Small rural hospitals are little in size, not importance (part two)

Posted on May 19, 2015 by crem

Small rural emergency departments are said to be not worth worrying about. Last post we tackled the question of whether they saw too few patients to be important. We saw, from the study described, that although each facility saw only small numbers, together they combined to be a significant proportion of a state’s emergency medical presentations.

But perhaps the patients that these small rural emergency facilities manage are not really that unwell. Perhaps these facilities provide little more than dressings and antibiotics?

Like last post, we looked at what was happening in our state of Victoria, Australia. We turned again to the 20,000 emergency medical presentations analysed in our original study as they were managed in six small rural hospital-based emergency care facilities. We compared them to the one million patients seen in Victorian metro hospitals. We used the 28 level codes developed by the Independent Health Pricing Agency for calculating ED activity. We created two 28 by 5 charts to show the data. We have decided not to show them to you. Instead we created a Wordle.

On a wordle, each word is proportional to the number of items represented by that word. The bigger the word, the more patients presented with that diagnosis.

At a glance, you can see the the same spectrum of patients for both groups. Can you guess which is small rural and which is metro? You should be able. Respiratory, circulatory and digestive problems are common at both. So is injury, but small hospitals see more minor injury, and less multi-trauma. They are not the same, but they are not vastly different either.

It is similar with triage categories. There is a general decrease in the urgent categories as you get to smaller hospitals, but not an order of magnitude less. In metro hospitals 5 patients per 1000 were category one and 100 per 1000 category two, in the small rural hospitals it was 3 per 1000 category one and 60 per 1000 category two. In both small rurals and metros, 4 was the most common category.

This makes sense to me. I never really understood how experts could be so sure that small rural hospitals saw no sick patients when rural patients are thought to have more risk factors and poorer health, present later, don’t like to travel as much, and don’t call the ambulance as often.

So small rural emergency facilities do see similar patients to larger facilities, with about half as many critical cases. When combined they see a significant proportion of emergency medicine presentations. I think this justifies our statement that small rural emergency facilities are little in size, not importance.

South West Healthcare Upskilling Emergency Department Doctors Under the Emergency Medicine Programme

Posted on April 20, 2015 by crem

South West Healthcare has employed three trainee doctors undertaking their specialist emergency medicine training thanks to funding under the Emergency Medicine Programme (EMP) from the Commonwealth Government.

EMP funds Specialist Training Posts to enable trainee emergency doctors to experience the lifestyle and work environment of rural and regional settings.

Director of South West Healthcare Emergency Department and the Centre for Rural Emergency Medicine, Dr Tim Baker said ‘our aim is to help recruit rural medical students, train them locally at Deakin University and provide as much of their specialist training as possible, here in the country. This is the best way to have doctors build country lives and, therefore, stay in the country.’

In addition, the Emergency Education and Training (EMET) program provides surrounding small hospitals, including Portland, Camperdown, Terang and Hamilton with visits, assistance, and training from the emergency specialist doctors based at Warrnambool.

South West Healthcare is one of 43 EMET hubs across Australia. In the past 30 months, the EMET program has been responsible for delivering more than 3,000 training sessions to 25,000+ doctors and nurses in more than 200 regional, rural and remote hospitals.

The EMET programme seeks to improve care for patients requiring urgent and emergency medical services in rural and remote areas by providing education, training and support to the large number of doctors and nurses working in the smaller hospitals and emergency care services who are not specifically trained in emergency medical care.

Dan Tehan, Member for Wannon said “that programs such as the EMP and EMET help to encourage health professionals who are committed to rural and regional areas at the completion of their training.”

Small rural emergency services can electronically collect accurate episode-level data: A cross-sectional study

Posted on March 25, 2015 by crem

Small rural emergency services (SRES), unlike larger emergency departments, seldom collect clinical and administrative data about every patient they manage.

Samantha Dawson, Tim Baker, and Scott Salzman studied six SRES that collected this type of detailed data for 12 months.

The SRES were able to collect accurate and mostly complete electronic episode-level data for 12-months with four hours per week of support. This study provides starting data accuracy benchmarks for specific fields collected in SRES and could be used to inform decisions about widespread electronic data collection across these services.

Access article on publisher’s site

Dawson SL, Baker T, Salzman S. Small rural emergency services can electronically collect accurate episode-level data: A cross-sectional study. Aust J Rural Health. 2015, Apr;23(2):107-11.

Last drinks: mapping alcohol harm in the country

Posted on March 6, 2015 by crem

Packaged liquor sales are acting as a major contributor to alcohol-related harm in rural areas, according to a new study published in Emergency Medicine Australasia, the journal for the Australasian College for Emergency Medicine (ACEM).

In the eight-month study, people presenting with injuries at an emergency department in rural South West Victoria were asked a series of questions including whether they had consumed alcohol in the 12 hours prior to injury, how much they had drunk and where they had bought most of the alcohol.

60% of respondents had bought most of their alcohol at packaged liquor outlets like bottle shops or supermarkets, the study found.

Approximately a quarter of these had gone on to have further drinks – including their ‘last drink’ prior to injury – at a licensed venue or public event.

“This is the first study of its kind to effectively map the source of alcohol-related ED attendances in a rural community,” said Associate Professor Peter Miller, lead researcher on the study, “It allows for the identification of problematic licensed venues and public areas and opens up great opportunity for further intervention; it’s a powerful tool to help communities tackle the problem of alcohol harm.”

Over half of the respondents who had bought most of their alcohol at packaged liquor outlets had consumed their last drink before injury at home, adding to the body of evidence that indicates many problem drinkers ‘pre-load’ at home with alcohol bought at a bottle shop or supermarket.

“The permissive culture that exists around the advertising, regulation and taxation of alcohol needs to be urgently addressed if we want to diminish the amount of harm it causes,” said Associate Professor Diana Egerton-Warburton, Chair of the ACEM Public Health Committee and Clinical Lead on the ACEM Alcohol Harm in Emergency Departments (AHED) Project.

There was also scope to introduce further measures to help reduce the harm caused by alcohol, Associate Professor Egerton-Warburton said.

“An effective brief intervention program – whereby drunks coming into the ED are screened and possibly referred for further treatment – could reduce the number of bloody idiots that we end up having to deal with,” she said, “Our research suggests that these drunks are often violent to staff, adversely affect other patient care and use a huge amount of resources.”

Dr Miller worked with Researchers from the Centre for Rural Emergency Medicine to add questions to a computerised triage system. “These data were generated with minimal cost, great cooperation among staff and no impact to the quality of patient care,” added Associate Professor Miller, “We’re already refining this model and hope to be engaging in a much larger trial very soon.”

Last drinks: A study of rural emergency department data collection to identify and target community alcohol-related violence

Posted on February 26, 2015 by crem

Alcohol-related violence and injury is a significant public health problem and a substantial burden on hospital EDs, especially on weekends during ‘high-alcohol hours’.

In this study by Peter Miller and Nic Droste, from Deakin School of Psychology, and Tim Baker from CREM, all patients aged 15 years or older presenting to a regional emergency department were asked whether alcohol was consumed in the 12 hours prior to injury, how many standard drinks were consumed, where they purchased most of the alcohol and where they consumed the last alcoholic drink.

The study found that this ED data collection was feasible, alcohol injuries were linked to identifiable venues and public areas, and packaged liquor sales substantially contribute to emergency department attendances.

Access article on publisher’s site

Miller P, Droste N, Baker T, Gervis C. Last drinks: A study of rural emergency department data collection to identify and target community alcohol-related violence. Emergency Medicine Australasia 2015, Jun;27(3):225-31.

Small rural hospitals are little in size, not importance (part one)

Posted on February 7, 2015 by crem

Small rural emergency departments are said to be not worth worrying about. They see too few patients. Is that really true? We decided to look at what was happening in our state of Victoria in Australia.

The Australian Hospital Statistics 2012–13 reports that there are 621 hospital-based emergency care facilities of some size and sort in Australia. 204 are what has been traditionally thought of as emergency departments – in metropolitan and large regional centres. The Australasian College for Emergency Medicine accredits about 180 of these for training. 469 are smaller, mostly rural, facilities.

I would love to describe the activity at these small rural facilities for you but, I can’t do it easily, because almost no data is collected from these 469 facilities. Large emergency departments submit episode level data on every patient they see – demographics, diagnosis, waiting times, disposition. Small emergency facilities often don’t have to submit anything but a count of how many people went through the door each year.

So we decided to collect some episode level data. There is no point being a Centre for Rural Emergency Medicine if you don’t even know what is going on. We created the SHED project – the Small Hospital ED project. We aimed to collect full episode level data from six small rual emergency departments. It wasn’t as easy as we expected. Some were still writing patient names in big old books. We put an emergency department IT system at each hospital, we took all the nurses through triage training, we educated the staff, we employed research assistants for over 12 months at each site, we audited about 10% of the patient notes.

The project ran from Feb 2011 until Jan 2012 and collected full episode level data from over 20,000 patients. We then expanded the project with the help of the Activity Based Funding Project at the Victorian Department of Health. We ran all our research queries through the data for all larger Victorian Emergency Departments over the same time, and we obtained the simple counts of patients presenting to Victoria’s other small rural emergency facilities over the same period. We think Victoria is a good state to study for this project as it is a small and fairly urban and centralised state. It is unlikely to exagerate the importance of rural hospitals.

So could we answer the thought that there are not many small hospital emergency facilities and they don’t see many patients.? We think we have something to add.

This is Victoria’s public emergency system represented with each icon scaled to the average number of emergency presentations seen in each class.

It is certainly true that metropolitan hospitals are bigger. They see on average 46,000 presentations each year (some are much bigger), and large regional hospitals average 42,000. Subregional hospitals see 17,000 and small rural hospitals 3,000.

You will notice though, that the number of hospitals goes the other way. There are 22 metropolitan emergency facilities compared to 62 rural emergency facilities- 45 of them are at small rural hospitals.

So can we multiply things to see where patients are seen? Yes we can.

Over a third of emergency department presentations in an urban state like Victoria are to a rural, regional, or remote emergency facility; one million metro, half a million rural. That means there are almost half as many reasons for Australasian College for Emergency Medicine to be a rurally-based college with a metro committee as a metro-based college with a rural, regional and remote committee.

And even the smallest emergency facilities, like some of those I work at, see 8% of the total presentations, or 140,000 per year. That means that the sector sees many more presentations Victoria’s largest single emergency department ED. When combined, at least in the number of presentations, small rural emergency facilities are big enough to be important.

(To be continued in part two)

Emergency department data sharing to reduce alcohol-related violence

Posted on June 16, 2014 by crem

This paper reviews the current evidence for reducing alcohol related injuries by sharing data collected by emergency departments, with agencies such as police, local council, liquor licensing regulators and venue management.

Nicolas Droste and Peter Miller from the School of Psychology at Deakin University, along with Tim Baker from CREM, performed a quantitative and narrative synthesis on 8 articles selected from an original search of 19,506 articles.

All studies found that data collection could be cheaply and easily implemented into modern ED triage systems. All but on study study reported substantial reductions to assault or injury. One reported no change.

Access article on publisher’s site

Droste, N., Miller, P., & Baker, T. (2014). Review article: Emergency department data sharing to reduce alcohol-related violence: A systematic review of the feasibility and effectiveness of community-level interventions. Emergency Medicine Australasia, 26(4), 326-35. doi:10.1111/1742-6723.1224

Small rural emergency services still manage acutely unwell patients

Posted on May 20, 2014 by crem

Australian small rural emergency services need to be prepared to manage diverse problems and urgent patients.

Dr Tim Baker and Samantha Dawson conducted a study that collected 12-months worth of episode-level data from 6 small rural emergency departments in Victoria’s south-west.

They found that a wide range of problems presented and that most of the common procedures were performed. Most importantly, almost 6% of 14318 emergency patients were in the two most urgent triage categories.

Baker T, and Dawson SL. Small rural emergency services still manage acutely unwell patients: A cross-sectional study [Internet]. Emergency Medicine Australasia. 2014;26(2):131-138.Available from: http://dx.doi.org/10.1111/1742-6723.12229

How many emergency departments?

Posted on April 7, 2014 by crem

How many ‘EDs’ does Australia have: 122, 126, 162, 181 or 203? How many rural hospitals have an emergency area that fails to make the grade: 483 or 406? We do not know because national organisations cannot agree when a rural hospital’s emergency service meets the criteria to be called an ‘ED’.

This brief article outlines the various counts and classifications of emergency departments and other hospital-based emergency care facilities in Australia.

http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12199/abstract

Baker T, Dawson S. How many emergency departments? Emergency Medicine Australasia 2014, Apr;26(2):212-3.

What do small rural emergency departments do?

Posted on October 30, 2013 by crem

There is a vast difference in settings and scales used by rural emergency departments reported in studies over the last 30 years that it is difficult to compare them.

Dr Tim Baker and Samantha Dawson from CREM reviewed 19 studies from Australia, Canada and the United States that described rural emergency department activity and performance, and identified common characteristics.

They found that the most common presentation was for injury or poisoning, and that a lot of patients presented outside of business hours. There were some urgent patients but this was only a small proportion of presentations. Nurses also managed many patients without medical input.

This study highlighted the need to support nurses as practitioners, and called for the use of common classification systems within the ED for ease of comparison.

Baker T, and Dawson SL. What small rural emergency departments do: A systematic review of observational studies. Aust J Rural Health. 2013;21(5):254-261.