Point of Care Troponin (POCT) Brief

Posted on February 28, 2012 by crem

February 2012

The Department of Health with South West Healthcare Warrnambool support have engaged on a six month pilot study followed by evaluation to trial Point of Care Troponin ( POCT) testing in emergency departments or urgent care centres in seven health services. Heywood, Portland, Moyne, Warrnambool, Camperdown, Terang and Timboon are the pilot sites.
POCT testing hopes to improve outcomes for patients by:

Faster results
Faster treatment
Better patient flow

The overall aim is to introduce an acute coronary syndrome pathway to Southwest Victoria and evaluate its impact by improving access to evidence-based acute and follow-up cardiac care through the provision of:

Agreed clinical pathway for chest pain
Introduce POCT testing
Improved access to a specialist cardiology advice line
Education for medical and nursing staff
Adherence to cardiac guidelines
Cardiac nurse facilitator

Project Lead: Dr. Tim Baker
Project Coordination: Integrated Cardiovascular Clinical network. Dr. Phil Tideman as Clinical Director and Rosy Tirimacco as the Network Operations and Research Manager.
Clinical Support: Geelong Hospital Cardiology Dr. Sandy Black.
Project Support: Victorian Cardiac Clinical Network

Margaret Bull. Cardiac Clinical Facilitator

Improving Rural Emergency Care

Posted on April 30, 2011 by crem

April 2011

Small rural emergency departments are important. They are a significant fraction of a state’s emergency medical system. Although they each see only a few thousand patients a year, as a group they are likely to treat more emergency patients than the largest city hospital. It is a myth that they only deal with minor ailments. Many isolated rural hospitals receive ambulances because ambulance services are reluctant to send their only local ambulance out of area. In addition, many patients with serious illness come directly to the emergency department without calling an ambulance.

There is little ongoing research into how these departments operate, and how their performance can be improved. Here we offer three ways to improve emergency care for communities around small rural hospitals.

Provide a simple access point for rural families, and advertise it.

We have found that country people are uncertain how to access help in a medical emergency. When we asked farming families to nominate their nearest emergency department, 10 % incorrectly nominated towns with no emergency department at all. Only some of these towns had a medical centre. Many studies have demonstrated rural families’ reluctance to call ambulance services. It is easy to imagine a scenario where people drive through the night to find the only available emergency care was in the other direction.

Improve co-operation between rural hospitals and ambulance services. Work out the number of critical care procedures required each year, and use simulation to keep a small number of clinicians competent to perform them.

It is hard for a small town to recruit enough doctors with critical care skills. It is just as hard to recruit paramedics with those skills. And there are not enough emergencies in most towns to keep a full complement of doctors, remote area nurses and paramedics from becoming rusty. Unfortunately, there are often too many to ignore. And unfortunately, a helicopter service is not always available either. Many small towns have a hospital and an ambulance base, but their rosters are not co-ordinated. One day there will be an intensive care paramedic and General practitioner Anaesthetist in town. Later in the week there will be nobody with critical care skills. An integrated system will also provide certainty for rural general practitioners who are concerned that they may have no role in rural emergency care in the future.

Add a key performance indicator for regional emergency departments that gives a minimum percentage of transfers from their surrounding small hospitals that must be accepted.

Every emergency department has an Admitting Officer to receive calls from surrounding health services. Most are helpful, but to meet the performance targets of their own department, they often become Deflecting Officers who refuse patients when they are busy. There is little downside to this for large hospitals, but a doctor at a small hospital can waste many hours looking for someone to accept his or her patient.

These three tasks – advertising a single access point, co-ordinating critical care cover, and auditing the responsiveness of regional services – will require different approaches in different jurisdictions. They will also require research, so that the solutions can be well targeted and evidence based. The Centre for Rural Emergency Medicine is committed to assisting in this process.

Small Hospitals Emergency Database (SHED) project results for the first quarter of 2011

Posted on April 30, 2011 by crem

April 2011

The first quarter SHED project results are currently being extracted for the 6 participating Emergency Departments. Between January and March close to 5000 people presented to an Emergency Department and saw a clinician. Overall the patient gender breakdown was fairly even, and weekdays saw higher patient volumes than weekends. When we have extracted a full years’ worth of data we will be able to determine trends in ED presentation. Over the next month the project team will be visiting participating hospitals to feed back the first quarter findings to the ED staff. We would like to thank the hospitals and staff for their continuing participation and we look forward to our next visit.

Farmers with acute chest pain are uncertain how and when to seek help

Posted on April 30, 2011 by crem

April 2011

A pilot study of the prevalence of cardiac risk factors in a group of agricultural workers and of their decision-making abilities with regard to when and how they would seek help when experiencing chest pain has found that most put themselves at risk of dying.

Dr Tim Baker, from the Centre for Rural Emergency Medicine at Deakin University School of Medicine, and Scott McCombe, Cate Mercer-Grant, and Susan Brumby, from the National Centre for Farmer Health at Deakin University School of Medicine and Western District Health Service, studied almost 200 farm men and women recruited from 20 rural Victorian sites.

Their study is published as an Early View article in Emergency Medicine Australasia, the journal of the Australasian College for Emergency Medicine.

The farmers underwent health assessments for total cholesterol, blood glucose, weight, height and blood pressure, and they completed a survey to determine their knowledge of chest pain treatment, local emergency services, and likely response to chest pain.

Each year in regional Australia approximately 9000 people die of coronary artery disease, with acute myocardial infarction accounting for approximately half of these deaths.

Nine hundred of these lives would be saved if mortality rates in regional areas were the same as those in metropolitan areas.

Delays in initiating treatment for acute cardiac events in rural areas might also contribute.

Treatment in the first two hours following a myocardial infarction can decrease mortality by half. Also, one in four people who experience a myocardial infarction die from cardiac arrest within one hour of their first chest pain.

Farmers and non-town dwellers are often thought to be the slowest rural Australians to seek emergency medical treatment.

Reasons given include the poorly defined and stereotypical concept of stoicism and an apparent fatalistic acceptance of supposed outcomes.

In this study, the researchers found 61% of the farmers had cardiac risk factors, with 61% of men and 74% of women either overweight or obese.

When asked to name their nearest ED, 10% of participants nominated health services or towns where no ED exists.

And 67% of respondents believed it was safe to travel to hospital by car while potentially having a myocardial infarction.

“This group of agricultural workers were at considerable risk of experiencing acute coronary events, but many would make decisions about when and how to seek medical help for chest pain that are at odds with published community guidelines,” the researchers concluded.

The researchers said a close relationship with a general practitioner remains the cornerstone of good rural health care, but contacting or visiting a local doctor at their clinic is not recommended when a patient has chest pain.

“Despite this group’s beliefs to the contrary, acute coronary syndrome can seldom be excluded in a clinic setting, and it has been shown to delay hospital presentation by at least one hour.

“In the present study, it appears that many farmers saw being driven to hospital as an acceptable alternative to calling the ambulance. Many reasons have been suggested for the reluctance of rural people to use ambulance services.

“Most rural people can recall an anecdote, from word of mouth or the media, where the use of an ambulance service was said to result in a poor health outcome.

“ There is a widespread belief that travelling by car is quicker and thus safer.

“One participant wrote on their questionnaire that it was ‘sometimes quicker to drive to hospital rather than get an ambulance’. Although the wait at home might be shorter in this scenario, the time to care, which is the most important factor, has been shown to be longer on average.

“Calling the ambulance also provides immediate telephone advice and activates the emergency medical system.

“Paramedics also have the ability to defibrillate once on the scene. From our group, it is not difficult to foresee a tragedy when someone travels by car for 30 minues to an ED where the doctor is unavailable or, even worse, to a town without an ED.”

Improving health literacy among farm men and women is of the utmost importance as they have higher rates of clinical risk factors and appear to be lagging in emergency knowledge and services when compared with their urban and regional counterparts, the researchers maintain.

“Farmers are generally the most remotely located within a population and would achieve greater benefit from acting rapidly in response to acute myocardial events and other medical emergencies.

“Programmes addressing behavioural barriers to accessing care and improving emergency decision making within the farming cohort might be readily translatable into rural lives saved.”

FURTHER INFORMATION:

Dr Tim Baker, phone 03 55633500, 0400 902 758

Australasian College for Emergency Medicine, phone 03 9320 0444

Issued for the Australasian College for Emergency Medicine by Marilyn Bitomsky, Impact Promotions & Publications, phone 07 3371 3057 or 0412 884 114. Media please note: I am overseas for a couple of weeks so if you need assistance, please contact Kerry Reeves, 07 3882 1068, 0407 036 791, kreeves@bytesite.com.au.

Farmers with acute chest pain are uncertain how and when to seek help

Posted on April 30, 2011 by crem

Researchers Dr Tim Baker, (Centre for Rural Emergency Medicine), and Scott McCombe, Cate Mercer-Grant, and Susan Brumby, from the National Centre for Farmer Health and Western District Health Service, studied almost 200 farm men and women recruited from 20 rural Victorian sites. The farmers underwent health assessments for total cholesterol, blood glucose, weight, height and blood pressure, and they completed a survey to determine their knowledge of chest pain treatment, local emergency services, and likely response to chest pain.

In this study, researchers found that 61% of the farmers had cardiac risk factors, with 61% of men and 74% of women either overweight or obese. When asked to name their nearest ED, 10% of participants nominated health services or towns where no ED exists. Sixty seven percent of respondents believed it was safe to travel to hospital by car while potentially having a myocardial infarction.

Baker, T., McCoombe, S., Mercer-Grant, C. and Brumby, S. (2011), Chest pain in rural communities; balancing decisions and distance. Emergency Medicine Australasia, 23: 337–345. doi: 10.1111/j.1742-6723.2011.01412.x

Out of hours radiology

Posted on March 30, 2011 by crem

March 2011

Introduction

Although Rural Emergency Departments operate 24 hours a day, not all hospital resources can do the same. In order to maximize the number of daytime radiographers, a reduced service is often in place after hours. Deciding to call in a radiographer at night may reduce the number of radiographers available the next day.

Unfortunately there is little research to base out of hours radiology guidelines on. Nobody really knows which images can be safely delayed until morning. The best that can be done is to see what has worked in other rural hospitals.

These guidelines were originally written for Portland District Hospital in Western Victoria. Portland is a town of 10,000 people on the South West Victorian coast, four hours drive from the capital city and over one hour drive to the nearest regional centre. The hospital has 69 beds, and the Emergency Department sees 9000 patients annually. The radiology facilities available between nine AM and five PM on weekdays include X-rays, CT scans and ultrasound. The radiographer is on call from home after these hours and on public holidays. There is no onsite radiologist, but opinions are obtainable by telemedicine 24 hours each day.

Principles

Radiographic imaging should only be ordered at night if it will significantly change the management of a patient. Positive images that confirm a diagnosis and negative images that exclude a diagnosis can both be useful. Radiographs should be ordered if a delay in imaging could adversely affect patient outcome. This can occur when uncertain diagnosis or inability to exclude important diagnoses result in

1. Delayed critical treatment

– Example: Confirming air under the diaphragm prior to laparotomy

2. Delayed critical investigation

– Example: excluding asymmetrical ICP rise prior to lumbar puncture

3. Delayed transport to critical care services

– Example: excluding pneumothorax prior to trauma transport by air

4. Delayed transport for urgent surgery

– Example: confirming fracture type underlying open wound

5. Prolonged patient pain because treatment cannot be initiated

– Example: confirming first dislocation of shoulder prior to reduction

6. Prolonged patient pain because treatments cannot be removed

– Example: Many hours in cervical collar when it could be removed if imaging showed no fracture

Approval

Several options are available

1. Emergency department staff can order any image, using this protocol as a guide

2. All image requests have to be cleared by the radiologist

3. Requests in accordance with this protocol can be ordered without radiologist approval. Borderline cases or cases outside the parameters of this guide have to be cleared by a radiologist. This is the option chosen by Portland District Hospital.

Weekends and public holidays

These are officially out of hours, but sometimes it is inappropriate for patients seen on Friday night to wait for two days for their imaging. This is particularly problematic on long weekends. For this reason, consider a system where a number of patients may be brought back on a weekend afternoon who do not strictly meet the after hours parameters. An example of this would be a deformed wrist fracture: Imaging can wait until morning, but should not wait for two days.

Trauma imaging

Portland is designated as an Urgent Care Service in Victoria’s Trauma system. It is tasked with rapidly assessing and stabilizing trauma patients and then moving them quickly to definitive care. Delayed diagnosis of traumatic injury, especially head injury or occult bleeding increases the likelihood of an adverse outcome.

Urgent radiology is indicated for

• Any trauma meeting major trauma criteria

• Head injury with any of the following

– Focal neurology

– Glasgow Coma Score < 14 (even if possibly due to intoxication)

– Severe headache

– Anticoagulant use (will need rescan at 24 hours also)

• Neck injury with any of the following

– Focal neurology

– Severe neck pain

– Inability to maintain c-spine precautions due to poor patient compliance

– Significant patient discomfort due to hard collar when delay in imaging is likely to be many hours.

• Chest trauma with any of the following

– Respiratory distress

– Hypoxia

– Significant pain

– Significant chest wall or sternal tenderness

• Abdominal trauma with any of the following

– Rebound or guarding

– Hypotension or tachycardia

– Macroscopic haematuria

• Pelvic trauma with

– Pain on pelvic springing

Urgent radiology is seldom indicated for

• Mild symptoms in low impact injury

• Intoxicated patients (GCS14) tolerating the hard collar, where intoxication precludes collar removal, even with a clear CT scan

Respiratory imaging

It can be difficult to diagnose the underlying cause for a patient’s respiratory distress. As treatments can be quite different (diuretics, anticoagulants, bronchodilators), it is important to make the diagnosis as soon as possible. Certain diagnoses (such as pneumothorax or large pleural effusion) can be treated immediately if they can be confirmed.

Urgent radiology is indicated for

• Shortness of breath of uncertain diagnosis with any of the following

– Increased work of breathing

– Tachypnoea

– New hypoxia (saturation < 95%)

• Possible pneumothorax

• Possible thoracic dissection

• Possible large pleural effusion requiring urgent aspiration (and post aspiration film also)

Urgent radiology is seldom indicated for

• Shortness of breath were the patient is not in respiratory distress

– Example: Probable mild to moderate pneumonia

• Shortness of breath where the diagnosis is certain and the patient is improving

– Example: acute asthma

• Possible pulmonary embolus where the patient is stable

– Unless the patient has a high risk of bleeding, the patient can be anticoagulated and imaged the next day

Abdominal imaging

Unless the diagnosis under consideration is likely to require immediate surgery, imaging can be delayed. It is often sensible to discuss the case with surgical staff prior to imaging.

Urgent radiology is indicated for

• Acute abdomen

– Obtain surgical advice. Immediate transfer or operation may be a better option

• Possible organ rupture

• Possible volvulus

• Possible leaking aortic aneurysm

• Possible ectopic pregnancy

• Unfortunately out of hours ultrasound is not available in many rural hospitals. The patient will need to be transferred

Urgent radiology is seldom indicated for

• Abdominal pain with localised abdominal signs

Orthopaedic imaging

Most patients with limb fractures can be made comfortable with splinting and analgesia. They can return the next day for x-ray. Even moderately displaced fractures are unlikely to be operated on after hours. They should also be splinted, but the patient may need to remain in the emergency department until x-ray is available the next morning.

Urgent radiology is indicated for

• Open fractures

• Fractures with significant limb deformity or neurovascular compromise

• Possible dislocation, if immediate relocation is possible

– Patients with recurrent shoulder dislocation may sometimes be relocated without x-ray, and remain in the emergency department for a post reduction film in the morning

• Possible cauda equina syndrome

Urgent radiology is seldom indicated for

• Mild or moderately displaced fractures with little chance of neurovascular problems

• Suspected fractures

Neurological imaging

Urgent radiology is indicated for

• Cerebrovascular accident with any of the following

– Time since symptom free < 3 hours

– Possible intra-cerebral bleed

– Example: associated anticoagulation, hypertension, headache

– GCS < 14

– Deterioration

• Focal seizures

• Prior to lumbar puncture

– Discuss with consultant staff. CT is occasionally not needed

Urgent radiology is seldom indicated for

• Transient ischaemic attack, if symptoms resolved

• Post seizure, if patient is returning to normal GCS

• Syncope, without focal neurology or abnormal vital signs

Other imaging

In general, patients being transferred to intensive care should not have their imaging delayed. If a patient requires urgent transfer for surgery, but that cannot be arranged until imaging results are known, imaging may have to be performed out of hours.

Urgent radiology is indicated for

• Patients being transferred to a critical care bed or for urgent surgery

– Example: post central venous line placement

• Patients requiring anticoagulation, but require exclusion of bleeding

– Example: Possible pulmonary embolus and altered mental state – exclude intracerebral bleed

Urgent imaging is seldom required for

• Possible acute coronary syndrome, if chest is clear and the patient is not being transported

• Peripheral foreign bodies

Dr Tim Baker

Small Hospitals Emergency Database (SHED) project begins data collection

Posted on February 28, 2011 by crem

February 2011

The SHED project is going full steam ahead with its data collection phase underway having started in January 2011. This phase of the project captures 12 months of emergency department data across six rural hospital locations. The data entered into the system will be used to accurately describe what happens in small rural emergency departments. We have had a high level of enthusiasm from participating hospital emergency departments and they are all entering their data with a high level of data accuracy.

Small Hospitals Emergency Database (SHED) project has employed 6 research assistants

Posted on December 30, 2010 by crem

December 2010

Six new casual research assistants have been hired to support the SHED project at each of the participating hospital locations. The research assistant role is central to the success of the data gathering phase of the project. Our research assistants will be helping hospital emergency department staff to understand the project requirements for data entry accuracy, along with training and providing support. CREM are pleased to announce and welcome our latest recruits: Nicola Taylor (Portland), Jenny Foster (Heywood), Margaret Tesselaar (Timboon), Grant Holmes (Camperdown), Carolyn Crowe (Moyne) and Heather Hicks (Terang).

Major partnership for Deakin Medical School in rural emergency medicine

Posted on November 30, 2010 by crem

November 2010

The Victorian Government, Alcoa of Australia and Deakin University’s Medical School have joined forces to create a Centre for Rural Emergency Medicine.

The Centre, to be launched in Portland on Tuesday 27 November, will operate through Deakin’s School of Medicine, hospitals at Portland District Health and South West Healthcare Warrnambool and through a network of regional doctors.

The Director of the Centre will hold a position in the Deakin Medical School.

Deakin researcher and paramedic hopes to improve paediatric policies

Posted on September 30, 2010 by crem

September 2010

Warrnambool paramedic and PhD student with Deakin University’s Centre for Rural Emergency Medicine Kate Cleverley hopes a study she is conducting will lead to improved procedures for transferring paediatric patients to hospitals.

Ms Cleverley said the study could lead to new guidelines that could be used across rural Victoria for the best procedures for taking paediatric patients to the most appropriate facility.

A paramedic with 10 years experience, Ms Cleverley said there were no current guidelines to direct paramedics.

“The intention of the study is to look at paramedic decision-making and to develop protocols and guidelines to make sure paediatric patients who need to go to a higher level of facility are transported there as rapidly as possible,” she said.

“It is not only about the timely nature of the transportation but determining the most appropriate facility to take patients to depending on the level of care required.”

Ms Cleverley said that anecdotally there had been some reports over time of cases where young patients had not been taken to the most appropriate facility.

“It isn’t a common problem but I think having guidelines for paramedics to follow would make the situation less likely to arise.”

She is conducting her research across the Barwon South West region and will include paramedic focus groups, interviews and information from the ambulance service databases. However, she said the planned guidelines could apply to any rural region.

Ms Cleverley completed her Master’s thesis in paediatric weight calculations used by paramedics and was keen to continue her studies in a similar field. She started her PhD studies this year and expects it will take several years to complete. “I am studying part-time at Deakin University in Warrnambool and working at the same time. It’s still in the early stages.”

Ms Cleverley has worked from Warrnambool for the past 18 months and for the six years prior to that was based at Hamilton.

Deakin’s Centre for Rural Emergency Medicine (CREM) is a joint initiative between the Department of Human Services, Portland District Health, South West Healthcare (Warrnambool), Alcoa of Australia and the Deakin Medical School.