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.



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:

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.

Point of Care Troponin (POCT) Brief

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

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.

Deakin research into regional head trauma

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.