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.

Providing a lifeline for rural doctors

Rural doctors often have specific training for rural emergency medicine. What they lack for difficult cases is immediate access to onsite specialist advice. Unfortunately, telemedicine programs are often designed to meet the needs of specialists rather than rural doctors and their patients.

This editorial by the Director of CREM, Tim Baker, outlines the view of advice lines and telemedicine programs from the perspective of the rural doctor making the call, and makes a plea for a more coordinated approach.

Access article on publisher’s site

Baker T. Providing a lifeline for rural doctors. Medical Journal of Australia -1 Nov 23 2015, Oct 5;203(7):277.

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.”

 

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

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.

Vic Emergency facilities

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.

Victorian emergency presentations

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?

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?

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.

Improving Rural Emergency Care

 April 2011

terang

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

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.