Requesting air ambulance transport of patients with suspected appendicitis: The decision-making process through the eyes of the rural clinician.

OBJECTIVE: The primary aim is to explore rural clinicians' self-reported knowledge, skills and attitudes in the decision-making process for requesting aeromedical retrieval of patients with suspected appendicitis. A secondary aim is to understand the supports and barriers of rural clinicians experience in this clinical scenario. SETTING: Clinician interviews conducted face-to-face in three rural hospitals in Central Queensland. PARTICIPANTS: Rural doctors and nurses. DESIGN: A five-part qualitative content analysis. RESULTS: The majority of 44 participants identified the strong and effective teamwork. The decision to request aeromedical retrieval was a shared, joint process and identified a supportive collegial culture which supported the asking of questions and not expecting to have all the answers. Perceived barriers were lack of receiving clinicians understanding of transfer agreements, and data connectivity. Clinician pessimism was identified for perceived patient outcomes. DISCUSSION: Effective teamwork can nurture trust and collaboration across multiple health service roles. High job satisfaction may counter the physical isolation in some rural environments. Fragmentation of care is the unintended consequence of interhospital transfer and may impact rural clinicians' perception of patients' outcomes and hinder receiving clinicians' understanding of rural service limitations. CONCLUSION: Future work in the area of linked electronic medical records could remove a barrier for rural clinicians and improve their reflective practice by challenging their perception of definitive patient outcomes. Increased awareness by receiving clinicians of the limitation of rural services, may minimize communication barriers and thereby, improve timely patient care transfers.

Air ambulance retrievals of patients with suspected appendicitis and acute abdominal pain: The patients' journeys, referral pathways and appendectomy outcomes using linked data in Central Queensland, Australia.

INTRODUCTION: Acute appendicitis is the most common cause of acute abdominal pain presentations to the ED and common air ambulance transfer. AIMS: describe how linked data can be used to explore patients' journeys, referral pathways and request-to-activation responsiveness of patients' appendectomy outcomes (minor vs major complexity). METHODS: Data sources were linked: aeromedical, hospital and death. Request-to-activation intervals showed strong right-tailed skewness. Quantile regression examined whether the longest request-to-activation intervals were associated with appendicitis complexity in patients who underwent an appendectomy. RESULTS: There were 684 patients in three referral pathways based on hospital capability levels. In total, 5.6 % patients were discharged from ED. 83.3 % of all rural origins entered via the ED. 3.8 % of appendicitis patients were triaged to tertiary hospitals. Appendectomy patients with major complexity outcomes were less likely to have longer request-to-activation wait times & had longer lengths of stay than patients with minor complexity outcomes. CONCLUSIONS: Linked data highlighted four aspects of a functioning referral system: appendectomy outcomes of major complexity were less likely to have longer request-to-activation intervals compared to minor (sicker patients were identified); few were discharged from EDs (validated transfer); few were triaged to tertiary hospitals (appropriate level for need), and no deaths relating to appendectomy.

Using a Quality Framework to Explore Air Ambulance Patients' Journey Outcomes in Central Queensland, Australia.

INTRODUCTION: In Australia, aeromedical retrieval provides a vital link for rural communities with limited health services to definitive care in urban centers. Yet, there are few studies of aeromedical patient experiences and outcomes, or clear measures of the service quality provided to these patients. STUDY OBJECTIVE: This study explores whether a previously developed quality framework could usefully be applied to existing air ambulance patient journeys (ie, the sequences of care that span multiple settings; prehospital and hospital-based pre-flight, flight transport, after-flight hospital in-patient, and disposition). The study aimed to use linked data from aeromedical, emergency department (ED), and hospital sources, and from death registries, to document and analyze patient journeys. METHODS: A previously developed air ambulance quality framework was used to place patient, prehospital, and in-hospital service outcomes in relevant quality domains identified from the Institutes of Medicine (IOM) and Dr. Donabedian models. To understand the aeromedical patients' journeys, data from all relevant data sources were linked by unique patient identifiers and the outcomes of the resulting analyses were applied to the air ambulance quality framework. RESULTS: Overall, air ambulance referral pathways could be classified into three categories: Intraregional (those retrievals which stayed within the region), Out of Region, and Into Region. Patient journeys and service outcomes varied markedly between referral pathways. Prehospital and in-hospital service variables and patient outcomes showed that the framework could be used to explore air ambulance service quality. CONCLUSION: The air ambulance quality framework can usefully be applied to air ambulance patient experiences and outcomes using linked data analysis. The framework can help guide prehospital and in-hospital performance reporting. With variations between regional referral pathways, this knowledge will aid with planning within the local service. The study successfully linked data from aeromedical, ED, in-hospital, and death sources and explored the aeromedical patients' journeys.

Measuring More than Mortality: A scoping review of air ambulance outcome measures in a combined Institutes of Medicine and Donabedian quality framework.

INTRODUCTION: Measuring the performance of air ambulance services are complex and dynamic due to the variability and interconnectedness of emergency systems. The aim of this study is to review the range and nature of air ambulance outcome measures published in peer review articles and construct a quality framework based on the results. A scoping review of the literature was conducted to identify outcome measures that evaluate the quality of air ambulance services. Combined frameworks from the Institutes of Medicine (IOM) and Dr. Avedia Donabedian were used to create a dashboard structure for a framework of air ambulance outcome measures. METHODS: A literature search strategy was undertaken, following PRISMA-ScR guidelines and included eight databases over the period 2001-2019. Qualitative content analysis was conducted in 4-phases: 1) table summary of selected article outcome measures, 2) content analysis themes, codes of outcome measures and independent variables 3) narrative description of main themes 4) visual dashboard diagram of service priorities and quality strategies, based on the findings. RESULTS: Thirty-four articles were screened by full text and eighteen met the selection criteria. Twenty codes emerged and were grouped to form eight consistent outcome themes; asset/ team type, access to definitive interventions, prehospital factors, mortality, morbidity, responsiveness of service, accessibility of service and patient disposition. CONCLUSIONS: A quality framework consisting of eight outcome measures was created, it also identified seven gaps which ordinarily require performance evaluation; patient comfort and satisfaction reporting, cultural awareness training, safety alarms in place to identify volume stress, optimal coordination of resources, cost of service analysis, comprehensive patient journey time and an adaptive referral system analysis. The measures in the framework provide a broad perspective of air ambulance performance we believe will help decision-making and planning to improve patients experience and outcomes.

Air ambulance outcome measures using Institutes of Medicine and Donabedian quality frameworks: protocol for a systematic scoping review.

BACKGROUND: Dedicated air ambulance services provide a vital link for critically ill and injured patients to higher levels of care. The recent developments of pre-hospital and retrieval medicine create an opportunity for air ambulance providers and policy-makers to utilize a dashboard of quality performance measures to assess service performance. The objective of this scoping systematic review will be to identify and evaluate the range of air ambulance outcome measures reported in the literature and help to construct a quality dashboard based on a healthcare quality framework. METHODS: We will search PubMed, MEDLINE, CINAHL, Scopus, and Cochrane Database of Systematic Reviews (from January 2001 onwards). Complementary searches will be conducted in selected relevant journals. We will include systematic reviews and observational studies (cohort, cross-sectional, interrupted time series) in critically ill or injured patients published in English and focusing on air ambulance delivery and quality measures. Two reviewers will independently screen all citations, full-text articles, and abstract data. The study methodological quality (or bias) will be appraised using appropriate tools. Analysis of the characteristics associated with outcome measure will be mapped and described according to the proposed healthcare quality framework. DISCUSSION: This review will contribute to the development of an air ambulance quality dashboard designed to combine multiple quality frameworks. Our findings will provide a basis for helping decision-making in health planning and policy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019144652.

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.