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.

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)

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.

Deakin research into regional head trauma

Posted on March 30, 2010 by crem

March 2010

A research project has started in south-west Victoria to find out why people who suffer major trauma head injuries recover better in city areas than in country regions.

Deakin University Warrnambool Campus PhD student Ben Fisk said there was a common belief that people injured in metropolitan areas fared better than those with comparable injuries in country areas.

“Anecdotally there seems to be different outcomes between city and country regions so our first task is to identify and analyse the existing data to see if that is the case,” Mr Fisk said.

The research will consider the total range of trauma head injuries from car crashes and home falls to farm and industrial accidents.

Mr Fisk said his research would investigate and report on possible factors which could influence the apparent imbalance.

“The most obvious would seem to be the time delay in getting injured people to treatment but there hasn’t been a study into the whole situation which will make the findings important for future planning.”

“The goal for this year is to create a picture of what is happening in Western Victoria and compare it to Melbourne.”

Mr Fisk comes from a paramedic background and has worked with the Victorian Ambulance Service in Geelong and Warrnambool for the past nine years. He hopes to use his research to learn more about pre-hospital management systems and how rural and regional people access and utilise ambulance services.

The impact of an emergency rescue helicopter in south-west Victoria will be considered in the three-year study. “There are not enough statistics yet in the south-west area to judge what impact it is having,” Mr Fisk said.

The research will also look at the processes when head trauma patients are taken to small country hospitals.

The research has been funded by the Windermere Foundation which provides special grants for the development, introduction and/or evaluation of new practices, models and interventions to improve health in country Victoria

Deakin University’s Warrnambool Campus Pro Vice-Chancellor (Rural and Regional) Professor Sue Kilpatrick and the Director of the Centre Rural Emergency Medicine Tim Baker are joint supervisors of the research.