A geospatial examination of specialist care accessibility and impact on health outcomes for patients with acute traumatic spinal cord injury in New South Wales, Australia: a population record linkage study.

BACKGROUND: Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. METHODS: This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013-2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. RESULTS: Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others. CONCLUSIONS: Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.

A proof-of-concept randomized controlled trial of follow-up mental health care for traumatic injury patients following hospital discharge.

INTRODUCTION: Traumatic injuries account for a huge burden of disease. Many patients develop persistent mental health problems in the months following hospital discharge. This proof-of-concept trial investigated whether Stepped Care comprising follow-up assessment telephone calls and appropriate referral information would lead to better mental health and functioning in traumatic injury patients. METHODS: Patients admitted to the Trauma Service at Royal North Shore Hospital were randomized to either Stepped Care (n = 84) or Treatment as Usual (n = 90). All patients were assessed for anxiety, depression, and posttraumatic stress prior to hospital discharge. Those in Stepped Care received a telephone call at 1-month and 3-months after hospital discharge in which they were administered a brief assessment; patients who reported mental health or pain difficulties were provided with information for local specialists to address their specific problem. All patients were independently assessed by telephone interview 9- months after hospital discharge for posttraumatic stress disorder (PTSD) (primary outcome), as well as for anxiety, depression, disability, and pain. RESULTS: There were 58 (73%) patients that could be contacted at either the 1-month or 3-month assessments. Of those contacted, 28 patients (48% of those contacted) were referred for specialist assistance. There were no differences between treatment arms on PTSD symptoms at follow-up [F1,95 = 0.55, p = 0.46]. At the 9-month assessment, patients in the Stepped Care condition reported significantly less anxiety [F1,95 = 5.07, p = 0.03] and disability [F1,95 = 4.37, p = 0.04] relative to those in Treatment as Usual. At 9 months there was no difference between conditions on depression [F1,95 = 1.03, p = 0.31]. There were no differences between conditions on self-reported pain difficulties. CONCLUSIONS: This proof-of-concept trial suggests that brief screening assessments of traumatic injury patients following hospital discharge, combined with appropriate referral information, may lead to better functional outcomes. Further research is needed with larger sample sizes and greater verification of referral uptake to validate this finding.

Paediatric trauma at an adult trauma centre.

BACKGROUND: Trauma in children remains the commonest cause of mortality. The majority of injured children who reach hospital survive, indicating that additional more sensitive outcome measures should be utilized to evaluate paediatric trauma care, including morbidity and missed injury rates. Limited contemporary data have been presented reviewing the care of injured children at an adult trauma centre (ATC). METHODS: A review was undertaken of injured children who warranted activation of the trauma team, treated within the emergency department of an ATC (Royal North Shore Hospital) situated in the Lower North Shore area of Sydney. Data were collected prospectively and patients followed through to death or discharge from the ATC or another institution to which they had been transferred. RESULTS: A total of 93 children were admitted to the ATC between January 1999 and April 2002. Mean age was 9 years 3 months (range 5 weeks-15 years 9 months) and 70% were male. The median injury severity score was 15 (range 1-75) and there were three deaths. Forty-two children were transferred to a paediatric trauma centre (PTC), including three children who had been transferred to the ATC from another hospital. There was one missed injury and one iatrogenic urethral injury. CONCLUSIONS: The majority of children with trauma were treated safely and appropriately at the ATC. The missed injury rate was < 1% and there were no adverse long-term sequelae of initial treatment. Three secondary transfers could have been avoided by more appropriate coordination of the initial referral to a PTC.

Motor vehicle accident or driver suicide? Identifying cases of failed driver suicide in the trauma setting.

Many authors have suggested that some road traffic crashes are disguised suicide attempts. A case report and literature review is used to explore this claim and to examine the frequency and risk factors associated with driver suicide. The author concludes the methodological difficulty of establishing the driver's intent of suicide accounts for an under-estimation of the frequency of this event and that many cases of driver suicide go unrecognised. Familiarity with the risk factors associated with driver suicide may assist in the identification of cases of failed driver suicide and referral to psychiatric services.

Access block and ED overcrowding.

Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998-1999) to 2.4 beds per 1000 (2002-2007) in 2002, and has remained steady at between 2.5-2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998-1999 rates, the number of available beds in 2006-2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.

Access block can be managed.

Hospitals cannot manage their emergency patients when there is significant access block. There are solutions that should be implemented but require national leadership to be effective. These solutions include an immediate increase in the number of acute hospital beds, improved coordination and increased community capacity to manage medical patients with complex conditions outside acute public hospitals, improved hospital processes, and better standardisation of treatment within emergency departments. There is little evidence that telephone triage, ambulatory care clinics or disaster management techniques, including ambulance diversion, reduce access block.

The Royal North Shore Hospital inquiry: an analysis of the recommendations and the implications for quality and safety in Australian public hospitals.

In October 2007, the New South Wales Parliament appointed a Joint Select Committee to inquire into the quality of patient care at Royal North Shore Hospital (RNSH). The inquiry was initiated in response to the publicity and complaints surrounding a patient who had a miscarriage in the toilets of the RNSH emergency department waiting area. The Committee held four public hearings and received 103 submissions. It handed down 45 recommendations in its report on 20 December 2007. There has been criticism from clinicians and others that the recommendations are too general and will not effect significant change for the severe systemic problems affecting the hospital. This article represents the view of some of the clinicians who work at RNSH, and who gave evidence at the inquiry, on the recommendations and some possible solutions for the health system in general.

The Surge Capacity for People in Emergencies (SCOPE) study in Australasian hospitals.

OBJECTIVES: To measure physical assets in Australasian hospitals required for the management of mass casualties as a result of terrorism or natural disasters. DESIGN AND SETTING: A cross-sectional survey of Australian and New Zealand hospitals. PARTICIPANTS: All emergency department directors of Australasian College for Emergency Medicine (ACEM)-accredited hospitals, as well as private and non-ACEM accredited emergency departments staffed by ACEM Fellows in metropolitan Sydney. MAIN OUTCOME MEASURES: Numbers of operating theatres, intensive care unit (ICU) beds and x-ray machines; state of preparedness using benchmarks defined by the Centers for Disease Control and Prevention in the United States. RESULTS: We found that 61%-82% of critically injured patients would not have immediate access to operative care, 34%-70% would have delayed access to an ICU bed, and 42% of the less critically injured would have delayed access to x-ray facilities. CONCLUSIONS: Our study demonstrates that physical assets in Australasian public hospitals do not meet US hospital preparedness benchmarks for mass casualty incidents. We recommend national agreement on disaster preparedness benchmarks and periodic publication of hospital performance indicators to enhance disaster preparedness.

The accuracy of focused assessment with sonography in trauma (FAST) in blunt trauma patients: experience of an Australian major trauma service.

UNLABELLED: Focused assessment with sonography for trauma (FAST) is a method for detecting haemoperitoneum in trauma patients on initial assessment in the Emergency Department. The aim of this paper is to present an Australian trauma centre's experience with FAST as a tool to screen for intraabdominal free fluid in patient's sustaining blunt truncal trauma. METHOD: Over a 63-month period, FAST scans were prospectively studied and compared with findings from a gold-standard investigation, either computed tomography (CT) or laparotomy. RESULTS: 463 FAST results were collected prospectively from 463 patients. 53 scans were excluded due to lack of a corresponding confirmatory gold-standard test. Overall sensitivity, specificity, positive and negative predictive values for FAST in detecting free fluid were 78%, 97%, 91%, 93%, respectively. Analysis of the credentialed operators demonstrated an improvement in accuracy (sensitivity 80%, specificity 100%, positive predictive value 100%, negative predictive value 94%). These findings are comparable with documented international experience. CONCLUSION: The study demonstrates that the use of non-radiologist performed FAST in the detection of free fluid is safe and accurate within an Australian Trauma Centre.