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Type: Thesis
Title: Medically staffed, out of hospital critical care patient transport (retrieval) services : performance, incidents and patient outcomes.
Author: Flabouris, Athanasios
Issue Date: 2008
School/Discipline: School of Medicine
Abstract: The provision of equitable access to health care, particularly acute care remains a challenge. This challenge is often met through the provision of outreach critical care services. These services may take the form of Medical Emergency Teams responding to hospital in-patients who become acutely ill outside a hospital critical care environment (eg a general medical ward) or medically staffed retrieval services that respond to patients who become acutely ill in an out of hospital environment for which critical care resources are not immediately available and are delivered to the patient by a responding retrieval team. In both circumstances the intention is early recognition of the acutely ill patient, a timely response by a team with the desired critical care skills, where appropriate deliver the patient to a Critical Care environment (eg an Intensive Care Unit) for ongoing management and by doing so prevent potential adverse patient events. Retrieval services are becoming increasingly important as centralisation of specialty and acute medical services is increasing. These processes involve many complex interactions, with the potential for adverse patient events. Thus it is important to better understand the nature, frequency of occurrence and patient outcomes associated with out of hospital patient transportation, particularly with critically ill patients requiring admission to an Intensive Care Unit. This body of work, across a number of studies, showed that patients whose ICU source of admission was another hospital had a severity of illness that was higher than for other ICU admissions, had a greater than expected mortality and a mortality and hospital length of stay that exceeded that of similar patients, matched for demographics and casemix who had not undergone a interhospital transfer. These findings varied according to the diagnostic category (being stronger for trauma, respiratory illness, sepsis and intra cranial haemorrhage) and varied across geographical regions. These studies also showed that there was regional variation in the proportion of patients admitted to an ICU from another hospital, the proportion of such patients was increasing (particularly for sepsis) as well as patterns of variation based upon day of the week (highest occurrence Friday and Saturday) and moth of the year (mostly July to October). They also revealed that there is a negative correlation between the proportion of patients admitted to an ICU from another hospital with the proportion of elective and post operative admissions to the ICU. This information is important in regards to planning for the provision of acute care and emergency services resources. The interhospital transfer of critically ill patients has been previously documented to be associated with significant adverse patient events. However our understanding of these events in terms of contributing factors, preventability, potential for harm and minimizing factors has not been well documented. This body of work also showed that medical treatment may be altered based solely on the fact that a patient is undergoing retrieval. An example of this is the finding that such patients have a significantly greater likelihood of endotracheal intubation and mechanical ventilation that similar patients matched for demographics, severity of illness and diagnosis who have not undergone retrieval. Retrieval however can provide significant patient benefit, and this body of work illustrates that through the description of a number of unique and challenging cases and the retrieval specific factors that were associated with a good outcome for each of those cases. This information points to the importance of identifying quality in retrieval practice. This body of work outlines the original development of an incident monitoring tool for retrieval, based upon existing examples of use of the incident monitoring methodology within other medical and non medical domains. Following a retrospective review and analysis of comments from retrieval patient records and consultation a tool for Retrieval Incident Monitoring was developed. An investigation of the use of Retrieval Incident Monitoring across a number of retrieval organisations and pre hospital activities, including during deployment at a major public event (2000 Sydney Olympics) was undertaken. The findings of this study showed that the majority of incidents during retrieval are preventable (91%) and that most incidents were related to problems with equipment, then patient care, and transport operations, interpersonal communication, planning or preparation, retrieval staffing and tasking. Incidents were most likely to occur during patient transport to the receiving facility, at patient origin, during patient loading and at the retrieval service base. Contributing factors were almost equally spread between those that were system and human based. Patient harm was documented in 59% as well as a death. The importance of good crew skills/teamwork was highlighted as a minimising factor to incident occurrence. Subsequently this knowledge, experience and data was used to develop and validity a Retrieval and Ambulance Healthcare Incident Type within the generic and widely used Advanced Incident Management System (AIMS). Finally the occurrence of retrieval can be used as a quality measure for the wider health system. Ideally, because of the findings from this body of work of an associated greater than expected mortality and hospital stay of patients undergoing retrieval, particularly for certain diagnostic categories, then a measure of the occurrence of retrieval could be used as a quality indicator of health service provision across a region. As the need for retrieval will never be negated, outcomes associated with retrieval can be measured and benchmarked across a number of regions In summary, in its entirety, this work has added and tested new knowledge and methods as well as value added to existing knowledge for critical care delivery in the out of hospital environment, in particularly to medical retrieval of critically ill patients admitted to an Intensive Care Unit within Australia and New Zealand. It has developed and validated the efficacy of a new quality tool for retrieval and retrieval based quality measures. It has also pointed towards new areas of future investigation particularly in relation to factors that may favourably or adversely impact upon retrieval outcomes and outcomes of patients undergoing retrieval.
Advisor: Runciman, William Ben
Dissertation Note: Thesis (M.D.) - University of Adelaide, School of Medicine, 2008.
Keywords: Patient safety; Medical retrieval; Patient transportation; Emergency medical service; Trauma; Aeromedical transportation; Pre hospital care
Provenance: Copyright material removed from digital thesis. See print copy in University of Adelaide Library for full text.
Appears in Collections:Research Theses

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