The best not quite there yet…

Tuesday, November 19th, 2019 | Rory | No Comments

Hutten‐Czapski P. Is Northern Ontario School of Medicine there yet? Can J Rural Med 2019;24:103‐4.

Full text available at the CJRM website

This editorial is in the latest edition of the Canadian Journal of Rural Medicine. The Northern Ontario School of Medicine is considered the gold standard in rural medical education. But it appears that rural communities in Northern Ontario are still more likely to see medical students than the finished product, and most of the graduates are still headed to the cities; albeit the provincial cities in Northern Ontario.

This tells us what we already know. It’s not easy, and it’s important not to confuse workforce success in provincial centres with success in rural areas.

I am however sure we still have much to learn from NOSM.

Thanks to Assoc. Prof Nixon for the commentary

Congratulations Sarah – Clinical Research Training Fellowship

Wednesday, November 6th, 2019 | Rory | No Comments

Congratulations to Central Otago physiotherapist Sarah Walker who has received a Clinical Research Training Fellowship from the Health Research Council to undertake a PhD. Sarah is interested in defining the broader skill set practiced by rural allied health professionals and how best to support it. Sarah will be jointly supervised by the School of Physiotherapy and the Section of Rural Health and will join the growing community of rural higher degree students.

Well done Sarah.

Link to the Otago University Bulletin

Sarah on a hill

1’s and 0’s of wisdom: Don’t be afraid

Monday, November 4th, 2019 | Rory | No Comments

Gutenstein M. Daring to be wise: We are black boxes, and artificial intelligence will be the solution. Emergency Medicine Australasia. 2019 Oct;31(5):891–2. EZProxy link

A very well written and thoughtful piece on the future of emergency medicine in a technologically advanced age. There are many similarities between emergency and rural medicine – e.g. just substitute overwhelming patient and time pressure with (professional and geographic) isolation and workforce shortages – and the technology is and will have a very positive effect on the care of our patients – if we let it. I don’t think we will lose our jobs, we will work differently – hopefully more enabled, with more compassion and more satisfaction (and more time at the beach?)

Abstract

Emergency physicians seek wisdom through personal resilience, deliberate reasoning, clinical consensus and reflective practice. However, there is a limit to how useful psychological training, clinical guidelines and audit initiatives can be in the face of inherent human fallibility, increasing system complexity and escalating demand. Wisdom may be more easily attained through the careful design of new technology and this should be a priority for the emergency medicine community.

Marc is a convener of GENA 723 Trauma and Emergency Medicine in Rural Settings and the Rural Inter-professional Simulation Course. You can find out about both these courses at the Rural Postgraduate Page

Rural and Remote – making it work: Learning from our Euro colleagues

Tuesday, October 29th, 2019 | Rory | No Comments

Making it work
open access
Longer and summary documents available

Taking the long view is essential

Some good stuff in this document. NZ has some of this in place, but tying it together without extra investment hard.

Plan/Recruit/Retain

  • Intersectoral investment in training and career promotion
  • Create desirable workplace
  • Create and incentivise a pool of transient workers to make a longer term commitment to your region

Plan/Recruit/Retain

Thanks to Fiona Doolan-Noble for the link

 

The Orange Declaration

Monday, October 21st, 2019 | Rory | No Comments

Perkins D, Farmer J, Salvador‐Carulla L, Dalton H, Luscombe G. The Orange Declaration on rural and remote mental health. Aust. J. Rural Health. 2019;00:1–6. https://doi. org/10.1111/ajr.12560

Open Access: https://onlinelibrary.wiley.com/doi/full/10.1111/ajr.12560

Contribution by Dr. Fiona Doolan-Noble

The Orange Declaration on rural and remote health evolved out of a meeting in Orange, New South Wales in October 2018 between mental health researchers and service providers from New South Wales, Victoria, the Australian Capital Territory and Western Australia to examine the issue of rural mental health and well‐being. Following the meeting five iterations of the document were developed, with participants agreeing upon a consensus statement that outlined ten problems related to current models of rural mental health and well‐being and ten potential solutions to the problems.

Reading the paper the identified problems and associated solutions could easily be applied to any health and social care service. As the authors highlight this is driven by the association and relationship between the challenges associated with provision of services in rural areas- geographical, demographic, social, economic and environmental. All of which are not addressed satisfactorily by the current mix of services, the distribution of the health and social care workforce, nor the associated skill mix within those workforces.

Sadly what is missing from the Declaration is any mention of the need to prioritise addressing the crisis in Aboriginal and Torres Strait Islander mental health and well-being.

The publication of the Declaration is a useful way to start a conversation about rural mental health and well-being and as a strategy for bringing the varied organisations and academic institutions working in the space together. However, it is to be hoped that any funding secured will be used in the first instance to co-develop programmes and interventions that are culturally appropriate for rural Aboriginal and Torres Strait Islander people.

 

“4 TEN PROBLEMS

Ten problems related to current models of rural mental health and well‐being were identified. They are as follows:

  1. Rural communities are different from cities and are not homogenous: they are distinctive, each with different local assets and challenges. Community contexts can change rapidly due to economic instability, dependence on particular leaders or natural disasters. One‐size‐fits‐all service models that cannot adapt to time, place and context are therefore inappropriate.
  2. The rural mental health system is not working: Indicators of rural health and illness suggest that current service models are failing, not fit for service or overly stretched; this situation has been recognised in the public imagination, the media and in political debate.
  3. Top‐down service models are based on urban assumptions: Rural service models in Australia are based on large region‐wide analyses of service activity data, with relatively little evidence of community co‐design or co‐production. People in rural communities can draw on available local evidence and participate effectively in service design. This requires providing them with appropriate data so that they can partner with local providers and commissioners. An example of these productive partnerships is the rural and remote Aboriginal Community Controlled Health Services that provide integrated and locally managed services which have achieved notable health gains.
  4. Services are not based on needs: Emerging evidence suggests that service provision does not always map to population need, nor does spending necessarily achieve better mental health outcomes. This suggests that the available services are failing to provide what is needed and could be due to demand exceeding supply, service fragmentation, challenges in service navigation or services not reaching vulnerable rural clients.
  5. The current forms of public financing are misaligned disproportionately rewarding outreach, telehealth and city‐centric models at the expense of the local public, private and NGO services from medical, allied health, nursing, peer and care partners. Short‐term funding constraints such as 12‐month contracts offered by Primary Health Networks discourage providers from making investments in rural and remote communities.
  6. Fragmentation and competition hinder sustainable, robust service provision: With a large number of service providers in small communities competing for short‐term contracts, addressing different performance targets and often based elsewhere; the role, past performance and track record of services can be highly confusing and their work uncoordinated. Navigating fragmented services increases transaction costs is a challenge for both clients and for health practitioners.
  7. Structural inequity in mental health service provision is amplified in rural areas: While there are rural residents with acute mental health needs, many of the current gaps in rural mental health might lie in areas of awareness, acceptability, prevention, mental health literacy and social connectedness. An over‐emphasis on specialist and hospital services neglects the first‐line “self‐care” that community members could provide for themselves.
  8. The rural mental health workforce cannot be a miniature version of that found in large cities. Its location, skills, scope of practice, supervision, support and development are all problematic. Mental health jobs are very demanding, responses are needed around the clock, personal and professional boundaries are hard to maintain in small communities and burnout is common.
  9. While telehealth and online services should augment mental health services for all clients whether rural or urban, people with mental health challenges often need to speak in person with a health professional, and on some occasions, very quickly. Rural residents need a range of appropriate options to cater for the different situations in their lives.
  10. Data sets are incomplete, disjointed and limited: many different and incompatible data sets are gathered and there is little data‐sharing or linkage. It is therefore complex to analyse service data and find out which services are associated with improvements in access or health outcomes in which communities.

5 TEN SOLUTIONS

Ten solutions are proposed for rural mental health and well‐being that together would benefit from robust testing and evaluation. They are as follows:

  1. Whole‐of‐community, place‐based approaches are promising: These approaches are established in many countries and place‐based planning is increasingly popular in Australia. Resources and toolkits have been developed by organisations such as the World Health Organisation (WHO). The WHO model has been shown to be successful in an international systematic review but has not yet been trialled in Australia.
  2. New service models tailored to context must be considered: There are numerous innovative models, methods and ideas being tested at a community level that could be scalable. These models need to be tested at a larger scale using appropriate investigative methodologies. Ideally, much of this research would be conceived and conducted by rurally based researchers and partnerships, helping to build rural research capacity. Moreover, these new ways of working (different models) are likely to require new skills in health care providers and new organisational arrangements, which will also require development.
  3. Co‐designed bottom‐up processes should be pursued in collaboration with state and federal partners: Involving place‐based communities in collaborative co‐design can help to build local partnerships, awareness and generate appropriate solutions. These are beginning to be tested using rigorous methodologies. Such approaches can build empowerment, capacity, resilience, social connection and empathy in diverse cultures. Local partnerships are best placed to plan models about how to care for people in crisis locally who could be at serious risk if they cannot access timely assistance.
  4. Holistic and integrated care models need testing: Many rural communities and primary health services have already given‐up on one‐size‐fits‐all centrally imposed models. Many new non‐clinical, community‐based roles are emerging, including service navigators, connectors, peer supporters and outreach workers who can visit isolated‐community members, provide navigation and support. Such workers can provide a cost‐effective source of local prevention, connection and support. However, models engaging lay personnel to complement health and community services would benefit from large‐scale testing.
  5. New better‐aligned funding models are needed: New funding models that reward collaboration provide rural residents and service providers with choices and referral options, enable clinical supervision and professional mentorship need to be developed, modelled and tested.
  6. Whole of community approaches are needed, not pilot studies: These should be co‐designed with rural communities and tested over longer time periods (at least 3‐5 years). Incremental design and improvement is a much better model with a clear recognition that one size will not fit all and that those without personal experience of living in rural communities might not be the best source of wisdom.
  7. Prevention and early intervention must be considered: Local providers and community leaders suggest that prevention is a largely neglected strategy. Building local strategies to address social connection, transport accessibility, mental health literacy and stigma reduction is a fundamental step. Further research summarising and exploring effective and ineffective approaches at the community level would help identify locally relevant strategies.
  8. New rural workforce models are needed: To address specific rural mental health workforce challenges “grow‐your‐own” and “skills escalation” strategies appear promising. These approaches seek to identify existing local practitioners and residents with the potential to become future health and community service workers, peer supporters or volunteer navigators. These strategies require local incentives to encourage staff to work at the top of their scope of practice; “task‐shifting” to non‐clinical or community roles; effective supervision and governance structures. Workers involved could include personnel from the health sector in general, alcohol and other drugs workers, social care, police, social workers and finance/banking workers.
  9. Digital technology contributes now and can do more as part of new systems: Digital and telehealth services continue to play an important role in extending services to rural communities, but they are not a panacea and people might also need immediate face‐to‐face help or specialist advice and care. Understanding the place and value of online, digital and telehealth offerings is a significant research gap. Social media such as Facebook pages that are created and maintained by local practitioner‐community member collaboratives might be useful for people isolated by distance, culture, poverty, negative relationships or lack of connection. The use of online sources of care and support is partly dependent on increased access and expanded bandwidth.
  10. Enhance data collection, monitoring, linkage, analysis and planning: To address the issues of service fragmentation, gaps, duplication and lack of information sharing, there needs to be a substantial investment in better data collection, monitoring and evaluation to enable services to assess outcomes in a timely manner, thereby facilitating responsive service improvement activities.”

CRASH into a post – get tranexamic acid. Or not?

Friday, October 18th, 2019 | Rory | No Comments

The CRASH–3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH–3): a randomised, placebo-controlled trial.Lancet. 2019

EZ-PROXY link

A follow-on from the CRASH2 trial (tranexamic acid (TXA) in trauma), this large randomised placebo-control multi-centre study looked at Traumatic Brain Injury (TBI). 1g of TXA was infused over 10minutes followed by a 1g over 8 hours or placebo within 3 hours of injury. The primary outcome was death in hospital related to the head injury within 28 days.

Although the authors conclude that TXA reduced head injury related death this conclusion has come under fire on the internet. In all head injured patients the confidence interval for the risk reduction includes 1. However, in the mild-moderate injured patient (GCS 9–15) there was a clear reduction in head injury related death (RR 0.78 – 0.64–0.95). Also importantly the risk of VTE and other complications – including stroke – was similar in both treatment and placebo groups

Many authors (urban based ED docs) are hesitant to give TXA in the isolated head injured patient, like they are in post-partum haemorrhage on the basis of the results of the WOMAN trial1 but I see TXA as a really important drug – when there is little else you can do. It might be effective and save a life and it is unlikely to do any harm! Give it and give it early!

 

Give it early…

Would like to hear what you think or disagree in the Comments.

There are lots of blogs discussing this trial and will let them go into the nitty gritty of Evidence Based Medicine.

Abstract

Background

Tranexamic acid reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury (TBI) and can cause brain herniation and death. We aimed to assess the effects of tranexamic acid in patients with TBI.

Methods

This randomised, placebo-controlled trial was done in 175 hospitals in 29 countries. Adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major extracranial bleeding were eligible. The time window for eligibility was originally 8 h but in 2016 the protocol was changed to limit recruitment to patients within 3 h of injury. This change was made blind to the trial data, in response to external evidence suggesting that delayed treatment is unlikely to be effective. We randomly assigned (1:1) patients to receive tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was head injury-related death in hospital within 28 days of injury in patients treated within 3 h of injury. We prespecified a sensitivity analysis that excluded patients with a GCS score of 3 and those with bilateral unreactive pupils at baseline. All analyses were done by intention to treat. This trial was registered with ISRCTN (ISRCTN15088122), ClinicalTrials.gov (NCT01402882), EudraCT (2011–003669–14), and the Pan African Clinical Trial Registry (PACTR20121000441277).

Results

Between July 20, 2012, and Jan 31, 2019, we randomly allocated 12 737 patients with TBI to receive tranexamic acid (6406 [50·3%] or placebo [6331 [49·7%], of whom 9202 (72·2%) patients were treated within 3 h of injury. Among patients treated within 3 h of injury, the risk of head injury-related death was 18·5% in the tranexamic acid group versus 19·8% in the placebo group (855 vs 892 events; risk ratio [RR] 0·94 [95% CI 0·86–1·02]). In the prespecified sensitivity analysis that excluded patients with a GCS score of 3 or bilateral unreactive pupils at baseline, the risk of head injury-related death was 12·5% in the tranexamic acid group versus 14·0% in the placebo group (485 vs 525 events; RR 0·89 [95% CI 0·80–1·00]). The risk of head injury-related death reduced with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64–0·95]) but not in patients with severe head injury (0·99 [95% CI 0·91–1·07]; p value for heterogeneity 0·030). Early treatment was more effective than was later treatment in patients with mild and moderate head injury (p=0·005) but time to treatment had no obvious effect in patients with severe head injury (p=0·73). The risk of vascular occlusive events was similar in the tranexamic acid and placebo groups (RR 0·98 (0·74–1·28). The risk of seizures was also similar between groups (1·09 [95% CI 0·90–1·33]).

Interpretation

Our results show that tranexamic acid is safe in patients with TBI and that treatment within 3 h of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.

Funding

National Institute for Health Research Health Technology Assessment, JP Moulton Charitable Trust, Department of Health and Social Care, Department for International Development, Global Challenges Research Fund, Medical Research Council, and Wellcome Trust (Joint Global Health Trials scheme).


  1. Shakur H, Elbourne D, Gülmezoglu M, Alfirevic Z, Ronsmans C, Allen E, Roberts I. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Dec;11(1):40.

The golden hour – unachievable for a chunk of NZ – a problem?

Thursday, October 3rd, 2019 | Rory | No Comments

Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand

Lilley R, Graaf B, Kool B, Davie G, Reid P, Dicker B, Civil I, Ameratunga S & Branas C. (2019). Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand: a cross-sectional study. BMJ Open. 9.

Open Access https://bmjopen.bmj.com/content/9/7/e026026

 

This is a very interesting study that shows that 16% of NZ doesn’t have access to an ‘advanced-level’ hospital within a hour. They have used a novel approach to identifying this population. With regards to trauma care this is a significant finding and something to consider for rural NZ, especially with planning emergency service networks. The average time the ambulance spends responding, travelling to and on the scene (even scoop and run) seems short based on practical experience in areas staffed by volunteer crews that are often 30 minutes to an hour away when called. This will only worsen this ‘inequity’ though

However, for medical events this hour cut-off is a bit more arbitrary. There are few medical events that require treatment within an hour in a major centre that cannot be initiated in rural practice. STEMI can be and are lysed. Airways can be secured. Vasopressors and antibiotics initiated. There are also CT scanners available in a few rural hospitals with Telestroke and stroke fibrinolysis also being available – although stroke care is a mobile beast with the advancement of clot retrieval. Further, many undifferentiated cases may never require transfer to a major centre once proper assessment and investigations are completed in a capable rural centre (either Hospital/GP). If all these patients were transferred immediately, would this be a good use of NZ’s limited resource?

Involving the established rural sector in this care is going to be important to ensure the best use of these resources.

It would be good to use this methodology to look at more patient centred outcomes in the (hopefully near) future.

Abstract

Objective Rapid access to advanced emergency medical and trauma care has been shown to significantly reduce mortality and disability. This study aims to systematically examine geographical access to prehospital care provided by emergency medical services (EMS) and advanced-level hospital care, for the smallest geographical units used in New Zealand and explores national disparities in geographical access to these services.

Design Observational study involving geospatial analysis estimating population access to EMS and advanced-level hospital care. Setting Population access to advanced-level hospital care via road and air EMS across New Zealand. Participants New Zealand population usually resident within geographical census meshblocks. Primary and secondary outcome measures The proportion of the resident population with calculated EMS access to advanced-level hospital care within 60 min was examined by age, sex, ethnicity, level of deprivation and population density to identify disparities in geographical access.

Results An estimated 16% of the New Zealand population does not have timely EMS access to advanced-level hospital care via road or air. The 700 000 New Zealanders without timely access lived mostly in areas of low-moderate population density. Indigenous Māori, New Zealand European and older New Zealanders were less likely to have timely access.

Conclusions These findings suggest that in New Zealand, geographically marginalised groups which tend to be rural and remote communities with disproportionately more indigenous Māori and older adults have poorer EMS access to advanced-level hospitals. Addressing these inequities in rapid access to medical care may lead to improvements in survival that have been documented for people who experience medical or surgical emergencies.

 

Edit; fixed link. Thanks to Linda Reynolds for pointing out!

Conveners wanted!

Thursday, October 3rd, 2019 | Rory | No Comments

We want you

The Rural Postgraduate Programme is seeking two conveners (professional practice fellows). Position(s) would ideally suit clinicians working in rural NZ.

Papers available:

  • GENA723 Trauma and Emergencies in Rural Environments
    • 0.15 FTE (6hrs/week)
    • start Jan 2020
  • GENA724 Context of Rural Hospital Medicine
    • 0.1 FTE (4hrs/week)
    • start immediately

Please send CV or direct any questions, including the job description to Mitty: maryanne.neill@otago.ac.nz

 
 
 

Any views or opinion represented in this site belong solely to the authors and do not necessarily represent those of the University of Otago. Any view or opinion represented in the comments are personal and are those of the respective commentator/contributor to this site.

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