRALIA: IMPLICATIONS FOR SURGICAL TRAINING

BACKGROUND

Australia's vast size and small population preclude a neurosurgical service in most rural areas. Thus, general surgeons often initially manage rural neurotrauma. This study aimed to define the neurotrauma surgical caseload in rural Australia and to examine the level of training and confidence of rural surgeons for neurotrauma management.

METHODS

A questionnaire was sent to all Australian members of the Division of Rural Surgery of the Royal Australasian College of Surgeons. Responses were grouped by distance from a neurosurgical centre and analysed using one-way anova.

RESULTS

The response rate was 91%, and 161 rural surgeons were included. In total, 90 surgeons carried out approximately 600 procedures for neurotrauma in 5 years. The number of procedures per surgeon increased with distance from a neurosurgical centre (P < 0.0001), as did pre-transport delays (P < 0.001). Combined pre-transport and transport time was at least 2 h for 84% of surgeons. The majority (75% or more) of rural surgeons accessed hospitals with necessary basic infrastructure, including 24-h computed tomography scan, emergency department, and intensive care unit. There was no association between distance from a neurosurgical centre and level of neurosurgical training. Only 28% of rural surgeons had neurosurgery training more advanced than resident level. However, confidence with management of cranial trauma increased significantly with distance. More distant surgeons felt more confident with computed tomography reading (P = 0.02); burr hole (P = 0.02); craniotomy (P = 0.03) and intracranial pressure monitor insertion (P < 0.0001).

CONCLUSIONS

A significant volume of neurotrauma is managed surgically in rural Australia as dictated by distance. However, neurotrauma training of rural surgeons has occurred on an ad hoc basis, with those most exposed and most distant developing some confidence. Evidence for specific adequate training is lacking, but this study suggests that it is necessary.

Paediatric trauma

Trauma remains the most common cause of death in childhood after the first year of life. It accounts for considerable morbidity that may extend into adult life at great cost to the community. Despite the scale of the disease, paediatric trauma and injury prevention research attract little funding. International data indicate that children in Australia and New Zealand would benefit from improved injury prevention strategies and the introduction of a more formalized paediatric trauma system. Such a system would need to take account of Australasian geographical and population distribution characteristics, which mandate local provision of expert and immediate care in rural areas. There would appear to be economic and clinical arguments for the introduction of an ambulance trauma bypass system for stable but severely injured children in metropolitan areas with a paediatric trauma centre.

Interhospital transfers of patients with surgical emergencies: Areas for improvement

OBJECTIVE

To review mortality associated with interhospital transfers of patients with surgical emergencies from rural and peripheral metropolitan areas.

DESIGN

A retrospective case note review.

SETTING

All hospitals within an area health service including metropolitan and rural hospitals.

SUBJECTS

All patients with a surgical emergency who died in hospital after interhospital transfer within an area health service.

MAIN OUTCOME MEASURES

Factors associated with death and interhospital transfer.

RESULTS

In total, 22 patients were identified. The mean age was 77 years. Thirty-six per cent of patients were assessed by a surgeon prior to transfer. The mean time taken for transfer was five hours. Ten patients were physiologically unstable prior to transfer. No medical escort accompanied these patients. Four patients deteriorated during the transport process. Seventy-three per cent of patients arrived out of normal working hours. Fifty per cent of patients required an operation within 24 hours of arrival. All of these patients had significant medical co-morbidities. Seventy-two per cent of these operations were performed out of hours as an emergency case. Twenty-three per cent did not receive any operative intervention or intensive care admission at the tertiary referral centre. Forty-one per cent of deaths were related to peritonitis and intra-abdominal soiling.

CONCLUSIONS

Hospital systemic issues associated with mortality included extensive time delays in transfers, an inadequate transport process and frequent out-of-hours emergency operations. Patient features related to mortality included advanced age, significant medical co-morbidity and surgical pathology with a poor prognosis. Improvements concerning interhospital transfers of patients should address both systemic and patient issues.