Optimizing access and configuration of trauma centre care in New South Wales

Utility of point of care viscoelastic haemostatic assays for trauma patients in the emergency department

BACKGROUND AND OBJECTIVES

Traumatic haemorrhage often requires initiation of a massive haemorrhage protocol (MHP). The primary aim of this exploratory Emergency Department (ED) study was to examine the utility of point of care Viscoelastic Haemostatic Assays (VHA) in terms of accuracy. The primary outcome was prediction of the need for massive transfusion (MT) at 24-hours.

METHODS

Prospective observational study of consecutive trauma patients investigated with reported using STARD guidelines. Patients in an Australian ED setting < 1-hour from triage enrolled in a three-year window. The point-of-care device used was a TEG6s™ (Haemonetics, Braintree, MA, USA). The primary outcome was accuracy VHA testing for predicting MT delivery at 24-hours (an internationally recognised of massive transfusion was used). Other trauma outcomes such as product transfusion, injury severity score (ISS) and demographics were recorded. For analysis of accuracy the cohort was divided into VHA-normal (n = 44) and VHA-abnormal (n = 70) binary groups. Secondary outcomes included utility of TEG6s™ individual components and accuracy of VHA when combined with validated MHP decision scores.

RESULTS

Among eligible cases (n = 114) in-patient mortality was 7.0% with 91.2% receiving transfusion. Presence of (any) abnormal VHA result provided a 73.6% (95%CI 59.7-84.7) sensitivity and 49.3% (95%CI 36.1-62.3) specificity for predicting MT. Citrated Functional Fibrinogen (CFF) component had a higher performance for MT "rule-in" specificity (86.9%). When VHA was combined with validated MHP decision scores performance was increased. For example, normal VHA with Trauma Associated Severe Haemorrhage score < 8.5 was observed to yield a sensitivity of 96.2% for MT requirement rule-out. Further studies should examine if VHA test parameters can be added or (replace INR) in the existing clinical scores used to make decisions about transfusion in ED patients.

CONCLUSION

The standalone performance of early VHA testing in the ED setting was insufficient to reliably for predict a need for massive transfusion.

Economic Optimization Through Adherence to Best Practice Guidelines: A Decision Analysis of Traumatic Spinal Cord Injury Care Pathways in Australia

Traumatic spinal cord injuries (TSCIs) have significant health, economic, and social effects on individuals, families, and society. In this economic analysis modeling study, we used record-linked administrative patient data from New South Wales, Australia, to construct a decision tree model to compare the economic cost of acute care for patients with TSCI under current clinical pathways with an optimal care (consensus guidelines-informed) modeled pathway. The optimal care pathway included direct transfer to a specialist SCI Unit (SCIU) or indirect transfer to SCIU within 24 h of injury, surgical intervention within 12 h of injury, and subsequent inpatient rehabilitation. Propensity score matching with inverse probability of treatment weighting (IPTW) was used to reduce potential confounding from baseline differences in patient characteristics. A generalized linear model regression with gamma distribution and log link, weighted with IPTW scores, was used for cost and length of stay (LoS) estimations to reduce any residual bias. Sensitivity analyses quantified the sensitivity of the findings to key model parameters. From the healthcare payer perspective, our economic analysis found acute TSCI care at an SCIU was more expensive, with delayed patient transfer pathways, surgery, and timing of surgery driving higher per-patient costs ($14,322 at specialist centers). Probabilistic sensitivity analysis (PSA) using 10,000 Monte Carlo iterations showed the modeled optimal pathway as the expensive option in the majority (86%) of stimulations. However, the modeled direct transfer care pathway demonstrated economic improvements compared to current care pathways, despite a higher upfront cost ($25,428 per patient), the modeled pathway reduced the episode LoS by 5 days (23 days vs. 28 days) on average, generating system-level savings of $20,628 per patient. In PSA, increasing the proportion of patients directly transferred to SCIU by 25%, the optimized pathway was preferred in 28.3% of the simulations. Furthermore, adopting this pathway lowered the incremental per patient cost to $17,157 while preserving a 5-day LoS benefit compared to current pathways (22 days vs. 27 days), which could generate potential savings of $3,471 per patient. Our findings show that guideline-based acute care management is initially resource-intensive but efficient in terms of patient LoS, with a higher proportion of direct transfers resulting in cost savings of $3,471 per patient, which represent system-level benefits from adopting the modeled pathway, rather than episode-level savings. Following consensus guidelines for acute care can provide an economically sustainable approach to resource-intensive patient needs while improving outcomes, as demonstrated in previous studies. In summary, while more intensive, adhering to clinical guidelines of direct transfer to SCIU demonstrates value for patients and health systems. Standardization to optimize time to surgery can achieve improved outcomes through earlier access to rehabilitation and substantial care efficiencies. These findings highlight the economic case for adherence to best practice care guidelines at the healthcare system level to inform future healthcare planning for patients with TSCI.

The application of spatial measures to analyse health service accessibility in Australia: a systematic review and recommendations for future practice

BACKGROUND

Australia's inequitable distribution of health services is well documented. Spatial access relates to the geographic limitations affecting the availability and accessibility of healthcare practitioners and services. Issues associated with spatial access are often influenced by Australia's vast landmass, challenging environments, uneven population concentration, and sparsely distributed populations in rural and remote areas. Measuring access contributes to a broader understanding of the performance of health systems, particularly in rural/remote areas. This systematic review synthesises the evidence identifying what spatial measures and geographic classifications are used and how they are applied in the Australian peer-reviewed literature.

METHODS

A systematic search of peer-reviewed literature published between 2002 and 2022 was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Search terms were derived from three major topics, including: [1] Australian population; [2] spatial analysis of health service accessibility; and [3] objective physical access measures.

RESULTS

Database searches retrieved 1,381 unique records. Records were screened for eligibility, resulting in 82 articles for inclusion. Most articles analysed access to primary health services (n = 50; 61%), followed by specialist care (n = 17; 21%), hospital services (n = 12; 15%), and health promotion and prevention (n = 3; 4%). The geographic scope of the 82 articles included national (n = 33; 40%), state (n = 27; 33%), metropolitan (n = 18; 22%), and specified regional / rural /remote area (n = 4; 5%). Most articles used distance-based physical access measures, including travel time (n = 30; 37%) and travel distance along a road network (n = 21; 26%), and Euclidean distance (n = 24; 29%).

CONCLUSION

This review is the first comprehensive systematic review to synthesise the evidence on how spatial measures have been applied to measure health service accessibility in the Australian context over the past two decades. Objective and transparent access measures that are fit for purpose are imperative to address persistent health inequities and inform equitable resource distribution and evidence-based policymaking.

A system in crisis: exploring how recent emergency department closures influence potential access to emergency care in Ontario

OBJECTIVES

Access to emergency medical care in Ontario has been under stress, mainly due to a lack of human resources (staffing of nurses and doctors). Over the past year, several emergency departments in Ontario have closed. Some of these closures are nightly, while others have closed for weeks at a time, leaving Ontario residents without access to emergency medical care which can lead to poor or more severe outcomes. The purpose of this paper was to examine how closures of ED's in Ontario have influenced potential access to emergency medical care.

METHODS

We performed population-level geographic information systems (GIS)-based analysis of potential access to ED hospitals in Ontario. The number of people with access to an ED was calculated when all ED's in Ontario were open, then recalculated with the 14 ED closures. Access was defined by ground travel with 30 min, 45 min, and 60 min travel times used for analysis. Differences in the number of people at the census block level who potentially lost access were compiled and examined by census subdivision.

RESULTS

If all 14 ED's had closed at the same time, there would be 35,808 people at 30 min, 15,018 at 45 min, and 12,131 at 60 min travel times in Ontario who lost access to ED care. Certain areas of the province saw more significant decreases in ED access. At 45 min travel times, nearly 2000 people in Central Frontenac lost access (44% of population), while 7298 people in Cochrane (North Part) lost access (20% of population).

CONCLUSIONS

ED closures have led to decreases in potential access to emergency care for predominantly rural populations. Health human resource recovery strategies must focus on areas where lack of overlap exists.

Potential Access to Emergency General Surgical Care in Ontario

Limited access to timely emergency general surgery (EGS) care is a probable driver of increased mortality and morbidity. Our objective was to estimate the portion of the Ontario population with potential access to 24/7 EGS care. Geographic information system-based network-analysis was used to model 15-, 30-, 45-, 60-, and 90-min land transport catchment areas for hospitals providing EGS care, 24/7 emergency department (ED) access, and/or 24/7 operating room (OR) access. The capabilities of hospitals to provide each service were derived from a prior survey. Population counts were based on 2016 census blocks, and the 2019 road network for Ontario was used to determine speed limits and driving restrictions. Ninety-six percent of the Ontario population (n = 12,933,892) lived within 30-min's driving time to a hospital that provides any EGS care. The availability of 24/7 EDs was somewhat more limited, with 95% (n = 12,821,747) having potential access at 30-min. Potential access to all factors, including 24/7 ORs, was only possible for 93% (n = 12,471,908) of people at 30-min. Populations with potential access were tightly clustered around metropolitan centers. Supplementation of 24/7 OR capabilities, particularly in centers with existing 24/7 ED infrastructure, is most likely to improve access without the need for new hospitals.

Mapping the Way to Good Health: The Interdisciplinary Challenges of Geographers in Medical Research

Geography has an important role to play in shaping the direction of medical research. In particular, its tools and theory provide essential understanding to the impacts of place on health behaviors and outcomes. Understanding some of its evolution-particularly into the subfield of medical geography-is therefore useful both for geographers and medical researchers. In this paper, we present some of the debates that geographers have grappled with, the growth of GIS (particularly in the context of medical research), some important methodological considerations that geographers help center, and some recommendations for future work at this nexus. Throughout, we speak from the perspective of geographers who have worked nearly exclusively in the health sciences since obtaining our PhDs.

Pathways and factors that influence time to definitive trauma care for injured children in New South Wales, Australia

BACKGROUND

Timely definitive paediatric trauma care influences patient and parental physical and emotional outcomes. New South Wales (NSW) covers a large geographical area with all three NSW paediatric trauma centres (PTC) located in two approximated major cities, meaning it is inevitable that some injured children receive initial treatment locally and then require transfer. Little is known about the factors that then impact timely arrival of injured children to definitive care.

METHODS

This included children admitted between July 2015 and September 2016, <16 years with an injury severity (ISS) ≥9; or requiring intensive care admission; or deceased following injury. Children were identified through the three PTCs, NSW Trauma Registry and NSW Medical Retrieval Registry.

RESULTS

There were 593 children admitted following injury and 46% required transfer to a PTC. There was no significant difference in age, ISS, ICU admission or head injury (AIS >2) between transferred and directly transported cohorts. There were significant differences in mechanism of injury between the two groups (χ²(9) = 45.9, p < 0.001). The median (IQR) time to book a transfer from arrival at the referring facility, was 146.5 (86-238) minutes. Time from injury to arrival at the PTC more than doubled for children transferred, with significant and unwarranted variability between transporting agencies resulting in unwarranted delays to surgical intervention. For example, time spent at the referring facility by Aeromedical Retrieval Service was less than half that of the Newborn & paediatric Emergency Transport Service [53 (IQR:47-61) vs 115 (84-155) minutes (p <0.001)].

CONCLUSION

Clinicians caring for paediatric trauma patients in facilities outside trauma centres require the capability and opportunity to identify and notify early those requiring transfer for ongoing management. The provision of a streamlined referral and transfer process for all paediatric trauma patients requiring treatment in NSW PTCs would reduce the burden on the referring facility, reduce variation amongst transport providers and improve time to definitive care.

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.

Quantification of Trauma Center Access Using Geographical Information System-Based Technology

OBJECTIVES

There is no generally accepted methodology to assess trauma system access. The goal of this study is to determine the influence of the number and geographical distribution of trauma centers (TCs) on transport times (TT) using geographic information system (GIS)-technology.

METHODS

Using ArcGIS-PRO, we calculated differences in TT and population coverage in 7 scenarios with 1, 2, or 3 TCs during rush (R) and low-traffic (L) hours in a densely populated region with 3 TCs in the Netherlands.

RESULTS

In all 7 scenarios, the population that could reach the nearest TC within <45 minutes varied between 96% and 99%. In the 3-TC scenario, roughly 57% of the population could reach the nearest TC <15 minutes both during R and L. The hypothetical geographically well-spread 2-TC scenario showed similar results as the 3-TC scenario. In the 1-TC scenarios, the population reaching the nearest TC <15 minutes decreased to between 19% and 32% in R and L. In the 3-TC scenario, the average TT increased by about 1.5 minutes to almost 21 minutes during R and 19 minutes during L. Similar results were seen in the scenarios with 2 geographically well-spread TCs. In the 1-TC scenarios and the less well-spread 2-TC scenario, the average TT increased by 5 to 8 minutes (L) and 7 to 9 minutes (R) compared to the 3-TC scenario.

CONCLUSIONS

This study shows that a GIS-based model offers a quantifiable and objective method to evaluate trauma system access under different potential trauma system configurations. Transport time from accident to TC would remain acceptable, around 20 minutes, if the current 3-TC situation would be changed to a geographically well-spread 2-center scenario.