Department of Human Services
Service Specifications for Medical Retrieval in Victoria
Service Model Options Paper
KPMG Consulting 22 October 2000 This report contains 94 pages Service Specifications for Medical Retrieval in Victoria Department of Human Services
Contents
1 Introduction 3
1.1 The objective 3
1.2 Definition of “retrieval” 4
2 The basis for change 6
2.1 Key issues 6
2.2 Core principles 7
3 Core system elements 13
3.1 Funding 13
3.2 Retrieval directorate 13
3.3 The coordination role 18
3.4 Improved communications capability 21
3.5 NETS and PETS 22
3.6 Regional services 22
3.7 Scope 25
3.8 Responsiveness 26
3.9 Education 32
3.10 Data collection and quality assurance 33
3.11 Protocols and guidelines 34
3.12 Transport platform issues 35
4 Service model components for retrieval operations 39
4.1 System core principles and elements 39
4.2 Model elements 40
5 Model Options – Adult retrieval operations 42
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5.1 Current MEARS model 43
5.2 Central service model 1 47
5.3 Central Service Model 2 51
5.4 Hospital-based service model 1 55
5.5 Hospital-based service model 2 58
5.6 Dual response model 62
5.7 Ambulance based model 66
5.8 Towards a preferred model 69
6 Demand projections 73 7 Operational issues 78
7.1 Stretcher compatibility 78
8 Funding and finance issues 79
8.1 MEARS 79
8.2 Model Options 79
9 Conclusions 81
Appendix 1 – Model for early recognition of adult patient instability 82
Appendix 2 - Current services 84
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1 Introduction
This report is the second to be produced as part of a project to develop service specifications for the provision of medical retrieval in Victoria. The project objectives are to:
n develop a service model for the operation of an integrated, state-wide medical retrieval system;
n identify the management and operational requirements of the service; and
n develop an implementation strategy for elements of the service plan.
The purpose of this paper is to outline the component elements of an integrated retrieval system and to configure these elements into several alternative service models. These options are intended to:
n demonstrate that there is more than one way to configure the system; and
n identify the impact that various assumptions and system configurations can have on service provision and viability.
The intention is to support discussion of the broad concepts and principles of future retrieval services.
The development of operational detail is intended as part of subsequent stages of the project. The objective at this time is to achieve broad agreement on future direction.
In considering the issues raised in this paper, it also needs to be recognised that while this project has not focussed on the future models for provision of transport platforms for retrieval, transport is an integral and critical component of effective retrieval. Transport issues are currently under active consideration as part of other processes, the outcomes of which will need to dovetail with the future model chosen for retrieval services.
1.1 The objective
Our objective in undertaking this project has been to achieve:
An integrated statewide medical retrieval system for Victoria
This report is part of the process of developing a service model for such a system.
It needs to be emphasised that the purpose of the model options is to establish a framework for discussion about the basic approaches and structures. Operational details will be developed in subsequent stages.
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This paper therefore aims to foster understanding and agreement on the broad concepts and the strengths and weaknesses of various approaches. Broad agreement on a high- level model should provide a way forward, a basis on which to proceed to the next stage – the operational requirements of the service.
1.2 Definition of “retrieval”
There has been considerable debate during the consultation process about the meaning of the term “retrieval” and the nature of the service that a retrieval service should provide. The term has generated discussion about the distinction between retrieval and inter- hospital transfer, whether it implies medical staffing and whether or not a transfer escorted by medical staff of the sending hospital should be regarded as relevant to this review and in what circumstances.
The vast majority of patients transferred between hospitals (inter-hospital transfers) do not require medical support and are well managed by ambulance paramedics and MICA paramedics.
However, while the training and skills of ambulance staff in Victoria are generally regarded as among the best in the world, there are patients who require medical support during transport due to the nature of their condition or the equipment required in their management. This medical staffing may be provided by the sending hospital or by a retrieval service.
Retrieval services are designed to support those hospitals that do not have the skills or resources to provide a medical escort to patients being transferred to other hospitals. More importantly, the establishment of such services recognises that specialised skills are required in medical management of patients in transit. These skills relate to both the nature of the care and to the often-difficult environment in which it is provided.
In its policy on minimum standards of transport of the critically ill, the Faculty of Intensive Care of the Australian and New Zealand College of Anaesthetists and the Australian College for Emergency Medicine state that:
an important principle is that transport of the critically ill patient should be aimed at achieving improved patient care. Management during transport should equal or better management at the point of referral.
Key issues therefore are:
n to identify those patients for whom the services of a specialist retrieval service are required;
n to define the nature of the care required to maintain or improve the level of patient care management.
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In other words, the issue is not about how to define “retrieval” (which is a service), but how to identify and manage those patients requiring medical support during interhospital transfer or transport.
Therefore the focus should be on patients involving time-criticality and where a medical escort is required and involving: n rural cases where transfer is required to convey patients from a lower level hospital service to a higher level hospital service.
OR n specialised retrieval response and transport to an ICU/CCU or super-specialty treatment not available at the sending hospital (including metropolitan group A and B hospitals in exceptional circumstances);
It needs to be emphasised that where a rural hospital or medical practitioner requests retrieval, the service err on the side of over-responsiveness to ensure that practitioners are not left to manage cases with which they are not comfortable.
It has also been suggested that there are subgroups of medical retrievals that can be distinguished by: n the nature of the escort: § Ambulance paramedic; § MICA paramedic; § nurse; § general physician; and § specialist physician with retrieval experience n the source of the escort: § sending hospital; § receiving hospital; § retrieval service. n the origin and destination of the retrieval § Primary Retrieval – not originating in a healthcare facility; § Secondary retrieval – from one healthcare facility to another - Rural - to definitive care in a larger (usually metropolitan) hospital; - Category A metropolitan – where required service is not available at the sending hospital - Category B metropolitan – where a bed is not available at the sending hospital
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2 The basis for change
There is wide recognition that retrieval services in Victoria have progressed substantially and the model that has been adopted has many positive features, particularly in relation to independence, coordination and quality of care. However, there is also strong anecdotal evidence that the current system now requires reform. Underpinning this view are a number of key issues that have been identified in the consultation process, as well as some core principles that appear to have wide-spread acceptance.
However, it also needs to be emphasised that one of the key difficulties in considering the current system is the absence of comprehensive whole-of-state data on utilisation, costs, outcomes and un-met needs. As a result, any decision to upgrade services must of necessity be based on little if any hard data about the true underlying demand for retrieval services.
2.1 Key issues
KPMG’s consultations with key stakeholders indicated a number of key issues in relation to medical retrieval:
n There is no state-wide approach to development of system coordination, policy development, quality monitoring and assurance, education, data collection and research.
n Communication on retrieval issues and teamwork among key stakeholders could be significantly improved.
n Late notification by referring hospitals of the possible requirement for retrieval is a common problem.
n There is a lack of knowledge of retrieval services and procedures among health service providers.
n MEARS response times are regarded as inadequate for time-critical cases.
n Demand for adult retrieval is considered to be in excess of current service levels, but available data is inadequate to quantify the gap.
n There is evidence that if action is not taken to create an integrated approach, the system will fragment, with individual hospitals developing their own “solutions”, reducing coordination and integration and increasing total system costs.
n While there is little evidence that a faster response will provide an improved clinical outcome in the majority of cases, the adult retrieval system currently lacks the
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capacity to deal with time-critical trauma and other cases that may benefit from medically supported transfer.
n Some patients are not receiving a level of clinical care during transport that is appropriate to their clinical need, including patients transferred between metropolitan hospitals with medically qualified escorts.
n There is an inconsistent approach to provision of regional retrieval services, with some areas having effective retrieval systems to regional base hospitals and others having little or no regionally based service.
n Current funding for retrieval services has enabled a base service to be provided, but with little capacity to improve retrieval response times beyond current levels.
n While improvement in outcome from appropriate retrieval is difficult to demonstrate, the converse, arising from inadequate systems is easy to allege and difficult to refute.
2.2 Core principles
The process undertaken to date has indicated a number of principles that appear to be generally regarded as essential elements of the system. As such, they should underpin any model that is adopted for the future operation of retrieval services in Victoria. These are:
2.2.1 Philosophy The primary focus for retrieval services must be to provide the highest quality of service to patients before and during transportation.
2.2.2 Building on the achievements of the current system Reform should build on the achievements and positive elements of the current system.
2.2.3 Service integration The Review on Trauma and Emergency Services (RoTES) report1 stated that retrieval services should be “integrated”. Integration is about combining “parts into a whole”. In the case of retrieval services, the current parts can be seen to require integration in three ways:
1 Acute Health Division, Department of Human Services (Victoria), Review of Trauma and Emergency Services – Victoria 1999, February 1999
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2.2.3.1 Patient level
The objective of the system at this level should be to “maximise the integration of continuity of care”.
This requires a focus on the care provided to individual patients and its quality and continuity from: n referring hospitals; to n transport platforms staffed by retrievalists and/or paramedics; and n receiving hospitals.
2.2.3.2 Service level
The objective at this level should be to “maximise efficiency and effectiveness of resources utilisation and communications within individual services and between services” .
This requires a focus on how services should be structured: n by geographic area (statewide and regional) n by clinical need (trauma and medical categories such as neurosurgical, cardiac, respiratory etc) n by age-related disciplines (paediatric, neonatal, adult) n by role (coordination, communication, transport, retrieval/escort, transferring hospital, receiving hospital)
2.2.3.3 System level
The objective at this level should be to “maximise the clinical benefits of a system” (as opposed to individual services).
This requires a focus on policy and management elements such as funding, system policy and planning, demand forecasting, technological change, clinical policy, education, quality assurance and audit, data collection and research.
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NOTE: Discussion in this report relating to the broader system integration (including the structure, communications, funding and broader policy/standards of emergency retrieval services), incorporates all current services - including adult retrieval, regional, neonatal and paediatric services. However, when discussing integration at a patient or service level (which incorporates how the services at an operational or ‘mission’ level) it is intended to distinguish between adult, neonatal and paediatric services.
2.2.4 Independence The system should be structured to ensure that retrieval decisions are based on a policy and protocol framework as well as clinical and system resource issues, independent of any pecuniary interest in patient destination. This principle would therefore suggest that the adult retrieval coordination role should therefore be independent of receiving hospitals.
While recognising that patient destination is predominately determined by the sending hospital and often by the clinical requirements of the patient (eg trauma, burns, spinal), independence was seen to be a key feature of the system. This should ensure that there is no ‘selectiveness’ as to the type of patient retrieved or ‘inappropriate’ diversion of patients to particular hospitals.
Establishing independence as a key criterion was seen as preferable to retrospective audit and subsequent attempts to modify behaviour.
2.2.5 Support for rural practice The development of retrieval and related services (such as coordination, advisory services and education) should be seen as supporting and enhancing rural practice. The model chosen should increase the level of awareness of clinically appropriate practice, provide a one-stop-shop for expert clinical advice as well as a responsive and efficient retrieval service. These elements should be designed to ensure that practitioners, ambulance officers and other health care professionals, feel supported to work in a rural environment. The message needs to be made clear – effective retrieval services are not about increasing the flow of patients to the city. They are about: n providing all Victorians with access to the most appropriate clinical services irrespective of location; n ensuring that rapid transfer is available when required;
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n ensuring that rural and regional practitioners are aware of, and comfortable with, the level of support available should a patient’s clinical needs require higher level expertise and/or facilities; n ongoing commitment to the development of rural and regional emergency and retrieval capability/capacity; and n developing and maintaining rural/regional practitioner “confidence” in the retrieval service, as a whole.
2.2.6 Critical mass A key requirement for effective retrieval is the use of staff who are trained and experienced in the transport of critically ill patients. It is also important that retrieval teams have access to appropriate equipment.
These observations suggest that retrieval resources should be focussed on a small number of specialist teams with state-of-the-art equipment, rather than spreading retrieval missions across a larger number of retrievalists. While there is no agreement on the “critical mass” point (the minimum number of missions (caseload) that a retrievalist should perform each year), there is general acceptance that experience and training are important elements. “Critical mass” must therefore be regarded as a fundamental principle in the development of alternative models.
2.2.7 Response flexibility to match patient’s needs There is broad agreement that the retrieval system should, ideally, have the capacity to match clinical need and the type of response provided. This view recognises that the training and experience of different professional groups provide capabilities to meet a variety of patient needs and that the system should make the most effective possible use of these resources. This also involves ensuring that the skills of the escort personnel are matched with the acuity of the patient.
While it is recognised that in practice there may not be a capacity to select on a case by case basis, it is apparent that retrievals are currently supported by a range of professional groups including emergency medicine specialists, intensivists, anaesthetists, paramedics and nurses. Each group has specific training and expertise that can be matched to the needs of individual patients.
The principles arising from these observations are: n the system should encourage a multi-disciplinary approach; n patients should receive care from those most qualified to meet their clinical needs; n retrievalists should be drawn from a number of appropriate professional disciplines;
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n case allocations should be audited; and n retrieval services should have the capacity to provide a tiered response starting with clinical advice and support and case monitoring through to scheduled retrieval, rapid response retrieval and high-tech retrievals drawing on a range of disciplines.
In short, the system should enable flexibility of response to meet the varying needs of different clinical situations.
2.2.8 Maintenance of standard of care Consistent with the principle of a tiered response is the principle that the standard of care during inter-hospital transport must be equivalent or better than at the referring hospital. This principle is enunciated in “Policy on Minimum Standards of Transport of the Critically Ill” which has been developed by the Faculty of Intensive Care of the Australian and New Zealand College of Anaesthetists (FICANZCA) and the Australasian College for Emergency Medicine (ACEM).
Only a minority of inter-hospital transfers require medical support. However, this policy position reinforces the view that there an effective system must have the capacity to provide a spectrum of care providers including nurses, paramedics, mica paramedics, registrars and consultants and the flexibility to match individual patient requirements with retrievalists’ capabilities.
2.2.9 Policy consistency The model adopted for retrieval services should be developed in the context of its relationship with, and impact on, emergency and other health services and should be consistent with: n policy directions in rural and regional health; n DHS and other relevant policies; n professional and other practice guidelines; n triage and transfer guidelines; and n the capabilities and expertise of individual hospitals.
2.2.10 Primary response The provision of pre-hospital trauma care by paramedics (with little role for medical practitioners) in the pre-hospital setting was a common element in all models considered by members of the Medical Retrieval Subgroup of the Ministerial Task Force on Trauma and Emergency Services.
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Given that the high levels of training and experience of ambulance paramedics in Victoria, it is accepted as an underlying principle that there is little requirement for the involvement of medical staff in primary response work in the metropolitan area. It is envisaged that the need for medical practitioner involvement in primary response work in rural settings will remain and must be supported consistent with the model adopted for retrieval services.
There is also a need to ensure that ambulance paramedics have responsive access to medical advice, a view that is consistent with recommendations of the Review of Trauma and Emergency Services (RoTES) report. This could involve, for example, access to a 24-hour medical advice service as part of the coordination role. This is seen to be particularly important for rural areas.
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3 Core system elements
A number of system elements that could be regarded as core components of the future model for retrieval services in Victoria have been identified. These elements should be seen as the platform on which all model options are constructed. They are:
3.1 Funding
It is apparent that the current MEARS system provides exceptionally good value for the funding provided. However, it is also clear that any improvement in the adult retrieval system will require additional expenditure to create an integrated system and to improve responsiveness to the levels available in other states.
However, it also needs to be recognised that funding comparisons with other states are not straightforward. For example, a significant component of the NSW system is provided by hospital-based helicopters that perform both primary response and retrieval work using medically qualified staff and paramedics. In other words, the cost of the service is spread across primary and secondary retrieval work. By contrast, Victoria’s retrieval services are hospital-based and discussion of how to spread costs has mainly involved consideration of how medical staff “down-time” can be used in the emergency department environment. In other words, medical involvement in primary response work is not generally regarded as an approach that will be acceptable in the context of the Victorian system.
Nevertheless, it is apparent that additional funding is a primary pre-requisite to improving retrieval services in Victoria.
3.2 Retrieval directorate
It has been noted that integration of the retrieval system is required at three levels – patient, service and system.
The approach taken to achieve integration at the system level can be seen as another essential platform upon which all models should be based. For example, there is significant scope for development of:
n approaches that bring together the organisations providing the operational elements of the system to improve:
- policy and planning for retrieval services; and
- operating systems and cooperation;
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n quality assurance and data collection systems; n more systematic and consistent approaches to adult retrieval services (eg. in relation to regional services, the role of the medical retrievalist relative to the paramedic etc); n improved education aimed at:
- creating a greater sense of teamwork among doctors and paramedics;
- providing orientation and on-going training for retrievalists in the context of a multi-disciplinary “team” approach to retrieval and transport and aviation medicine;
- ensuring that referring hospitals and doctors are more aware of the clinical issues and services available and the need to liaise with the coordinator earlier rather than later; n research to improve knowledge of the costs and clinical outcomes of retrieval services; and n more considered and consistent approaches to costing and funding of retrieval services.
The establishment of a “Retrieval Directorate” is widely supported as a way of bringing the various stakeholders together to develop a more integrated approach. This is consistent with recommendations in previous reports for the appointment of a Director of Retrieval, but goes a step further to suggest that this role encompass all aspects of medical retrieval. This does not imply that the Directorate is responsible for the operational aspects of regional retrieval or NETS and PETS and clearly its role would need to be clearly delineated in respect to these and other organisations (such as MAS, and RAV for example). What is important however, is that the Directorate: n be established and structured with broad support to provide a vehicle that brings all stakeholders together to address key system-wide issues; and n has the authority and capability to make decisions and influence key stakeholders.
Structural options for the Directorate include separation from or incorporation into OCECCS. There is wide support for the creation of a separate entity that works closely with OCECCS and its staff, probably on a collocated basis.
Consideration also needs to be given to governance arrangements. It has been suggested that accountability to a Board of Management for the implementation of a charter (as depicted in Figure 3.1) would be more effective than a looser consultative arrangement with reporting to an advisory committee (Figure 3.2). For the establishment of a Directorate to be successful, it will be important for key players to actively participate, support and “own” the initiative, particularly in the formative stages. However, it also needs to be acknowledged that if the initiative were seen to create unnecessary bureaucracy and duplication, it would not be positively regarded.
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The preferred option is for the establishment of a Board of Management rather than an advisory structure. However, given the concerns that have been raised and the importance of ensuring that stakeholders time is used effectively, it is proposed that a sunset clause be applied. This would recognise that a committee structure may only be required for a relatively short time to ensure that the key objectives are instilled into the service. The structure would then be reviewed and modified if required to ensure that it reflects the changing nature of the service.
Figure 3.1 – Board-based Structure
Minister for Health
Ministerial Emergency & DHS Acute Critical Care Committee Health
State Trauma Committee Retrieval Board
Retrieval Director OCECCS
Adult Regional PETS NETS
Regional CCECCS
Advisory relationship Direct responsibility Advisory and liaison role Contractual relationship
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Figure 3.2 – Advisory Structure
Minister for Health
Ministerial Emergency & Critical Care Committee DHS Acute Health
State Trauma State Retrieval Committee Committee Retrieval Director OCECCS
Adult Regional PETS NETS
Regional CCECCS
Advisory relationship Direct responsibility Advisory and liaison role Contractual relationship
Other issues will also need to be considered in relation to the establishment of a Directorate. For example, the relationship with the ambulance services, interface with the trauma structure and the role of regional consultative committees.
In relation to ambulance services, it needs to be remembered that the key purposes of the Directorate relate to policy, planning and cooperation and not day-to-day operational retrieval. It would be essential, for example, for ambulance services to be included on the Board of Management to ensure that planning processes become more transparent and integrated. Similarly, a consistent and integrated approach to training, data collection and quality assurance across all services can only service to improve the quality of retrieval services on a Statewide basis.
In the Figures above, it has been assumed that the Ministerial Emergency and Critical Care Committee will play a key role in ensuring that there is a consistent policy approach to trauma and retrieval services.
Similarly, it has been assumed that by recognising and funding regional retrieval services, the role of Regional Consultative Committees on Emergency and Critical Care Services (CCECCS) will be enhanced and better supported. However, this is an aspect that may be determined on a region-by-region basis.
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RECOMMENDATION 1
It is recommended that a “Retrieval Directorate” be established with responsibility for:
n policy and planning advice
n education
n systems development
n data collection
n quality assurance
n research
n infrastructure planning
across all retrieval services in Victoria.
RECOMMENDATION 2
It is recommended that the Directorate be established as a health entity governed by a Board of Management with representation from a broad range of stakeholders (possibly including ambulance services, DHS, hospitals, OCECCS, NETS, PETS and Regional Retrieval Services, trauma services, amongst others).
The Directorate could also be responsible for the provision of the retrieval coordination function. However, this is an option to be explored later with the development of service models options.
In developing this proposed approach, further consideration will also need to be given to the nature of the relationship between the Directorate and providers of retrieval services, including the extent to which it could require compliance, as opposed to operating on the basis of consensus.
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3.3 The coordination role
The coordination role should support clinicians in regional, rural and remote locations. This role has the potential to:
n reduce the need for transfers through provision of advice early in the care process; and
n ensure that patients requiring transfer are identified as early as possible.
The effectiveness and utilisation of the service will depend on its capacity to provide high quality advice, mobilise rapid response and provide a service which efficiently brings together the required service elements including transport, retrieval and receiving hospital. It should provide a single point of entry for both central and regional services, while recognising that clinicians will continue to contact local services direct when appropriate and convenient. However, the objective should be to change clinician behaviour by providing a high level of service that meets their needs and exceeds expectations.
It is our view that the current centralised coordination role should not only be continued, but should be further developed to become a key resource for rural and other health services in Victoria. It should be available on a 24-hour basis and should be developed as the definitive central advisory service with access to a range of specialists, as well as a retrieval entry point.
This is consistent with the RoTES report, which stated:
Effective coordination should provide the following key functions:
n Single point of communication and dispatch.
n Medical control providing expert and timely clinical advice.
n Capacity to utilise and task the most suitable transport platform.
n Crew mix determined by mission.
The coordination role should also be the point at which issues in relation to transport allocation/priority issues are managed and bed availability and admission arrangements sorted out. The Coordinator needs to hold strong authority in the system to be able to ensure that resources are made available as required to meet patient needs. How this is achieved will depend on the model chosen for retrieval operations. However, there is a strong argument to suggest that this role should move towards becoming a 24-hour on- site position that has strong links into the ambulance service communications infrastructure. For example, the position could be collocated with the Air Ambulance control centre.
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Again, the strengthening of the coordination role is consistent with the RoTES report’s recommended Retrieval Activation Sequence which was intended to “streamline communication and relieve the referring clinician of the need to make multiple contacts”. The report also suggested that “regional coordinator contact would, in most regional retrievals, be the appropriate first contact”. It should also be noted NETS and PETS would also be the appropriate first contact point for neonatal and paediatric retrieval. However, the central coordination function should have the capacity to provide a single point of entry for all retrievals including regional and specialist services. This will require the development of more sophisticated communications arrangements and the creation of a climate of cooperation. For example, the paediatric/neonatal service in NSW has been cited as a technology model that could be used in developing communications capability.
The approach is illustrated in Figure 3.3, which summarised the RoTES report Retrieval Activation Sequence, but highlights the interactive relationship between the coordinator and other services.
In summary, the development of the coordination function, in conjunction with the Retrieval Directorate (or as part of it), will provide a single point of responsibility and accountability for retrieval services in Victoria and a focus for greater interaction between all service elements. Furthermore, it should be enhanced in a manner that enables it to be: n technologically enabled; n the system’s recognised entry point for clinical advisory services; n independent; and n a one-stop-shop for organising retrieval support and transport.
RECOMMENDATION 3
It is recommended that the coordination role be further developed to provide a recognised statewide, definitive specialist advisory service for Victoria to support clinicians with complex clinical issues on a 24-hour per day basis.
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Figure 3.3 – Retrieval Activation
Is patient management advice, bed finding or retrieval needed?
Yes Consult Central Consult Local/Specialist
Service Level Advice & Bed Finding NETS
Advisory PETS Coordinator Regional
MTS VSCS Other
Is central adult Yes Coordinator contacts bed finding OCECCS for adult needed? bed allocation
No
No Is retrieval End needed?
Yes
Coordinator or service level determination of retrieval requirements re transport, escort
Coordinator/service Coordinator/service Coordinator/service activates retrieval liaises with ASV re advises reception team at service transport destination hospital Retrieval Activation
Transport
Definitive Care
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3.4 Improved communications capability
The potential of communications technologies is not being fully realised by the current system, particularly in relation to coordination. This should be developed to provide streamlined contacts with ambulance and hospitals and access to bed availability, clinical and other information. Telephone conferencing, re-routing of calls, on-line information access should be used to maximum advantage to enhance the coordination role. These opportunities need to be thoroughly explored and exploited to maximise the effectiveness of the coordination role.
It also needs to be recognised that even within the current MEARS service configuration, there are resource constraints on the communications process. For example, the hours of operation of the MEARS switchboard are limited and after-hours calls are directed to the St Vincent’s Hospital switchboard. Other communications issues involve the staffing of the Air Ambulance control room at Essendon after hours and the need for the coordinator to make contact through the MAS Duty Team Management after hours. These arrangements have all added to the complexity of communications after normal working hours in particular.
The telecommunication system for retrieval advice and request should provide a “hot-line” for rural medical staff and/or hospitals. Requesting doctor/hospital should have the choice of communicating with the regional service, NETS, PETS, or adult coordinator with additional access to specialised information (trauma, burns, spinal, etc). Once communication is made, the cascade of events/activities/processes for both the rural hospital, the regional retrieval service or the metropolitan based tertiary retrieval service should be automatically triggered, with all personnel involved confident in the “system” activation.
The other aspect of communication that offers significant potential is the use of telemedicine and other communications technologies to support the provision of clinical advice and support by the coordinator. There appears to be potential for retrievals to be reduced through better sharing of clinical information between the treating doctor and the coordinator. This may involve advice that patients are unlikely to benefit from retrieval due to the seriousness of their condition. Alternatively, it may enable care to be provided locally.
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RECOMMENDATION 4
It is recommended that the potential for improved use of communications technology be investigated to ensure that coordinators can effectively and efficiently carry out their role within an expanded advisory and support role, including shared use of ambulance communications infrastructure.
3.5 NETS and PETS
In considering the provision of paediatric and neonatal retrieval services, three key factors need to be taken into account:
n the highly specialised nature of neonatal and paediatric care means that retrieval should only be undertaken by those with relevant specialist clinical expertise;
n the limited number of hospitals that can receive neonatal and paediatric patients means that issues of retrieval service independence are less relevant for NETS and PETS than they are for adult retrievals; and
n the acceptable level of satisfaction with current services.
Given these observations, it is proposed that at an operational level, both NETS and PETS should continue to function as currently structured.
RECOMMENDATION 5
It is recommended that on an operational basis, NETS and PETS should continue as presently structured.
3.6 Regional services
Regional retrieval services are seen as another core element of an integrated retrieval service. Rural and regional retrieval services will generally be the first “port of call” for critically ill patients, with involvement mainly in secondary retrievals (from rural to regional hospital) as well as a small number of primary retrievals (from the road side/or site of injury). Secondary retrievals to metropolitan teaching hospitals are principally seen as the role of a centrally based retrieval service.
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Some regional services have maintained effective retrieval with little or no funding for many years. Recognition needs to be given to the commitment and professionalism of the local staff who have ensured that these services have been available and have formed a vital component of local health services for many years.
Details of the current regional services are provided in Appendix 2. Approximate annual volumes for each service are: n Ballarat – 100; n Bendigo - 50 n Albury – 30 n Geelong - 50
Many rural hospitals have taken action to ensure they are prepared to manage local emergencies, with significant numbers of staff have completing emergency medical training. Staff skills in emergency care will continue to be required in both managing patients locally and as a first response for those that require transfer to a tertiary level facility. For example, rural hospitals have developed skills to accommodate cardiac thrombolysis, with patients requiring cardiac surgery and catherisation being transferred for tertiary care.
Regional retrieval services also play an important role in providing advice to surrounding hospitals. They generally know the doctors and the facilities, understand their patient management capabilities and in most regions, have the capacity to care for many acutely ill patients at the consultant medical level. Retrievals from rural areas may therefore be avoided through provision of advice, support and local care. Knowledge of the local environment is critical to the requesting provider’s confidence in the retrieval process and needs to be married with the central coordination function’s expertise and resources through improved communications capabilities and building retrieval as a coordinated system rather than as a series of unrelated services.
There are a number of examples where regional services are operating very effectively and serve as a model for the future. These models generally involve positive relationships between the local ambulance service and hospital staff. This view is entirely consistent with previous reports, which have recommended funding to support these services. The RoTES report recommendations stated:
Recommendation 7.2.1
Funding be enhanced to rural retrieval services to effectively operate as part of a statewide retrieval system.
Recommendation 7.2.2
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Regional retrieval services continue to coordinate missions that require treatment at a regional hospital level but, for missions requiring tertiary level care, there be timely liaison with the statewide retrieval system.
Recommendation 7.2.3
Simultaneous dispatch of regional and statewide retrieval services be an option on a case-by-case basis to minimise time to definitive care and enhance support available to regional ambulance services and local hospitals.
Consistent with the principle that the model adopted should support rural practice, the need to provide resources to designated rural health services for provision of retrieval services is reiterated.
However, it does need to be recognised that: n The development of these services has traditionally been driven by individuals rather than by any system-wide policy approach. n Local factors will mean that each service may operate in different ways. n The state’s central retrieval services should cover “gaps” in regional services as required. The capacity of regional services may vary from location to location and over time. The Retrieval Directorate should have a strong role in making alternative arrangements where required.
The model for regional retrieval should be based on enhancement and ongoing support of current best practice in regional services. Fundamental to such services is: n development and support for local capability; n knowledge of local resources and capability; and n coordination, collaboration and teamwork between local providers; rural and regional hospitals, GPs and rural ambulance services.
Effective regional retrieval services require systemic planning and leadership. This normally involves the appointment of a Director (as an adjunct to a full-time role such as Director of Emergency or Director of Intensive Care). It could also include a regional Clinical Nurse Consultant (CNC), Emergency Services to support day-to-day coordination, education, monitoring and review.
Communication and liaison between rural hospitals and the regional retrieval service is also fundamental. Regional emergency and retrieval coordination committees have an important role in monitoring and reviewing service need, utilisation, outcomes, service development and funding.
The achievement of more consistent availability of regional retrieval services will require:
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n the establishment of criteria for recognition as a regional retrieval service (eg staffing and facilities);
n funding to support the necessary resources - staff, equipment, data collection consistent with common monitoring and review processes, education and training, consultative committees, etc.
n a review of access to transport in each region to identify those areas where this is an impediment to the service; and
n improved communication systems between regional services, the coordinator and the Retrieval Directorate.
It is apparent that the first task required in relation to regional services is to ensure that current services are able operating effectively. Key issues in this respect will be to ensure that there is adequate availability of transport and staffing. A key issue for some regional services is lack of access to rotary wing support (refer Section 7).
The second issue is to ensure that there is appropriate geographic coverage. Effective coverage appears to be available from Bendigo, Ballarat and Albury, although staffing changes have and will continue to impact on the capacity of these services.
It is essential to reiterate the objective of ensuring that regional services can operate as an integral element of a statewide service and not as unrelated and unsupported services.
RECOMMENDATION 6
It is recommended that the Retrieval Directorate be tasked to support the development of regional retrieval services as a collaborative venture between the relevant hospitals and Rural Ambulance Victoria. These services should be based in regional emergency departments/intensive care units and should work collaboratively with the central retrieval service in managing patients, education, data collection and quality assurance.
3.7 Scope
Another key issue that impacts on the model to be adopted for retrieval is the scope of services to be provided. For example, it was suggested that some metropolitan hospitals are not staffed to provide medical escorts for patients being sent to other hospitals. If a senior escort is sent, this can leave the hospital under-resourced and “exposed” while the
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doctor is absent. It can also mean that to prevent such exposure, junior staff who are inadequately prepared to manage the transfer are used, compromising patient care.
It is recognised that the retrieval service should have a role in metropolitan transfers where there is evidence that patient’s clinical condition requires specialised support or where the sending hospital does not have the resources to support a transfer. It is also recognised that in principle, retrieval should be undertaken by staff who are regularly involved in such work – achieving a critical mass. However, there does not appear to be sufficient evidence at this time to support the substantial increase in resources that would be required for a central service to undertake all medically supported inter-hospital transfers in Melbourne. A monitoring role needs to be undertaken by the Retrieval Directorate to assess the appropriateness of Melbourne IHT requests.
The development of better information systems and a process of quality assurance and monitoring to assess the current situation is required. It is a key element in the establishment of a Retrieval Directorate.
RECOMMENDATION 7
It is recommended that the operational model adopted for retrieval at this stage should not be based on the extension of adult services to cover all medically supported metropolitan interhospital transfers, but should allow for such transfers where the Coordinator determines that specialist retrievalist skills are required and not available at the sending hospital.
3.8 Responsiveness
3.8.1 Response time The following diagram from the RoTES report shows the components of total retrieval time. The issues that were most commonly identified in our consultations were the pre- travel response time (ie. activation and dispatch), particularly in relation to delays by referring hospitals and time taken to get retrievalists and transport platform mobilised.
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Figure 3.4 – Retrieval Time and Response Time
Retrieval time
Response time
Activation Dispatch Travel Patient preparation and treatment Travel
Time to notify Time for crew crew to depart
Dispatch
Users of the service expressed the view that dispatch time needs to be faster. It was continually suggested that if retrieval services in Victoria are to move forward to the next stage of development they must develop an improved response capability.
However, the issue of the MEARS response time is contentious. On the one hand it was suggested that delays due to the current system of rostering retrievalists on-call and/or delays in the availability of aircraft or pilots mean that hospitals in rural areas will often make alternative arrangements rather than use MEARS. On the other, it has been argued that most retrievals are not time-critical, that improved clinical outcomes have not been demonstrated and that the development of a faster response capacity would not be cost-effective given the clinical nature of the cases involved.
In considering response times and possible reductions, it also needs to be recognised that there are many components of overall mission time. These are depicted in the following diagram prepared by OCECCS in relation to current MEARS missions. This indicates that with changes in retrievalist availability and transport availability, reductions can be made in response times and that with other improvements (such as stretcher compatibility), overall mission time can also be reduced, but within fairly defined parameters. These parameters and the components of overall retrieval time are often not well understood.
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Figure 3.5
Fixed wing 73% Current retrieval Retrieval Mission Profile mix
Retrieval physician mobilisation Retrieval Mission Profile (Source – OCECCS) time + aircraft & pilot Helicopter 7% mobilisation time
Road car Mica 20% 0%
Current R/wing 130kts H/copter Ave. mission 3 - 4 hours Possible
Ave. mission 6 - 7 hours Current Kingair 245kts F/wing Platform compatibility reduction Possible
Ave. mission 5.5 - 6.5 hours Important pragmatic considerations Current •Infrequent events cluster •Access to rotating wing platforms will continue Roadcar to be limited •Weather conditions in Victoria sometimes Possible mean road transport is only option
0 50 100 150 200 250 300 350 400 450 Minutes
Advice/Coordination Arrangements pre-departure Flight time out
Airport to hospital Patient assessment & stabilisation Wait for roadcar
Patient into roadcar Hospital to airport Patient into aircraft
Flight time back Patient into roadcar Airport to hospital
Handover at destination hospital Estimated 90th percentile response time
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3.8.2 Trauma One of the key areas in which it has been suggested that improved response times are required is major trauma, principally the inter-hospital transfer of patients from rural to metropolitan hospitals. The proportion of trauma cases in the current MEARS figures is approximately 10%, which suggests a total of perhaps 15 cases per year. The report “An estimate of the impact of trauma triage and transfer guidelines on the resources of Ambulance Service Victoria” prepared by the Monash University Department of Epidemiology and Preventive Medicine identified a case-set of 335 (unadjusted) Major Trauma cases transported between hospitals in 1997/8. If cases originating in the metropolitan area (indicated by ambulance branch) are eliminated along with transfers to regional and rural hospitals (that would be managed by a regional retrieval service), an assessment can be made of the number of rural major trauma cases transferred to metropolitan hospitals.
The total number is 74, with destination hospitals and source ambulance branch shown in Table 3.1:
This suggests that a retrieval service that provides a faster response time (and is principally involved in rural-metropolitan transfers) may attract up to 70 additional major trauma cases per year (assuming that all cases would require medical support).
However, it also needs to be recognised that new trauma guidelines will change the patterns of admission and transfer. The Monash report predicts an additional 125 IHTs per year and a substantial increase in the number of transfers by air to the Major Trauma Centres (260+).
Table 3.1
Current Inter-hospital Major Trauma Caseload by Ambulance Branch and Destination Hospital (unadjusted) – Rural to Metropolitan
Branch Destination Hospital Cases AIR1 ARMC – Austin Hospital 3 Bacchus Marsh ARMC – Austin Hospital 1 Ballarat ARMC – Austin Hospital 1 Echuca ARMC – Austin Hospital 1 HELIMED ARMC – Austin Hospital 1 Seymour ARMC – Austin Hospital 1 AIR Dandenong Hospital 1 Morwell Dandenong Hospital 1 Wonthaggi Dandenong Hospital 1 Yea Maroondah Hospital 1 AIR Monash Medical Centre – Clayton 2 Wonthaggi Monash Medical Centre – Clayton 1
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Branch Destination Hospital Cases Rosebud Mornington Peninsula Hospital 1 Seymour Preston & Northcote Community 2 AIR Royal Melbourne Hospital 8 Ballarat Royal Melbourne Hospital 1 Geelong Royal Melbourne Hospital 1 Seymour Royal Melbourne Hospital 1 AIR St Vincent's Hospital 12 Ballarat St Vincent's Hospital 1 HELIMED St Vincent's Hospital 1 AIR The Alfred 15 Ballarat The Alfred 1 Geelong The Alfred 6 HELIMED The Alfred 7 Seaford The Alfred 2 TOTAL 74
3.8.3 Medical Due to lack of hard data, an estimation of the likely demand for medical cases is more difficult. It has been suggested that medical cases requiring urgent transfer may include: n neurosurgical; n aortic aneurysm; n urgent angioplasty; n surgical cases requiring higher level support; n acute septicaemia; and n acute respiratory cases.
However it is recognised that consistent with current workload, the majority of medical cases are not time-critical.
3.8.4 Other response-time issues Finally, it needs to be emphasised that there has been a strong and consistent view in our consultations that sending hospitals are not using the current MEARS system due to perceptions about slowness of response. To illustrate the nature of the concerns, our attention was drawn to opinions stated in a survey by the Barwon and Western Region Emergency and Critical Care Committee. In response to the question “Is transport of patients to other facilities rapid and appropriate?” the following responses were received from hospitals in the west of the region:
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Transfer of patients … is anything but satisfactory. In the case of critically ill or trauma patients, there are a number of options. If we call MEARS, NETS or PETS there is a significant delay, particularly in the case of MEARS, where the staff are on call, rather than on stand by. The average time to transfer a seriously ill patient … to a Melbourne hospital is in the order of 7.5 hours and this is unacceptable.
As this hospital is outside of the area by which a helicopter can transport patients without re-fuelling, all our retrieval is by fixed wing aircraft. At a minimum, the expected time of arrival in Melbourne of a patient is three times the one-way travel time. To this must be added preparation time to get retrieval team into the air and delays on the ground at the forwarding Hospital.
3.8.5 Activation time It also needs to be recognised (as noted already in relation to the development of education and directorate capabilities) that referring hospitals should be activating the retrieval process earlier in many cases.
3.8.6 Summary In summary, while the available data is limited, there is evidence that while the current MEARS system is acceptable for non-time critical patients: n it is not servicing the needs of time-critical cases including major trauma; n the projected increase in air transfers from rural hospitals to Major Trauma Services are likely to lead to an increased need for retrieval services;
In light of these observations, the model options for adult retrieval operations developed in this paper address the issues of how to improve the retrievalist availability (ie how to provide faster on-the-ground support, thereby meeting the needs of time-critical patients and increasing rates of utilisation of the service). However, it is important to reiterate that improvements in overall response times will not be achieved if retrievalist availability is not matched by platform availability.
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3.9 Education
3.9.1 Retrievalists There is a clear requirement, irrespective of the operational model that is chosen, to provide improved education for retrieval (eg currency in EMST and APLS). In particular, this education should:
n focus on the retrieval team – developing a common training modules to promote improved cross-disciplinary understanding and cooperation; and
n ensure that retrievalists are fully trained in all safety and other aspects of the transport environment in which they are working.
3.9.2 Referring doctors and nurses Indications that retrieval may be required are often present many hours before MEARS is notified, potentially compromising the patient’s care. This has been a long-standing concern among MEARS retrievalists and something that requires on-going education. The problem may be addressed through a range of measures, some of which have been noted already:
n the enhancement of the coordination role should promote the increased utilisation of this advisory service;
n the appointment of a Director of Retrieval as part of the Retrieval Directorate should enable:
- an increased capacity to provide education; - follow-up of cases that have been compromised by late notification; - development of protocols and guidelines to assist practitioners; and - improved data collection and analysis to identify areas for improved practice.
RECOMMENDATION 8
It is recommended that as an integral component of the establishment of a Retrieval Directorate, a program of education be established to include regional retrieval services, metropolitan retrievalists, PETS, NETS, ambulance services, air crews etc to:
n create a greater sense of system and teamwork; and
n develop knowledge, understanding and skill.
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RECOMMENDATION 9
It is recommended that as an integral component of the establishment of a Retrieval Directorate and an expanded coordination function, a program of education of medical practitioners be established to promote awareness and effective utilisation of these services.
3.10 Data collection and quality assurance
As noted above, the development of a data collection and monitoring system is required to provide meaningful data on retrievals and clinical outcomes.
At present, there is no capacity to bring together information from across the system. There is no capacity to reconcile ambulance data, retrieval data, the VAED, trauma and other information to make any assessment of:
n retrieval volumes;
n response and elapsed times;
n mix and location of patients being transported;
n cost;
n unmet need for retrievals and equity of access; and
n clinical outcomes of the retrieval process.
While this issue has already been noted as part of the Retrieval Directorate function, it is a fundamental issue for the future planning and monitoring of retrieval services and a core requirement, irrespective of the operational model chosen.
It should also be recognised that data collection and case review should encompass all system retrievals irrespective of the escort provided to ensure consistency of treatment and communication. Medical practitioners should play an active role in the on-going education that evolves from case review. Such interaction across disciplines should result in education of all parties involved.
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RECOMMENDATION 10
To ensure collection of comprehensive and meaningful data on retrievals across the state it is recommended that as an integral component of the establishment of a Retrieval Directorate a system of data collection be implemented including a standardised retrieval dataset.
3.11 Protocols and guidelines
While there is a strongly held view that “codification” of best practice is not a panacea, there is a need for development of guidelines and protocols to:
n support clinicians;
n encouraging hospitals to provide early notification of possible retrieval;
n designate the roles of regional and other hospitals in the retrieval system; and
n designate the clinical situations in which retrieval should be initiated.
The RoTES report has already established Major Trauma Interhospital Transfer Guidelines with associated Specialist Trauma Transfer Guidelines for:
n neurotrauma,
n spinal trauma;
n barotrauma;
n paediatric trauma;
n obstetric trauma;
n burns; and
n musculoskeletal trauma.
While there are concerns about aspects of these guidelines in relation to their capacity to require transfer of patients that some clinicians believe can be managed locally, there is general recognition that similar guidelines could be developed for medical cases.
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However, this would be a longer-term process for the Retrieval Directorate and should be seen as integral to the development of education, quality review and data analysis.
An example of a guideline that could be used for early recognition of adult patient instability is attached as Appendix 1.
RECOMMENDATION 11
It is recommended that as part of its responsibility for education and quality assurance, the Retrieval Directorate be allocated the task of developing evidence- based retrieval protocols for non-trauma and for auditing the effectiveness and implementation of protocols in cooperation with hospitals.
3.12 Transport platform issues
It is important to recognise that availability of transport platform is an essential component in the overall responsiveness of the retrieval service –a core component.
It has already been noted that a key concern raised in consultations has been the dispatch time for retrievalists. However, it is the overall response time that is clearly of primary concern to requesting hospitals. In other words, platform availability, mobilisation time and total travel time are as relevant as retrievalist mobilisation time.
In short, if the increased responsiveness inherent in the models for retrieval operations is to be translated into improved response times, matching access to transport platforms will be needed.
It also needs to be recognised that transport issues, particularly in relation to rotary wing capacity, are being addressed though processes separate (but complementary) to this project (eg. third helicopter, upgrade of existing fleet, incorporation of helipads into hospital design etc).
3.12.1 Road Our consultations have indicated that there are few concerns about the availability of road ambulances. Given that the majority of retrievals use road platforms, this is a significant positive.
However, it was indicated that there are occasions when the level of ambulance available on transfer from air to road platforms is inadequate. For example, a contracted road ambulance is tasked to meet a fixed wing retrieval and does not provide a consistency of support.
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3.12.2 Fixed wing With regard to missions using FW aircraft, pilot and/or aircraft availability has been cited as a delaying factor in some missions. However, a number of other issues have been addressed or are under active consideration (eg availability of pressurised aircraft, 24- hour manning of Essendon, NETS cot compatibility etc).
3.12.3 Rotary wing It is clear perception among stakeholders that in practical terms, rotary wing aircraft are not generally available for most adult retrieval missions.
At present, due to the limited availability of RW aircraft, primary response work is, understandably, allocated first priority. Furthermore, due to the often-lengthy duration of missions, the ambulance service has been reluctant to allocate RW aircraft to retrieval missions in case more urgent primary response priorities develop during its absence. However, it also needs to be recognised that the RW platform should be allocated on the basis of urgency and that there may be many instances in which secondary retrievals may be more urgent than primary work.
While it is dangerous to base service development on the use of individual cases, the following examples illustrate the nature of concerns expressed in some regional areas. n Arrangements were made to transfer a patient urgently to Geelong as a consequence of arterial occlusion to his leg. The case was considered urgent since delay might lead to amputation. The helicopter was arranged but did not arrive due to having been diverted to another emergency. The patient eventually arrived in Geelong 7 hours after the original call was made. n A patient presented at a regional hospital with a ruptured abdominal aorta. The diagnosis was rapidly confirmed and arrangements made for urgent transfer to Geelong for emergency surgery. The helicopter (495) was unavailable and the patient was transferred by road (2 hours 20 minutes, code 1 with lights and sirens). Emergency surgery was eventually performed 5 hours after initial presentation.
These observations are consistent with the following recommendations of the RoTES report:
Recommendation 7.6.1
Access to additional rotary wing aircraft is required to ensure retrieval response capacity in time-critical cases.
Recommendation 7.6.2
Payload capacity and range of any additional rotary wing aircraft be appropriate for the requirements of statewide medical retrieval.
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Recommendation 7.6.3
Review of the location and accessibility of helipads when planning new hospitals and for existing hospitals which will play a substantial role in the transfer of major trauma and other time-critical cases.
Subsequently, a decision was made by government to add a third helicopter to the AAV fleet.
Some of the key issues in relation to the transport platform are: n Whether a helicopter allocated specifically for retrieval is required or whether a general increase in RW availability in the system will suffice. n Whether individual hospitals or groups of hospitals should be permitted to enter private arrangements with helicopter operators independent of the service operated by Air Ambulance Victoria. n Cost. n Sponsorship of helicopter services.
3.12.4 Proposed model elements While there is understandable frustration at the current lack of RW retrieval capability, this should not be allowed to translate into the establishment of a range of disparate and uncoordinated responses with a spread of workload across a number of different providers.
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RECOMMENDATION 12
On the basis of our consultations it is recommended that:
n consistent with all models considered by members of the Medical Retrieval Subgroup of the Ministerial Task Force on Trauma and Emergency Services, all retrieval transport capability should be coordinated through AAV;
n increased RW capability (which may be provided wholly or in part by the government’s commitment to a 3rd helicopter) is required to support city based and some regional retrieval services;
n this increase should be met through an overall increase in RW capacity rather than through the provision of a dedicated helicopter;
n as the availability of RW capacity charged on a per-occasion-of-use offers an opportunity to supplement the existing system and to meet and test retrieval transport requirements without high up-front risk. These should be thoroughly explored with a view to capitalising on the opportunity subject to provision safety considerations and operation within the parameters of the retrieval/ambulance system; and
n sponsorship should be considered only on the basis that withdrawal would not prevent on-going access.
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4 Service model components for retrieval operations
4.1 System core principles and elements
It has already been noted that there are “core principles” and “core system elements” that could be adopted irrespective of the model chosen for the operational aspects of retrieval services. The core principles include:
n a focus on service quality;
n building on the achievements of the current system;
n development of an integrated service;
n independence of retrieval from receiving hospitals;
n concentration of retrievals on a specialist and experienced group;
n capacity to provide a ‘quick’ response;
n capacity to provide a tiered response;
n maintenance of standard of care during transport;
n a retrieval system that supports rural practice; and
n maintenance of current arrangements for primary response.
In relation to the core elements of the system, it has been recommended that:
n a Retrieval Directorate be established to take a whole-of-system view of policy and planning, promoting cooperation and process improvement, quality assurance, education, research etc.
n the coordination role be further developed to provide a central and definitive specialist advisory service to support clinicians with complex clinical issues;
n the operational aspects of NETS and PETS remain as currently structured;
n the responsiveness of the current system be improved;
n that via the establishment of a Directorate, additional resources be provided for education, data collection and analysis, development of protocols etc.
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n that there be a strong focus on improving the communications capacity of the current system.
It is our view that these are elements on which there is relatively wide agreement.
4.2 Model elements
Before considering potential models for retrieval services in Victoria, it is important to understand the key components or distinguishing features that have been used to describe each model. These components ensure that a consistent approach is taken to describing each model and enables an assessment to be made of how each model differs from others.
The components that have been used are:
n management structure – the organisational arrangements and relationships for the provision of coordination and retrieval services
n dispatch time – the speed with which the proposed model is likely to be able to respond to requests for retrieval and the availability of 2nd on-call and 3rd on-call (if relevant). For the purposes of this discussion, dispatch time is an indicative figure of (say) time taken for the retrievalist to be available for RW/FW take-off;
n process for ensuring independence – the structures and processes that ensure that retrievals are undertaken independent of any consideration of financial or related impact on the receiving hospital;
n communication process – the process though which retrieval is activated
n role of 2nd on-call – in some models the 2nd on-call will “back-fill” when a retrieval is activated, while others may involve the 2nd on-call providing the primary response to non-time-critical retrievals;
n coordination – where the coordination function is based, employment arrangements for the coordinator;
n retrievalists – where the retrievalists are based, employment arrangements, number of staff;
n relationship with other organisations – collocation and other potential cooperative arrangements with other organisations;
n restrictions on retrieval services/control – the extent to which the provision of retrieval services is restricted to designated providers or made is open;
n source of critical care advice – process for obtaining critical care advice;
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n access to bed finding – arrangements for the coordinator to access information on available critical care beds; n cost – the indicative cost of the model.
Once again, it needs to be recognised that the models focus on key variables and exclude elements that are outside the scope of this project or are seen as consistent across all models (eg the need to provide matching transport availability).
The following template has been used to illustrate the broad characteristics of each model in relation to the key components listed (excludes management structure, source of critical care advice, access to bed finding and cost).
Template PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Low Time
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Process Retrievalists Coordination Hospitals Contracted Service
Communication Contact central Left to referring Contact regional Process Central service first hospital discretion service first Dispersed
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Multiple Ambulance/RW Single hospital MTSs hospitals On Call Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Control Retrievals by central Designated hospitals only All hospitals None restrictions service only permitted to retrieve permitted to retrieve
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5 Model Options – Adult retrieval operations
Before describing the key model options for the operational aspects of adult retrieval, it is timely to note the recommendations of the RoTES report in relation to medical staffing. Recommendation 7.1.1 stated that:
The proposed medical staffing model for the statewide retrieval service be:
n A centrally-based pool of staff who are trained for and frequently undertake retrievals.
n Drawn from a number of hospitals on a roster basis, enabling most stakeholders to participate in the provision of the service.
n Available within a notification time of five minutes enabling an immediate response for rotary wing missions when clinically required.
n Consultant level medical practitioners or Senior Registrar level medical practitioners.
n Sourced from a range of craft groups (for example, emergency physicians, intensivists, anaesthetists, cardiologists) enabling the most appropriate practitioner for the mission.
n Located on a shift-to-shift basis with consideration of access to appropriate transport platform.
These are consistent with the recommendations and observations made so far in this report. However, their translation into operating models will require trade-offs and compromises. No model will maximise outcomes in terms of cost effectiveness, responsiveness, independence etc.
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5.1 Current MEARS model
The current MEARS model is depicted in the following diagram.
MEARS Model PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Low Time
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Contracted Service Process Retrievalists Coordination Hospitals
Communication Contact central Left to referring Contact regional Central Dispersed Process service first hospital discretion service first
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Ambulance/RW Single hospital Multiple On Call MTSs hospitals Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Retrievals by central Designated hospitals only All hospitals Control None restrictions service only permitted to retrieve permitted to retrieve
5.1.1 Management structure MEARS operates as part of OCECCS and the Director is responsible to the Director of Acute Health – DHS. A Management Committee existed until June 1999, with broad representation including Chief Medical Officer, Ambulance, Police and Displan.
Both retrieval and coordination are integrated into the service.
The support functions for MEARS are provided by an administrator, an administrative assistant, an executive assistant and four part-time clerical staff for evening and weekend work. The part-time after-hours staff support the functions of OCECCS.
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5.1.2 Process for ensuring independence Retrieval and coordination are not aligned to any hospitals. Retrievalists from a range of hospitals are employed by MEARS.
5.1.3 Dispatch time Retrievalists are on-call and are not expected to provide immediate availability. Dispatch times are considered inadequate for time-critical cases. A dispatch time of 45 minutes has been indicated. While this does need to be viewed in the context of an average mission time of more that 5 hours, it is apparent that the critical issue for many retrievals is the speed with which definitive assistance is available at the requesting hospital.
5.1.4 Communication process There is no mandated system-wide communication process and hospitals are able to contact their local regional service or a metropolitan hospital direct, arrange ambulance transfers etc independent of MEARS.
For those hospitals using MEARS, the transferring hospital contacts MEARS and is transferred to the coordinator if required. There are a number of concerns about after- hours systems and manning. These include manning of the MEARS office and the AAV control centre at Essendon.
5.1.5 Role of 2nd On Call The role of second on call is to provide a second-call capability for MEARS. The second on call position is not one that is regularly required to undertake retrievals.
5.1.6 Coordination Four senior specialists are employed on an on-call basis by MEARS on a rotating roster 24 hours a day to: n facilitate access to critical care beds; n provide advice to hospitals and the ambulance service on acute interhospital transfers: and n coordinate MEARS.
They are not located at a particular base, but are accessible by phone.
The coordinator has no mandated authority to allocate priorities to transport platforms or require hospitals to make beds available. The position uses influence to achieve these
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outcomes. There is no clear authority in the system to resolve conflicting demands for transport platforms by the various retrieval groups.
5.1.7 Retrievalist On-call retrievalists are not required to be immediately available and are therefore paged on a call-out basis. They may be at home or at work, but will be engaged in activities that do not involve devoting their full attention to the retrieval role. The contribution of those involved in the current system needs to be recognised as the rewards are not substantial and participation is often based on a commitment to and interest in retrieval medicine. This should not be lost.
The retrievalists are employed by MEARS and are therefore independent of receiving hospitals.
Given the nature of the arrangement, there is no issue of how to utilise retrievalists time between missions.
However, given that most have full time positions elsewhere in the system, there are concerns about the impact of having to present for work after, for example, a lengthy over-night retrieval.
MEARS employs two retrievalists on call concurrently, plus a coordinator.
There are 16 retrievalists employed, some of who act as coordinator on a rotating basis. The Director also acts as Coordinator.
5.1.8 Relationship with other organisations MEARS is integrally associated with OCECCS. The two effectively operate as an integrated entity. In addition, DISPLAN is collocated and closely associated with OCECCS.
5.1.9 Restrictions on retrieval services/control There are currently no restrictions or controls placed on hospitals wishing to undertake retrievals.
5.1.10 Source of critical care advice OCECCS
5.1.11 Access to bed finding OCECCS
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5.1.12 Advantages and disadvantages
5.1.12.1 Advantages
It is clear that the current system provides a number of important benefits. In particular, MEARS: n is extremely cost-effective, providing good value for the modest funding invested in the system; n is independent; and n provides central, statewide coordination capability.
These advantages are features lacking in many retrieval systems in other states or overseas.
5.1.12.2 Disadvantages
The key criticism of MEARS is that its doctors are on-call and are spread widely across Melbourne, making dispatch times variable and considered by many to be “mostly poor”. While this is acceptable for non-time-critical cases, it (along with the transport infrastructure which is discussed later) is not structured to respond to time-critical cases.
5.1.12.3 Points of fragmentation
The structure of the system also means that there is a “disconnect” between the ambulance component of the retrieval process and the medical staffing. This leads to no sense of team by the retrievalists and ambulance officers. There is also no ‘connection’ or ownership of the retrieval service by the receiving hospital.
5.1.13 Conclusion/recommendation Given that the key concern in the system is response time, the most obvious answer is to make retrievalists (and transport platforms) available within a shorter timeframe. The optimum in terms of timeframe would be to place retrievalists at the airport or permanently allocated to a dedicated helicopter.
While it is apparent that current volumes understate true demand, there is insufficient evidence at this stage to suggest that there is sufficient caseload to keep a retrieval service occupied on a 24/7 basis. It is therefore not considered an appropriate option to suggest that retrievalists be placed at an airport.
The next step back in terms of improving responsiveness would be to locate retrievalists at a hospital or hospitals. To the extent that staff would be “on duty” rather than “on call”, response times should be improved. This would be enhanced if they were located either
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close to the airport or had fast access to helicopter transport to the airport or direct to the referring hospital. Placement at a hospital also offers the potential for retrievalists’ time to be used more productively during down-time and therefore has the potential to be more cost-effective.
5.2 Central service model 1
This model involves retrievalists employed by a central retrieval service working at any one of a number of designated hospitals. Criteria would need to be established in relation to which hospitals would be acceptable, particularly in relation to location/access to transport.
This model varies from the current MEARS model in only a few respects:
n it moves from an ”on-call” to “on-the-ground” availability for retrievalists;
n with the adoption of the core elements recommended earlier, retrievalists would be employed by the Directorate rather than by MEARS/OCECCS.
n the model would improve retrievalist availability, but this would depend on the sites chosen for locating the retrievalists (ie the extent to which they provide helicopter access) and the availability of helicopters to transport retrievalists to the airport or to the requesting hospital.
The assumptions underlying this model are:
n employment of retrievalists sourced from a range of hospitals
n where possible, retrievalists working at their employing hospital during “down-time”
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Central Service Model 1 PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Low Time
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Process Retrievalists Coordination Hospitals Contracted Service
Communication Contact central Left to referring Contact regional Process Central service first hospital discretion service first Dispersed
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Multiple Ambulance/RW Single hospital MTSs hospitals On Call Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Control Retrievals by central Designated hospitals only All hospitals None restrictions service only permitted to retrieve permitted to retrieve
5.2.1 Management structure Consistent with the recommendations already made in relation to the establishment of a Retrieval Directorate, this model would involve the appointment of a Director of Retrieval with system-wide responsibilities for retrieval policy as well as operational responsibilities for adult retrieval services and coordination.
5.2.2 Process for ensuring independence Coordination would operate independent of any individual hospital in a similar manner to the current MEARS system.
5.2.3 Dispatch time This arrangement would provide an improved level of responsiveness as retrievalists would be on duty on a 24-hour basis. Arrangements would be made to ensure access to
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transport. For example, those in southern suburbs may arrange to travel to Moorabbin airport if a rapid air-based response is required.
However, dispatch times would vary depending on the retrievalist on duty and their hospital.
5.2.4 Communication process The coordinator would operate independent of the location of the retrievalist on duty and would be the first point of contact. Having retrievalists spread across a range of sites would require well-developed communication and rostering arrangements.
5.2.5 Role of 2nd On Call The role of second on call would be to provide back-filling after call-outs.
5.2.6 Coordination The coordination role would be a key element in bringing together resources spread a cross a range of sites. This would be similar to the current MEARS role, but as noted already, one that is further developed as the system’s definitive source of advice and links to specialist expertise.
The coordinator would have no mandated authority to allocate priorities to transport platforms or require hospitals to make beds available.
5.2.7 Retrievalist Retrievalists in this model would work at any one of a number of designated hospitals. They would be rostered and employed by the Retrieval Directorate.
5.2.8 Relationship with other organisations Depending on the approach taken to the structure of the Retrieval Directorate, the establishment of a Retrieval Directorate may, under all models, result in a separation of OCECCS from operational retrieval.
5.2.9 Restrictions on retrieval services/control This model does not imply restrictions or controls on other hospitals wishing to undertake retrievals. However, the Department of Human Services will need to monitor the extent to which other hospitals seek to establish competing or alternative arrangements that duplicate costs and resources.
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5.2.10 Source of critical care advice OCECCS
5.2.11 Access to bed finding OCECCS
5.2.12 Advantages and disadvantages
5.2.12.1 Advantages n Improves response time. n Retrieval structure that is independent of individual hospitals. n Marginal change in arrangements required relative to current system.
5.2.12.2 Disadvantages n Potentially complex rostering and communication arrangements. n Number of hospitals able to participate may be limited. n Unclear relationship between retrievalists and hospitals in relation to their role in “down-time”. n Spread of retrievalists across various sites may cause confusion or communication problems. n Makes development of a team approach more difficult.
5.2.12.3 Points of fragmentation n The “disconnect” between the ambulance and medical components of the retrieval system remains. n In addition, there is a separation between OCECCS and retrieval services.
5.2.13 Conclusion/recommendation This model has the potential to utilise retrievalists during “down-time”. However, it also has the potential to add complexity due to the use of multiple sites, particularly in relation to rostering and development of a team approach.
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5.3 Central Service Model 2
A variation on the model above is to locate retrievalists employed by the retrieval body at a single hospital site.
Central Service Model 2 PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Low Time
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Contracted Service Process Retrievalists Coordination Hospitals
Communication Contact central Left to referring Contact regional Central Process service first hospital discretion service first Dispersed
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Ambulance/RW Single hospital Multiple On Call MTSs hospitals Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Retrievals by central Designated hospitals only All hospitals Control None restrictions service only permitted to retrieve permitted to retrieve
This site would be selected on the basis of access to transport and its ability to support the retrieval role.
5.3.1 Management structure This model would again involve the appointment of a Director of Retrieval with system- wide responsibilities for retrieval policy as well as operational responsibilities for adult retrieval services and coordination.
5.3.2 Process for ensuring independence Coordination would operate independently of the host hospital. Retrievalists would be based at a single hospital, but would not be employed by that hospital.
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5.3.3 Dispatch time It is anticipated that this arrangement would provide a high level of responsiveness as retrievalists would not be part of the staffing establishment of the host hospital.
A site would be chosen to provide the best possible level of access to all transport modes.
5.3.4 Communication process With retrievalists based at a single site, the coordination process could also become based at a single geographic point and integrated into the retrieval role with back-filling from a second and/or third on-call position.
Consistent with current arrangements, there would be no mandated system-wide communication process and hospitals would be able to contact their local regional service or a metropolitan hospital direct, arrange ambulance transfers etc independent of MEARS. However, it would be expected that other metropolitan hospitals would have significantly fewer resources to provide retrieval and there would be a strong motivation to use the central service.
5.3.5 Role of 2nd On Call The role of second on call would be to provide back-filling after call-outs.
5.3.6 Coordination As noted above, an advantage of this approach is that some duties of the coordinator could be undertaken by the on-duty staff at the hospital. While it is important to recognise that retrievalists need to be able to be activated without being tied to clinical work at the hospital or to completing various aspects of the coordination task, there would be some capacity to make use of the retrievalists down-time in supporting the advisory and coordination role.
The coordinator would again have no mandated authority to allocate priorities to transport platforms or require hospitals to make beds available.
5.3.7 Retrievalist In this model, retrievalists would be located at a single hospital. They would be rostered on a 24-hour basis and would be employed by the central retrieval body, not the host hospital.
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5.3.8 Relationship with other organisations Depending on the approach taken to the structure of the Retrieval Directorate, this model may result in a separation of OCECCS from operational retrieval.
This model would also involve a closer relationship with a single hospital and would maintain the sourcing of retrievalists from across the system.
5.3.9 Restrictions on retrieval services/control This model does not imply restrictions or controls on other hospitals wishing to undertake retrievals. However, the Department of Human Services will need to monitor the extent to which other hospitals seek to establish competing or alternative arrangements that duplicate costs and resources.
5.3.10 Source of critical care advice OCECCS
5.3.11 Access to bed finding OCECCS
5.3.12 Advantages and disadvantages
5.3.12.1 Advantages n Significantly improved dispatch time. n Retrieval structure that is independent of individual hospitals.
5.3.12.2 Disadvantages n There are mixed objectives in siting retrievalists at a single hospital while retaining employment with the retrieval body. While the main benefits are likely to arise from their involvement in the work of the hospital during “down-time”, this is also likely in the longer term to lead to perceptions of alignment or lack of independence – a Catch- 22. n The difficulties likely to be encountered can be likened to those faced in the collocation of ambulance services in rural hospitals. n Significant issues in relation to the role retrievalists would take in “down-time” and their relationship with the host hospital. While it has been suggested, for example, that they could perform administrative, quality assurance and other work for the
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retrieval body, this is not seen as realistic. While the viability of this model will be influenced by the volume of retrievals (ie the greater the number of retrievals the less the “down-time” problem), collocation without integration into the hospital does not maximise the potential benefits. These potential benefits include the development of a site-based team focus, capacity to back-fill the retrieval function and the possibility of choosing from more than one retrievalist (eg intensivist, nurse etc) on a case-by- case basis
5.3.12.3 Points of fragmentation n The “disconnect” between the ambulance and medical components of the retrieval system remains. n In addition, there is a separation between OCECCS and retrieval services.
5.3.13 Variations/Options One option would be to rotate the placement of the retrievalists between various hospitals. However, this does not overcome the fact that the model fails to effectively integrate the workload and costs of the hospital and retrieval services.
5.3.14 Conclusion/recommendation The viability of this model would improve with increasing caseload. However, while it has the capacity to provide improved dispatch times, it is inherently inefficient because it fails to provide for effective utilisation of retrievalists during “down-time”.
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5.4 Hospital-based service model 1
This model involves provision of retrieval services by one or both Major Trauma Services (MTSs).
Hospital-Based Service Model 1 PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Low Time
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Process Retrievalists Coordination Hospitals Contracted Service
Communication Contact central Left to referring Contact regional Process Central service first hospital discretion service first Dispersed
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Multiple Ambulance/RW Single hospital MTSs hospitals On Call Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Control Retrievals by central Designated hospitals only All hospitals None restrictions service only permitted to retrieve permitted to retrieve
The basis for the model is that cases requiring “hot” response are similar in nature to (and include) trauma cases and that the fast response capacity should therefore be based at one or both of these centres (Alfred and RMH). These centres will also have capacity to provide helicopter access.
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5.4.1 Management structure This model envisages a contract relationship between the MTSs and the Retrieval Directorate to provide retrieval services. Day-to-day management of the services would be the responsibility of the contracted hospital(s).
5.4.2 Process for ensuring independence The development of a central advice and coordination service could provide a process for ensuring that the MTS operates with a degree of independence. However, this would require that all retrievals be processed through the coordination service and that the MTS would not undertake retrievals on a direct referral basis.
5.4.3 Dispatch time It is anticipated that this arrangement would provide a high level of responsiveness.
5.4.4 Communication process This approach envisages a mandated communication process to ensure that decisions about retrieval and allocation to a receiving hospital are made on an independent basis. Referring hospitals would be required to arrange retrievals through the coordinator rather than directly with the retrieval service.
5.4.5 Role of 2nd On Call The role of second on call would be to provide back-filling after call-outs. With two MTSs operating retrieval services, there would be rotation of 1st and 2nd on call.
5.4.6 Coordination To achieve independence, this model involves separation of the retrieval and coordination functions, with coordination provided through the Retrieval Directorate. This could be seen as consistent with the development of the coordination function into a comprehensive advisory service, but also creates a range of potential communication difficulties in relation to: n referring hospitals contacting the retrieval service direct rather than via the coordinator; n potential communication difficulties and conflicts between the coordinator and the retrieval service.
The coordinator would require increased authority to require the MTSs to undertake retrievals. However, there would be no mandated authority to allocate priorities to transport platforms or require hospitals to make beds available.
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5.4.7 Retrievalist In this model, retrievalists would be employed by and located at the MTSs - RMH and Alfred, with the hospitals rotating 1st on-call. This arrangement would enable the development of strong team-based approaches at each hospital. It would also enable back-filling of staff as retrievals are undertaken and may also enable staff to be matched with patient requirements on a mission-by-mission basis. For example, the MTSs may be able to choose between intensivists, emergency specialists and nurses depending on the specific requirements of each individual case. Senior Registrars may also be used where appropriate.
5.4.8 Relationship with other organisations Depending on the approach taken to the structure of the Retrieval Directorate, the establishment of a Retrieval Directorate may result in a separation of OCECCS from operational retrieval.
This model would also involve a separation between retrieval services and coordination if a degree of independence is to be achieved.
5.4.9 Restrictions on retrieval services/control This model does not imply restrictions or controls on other hospitals wishing to undertake retrievals. However, the Department of Human Services will need to monitor the extent to which other hospitals seek to establish competing or alternative arrangements that duplicate costs and resources.
5.4.10 Source of critical care advice Internal
5.4.11 Access to bed finding OCECCS
5.4.12 Advantages and disadvantages
5.4.12.1 Advantages n Maximises response capability with focus on MTS/helipad sites.
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5.4.12.2 Disadvantages
n The model involves either splitting the coordination and retrieval functions OR a lack of retrieval service independence
n May involve reduced coordination and integration.
n Lacks support among retrievalists and most hospitals.
5.4.12.3 Points of fragmentation
n The “disconnect” between the ambulance and medical components of the retrieval system remains.
n The separation between OCECCS and retrieval services remains.
n There is an additional separation between retrieval and coordination.
5.5 Hospital-based service model 2
This differs from the previous model to the extent that it does not require the retrieval service to be located at an MTS. It would involve the contracting of the retrieval service and coordination functions to a single hospital. Tender specifications would require various performance criteria to be met in relation to response times, independence of operation, coordination and advice functions, quality, training etc. This model is essentially an extension of the NETS/PETS model to the adult retrieval sector, but with contract requirements and periodic tendering to overcome concerns in relation to independence. The provider would be responsible to the Retrieval Directorate.
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Hospital-Based Service Model 2 PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Low Time
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Contracted Service Process Retrievalists Coordination Hospitals
Communication Contact central Left to referring Contact regional Central Dispersed Process service first hospital discretion service first
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Ambulance/RW Single hospital Multiple On Call MTSs hospitals Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Retrievals by central Designated hospitals only All hospitals Control None restrictions service only permitted to retrieve permitted to retrieve
5.5.1 Management structure This model envisages a contract relationship between the hospital and the Retrieval Directorate to provide retrieval services. Day-to-day management of the services would be the responsibility of the contracted hospital(s).
However, any hospital meeting key selection criteria could operate the service. This may or may not be a MTS.
5.5.2 Process for ensuring independence This model assumes that the hospital is contracted to provide coordination. Independence and other performance criteria would be subject to audit. Contract renewal
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would be on a competitive basis and subject to satisfactory performance. The contract could be discontinued on the basis of unsatisfactory performance.
5.5.3 Dispatch time It is anticipated that this arrangement would provide a high level of responsiveness.
5.5.4 Communication process The contracted hospital would be required to service a single point-of-entry system developed by the Retrieval Directorate and capable of being transferred on change of contract. However, it has been assumed that referring hospitals will be able to contact other hospitals.
5.5.5 Role of 2nd On Call The role of second on call would be to provide back-filling after call-outs.
5.5.6 Coordination In this model it has been assumed that the coordination role is contracted to the hospital. While this is not an essential feature of the model, it serves to illustrate an approach in which the whole “package” of retrieval is contracted to a single entity in a way that most closely matches the NETS/PETS services.
However, it does need to be recognised that the contracted hospital may face difficulty in influencing other hospitals to accept patients in some circumstances, as they may not be seen as being independent.
5.5.7 Retrievalist In this model, retrievalists would be located at a single hospital. They would be rostered on a 24-hour basis and would be employed by the host hospital.
The hospital may choose to employ retrievalists who are also based at other hospitals.
5.5.8 Relationship with other organisations Depending on the approach taken to the structure of the Retrieval Directorate, the establishment of a Retrieval Directorate may result in a separation of OCECCS from operational retrieval.
This model would also involve a close relationship between the Retrieval Directorate and the contracted hospital.
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5.5.9 Restrictions on retrieval services/control This model does not necessarily imply restrictions or controls on other hospitals wishing to undertake retrievals.
5.5.10 Source of critical care advice Internal
5.5.11 Access to bed finding OCECCS
5.5.12 Advantages and disadvantages
5.5.12.1 Advantages n Provides capability for fast response service. n Encourages development of a team-based approach at a single site. n High levels of integration due to provision by single provider. n Consistency of approach to neonatal, adult and paediatric services over-viewing and monitoring role by Retrieval Directorate.
5.5.12.2 Disadvantages n Perception that single provider will not operate independently. n Reliance on high levels of monitoring and accountability.
5.5.12.3 Points of fragmentation n The “disconnect” between the ambulance and medical components of the retrieval system remains. n The separation between OCECCS and retrieval services remains.
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5.6 Dual response model
This model is essentially a hybrid of the current MEARS model and the Hospital-Based Service Model 1. It is based on the view that the current MEARS system is appropriate for cases that are not time critical and that a separate, faster response capacity should be based at one or both MTSs.
Dual Response Model PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Time Low
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Process Retrievalists Coordination Hospitals Contracted Service
Communication Contact central Left to referring Contact regional Process Central service first hospital discretion service first Dispersed
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Multiple Ambulance/RW Single hospital MTSs hospitals On Call Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Control Retrievals by central Designated hospitals only All hospitals None restrictions service only permitted to retrieve permitted to retrieve
The Retrieval Directorate would operate the MEARS-type service and the “hot” response service would be contracted to a single MTS or to both on a rotating basis.
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5.6.1 Management structure This model envisages a contract relationship between the MTS(s) and the Retrieval Directorate to provide retrieval services. Day-to-day management of the MTS-based services would be the responsibility of the contracted hospital(s). Day to day management of the MEARS-type service would be the responsibility of the Retrieval Directorate.
5.6.2 Process for ensuring independence The MEARS-type service would operate independently of receiving hospitals. Coordination would provide a process for ensuring that the MTS operates with a degree of independence. Irrespective, the MTS is likely to be the destination for many of the “hot” retrievals, particularly trauma cases.
True operational independence would require retrievals to be processed through the coordination service.
5.6.3 Dispatch time It is anticipated that this arrangement would provide a high level of responsiveness.
5.6.4 Communication process This approach would require a mandated communication process to ensure that decisions about retrieval and allocation to a receiving hospital are made on an independent basis. Referring hospitals would be required to arrange retrievals through the coordinator rather than directly with the MTS providing the retrieval service.
5.6.5 Role of 2nd On Call The role of the second on-call (notionally in this case the MEARS-type retrievalists) would be to provide a 1st response for non-time-critical cases.
5.6.6 Coordination The key difference in this model is the role of the coordinator in assessing the retrieval requirements, making a decision about the level of response required and mobilisation of the relevant retrieval service.
5.6.7 Retrievalist There would effectively be two separate teams of retrievalists – one which is more oriented towards stable medical cases that do not require a “hot” response and one which
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is focussed more on trauma and unstable patients requiring time-critical support. There may or may not be overlap of retrievalists across the two groups.
5.6.8 Relationship with other organisations Depending on the approach taken to the structure of the Retrieval Directorate, the establishment of a Retrieval Directorate may again result in a separation of OCECCS from operational retrieval.
There would also be a separation of time-critical and non-time-critical retrieval teams.
This model would require a close relationship between the Retrieval Directorate and the contracted hospital.
5.6.9 Restrictions on retrieval services/control This model does not necessarily imply restrictions or controls on other hospitals wishing to undertake retrievals.
5.6.10 Source of critical care advice OCECCS
5.6.11 Access to bed finding OCECCS
5.6.12 Advantages and disadvantages
5.6.12.1 Advantages n It could be suggested that one of the advantages of this model is that it builds on the direction in which the current system appears to be evolving, but provides a degree of structure and coordination
5.6.12.2 Disadvantages n The provision of a two-tier service could be seen as a fragmentation rather than integration of retrieval services.
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5.6.12.3 Points of fragmentation n The “disconnect” between the ambulance and medical components of the retrieval system remains. n The separation between OCECCS and retrieval services remains. n There is an additional separation between two levels of adult retrieval
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5.7 Ambulance based model
This model is based on the view that retrieval has more in common with the role of the ambulance services than hospitals and that retrievalists should be seen as providing an extension to the capacity of the ambulance services to meet the needs of patients being transported.
It is also the only model that attempts to bring the ambulance/transport and retrieval elements together under a single structure.
Ambulance Based Model PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Low Time
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Contracted Service Process Retrievalists Coordination Hospitals
Communication Contact central Left to referring Contact regional Central Dispersed Process service first hospital discretion service first
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Ambulance/RW Single hospital Multiple On Call MTSs hospitals Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Retrievals by central Designated hospitals only All hospitals Control None restrictions service only permitted to retrieve permitted to retrieve
5.7.1 Management structure This model envisages the establishment of the Retrieval Directorate within the ambulance service. The inclusion of medical retrieval within the management structure of ambulance services could be structured in a number of ways. Probably most importantly, it would enable integration of the functions of Air Ambulance Victoria and retrieval coordination. This has the potential to create significantly more efficient management and communication processes.
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5.7.2 Process for ensuring independence This structure is, by definition, completely independent of receiving hospitals.
5.7.3 Dispatch time It is assumed that under this model, retrievalists would be attached to the air wing and located at the airport with ready access to both FW and RW aircraft. It would therefore provide high levels of response.
5.7.4 Communication process Communication processes would be rationalised into the current ambulance system.
5.7.5 Role of 2nd On Call The role of second on call would be to provide back-filling after call-outs.
5.7.6 Coordination The coordination role would also be incorporated into the ambulance communication system. It would clearly be important to attract practicing hospital-based specialists to the role.
5.7.7 Retrievalist The retrieval role would become more focussed, using a small number of highly trained specialist retrievalists. In this sense, the model is not dissimilar to helicopter-based services in NSW.
5.7.8 Relationship with other organisations Under this model, the Retrieval Directorate becomes part of the Ambulance Service’s structure. There would therefore be a separation from OCECCS and a need to access to bed availability data and critical care information. The arrangement would effectively separate retrieval from hospital services.
5.7.9 Restrictions on retrieval services/control This model implies that the ambulance service would be the only provider of adult retrieval services and that it would not make transport platforms available to other hospitals. However, sending hospital supported transfers would still be a part of the system.
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5.7.10 Source of critical care advice OCECCS
5.7.11 Access to bed finding OCECCS
5.7.12 Advantages and disadvantages
5.7.12.1 Advantages n Breaks down organisational divides within the retrieval process
5.7.12.2 Disadvantages n Fails to recognise cultural barriers and issues. n Assumes high volumes sufficient to keep retrievalists fully occupied. n Unlikely to attract sufficient and appropriate staff. n Volumes insufficient to keep retrievalists fully occupied. n Issues with maintenance of expertise.
5.7.12.3 Points of fragmentation n The type and level of coordination between the platform provider and sourcing and receiving hospitals will be a significant point of fragmentation.
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5.8 Towards a preferred model
On the basis of consultations with key stakeholders and discussion with the project Steering Committee, the following has is proposed as the basis for the development of a preferred model.
Towards a Preferred Model PARAMETER COMPONENT DESCRIPTOR
1st On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Dispatch 2nd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes Low Time
3rd On Call < 10 minutes < 20 minutes < 30 minutes < 45 minutes 60+ minutes
Independence Independent Independent Rotating Process Retrievalists Coordination Hospitals Contracted Service
Communication Contact central Left to referring Contact regional Process Central service first hospital discretion service first Dispersed
Role of 2nd Backup for 1st On Call Only 1st response for non-urgent On Call
Base Ambulance Independent Hospital Coordination Employment Ambulance Hospital Independent Retrieval body
Base Fast Access Single hospital Multiple On Call Sites MTSs hospitals Retrievalist Employment Ambulance Hospital Independent Retrieval body
Relationships Collocation AAV OCECCS Displan Other with other organisations Integration AAV OCECCS Displan Other
Provider Control Retrievals by central Designated hospitals only All hospitals None restrictions service only permitted to retrieve permitted to retrieve
Shading represents recommended/preferred approach Arrows indicate the desired direction for the model to develop in future
5.8.1 Management structure The establishment of a Retrieval Directorate with a Board of Management and with operational responsibility for:
n a statewide advisory and coordination service; and
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n central adult retrieval services
as well as the policy and other roles described already, including the development of collaboration among the key players – adult, regional, neonatal and paediatric retrieval services, ambulance services and hospitals.
The preferred management structure would be based on the establishment of a representative Board of Management, as depicted in Figure 3.1
5.8.2 Process for ensuring independence Coordination is seen as the key element in ensuring that the system operates independently. Retrievalists would be drawn mainly from a group employed by the Retrieval Directorate, but would also include specialist and other retrievalists employed by and available from individual hospitals.
5.8.3 Dispatch time Retrievalists employed by the Directorate would be stationed at their primary employment site where this provides “fast access” to transport platforms. However, if the retrievalist’s primary employment site did not meet access criteria, they would be stationed at another hospital with the required access.
The retrieval service would also use staff from individual hospitals where required. For example, staff from Major Trauma Services may be activated for urgent trauma retrievals.
Retrievalist availability would be improved as the system would move from an “on-call” to an “on-duty” situation.
5.8.4 Communication process While hospitals would not be precluded from contacting a specific hospital direct, a Statewide Coordination Service would be available to provide a single point of entry. Hospitals contacted direct would be required to arrange retrievals via the coordinator or at a minimum to provide advice of a retrieval being undertaken.
5.8.5 Role of 2nd On Call On-call staff would be available to back-fill or to respond to retrieval requests that do not involve time-criticality. Nevertheless, the primary role of the on-call retrievalists would be to back-fill retrievalists who have been called out. Consideration may need to be given to a 3rd on call, however, the increased utilisation of staff from various hospitals made obviate the need for this level of cover.
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5.8.6 Coordination The Coordinator is seen as the gatekeeper of the retrieval system. The role would be a key element in bringing together resources spread a cross a range of sites. This would be similar to the current MEARS role, but one that is further developed as the system’s definitive source of advice and links to specialist expertise.
5.8.7 Retrievalist Adult metropolitan-based retrievalists in this model would be employed by the Retrieval Directorate and would work at one of a number of designated hospitals with “fast access” to transport platforms. These would clearly include the Major Trauma Services, but may include other sites. Retrievalists would be rostered on 12-hour shifts and would be employed on a dual appointment basis by the Retrieval Directorate and the relevant hospital.
In addition, other retrievalists would be on-call and available to conduct “slow-stream” retrievals (as determined in consultation between the referring hospital and the Coordinator).
5.8.8 Relationship with other organisations The Retrieval Directorate would operate independently of OCECCS, but may be collocated.
Consideration may also be given to the collocation of the coordination role with the Air Ambulance control centre.
5.8.9 Restrictions on retrieval services/control This model does not imply restrictions or controls on other hospitals wishing to undertake retrievals. However, the Department of Human Services will need to monitor the extent to which other hospitals seek to establish competing or alternative arrangements that duplicate costs and resources.
5.8.10 Source of critical care advice OCECCS
5.8.11 Access to bed finding OCECCS
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5.8.12 Other elements The model would also involve improved access to retrieval equipment, with kits preferably being kept with the transport platform or being more readily available at the key hospital sites. This would require an investment in additional kits.
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6 Demand projections
Consultations undertaken for this project have suggested that the current workload of NETS and PETS is likely to be a relatively accurate indicator of future demand. Given these observations and the fact that the maintenance of the current model of service delivery for NETS and PETS has been recommended, demand projections for these services does not require further discussion as part of the development of service models.
However, given the observation that demand for adult retrieval would increase if response times improved, the provision of adult retrieval may be a different matter. The question to be addressed here is whether there is evidence to suggest that there is additional demand in the system that is not being met by the current service.
It has already been noted that new trauma guidelines are likely to increase the number of transfers from rural hospitals to Major Trauma Services. However, there a broader question about the total potential demand for retrieval services.
To understand the situation it is instructive to look at the retrievals currently undertaken by MEARS.
Since its inception, MEARS has averaged a little over 9 retrievals per month or 110 per annum. Analysis of these retrievals is shown in the following graphs:
Source of Retrievals
70%
60%
50%
40%
30% Percent 20%
10%
0% Rural Interstate Metropolitan Private hospital
Location
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Disposition of Retrievals
Private Hospitals
Western Hosp
Dandenong
Austin
MMC
Alfred
St Vincent's
Royal Melbourne
0% 5% 10% 15% 20% 25% 30% 35%
Average Mission Time
30.0%
25.0%
20.0%
15.0% Percent 10.0%
5.0%
0.0% 1 2 3 4 5 6 7 8 9 10 11 > 11 Hours
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Time of Retrieval Request
25%
20%
15%
10% Percent
5%
0% 00:00 – 03:00 – 06:00 – 09:00 – 12:00 – 15:00 – 18:00 – 21:00 – 02:59 05:59 08:59 11:59 14:59 17:59 20:59 23:59
Time
Transport Platform
80% 70% 60% 50% 40%
Percent 30% 20% 10% 0% Fixed Wing Road Helicopter MICA Road Aircraft Ambulance
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Diagnoses of Patients Retrieved
Spinal
Obstetric
Burns
Drug Overdose
Sepsis
SAH & CVA
Head Injury Case Type M’ Trauma
Other
Cardiac
Respiratory
0% 5% 10% 15% 20% 25% 30% Percent
The Medical Retrieval Subgroup of the Ministerial Task Force on Trauma and Emergency Services noted that there is unmet demand of 100-200 retrieval missions per year (excluding currently escorted metropolitan missions). The Report of the Interim Advisory Committee for the Medical Emergency Adult Retrieval Service (January 1995) also stated that:
Between 150 and 200 of the AIHTs usually destined for a critical care bed in another hospital occurring without a medical escort were thought to be in a category where their care during transport might be improved by the availability of an appropriately experienced medical escort.
It is generally agreed that the potential target population for adult retrieval services is defined by those patients who are transferred between hospitals and are admitted to an intensive care unit. Given the concentration of the current service on transfers from rural hospitals, this population has been down to those transferred from rural to metropolitan hospitals.
Using the “Interhospital Transfer” field in the VAED, those hospitals most likely to be receiving retrieval cases and those patients over 15 years of age who were admitted to an ICU following transfer were identified. Cases involving metropolitan to metropolitan transfer were then excluded, leaving cases that may have required medical support during transfer. Using this process, the 36,000 inter-hospital transfers per annum were reduced to approximately 900 cases as shown in the following table:
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Interhospital Transfers – Patients Over 15 Years Admitted to an Intensive Care Unit Following Transfer From a Rural Hospital – 1 July 1999 to 30 June 2000
Receiving Hospital Patients Received Monash Medical Centre - Clayton 85 The Alfred 292 Austin & Repatriation Medical Centre 129 Box Hill Hospital 28 Dandenong Hospital 33 Western Hospital 60 Royal Melbourne Hospital 62 St Vincent's Hospital (Melbourne) Ltd 221 Frankston Hospital 24 TOTAL 934
The available data does not allow an assessment of the proportion of these patients who received a medical escort or more importantly, the proportion of patients who would have benefited from such an escort. However, on the basis of the proportion of all patients transferred into an ICU (rural and metro) it is estimated that 70% of patients were placed on mechanical ventilation.
Given the number of retrievals undertaken by MEARS and the small proportion of regional retrieval service missions to metropolitan hospitals, it would appear that only a minority of patients transferred into metropolitan ICUs from rural hospitals receive medical support during transfer. However, as there is no assessment of the clinical condition of the patients involved, it is not possible to say how many of these patients were appropriately managed by the escort provided. However, what is clear is that the need for retrieval exceeds current service levels and that, excluding metropolitan retrievals, this demand could be anything from 1 mission per day (based on MEARS figures of 110 per year currently plus 150-200 unmet need) to 2 missions per day (based on the table above).
It needs to be re-emphasised that these figures exclude retrievals from smaller metropolitan hospitals and assume that there not be an extension of the current scope of service to cover all medically supported metropolitan interhospital transfers.
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7 Operational issues
7.1 Stretcher compatibility
One of the major issue cited by MEARS in relation to retrieval time is stretcher compatibility between the three core transport forms – road ambulance, helicopter and fixed wing plane.
It is apparent that retrievalists currently face a range of difficulties during the transport process, particularly in relation to transfer of patients between transport platforms. These transfers can often involve a range of equipment and multiple lines, with potential tangles and a risk of adverse events. However, there has not been unanimity of views on the most appropriate solution.
It is also relevant to note that from the point of view of requesting hospitals, the most important time-related issue at present is the time from request for retrieval to retrievalist arrival at the requesting hospital. Nevertheless, elapsed retrieval time is clearly important in relation to minimising patient risk factors in transit and in making best use of retrievalist time. Also, delays in the current retrieval process will become increasingly important as the service deals with higher numbers of time-critical patients.
RECOMMENDATION 12
It is recommended that expert engineering/technical advice be sought on the nature stretcher incompatibility issues, potential solutions and costs.
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8 Funding and finance issues
8.1 MEARS
The cost of the current MEARS service is approximately $400,000 per annum. This translates into a cost of $3,100 to $3,600 per retrieval (including coordination).
8.2 Model Options
Some broad estimates have been made of the costs of the model options discussed in this paper. These indicative costs would need to be refined as part of the next stage of the review. It should also be noted that they exclude the cost of transport platforms, which are being considered as part of separate processes by the Department of Human Services. The broad cost estimates for retrieval models are listed in the following table:
Core System Elements Low Estimate High Estimate $’000 $’000 Retrieval Directorate 250 350 Coordination 150 600 Regional Services 500 700 Education Included above Data Collection Included above Protocols & Guidelines Included above Model Options - Retrieval Operations
Central Service Model 1 1000 1400 Central Service Model 2 1000 1400 Hospital-Based Service Model 1 1700 2000 Hospital-Based Service Model 2 1200 1400 Dual Response Model 1200 1400 Ambulance Based Model 1200 1400
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These estimates suggest a cost ranging between $3.4 million and $5.4 million compared with a current cost of $0.4 million.
If it is assumed that the new service should be providing retrievals at a similar cost per retrieval as the current service, but with a premium for improved responsiveness of (say) 20%, the service should expect to be undertaking between 800 and 1100 missions per year.
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9 Conclusions
It is apparent that the current system of adult retrieval offers a cost-efficient service on a relatively modest budget and that to take the system to the next step will require the investment of substantial funding. This needs to be assessed against likely demand in the short, medium and long term to ensure that supply and demand factors are in relative balance. It also needs to be recognised that the costs involved in each option are a significant consideration.
It is KPMG’s view that the fundamental point of departure from the current system lies less in the operational aspects and more in the development of an integrated systems- approach to retrieval services. The establishment of a retrieval directorate, extended coordination capability, improved communications, enhanced regional services and development of better data, quality and education systems are fundamental elements in the creation integrated retrieval service. This will not happen overnight. It requires the system to build on the dedication and commitment of those that have built the current services and to take the development of the service to the next step.
In adopting a model for the operational aspects of adult retrieval, it needs to be recognised that there will be tradeoffs and that the system will evolve over time. There is strong support in Victoria for continuation of a centralised approach and the development of a single entry point where all aspects of the retrieval process can be managed.
The models outlined provide a strong basis on which to proceed with stakeholder consultations and to develop an understanding of the options and cost implications.
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Appendix 1 – Model for early recognition of adult patient instability
Early recognition of potential and real patient instability will assist in the optimal management of critically ill persons. Management of potentially or real critically ill persons includes: n early assessment and recognition of the patient’s clinical state, the patterns of disease or injury, the mechanisms of disease or injury, the age of the patient and co-morbidities; n notification of appropriate medical personnel to receive advise and for initiation of retrieval if required; n effective and appropriate mobilisation of the medical and transport platforms; n stabilisation and short term management on site; and n access to definitive treatment unit for the patient.
(Each step in the retrieval process needs to be mapped. How when, where, who, – all need to be defined once the model(s) are agreed.)
Early assessment and recognition will be enhanced with the use of the agreed standardised tool. The tool is to be used in conjunction with established Triage Processes, and to identify the potential need of retrieval.
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RESPIRATORY ALL RESPIRATORY RESPIRATORY RATE OXYGEN SATURATION PaO2 < 50 MMHG (ON PACO2 >50 MMHG STRIDOR/UPPER ARRESTS <8 OR >30 <90% (ON 10 LITRES 10 LITERS O2/MIN VIA (UNLESS LONG AIRWAY 02/MIN VIA HUDSON HUDSON MASK) STANDING OBSTRUCTION / MASK) HYPERCAPNEA) THREATENED AIRWAY
HAEMODYNAMIC ALL CARDIAC SYSTOLIC BP <90 SYSTOLIC BP >200 PULSE RATE < 40 PULSE RATE >130 URINE OUTPUT < ARRESTS MMHG MMHG BEATS/MIN BEATS/MIN 30MLS/HR OR < 100ML/6HRS
CONSCIOUS STATE SUDDEN DECREASE IN REPEATED OR THE LEVEL OF PROLONGED CONSCIOUSNESS SEIZURES (FALL IN GCS OF MORE THAN 2)
BIOCHEMISTRY / PH < 7.2 NA+ < 125 OR > 150 HAEMOGLOBIN < 70 K+ < 3.0 OR > 6.0 CREATININE GLUCOSE > 25 MMOL/L HAEMATOLOGY MMOL/L GMS/L OR DECREASE MMOL/L > 200 UMOL/L (IN THE BY > 20 ABSENCE OF PRE- GMS/L EXISTING RENAL DISEASE)
TEMPERATURE < 35 DEGREES C > 40 DEGREES C
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Appendix 2 - Current services
Overview
Victoria currently has three statewide retrieval services and three regional retrieval services. In addition, the service at Albury (NSW) serves a large part of north-east Victoria while a retrieval service from Adelaide services Mildura and surrounding areas.
The statewide services in Victoria are: n the Medical Emergency Adult Retrieval Service (MEARS); n the Paediatric Emergency Transport Service (PETS); and n the Neonatal Emergency Transport Service (NETS).
Regional services are located at: n Bendigo; n Ballarat; and n Geelong.
Retrieval services for the north-east sector of Victoria and the south-west region of NSW are provided by the Albury Base District Hospital Retrieval Service. A number of patients from south-west NSW are retrieved to Melbourne hospitals.
All these services effectively operate independently and are supported by ambulance services provided by: n the Metropolitan Ambulance Service (MAS); n Rural Ambulance Victoria (RAV); and n Air Ambulance Victoria.
OCECCS
The Office of the Coordinator of Emergency and Critical Care Services (OCECCS) was established in November 1984 and commenced operation in April 1985 to facilitate interhospital transfers of critical care patients within Victoria. Since 1985 the role of the Office has expanded to embrace 8 major functions:
1 Facilitating access to intensive and cardiac care units;
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2 Monitoring the availability and utilisation of intensive and cardiac beds and reporting on this to the Department of Human Services;
3 Patient Advisory Service, to assist patients gain access to the health system;
4 Operational assistance to the Department of Human Services and other Victorian and interstate health care agencies;
5 Acute interhospital transfer data monitoring;
6 Medical Emergency Adult Retrieval Service (MEARS);
7 Providing advice and assistance to Ambulance and other health providers in the placement of critical care patients, particularly in times of unprecedented demand; and
8 Assisting the public/private interface in acute health provision in Victoria, eg the monitoring and approval of transfers of public patients to critical care beds in private hospitals when no suitable public bed is available.
OCECCS has an annual budget of approximately $900,000 (including MEARS)
MEARS
Service description
The Medical Emergency Adult Retrieval Service (MEARS) is the principal Victorian adult retrieval service for major medical emergencies and trauma retrievals. The service was established in May 1993 with the objective of ensuring that adequately skilled and experienced medical escorts are available for acute interhospital transfers. Patients with major medical emergencies and trauma are retrieved from across Victoria, southern New South Wales and Tasmania to critical care services in metropolitan Melbourne hospitals.
MEARS provides a tiered response, from advice and support for initiating hospitals through to full medical retrieval.
Retrieval Processes
MEARS processes include: n request for retrieval - by rural/remote hospital or provider via phone through the OCECCS; n clinical assessment - by Coordinator/Deputy Coordinator via return phone call; n retrieval activation - by Coordinator/Deputy Coordinator; n resourcing:
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- transport - ambulance service reserves the right to nominate either road ambulance, helicopter or fixed wing plane. It is rare to use MICA.
- personnel - retrieval physician on-call notified.
MEARS patients are generally critically ill, with a mortality rate reputed to be approximately 30% (ie 30% of all patients retrieved are not discharged from hospital).
MEARS aims for a response time of 30 minutes (to take-off). However, it is apparent that to achieve this response is the exception rather than the rule.
There appears to be little liaison between MEARS and the Regional Retrieval Services, other than for routine updating of operational and contact material; eg phone numbers.
Staffing
MEARS utilises 16 consultant physicians on a sessional basis to undertake medical retrieval missions. The majority (14) of these physicians have fellowships in emergency medicine, with anaesthetist and intensivist specialties also represented. Retrieval staff are rostered according to availability and are sourced from a number of hospitals across metropolitan Melbourne.
MEARS in the past had a waiting list for recruitment for retrieval physicians. The waiting list is currently shrinking. Availability of medical staff for retrievals will become a problem in the future. Level of remuneration and impact on lifestyle would seem to be the major issues.
MEARS in the past had a waiting list for recruitment for retrieval physicians. The waiting list is currently shrinking. Availability of medical staff for retrievals will become a problem in the future. Level of remuneration and impact on lifestyle would seem to be the major issues.
The management functions are provided by an administrator, an administrative assistant, an executive assistant and four part-time clerical staff for evening and weekend work. The part-time after hours staff support the functions of the OCECCS.
Management
The Coordinator of the OCECCS is responsible to the Director of Acute Health – Department of Human Services. He is supported by four Deputy Coordinators and until June 1999 was supported by a Management Committee which had broad representation, including Chief Medical Officer, Ambulance, Police and Displan.
Data Collection
MEARS collects data in relation to retrievals, but does has little if any capacity to undertake analysis and synthesis of the data.
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Financing
MEARS annual budget is approximately $330,000 unchanged from 1993-4 funding allocation. MEARS has been described as having “battled for funding” for many years. It is recognised as having provided an economy service that has achieved good results relative to its available budget.
Support systems
MEARS is supported by SVH financial systems and stores infrastructure. These services are provided by way of a management fee. Communications systems include phone and IT providing a www and email.
PETS
The Paediatric Emergency Transport Service (PETS) provides retrieval for children throughout Victoria and some cross border areas. The service is based at the Intensive Care Unit, The Royal Children’s Hospital. Approximately 170 retrievals are performed annually.
Retrievals are initiated by phone call to the Consultant/Registrar on-call or the Intensive Care Unit. Between 450 and 500 calls are received annually, with the majority involving advice and support. An assessment is undertaken involving the child’s diagnosis and severity.
Where required, the Consultant/Registrar instigates retrieval, arranges necessary equipment and arranges for transport to be coordinated through the Ambulance Service.
If fixed wing aircraft is required, equipment and personnel are transferred to Essendon Airport via taxi to expedite the response.
In the case of helicopter response, staff and equipment can be picked up at the hospital’s helipad.
In the case of road transport, MICA can transport staff to the referring metropolitan hospital if the patient is in an unstable condition. If the patient is stable, a taxi is frequently used.
Road ambulance is used most frequently (approximately 64%) followed by fixed wing (24%) and helicopter (12%).
In contrast to MEARS, most retrievals (65%) come from metropolitan hospitals) with major regional hospitals and interstate retrievals comprising the remainder.
Retrieval times range from one to 16.25 hours, with an average of 3 hours per retrieval.
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Casemix is predominantly (75%) respiratory (asthma) and neurological disease. Trauma and sepsis makes up the remainder (25%).
Staffing
PETS retrievals are mainly undertaken by senior registrars, supported by consultants, ICU nurses and paramedics as required. Availability of nursing staff is restricted by workload in the ICU and helicopter weight limitations. Helicopter emergency retrieval is limited to one doctor and one paramedic.
PETS back-fills registrars involved in retrievals using on-call staff.
Management
The management PETS is incorporated into the RCH ICU. The Nurse Unit Manager of the ICU and on-duty medical staff manage the service on a day-to-day basis.
Financing
The Royal Children’s Hospital is funded to provide the PETS. Annual grant is understood to be approximately $300,000.
The grant funds one registrar and half of a medical consultant position.
Costs of staffing, consumables, equipment, on-call etc. are expensed to the ICU cost centre with no allocation of costs for retrieval.
NETS
Service description
Based at the Royal Women’s Hospital, the Neonatal Emergency Transport Service (NETS) was established in 1976. NETS provides emergency transport for infants up to the age of 6 months for special or intensive care. The service offers telephone consultation, bed allocation, liaison with specialist consultants and inter-hospital transport.
Phone advice is provided to nursing and/or medical staff, with retrieval requests assessed by a medical consultant or registrar.
In 1998 there were 753 primary retrieval transport, of which 65% were from metropolitan hospitals and 35% from rural and interstate hospitals (eg. Albury). The average number of emergency retrievals per month is approximately 63.
Transport is primarily to the Royal Children’s Hospital (58.3%), Mercy Hospital for Women (17.6%), Royal Women’s Hospital (11.9 %) and Monash Medical Centre (11%).
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The majority of neonatal transports are by road (66%) with the remainder by air with 1.5% by rotary wing aircraft. NETS also provides a convalescence (return) transport service, with transfers to Level 1 and 2 nurseries for ongoing care.
The major clinical indications for NETS retrieval are: n respiratory distress (30%); n asphyxia (APGAR less than 7 at five minutes) (5.9%); n bronchiolitis (5.6%); n bowel obstruction (4.7%); and n prematurity (gestation less than 37 weeks) 4.2%.
NETS also provides an extensive education program for medical and nursing staff in peripheral metropolitan, regional and rural Level 1 and 2 nurseries. The aim of the education program is to educate medical and nursing staff in the latest procedures for neonatal resuscitation and intubation. Information is also disseminated to hospitals in relation to requirements for the pre-transport stabilisation of newborns, resuscitation equipment, preparation for transfer by NETS, handling of pathology specimens and patent information.
Staffing
NETS is predominantly staffed by senior registrars and NICU nurses, supported by consultants and paramedics as required. Staffing includes a Director, Deputy Director and Associate Director, NETS Medical Consulting staff and Transport Registrars. Nursing staff consist of a Nurse Unit Manager - Transport, Clinical Nurse Practitioners, Convalescent Transport Nurses, NETS Education Coordinator and two Nurse Educators and two secretaries – transport and education.
A full-time Medical Registrar is employed Monday to Friday. All other shifts are covered by on-call Registrars. NETS on-call Registrars are shared between the Mercy Hospital for Women, Monash Medical Centre, the Royal Children’s Hospital and the Royal Women’s Hospital.
9.5 equivalent full-time (EFT) of nursing staff are funded for NETS. All are nurses with post-graduate qualifications in Neonatal Intensive Care Nursing. The NETS transport nurses have expanded their roles to include regular rotation into the Neonatal Intensive Care Units at the Royal Women’s and Royal Children’s Hospitals for continual revision of skills.
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Financing
NETS receives approximately $1 million per annum. The funds cover all costs – salaries, consumables and maintenance and repairs. NETS also receives revenue from its convalescent transport service and from sponsorship.
Support systems
NETS has three road ambulances that have been purpose-built to accommodate infants and the emergency retrieval team – up to five adults. NETS is the only retrieval service that operates its own transport vehicles. Road ambulance drivers are provided on contract from the Metropolitan Ambulance Service.
Regional retrieval services
The regional retrieval services operate independently of MEARS and usually retrieve patients from the surrounding rural hospitals for treatment at the base hospital. Some of the regional services also escort patients to metropolitan hospitals.
There are three Regional Retrieval Services in Victoria and one in Albury. Only one of the Victorian services (Bendigo) receives funding to support its function.
Ballarat
The Ballarat Retrieval Service was the first in Victoria and was established in 1985. Emergency physicians from Ballarat Base Hospital and St John of God Hospital jointly staff the service on a 24-hour on-call basis.
Approximately 90% of missions use road transport, with the remaining 10% by air (mostly rotary wing).
The service transports of retrieves approximately 100 patients per year, most of who are admitted to either St John of God Hospital or Ballarat Base Hospital.
The casemix of retrievals covers: n multi-trauma (approximately 30%); n cardiac (approximately 40%); and n medical (approximately 30%).
Neurotrauma and major thoracic trauma are transferred to Melbourne.
DHS Retrieval - Model Options Final.doc - 22 October 2000 16:38 90 Department of Human Services KPMG Consulting
Bendigo
The Bendigo Retrieval Service was established in January 1993 and is based at the Bendigo Base Hospital. The hospital’s Director of Intensive Care has led the service since January 2000,
The service provides “medical escort” complementing the existing MICA service as well as an advice service to rural doctors via a 24 hour “hotline”. The Director is also developing protocols for common emergencies, ie asthma, for use by rural hospitals, in an attempt to avoid the need for patient retrieval.
The service is provided between 8am and 6pm Monday to Friday and for the full 24-hour period on Saturdays and Sundays. After-hours services Monday to Friday are provided by MICA.
Four doctors share the roster, resulting in each being “on-call” one week in four. All are medical consultants or 2nd/3rd year Emergency Registrars.
The MEARS report (1995) noted that the Bendigo service is the only regional retrieval service funded with a specifically targeted appropriation, which is provided through the Loddon Mallee Region of the Department of Human Services. This Funding is $70,000 per annum and is largely directed to cover medical staffing costs.
Geelong
The South-Western Regional Retrieval Service was established in May 1991 and is based at the Geelong Hospital.
The 1995 report on MEARS projected 50-60 missions per year. However, this number has now diminished significantly and the service is reported to be “demoralised” due to its inability to provide an effective service. As a result, retrievals are now performed on an ad-hoc basis. Records of retrievals undertaken are no longer maintained.
Key concerns expressed by the Geelong retrieval service include: n lack of access to rapid transport, principally helicopter; and n lack of availability of ambulance/MICA crew;
Senior staff at Geelong Hospital remain convinced of the need and value of this service and continue to provide the service on a voluntary basis as required.
DHS Retrieval - Model Options Final.doc - 22 October 2000 16:38 91 Department of Human Services KPMG Consulting
Albury
The Albury Base Hospital, primary and secondary retrieval service was established in the early 1990’s. The service provides “cross border” assistance to small rural Victorian Hospitals. The Director of Intensive Care is the Coordinator of the services and a Clinical Nurse Consultant is also employed to assist with coordination and ongoing education and promotion of the retrieval service.
The Clinical Nurse Consultant – Emergency Care from the Albury Base Hospital also attends the Hume Region’s Emergency and Critical Care Consultative Committee.
The service performed a total number of 30 retrievals for the period, January through to December 1999. 43% were from Victorian hospitals. 86.7% were from small rural hospitals. 43% of patients were intubated prior to or during retrieval transport.
Retrieval sources included: n Wodonga Hospital (Vic.) (12); n Albury Private Hospital (NSW) (5); n Corowa Hospital (4); and n a number of smaller hospitals in NSW.
The average retrieval time, from activation to arrival was 68 minutes with a range of, 34 to 185 minutes.
The casemix of retrievals covered: n medical - 73% (22 cases); n trauma – 17% (5 cases); n surgical – 7% (2 cases), and n obstetric – 3% (1 case).
Staff and equipment for the retrieval service are funded through the Albury Base Hospital, Emergency Department.
Other cross-border retrieval to other states
The MEARS report (1995) noted that patients requiring retrieval from Mildura have traditionally been transported to Adelaide and this situation does not appear to have changed substantially.
DHS Retrieval - Model Options Final.doc - 22 October 2000 16:38 92 Department of Human Services KPMG Consulting
Issues
Regional Emergency Services Reviews, Hume (1999) and Loddon Mallee (2000) and the Study of urgent care in Victorian rural towns by The Monash University Centre of Rural Health (CRH, 1999) identified the following key issues facing rural and remote health regions of Victoria in relation to effective and responsive emergency services; n Lack of interdisciplinary, specialised training in emergency and trauma care and diagnosis specific treatments, eg thrombolytic therapy, mental health (Hume 1999, CRH 1999, Loddon Mallee 2000); n Lack of Emergency Department equipment and standardisation – the lack of desired equipment on hand (Hume 1999, CRH 1999, Loddon Mallee 2000); n Lack of consumables - short shelf life of expensive drugs/specialised “one-off” (Hume 1999); n Fragility of hospital-GP arrangements (Hume 1999); n Lack of counselling and debriefing services (Hume 1999); n Human Resources – lack of appropriately skilled people and services, senior nursing and medical staff, small pool of resources, lack of staffing flexibility, reliance on on-call GPs, lack of formally trained staff, staff recruitment and retention (Hume 1999, CRH 1999); n Poor data and information and standardisation (Hume 1999, CRH 1999, Loddon Mallee 2000); and n Lack of planning for interhospital/retrieval responsibilities, protocols, support, information, communication, standardisation and minimum service standards (CRH 1999, Loddon Mallee 2000).
DHS Retrieval - Model Options Final.doc - 22 October 2000 16:38 93