Retrieval and Transfer

Introduction

The Taskforce has considered strategies for redevelopment of the State's retrieval system as part of the terms of reference to 'provide advice on the effective coordination and management of emergency patients between health care facilities'. The recommendations in this section relate to the principles relevant to trauma retrieval. The Taskforce recognises that trauma retrieval is a small proportion of the overall retrieval workload in this State. The retrieval requirements of other patient groups will, therefore, need to be considered through a wider consultation process before the retrieval service redevelopment is finalised.

For its deliberations, the Taskforce defined retrieval as 'the transfer, including medical retrieval, of time-critical emergency patients (trauma and non-trauma) in rural and metropolitan Victoria'. Retrieval system requirements across Victoria were explored in assessing possible mechanisms of delivery of major trauma patients to definitive care in the most expeditious manner. This was necessary because, although the Medical Emergency Adult Retrieval Service (MEARS) provides a quality service for critically ill interhospital transfers, it does not have an immediate response capacity necessary for patients with time-critical injuries. The CCRTF (1997) previously recommended that:
'the current system of inter-hospital transfer, transfer and retrieval should be enhanced. A need is perceived to improve the responsiveness and capability of this system particularly in regard to optimisation of team-mix in transfer care.'

Principles

The Taskforce agreed that the following principles are an appropriate and necessary foundation for retrieval service redevelopment:

• Current and future retrieval services are integrated to provide a retrieval system for Victoria.
• Retrieval missions are coordinated in a timely and efficient manner.
• Skills of the escort personnel should be matched to the acuity of the patient, such that they are able to respond to most clinical scenarios within the constraint of the transport platform.
• Transport platform chosen for a retrieval mission must take into consideration the clinical condition of the patient, transport logistics, and limitations of the respective platform.
• Interhospital transfer of major trauma patients is a critical phase of care that must be undertaken with an escort who is trained and experienced in the transport of critically ill patients.
• The standard of care during interhospital transport must be equivalent or better than at the referring hospital.

Current and Projected Demand

There are four regional retrieval services and three statewide retrieval services in Victoria. In addition, there is a retrieval service at Albury (NSW) which services a large part of north-east Victoria and a retrieval service from Adelaide servicing Mildura and surrounding areas.

In 1996 - 97, the Victorian retrieval services collectively undertook 1, 760 missions (Appendix 9). All operate independently. Poorly integrated retrieval data collection limits current and projected retrieval workload estimations.

There is widespread consensus, however, that there are a number of transfers, probably of the order of 100 - 200 cases annually, currently occurring with less than optimal escort arrangements and in a poorly coordinated and untimely manner. The CCRTF (1997) identified a small number of instances of inappropriate escort in the 50 reviewed trauma cases in 1996 - 97. The Taskforce also noted anecdotal evidence that some patients inappropriately bypass the formal retrieval system, utilising ambulance services with often inadequate medical escort.

The Taskforce has made recommendations for triage and transfer that will result in increased transfer of major trauma patients to MTS. It is anticipated that there will be an increase in adult transfers from metropolitan hospitals to the adult MTS. Currently, there is an expectation that larger hospitals have the means to provide an experienced escort from within their own staffing establishment. This is not always appropriate and a central retrieval service could offer skilled medical escort for ground transport of trauma patients as required and in conjunction with ASV.

Projecting demand for retrieval services from rural areas is problematic. It is likely that there will be a number of additional major trauma transfers from rural hospitals to the MTS under the proposed trauma system and, with this, greater scope for retrieval from regional centres. Currently, approximately 80 per cent of major trauma is transferred from rural hospitals to tertiary metropolitan hospitals (VIMD, 1997).

Coordination and Communication

One of the aims of a trauma system is to minimise the time between patient injury and definitive care. Crucial to the success of a retrieval mission in achieving this is effective coordination and dispatch of the retrieval team (Figure 3.2). Effective coordination should provide the following key functions:

• Single point of communication and dispatch.
• Medical control providing expert and timely clinical advice.
• Capacity to utilise and task the most suitable transport platform.
• Crew mix determined by mission.

Currently, a single call can be made to the OCECCS to organise retrieval and interhospital transfers. It is common, though, for a referral to be made separately to a clinician selected hospital and then, additionally, to the retrieval team/ambulance service.

Figure 3.2 Response Components of a Retrieval Service

The Taskforce has recommended a Retrieval Activation Sequence (Appendix 10) to streamline communication and relieve the referring clinician of the need to make multiple contacts. The referring clinician needs to be able to discuss patient management prior to transfer with a consultant level coordinator, for both regional and central retrieval missions. This involves single regional and metropolitan 1800 contact numbers. Regional coordinator contact would, in most regional retrievals, be the appropriate first contact. Exceptions to this might be defined patient groups with a clear need for direct metropolitan referral and, therefore, central contact, such as paediatrics, neonates and neurotrauma.

The destination MTS will depend to some extent on the transport platform, be it road or air. When both adult MTS have equal rotary wing capability, then some form of regional or temporal distribution of patients will be necessary. This is to be addressed by the STC.

Regional retrieval services are always dispatched at a local level. There appears to be little interaction between regional and statewide adult retrieval services with regard to coordination of retrieval missions, nor does dual dispatch currently occur to assist compression of time to definitive care.

Regional Retrieval Services

Both central and regional services are required for an effective statewide retrieval system. Regional retrieval services provide a valuable service in the management of seriously ill and injured patients in Victoria. Regional autonomy needs to be recognised and is crucial to system success.

Improving regional retrieval requires faster, more appropriate direction of patient movement to definitive care locations, such as through the proposed major trauma transfer guidelines. The regional role of the smaller rural hospitals in managing critically ill patients, including major trauma, needs to be clarified. It is appropriate and necessary for such hospitals to initially stabilise major trauma patients, however definitive care should be provided at MTS.

With the exception of one regional retrieval service, there is no funding allocation for the services. Such funding would support medical escort and clinical management advice to time-critical patients within their region and would require provision of performance data to a central body.

Data

There is currently no common database that collects standardised comprehensive data on all retrieval missions in Victoria. Such a database would assist dramatically in health policy and service planning in Victoria.

A statewide focus for the coordination and operation of all medical retrievals in Victoria would be provided by a Director of Retrieval Services who would assume overarching responsibility for the statewide adult retieval service.

Education and Promotion of the Role of Retrieval Services

MEARS data (1996 - 98) identified that the time delay between patient arrival at the sending hospital and referral to a MEARS physician was longer than two hours in 15 of 22 major trauma patients. Prolonged activation times are related to:

• Lack of recognition of severity of illness/injury by referring clinician.
• Overestimation of the capability of the receiving hospital/clinician.
• Lack of awareness of the role and function of MEARS and OCECCS.
• A perception in rural areas that the MEARS service will often not be able to meet the need for timely response in retrieval of time-critical trauma patients. The current limitations in immediate response for such patients relate to staffing and aircraft factors.

Medical Staffing Models

The Taskforce considered the following factors in proposing a medical staffing model for a redeveloped statewide retrieval system.

Expert Clinicians

The interhospital transfer of major trauma patients is a crucial phase of patient care that should be undertaken with an escort who is trained and experienced in the transport of critically ill patients. Standards for the transport of critically ill patients have been established by the Faculty of Intensive Care, ANZCA, and ACEM. An important principle is that the standard of care during interhospital transport is equivalent to or better than at the referring hospital.

The personnel engaging in transport of critically ill patients should be selected for the transport role, be trained in the various aspects of patient transport and be regularly involved in this activity. Ability to communicate effectively and to function as part of the team is essential (ANZCA and ACEM).

The availability of expert clinicians is essential for the provision of clinical management advice, case coordination and being able to task a crew. Paramedical, nursing and medical staff could be appropriate crew members. The current staffing arrangements of NETS and PETS include predominantly senior registrars and ICU nurses supported by consultants and paramedics as required. All other retrieval services utilise consultant physicians (usually in emergency medicine).

The provision of good clinical advice to referring hospitals is crucial to system user satisfaction and clinical outcomes. This is currently problematic in interhospital transfer, especially after business hours and weekends when consultant coverage in hospitals is limited.

Location

There appear to be some service and cost efficiencies in co-location of a retrieval service's staffing and equipment at either a hospital or airport site. This can provide rapid access to staff and/or transport platforms. However, the benefits of this need to be weighed against significant concerns about 'slip-streaming' or the movement of high acuity, non-trauma patients to the MTS hospitals or the hospital where the retrieval service is located. This may detract from system ownership and potentially contribute to skill dilution and decay, difficulties in retaining and recruiting staff, and decreased training and patient care standards in hospitals losing significant high acuity, non-trauma caseload.

Impartiality

There is a need for the service to provide an impartial operation to all hospitals within the system if there is to be a sense of system ownership. A service that operates from a hospital should not preferentially retrieve patients to that hospital. The service operator should have a management/advisory board representing the key stakeholders of the service. The goal is to maximise major player and broad base involvement.

Bed Finding Capacity

Currently, the central coordination of MEARS missions through the OCECCS enables the patients to be allocated a critical care bed. This capacity is vital to optimal mission coordination.

This feature is of increased importance when the retrieval service operates in a multi-hospital system.

Transport Platforms and Equipment

Although nearly everywhere in Victoria is accessible by some form of aircraft, this is not always appropriate owing to the technical limitations of an aircraft and the clinical care needs of the patient, together with consideration of total transport times and alternative vehicles.

Minimal evidence exists upon which to evaluate the utility and functionality of RW aircraft retrieval. This relates to a current lack of integration of retrieval data between services and, possibly, perceptions about timely response of air retrieval. Anecdotal evidence suggests that currently some patients suitable for air retrieval are being filtered out by not being referred, and are subsequently being transported by road.

The Taskforce advocates that many of the current road and FW retrieval missions would be more appropriately undertaken by RW craft. There is widepread consensus amongst the Taskforce and wider emergency services that a need exists for improved immediate response capacity for time-critical patients, including major trauma. Evidence for the need for additional RW capacity is largely based on anecdotal reports, case series and system provider opinion. In spite of this, the

Taskforce considers that primary retrieval by RW craft has the potential to decrease time to definitive care in major trauma cases, especially in the 50-200 kilometre radius of a MTS. Such primary retrieval would then reduce the need for secondary transfer of critically ill major trauma cases with its attendant risks.

The Taskforce also considers that the payload capacity and range of any supplementary RW aircraft must be appropriate to service the requirements of statewide medical retrieval. The Taskforce recognises that RW requirements will be further evaluated during proposal development in early 1999 and all supporting data will be examined.

The Taskforce supports Air Ambulance Victoria operating pressurised FW aircraft to decrease travel time, improve patient/staff comfort, and enable safer transport of neurotrauma patients.

System responsiveness is also affected by current platform incompatibility, such that patient stretchers are not compatible in all vehicles. The ability to place a patient on a stretcher from which they will not be removed until arrival at destination, must be considered a best practice model. The patient stretcher would need to be compatible across transport platforms (FW, RW, road vehicle). Solutions to the problems of stretcher incompatibility require investigation.

Access to and egress from helipads in close proximity to facilities designated as having a trauma role are essential components of system performance.

Process

The proposed model requires wider consultation and development with other system users and stakeholders. The Department of Human Services will engage a consultancy to prepare a full proposal and costings on this retrieval service model for evaluation by the STC early in 1999.

Figure 3.3 Proposed Retrieval Service Model

Service components	Method of fulfilling components
Primary focus of service	The interhospital transfer of critical care patients. Prehospital missions in exceptional circumstances (ie. Medical Displan, surgical or difficult extraction).
Staff type, number and qualifications	Consultant medical staff of appropriate training (Emerg, Anae, ICU etc). Capable of having a limited number of training positions for appropriate medical registrars. Up to 24 staff required to supply a 3 oncall capability.
Staff location	1st oncall: onsite at a metropolitan hospital 24hr/day. 2nd oncall: 30 min oncall availability in metropolitan Melb. 3rd oncall: 30 min oncall availability in metropolitan Melb.
Road ambulance access	Vehicle supplied from ASV resources as required (location). Road crew determined by patient acuity.
FW & RW ambulance access (location)	FW: located at Essendon airport (operated by AAV). RW: located at Essendon and Moorabbin airports (operated and staffed by AAV). There is a need for an additional RW aircraft to support the service: - For rapid response capability it would pick up 1st oncall retrievalist from hospital site. - The aircraft will be utilised to perform prehospital or interhospital missions as required.
Process for mission coordination	Retrieval missions to be coordinated and dispatched by the OCECCS.
Speed of dispatch	1st oncall retrievalist available within 5 min of request Staff for FW missions to be located to enable the dispatch within 30 min of request.
Process for ensuring independence to hospitals	Retrieval missions coordinated and dispatched by OCECCS. Patient destination is not determined by the location of the retrievalist.
Access to bed finding	Through the OCECCS.
Source of critical care advice	Through the OCECCS.
Management structure of service	A broadly based management committee to be established. A Director of Retrieval Services to be appointed to provide operational management.
Other	The effective implementation of this model is contingent on the prior implementation of: funding for the operation of regional retrieval services. coordinated and centralised data collection from all retrieval services. appointment of a Director of Retrieval Services to provide operational management. improved 24hr access to AAV resources. availability of appropriate RW aircraft resources to enable a rapid dispatch capability.