Centre for Rural Emergency Medicine Part of NHMRC Grant for Alcohol Research

A 2015 alcohol screening pilot project undertaken at South West Healthcare Emergency Department has contributed to the awarding of a $1.5M research grant.

The Federal Government’s National Health and Medical Research Council (NHMRC) has announced South West Healthcare is part of a winning consortium to deliver the Driving Change: Using Emergency Department Data To Reduce Alcohol-related Harm pilot to emergency departments throughout Australia. SWH’s share of the funding will be approximately $100,000 over five years.

The NMHRC is Australia’s leading expert body for supporting health and medical research; developing health advice for the Australian community, health professionals and governments; and providing advice on ethical behaviour on health care and in the conduct of health and medical research. Becoming the recipient of an NMHRC grant is incredibly prestigious.

Joining SWH, the winning consortium includes Deakin’s Centre for Social and Early Emotional Development (SEED), Vincent’s Hospital Australia (Melbourne and Sydney), the Australasian College for Emergency Medicine, Australian National University, Barwon Health, Calvary Health Care ACT, Monash Health, University of New South Wales, and Cardiff University.

SEED’S Professor Peter Miller will lead the five-year project based on an international model that has shown to substantially reduce violent crimes, street assaults and hospital admissions related to alcohol. Building on the international evidence and pilot data gathered from Warrnambool and other Australian emergency department sites last year, he will oversee and evaluate an intervention that aims to reduce alcohol-related injury in the community through a randomised trial in eight emergency departments in Victoria, NSW and the ACT. A key aspect will be the introduction of mandatory ’last-drinks’ data collection within existing hospital IT systems that identifies areas of problem drinking.

‘Driving Change: Using Emergency Department Data to Reduce Alcohol-related Harm has the potential to improve the wellbeing of Australians,’ says the Director of the Centre for Rural Emergency Medicine’s Dr Tim Baker, who was heavily involved in last year’s pilot.

‘We are keen to continue to be involved so that the needs of rural patients and their families are considered, as well. Reducing the impact of alcohol and other drugs is our emergency department’s number one public health priority. Our share of the grant will allow a researcher to gather the information we need to find out what approach works best.’

According to the Australian Institute of Health and Welfare, over the past decade the number (from 40,000 – 60,000+) and rate (from about 200 – 270 hospitalisations per 100,000) of alcohol-related hospitalisations have risen annually.

SWH’s 2015 research highlighted the growing problem of ‘pre-loading’ – drinkers consuming vast amounts of (cheaper) alcohol at home before heading out to a licensed venue. The eight-month study asked people presenting with injuries at the Emergency Department whether they’d consumed alcohol in the 12 hour lead-up to their injury, and where they’d bought the alcohol they had at home before heading out for a night on the town.

The research also revealed Warrnambool’s May Racing Carnival is the peak time for alcohol-related injuries.

Early MRI versus conventional management in the detection of occult scaphoid fractures: what does it really cost? A rural pilot study

The scaphoid is the most frequently fractured carpal bone and accounts for a significant portion of presentations in the emergency department. Managing the patient in the emergency department with the help of an acute magnetic resonance imaging (MRI) allows early correct treatment and saves the patient wearing a splint unnecessarily if the scaphoid is not actually fractured.

This study by Tamika Kelson from South West Healthcare, Rob Davidson of the University of Canberra, and Tim Baker of CREM compared cost-effectiveness and patient impact for early MRI-based management and conventional management of occult scaphoid fractures in a rural setting.

The study found that MRI dramatically reduces the amount of unnecessary immobilisation, time of treatment and healthcare usage in a rural setting. It decreased societal cost, while the cost to the rural healthcare service was equivalent with either MRI or traditional approaches.

Access article on publisher’s site

Kelson T, Davidson R, Baker T. Early MRI versus conventional management in the detection of occult scaphoid fractures: what does it really cost? A rural pilot study. J Med Radiat Sci. 2016;63(1):9-16.

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

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.

Rural Diagnosis 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.

 

 

Last drinks: mapping alcohol harm in the country

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.”

 

Emergency department data sharing to reduce alcohol-related violence

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

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.

Read more: Access article on publisher’s site

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

What do small rural emergency departments do?

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.

Read more: Access article on publisher’s site

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.

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

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

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

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.

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.

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.

Read more: Access article on publisher’s site

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