Trauma by-pass guideline: A data-driven conformance analysis for road trauma cases in Queensland.

OBJECTIVE: Study objectives were to (i) develop and test a whole-of-system method for identifying patients who meet a major trauma by-pass guideline definition; (ii) apply this method to assess conformance to the current 2006 guideline for a road trauma cohort; and (iii) leverage relevant findings to propose improvements to the guideline. METHODS: Retrospective analysis of existing, routinely collected data relating to Queensland road trauma patients July 2015 to June 2017. Data from ambulance, aero-medical retrievals, ED, hospital and death registers were linked and used for analysis. Processes of care measured included: frequency of pre-hospital triage criteria, distribution of destination (trauma service level), compliance with guideline (recommended vs actual destination), trauma service level by threat to life (injury severity) (all modes of transport and aero-medical in particular), proportion of patients requiring only ED, transport pathway (direct vs inter-hospital transfer). RESULTS: 3847 cases were identified from data as meeting criteria for major trauma by-pass. The top five most frequently used criteria for qualifying patients as meeting the major trauma by-pass guideline were pulse rate, vehicle rollover, possible spinal cord injury, respiration rate and entrapment. The study demonstrates a 65% conformance to the clinical guideline. Overtriaged patients (transported to higher trauma service than recommended) generally reveal International Classification of Disease Injury Severity Score representing a high threat to life. CONCLUSION: Overall, the present study found good conformance, with overtriage rate as expected by clinicians. It is recommended to include data values to capture paramedics assessment of trauma level to enable more accurate assessment of conformance to guideline and future revision of the thresholds.

Aeromedical retrievals in Queensland: A five-year review.

OBJECTIVE: Aeromedical services are an essential part of the healthcare system. Centralised coordination of aeromedical retrieval tasking offers benefits for safety, timeliness and efficiency in service delivery. The aim of the present study is to review aeromedical retrievals in Queensland exploring patient demographics, temporal patterns and usage characteristics. METHODS: This is a retrospective cases series for the period 1 January 2010 to 31 December 2014 incorporating data from Retrieval Services Queensland and Queensland Newborn Emergency Transport Service. Ethics approval was obtained (JCU-HREC H6137 and Public Health Act #RD005673). Descriptive analysis of the de-identified data was undertaken included patient demographics, referral and receiving locations, retrieval platform and acuity of transport request. RESULTS: There were 73 042 aeromedical retrievals undertaken during the period, with an average of 40 cases per day (range 16-89). The majority (95%) of retrievals were for Queensland residents. Overall 23.1% of cases were cardiology-related and 12.7% were injury-related. Older adults aged 75-84 years had the highest rate of retrievals relative to the population with a crude rate of 942.4 per 100 000 per annum. Overall 14.9% of cases were Priority 1, which represents the tasking with the highest acuity but majority were Priority 4 (41.6%). One third (37.6%) of all patients were from inner regional locations. CONCLUSIONS: Potential investments in health service planning may alleviate the burden on aeromedical services, particularly related to cardiology services in inner and outer regional Queensland. Aeromedical services are pivotal in enabling all sick and injured residents' access to the highest quality of care regardless of the remoteness of their residence.

A Program Profile of Air Medical Transport in Regional Central Queensland, Australia.

OBJECTIVE: The purpose of this study was to investigate the epidemiology of air medical patients and referral patterns in Central Queensland Hospital and Health Service (CQHHS). METHODS: Analysis of air medical transport from January 2010 to December 2014. Air medical tasks within the local health service boundary were included. All patients transported on rotor or fixed wing aircraft for medical purposes were included. Patterns of air medical tasks in and out of the region by referring and receiving location, aircraft type, flight priority, time of day, month, sex, age, illness, and referral indexes were analyzed. RESULTS: There were 11,456 air ambulance tasks in CQHHS region during the study period, an average of 2,291 retrievals per annum or 191 per month. Frequent referrals were to a tertiary facility, located 800 km across economic and political boundaries. Referral pattern indexes highlight a net patient flow of 1.2 to 1. Cardiology was the largest illness category (24%). Males represented 59% overall as well as patients 66 years and older (33%). Fixed wing aircraft carried out 87% of the tasks with a frequent response time of 6 to 24 hours. CONCLUSION: Air medical transports are an integral part of the health system in Central Queensland communities with vast geographic distances. Identifying regional referral pattern rates and ratios aid in the planning of resource allocation.

Review article: Primary aeromedical retrievals in Australia: An interrogation and search for context.

Primary aeromedical retrievals are a direct scene response to patients with a critical injury or illness using a medically equipped aircraft. They are often high-acuity taskings. In Australia, information on primary retrieval taskings is housed by service providers, of which there are many across the country. This exploratory literature review aims to explore the contemporary peer-reviewed literature on primary aeromedical retrievals in Australia. The focus is on adult primary aeromedical retrievals undertaken in Australia and clinical tools used in this pre-hospital setting. Included articles were reviewed for research theme (clinical and equipment, systems and/or outcomes), data coverage and appraisal of the evidence. Of the 37 articles included, majority explored helicopter retrievals (n = 32), retrieval systems (n = 21), compared outcomes within a service (n = 10) and explored retrievals in the state of New South Wales (n = 19). Major topics of focus included retrieval of trauma patients and airway management. Overall, the publications had a lower strength of evidence because of the preponderance of cross-sectional and case-study methodology. This review provides some preliminary but piecemeal insight into primary retrievals in Australia through a localised systems lens. However, there are several areas for research action and service outcome improvements suggested, all of which would be facilitated through the creation of a national pre-hospital and retrieval registry. The creation of a registry would enable consideration of the frequency and context of retrievals, comparison across services, more sophisticated data interrogation. Most importantly, it can lead to service and pre-hospital and retrieval system strengthening.

Leveraging Data Quality to Better Prepare for Process Mining: An Approach Illustrated Through Analysing Road Trauma Pre-Hospital Retrieval and Transport Processes in Queensland.

While noting the importance of data quality, existing process mining methodologies (i) do not provide details on how to assess the quality of event data (ii) do not consider how the identification of data quality issues can be exploited in the planning, data extraction and log building phases of any process mining analysis, (iii) do not highlight potential impacts of poor quality data on different types of process analyses. As our key contribution, we develop a process-centric, data quality-driven approach to preparing for a process mining analysis which can be applied to any existing process mining methodology. Our approach, adapted from elements of the well known CRISP-DM data mining methodology, includes conceptual data modeling, quality assessment at both attribute and event level, and trial discovery and conformance to develop understanding of system processes and data properties to inform data extraction. We illustrate our approach in a case study involving the Queensland Ambulance Service (QAS) and Retrieval Services Queensland (RSQ). We describe the detailed preparation for a process mining analysis of retrieval and transport processes (ground and aero-medical) for road-trauma patients in Queensland. Sample datasets obtained from QAS and RSQ are utilised to show how quality metrics, data models and exploratory process mining analyses can be used to (i) identify data quality issues, (ii) anticipate and explain certain observable features in process mining analyses, (iii) distinguish between systemic and occasional quality issues, and (iv) reason about the mechanisms by which identified quality issues may have arisen in the event log. We contend that this knowledge can be used to guide the data extraction and pre-processing stages of a process mining case study to properly align the data with the case study research questions.

Pre-hospital and retrieval medicine: Clinical governance and workforce models.

Pre-hospital and retrieval medicine (PHARM) has developed significantly in the past decade. This perspective article proposes that PHARM should develop with a clear focus on contemporary health governance principles, and that its workforce and models of care adopt modern interdisciplinary approaches. Many of the older systems of managing clinical standards, and outdated cultural approaches to professional 'turf', workforce and scope of practice have little place in high-performance organisations. This paper calls us to attention with a recommendation that best and safest systems of care, structured to optimise patient outcomes and system performance should be our goal.

The effectiveness of telemedicine for paediatric retrieval consultations: rationale and study design for a pragmatic multicentre randomised controlled trial.

BACKGROUND: In many health systems, specialist services for critically ill children are typically regionalised or centralised. Studies have shown that high-risk paediatric patients have improved survival when managed in specialist centres and that volume of cases is a predictor of care quality. In acute cases where distance and time impede access to specialist care, clinical advice may be provided remotely by telephone. Emergency retrieval services, attended by medical and nursing staff may be used to transport patients to specialist centres. Even with the best quality retrieval services, stabilisation of the patient and transport logistics may delay evacuation to definitive care. Several studies have examined the use of telemedicine for providing specialist consultations for critically ill children. However, no studies have yet formally examined the clinical effectiveness and economic implications of using telemedicine in the context of paediatric patient retrieval. METHODS/DESIGN: The study is a pragmatic, multicentre randomised controlled trial running over 24 months which will compare the use of telemedicine with the use of the telephone for paediatric retrieval consultations between four referring hospitals and a tertiary paediatric intensive care unit. We aim to recruit 160 children for whom a specialist retrieval consultation is required. The primary outcome measure is stabilisation time (time spent on site at the referring hospital by the retrieval team) adjusted for initial risk. Secondary outcome measures are change in patient's physiological status (repeated measure, two time points) scored using the Children's Emergency Warning Tool; change in diagnosis (repeated measure taken at three time points); change in destination of retrieved patients at the tertiary hospital (general ward or paediatric intensive care unit); retrieval decision, and length of stay in the Paediatric Intensive Care Unit for retrieved patients. The trial has been approved by the Human Research Ethics Committees of Children's Health Services Queensland and The University of Queensland, Australia. DISCUSSION: Health services are adopting telemedicine, however formal evidence to support its use in paediatric acute care is limited. Generalisable evidence is required to inform clinical use and health system policy relating to the effectiveness and economic implications of the use in telemedicine in paediatric retrieval. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12612000156886 .

The evacuation of cairns hospitals due to severe tropical cyclone Yasi.

On February 2, 2011, Tropical Cyclone Yasi, the largest cyclone to cross the Australian coast and a system the size of Hurricane Katrina, threatened the city of Cairns. As a result, the Cairns Base Hospital (CBH) and Cairns Private Hospital (CPH) were both evacuated, the hospitals were closed, and an alternate emergency medical center was established in a sports stadium 15 km from the Cairns central business district. This article describes the events around the evacuation of 356 patients, staff, and relatives to Brisbane (approximately 1,700 km away by road), closure of the hospitals, and the provision of a temporary emergency medical center for 28 hours during the height of the cyclone. Our experience highlights the need for adequate and exercised hospital evacuation plans; the need for clear command and control with identified decision-makers; early decision-making on when to evacuate; having good communication systems with redundancy; ensuring that patients are adequately identified and tracked and have their medications and notes; ensuring adequate staff, medications, and oxygen for holding patients; and planning in detail the alternate medical facility safety and its role, function, and equipment.

Use of telehealth for patients referred to a retrieval service: timing, destination, mode of transport, escort level and patient care.

We examined the utility of telehealth in assisting the decision-making processes of aeromedical coordinators, with particular focus on the timing, destination, mode of transport and escort level. Medical coordinators from the Northern Operations site of the Queensland emergency retrieval service were asked to complete a survey form about the changes that telehealth made to their retrieval decision-making process. Information was collected in six areas: diagnosis, severity, priority, crew, mode of transport and destination. During a 12-month period, there were 403 emergency referrals from the five participating sites. There were 136 eligible patient referrals for analysis, of which 90 did not have teleconsultations performed; the most common reasons were that the medical coordinator was too busy with other work or the new procedure was forgotten (n = 39, 43%). The remaining 46 patients had a teleconsultation during the trial and 44 data sheets were available for analysis. In 21 cases some component of the decision-making process was altered by the use of telehealth, with decisions being significantly altered in nine cases. Most alterations were for severity of patient condition, then diagnosis and priority of transfer. The use of telehealth was thought to be beneficial in confirming the original decision in 30 cases. Telehealth was not of assistance in seven cases. Telehealth appears to assist in accurate decision-making during the medical coordination of aeromedical retrievals.

The use of telehealth to assist remote hospital resuscitation and aeromedical retrieval tasking: a 12-month case review.

We evaluated the use of telehealth for patients who had suffered a cardiac or respiratory arrest, and were medically coordinated from the Queensland coordination hub at Townsville. We conducted a review of all cardiac or respiratory arrest cases where teleheath had been used prior to aeromedical retrieval. The doctors involved in the cases completed an evaluation form about the use of telehealth during the resuscitation. During the 12-month study period 6460 patients were medically coordinated from Townsville. Telehealth was used 51 times, i.e. for 0.8% of all transfers. Of the 51 uses of telehealth, nine were for patients having a cardiac/respiratory arrest, i.e. 18% of telehealth use at Townsville was for patients undergoing resuscitation following cardiac or respiratory arrest. All eight medical coordinators and three of eight referring doctors responded to the survey. Most medical coordinators stated that telehealth assisted communication and aided assessment. Most medical coordinators and some referring doctors felt that it improved the quality of patient care. The free text comments on telehealth use for remote area resuscitation were generally very supportive. While the telehealth equipment was easy to use, minor audio problems reinforce the need for systems to be wholly reliable. A set of guidelines to aid future telehealth assisted resuscitation was produced. The present study suggests that telehealth use is beneficial during active resuscitation efforts.

Australian dust storm: impact on a statewide air medical retrieval service.

INTRODUCTION: The Australian dust storm during the week of September 22, 2009, resulted in the grounding of a large portion of the air medical retrieval fleet in Queensland. We sought to determine whether during this event an increase occurred in cases requiring retrieval as a result of the dust storm, and whether the grounding of the retrieval fleet resulted in any adverse outcomes as a result of its inability to respond. METHODS: A retrospective review of respiratory and injury cases referred to the Queensland Emergency Medical System Coordination Centre from September 8 to October 5, 2009 was conducted. All cases with any respiratory or injury complaints were included. The number of cases, priority for retrieval, and the ability to retrieve these cases within the allocated time were examined and compared with those for a similar time frame in the previous year. RESULTS: A 62.5% increase in respiratory cases was seen, and 13.3% increase in injury cases during the week of the dust storm event, when compared with the previous year. Neither of these results reached statistical significance, but they demonstrate a practically important difference. For the month surrounding the dust storm event, a 48.5% (P = .04) increase in respiratory cases occurred, but no increase in injury cases when compared with the previous year. Only one urgent case was unable to be air medically retrieved during the study period as a result of grounding of the aircraft because of the dust storm event, but contingency arrangements were made for alternative transport. No adverse events were recorded during the study period. CONCLUSION: An increased demand on retrieval services was demonstrated during the period of the dust storm event. Despite grounding of the air medical fleet, all cases except one were able to be retrieved within clinically appropriate time frames or by alternative transport methods. Contingency plans need to be developed to cope with the possibility of similar events in the future, to prevent adverse events from occurring.

Queensland emergency medical system: a structural and organizational model for the emergency medical system in Australia.

OBJECTIVE: The emergency medical system (EMS) can be defined as a comprehensive, coordinated and integrated system of care for patients suffering acute illness and injury. The aim of the present paper is to describe the evolution of the Queensland Emergency Medical System (QEMS) and to recommend a strategic national approach to EMS development. METHODS: Following the formation of the Queensland Ambulance Service in 1991, a state EMS committee was formed. This committee led the development and approval of the cross portfolio QEMS policy framework that has resulted in dynamic policy development, system monitoring and evaluation. This framework is led by the Queensland Emergency Medical Services Advisory Committee. RESULTS: There has been considerable progress in the development of all aspects of the EMS in Queensland. These developments have derived from the improved coordination and leadership that QEMS provides and has resulted in widespread satisfaction by both patients and stakeholders. CONCLUSIONS: The strategic approach outlined in the present paper offers a model for EMS arrangements throughout Australia. We propose that the Council of Australian Governments should require each state and Territory to maintain an EMS committee. These state EMS committees should have a broad portfolio of responsibilities. They should provide leadership and direction to the development of the EMS and ensure coordination and quality of outcomes. A national EMS committee with broad representation and broad scope should be established to coordinate the national development of Australia's EMS.

The medical and retrieval costs of road crashes in rural and remote northern Queensland, 2004-2007: findings from the Rural and Remote Road Safety Study.

OBJECTIVE: To estimate costs of retrieval, transport and acute medical services associated with road crashes in northern Queensland from March 2004 to June 2007. DESIGN, SETTING AND PARTICIPANTS: Case study of 696 people aged 16 years or older who had been involved in a road crash in the study area (all areas north and west of Bowen, excluding the urban areas of Townsville and Cairns) and had been admitted to hospital for a minimum of 24 hours after the crash. Data on mode of retrieval, acute care provided and total costs were obtained for each patient. MAIN OUTCOME MEASURES: Method of retrieval or transport; length of stay in intensive care unit (ICU) and/or hospital for each patient; costs of retrieval, transport and inhospital care. RESULTS: Retrieval data were collected for 614 of the 696 study participants (88%). Most primary retrievals (446; 73%) occurred by road. More than half of interhospital transfers were undertaken by fixed or rotary wing services. Casualties in the study occupied a total of 6360 bed-days, of which 734 were ICU bed-days. The total retrieval, transport and acute hospital care costs of road crash victims in northern Queensland over the study period were calculated to be approximately $10.4 million. CONCLUSION: The costs associated with rural and remote road crashes in northern Queensland represent a considerable economic burden.

The use of telemedicine to aid in assessing patients prior to aeromedical retrieval to a tertiary referral centre.

We evaluated the effect of telemedicine compared with traditional telephone conversations when evaluating patients for aeromedical retrieval. A convenience sample of consecutive patients referred for retrieval from Palm Island over a six-month period was compared retrospectively with patients referred during the previous six months. There was a significant difference (P = 0.014) in the number of patients referred in the telemedicine period (113) compared to the previous six months (78), which may have been a seasonal fluctuation. There was a smaller proportion of aeromedical retrievals in the telemedicine period (78%) compared to the control period (92%), P = 0.009. Other significant differences between the telemedicine and control period included a larger proportion of patients not transferred at all (16% compared to 5%, P = 0.022) and a smaller percentage of rotary flights (52% compared with 73%, P = 0.004). Retrieval coordinators perceived that telemedicine use prevented 10 aeromedical flights and six night flights. The coordinators and referrers felt that telemedicine improved patient care in 75% and 65% of consultations, respectively. The coordinators felt that it improved communication with the referring doctor for 84% of the consultations.

Safety of interhospital transport of cardiac patients and the need for medical escorts.

OBJECTIVE: To review the safety of the current retrieval service procedures and identify factors associated with the need for a medical escort. METHODS: Detailed retrospective chart review of the records of patients with confirmed or presumed cardiac disorders transferred for acute care by the Townsville Hospital Emergency Department retrieval service between June 2003 and December 2004. RESULTS: A total of 555 charts were reviewed. During transport, 118 complications and 111 interventions occurred. In total, 414 patients required no intervention, 96 required nurse or paramedic care, and 45 needed a medical escort. Only one patient determined to need a doctor was not accompanied by one; however, 183 patients were accompanied by a doctor when no need was identified. A logistic regression model was applied to 463 patients after excluding intubated patients and those with any missing observation data. This found that the following variables were significantly predictive of events during transport requiring a doctor to be present: myocardial infarction (OR 2.48; P = 0.016; 95% CI 1.2-5.1), having received lysis (OR 3.54; P = 0.004; 95% CI 1.59-7.92), on an infusion (OR 5.06; P < 0.001; 95% CI 2.37-10.82) or history of cardiac arrest (OR 7.77; P < 0.001; 95% CI 2.9-20.77). CONCLUSION: Transport of cardiac patients by the Townsville Hospital Emergency Department retrieval service were safely staffed and performed, guided by the expert decision making and clinical support of the clinical coordinators. Patients with a provisional diagnosis at the time of referral of myocardial infarction, a history of receiving lysis or cardiac arrest, or on a drug infusion were more likely to require the expertise of a doctor during transport.