Rural emergency doctors lack confidence in trauma control, study finds

In 2000 Victoria’s trauma services started to become more centralised, with increasingly more patients rushed to three major trauma hospitals in Melbourne for treatment.

Under the Victorian State Trauma System (VSTS) preventable road fatalities dropped considerably over time and trauma patient management was vastly improved. Emergency centres around the world now look to Victoria’s system as a model case.

But a study by critical care researchers has found that as the trauma cases drained from regional hospitals to The Alfred, Royal Children’s and Royal Melbourne hospitals, rural clinicians dealing with these patients have become ‘de-skilled’ and less confident in aspects related to care for injured patients.

“We know from data that about a third to 40 per cent of major trauma patients initially present to rural centres and a lot of them are transferred directly to the major trauma centres,” Dr Alexander Olaussen said. “We had a concern that clinicians in rural and remote settings were being de-skilled because they were not seeing as much as they used to see.

“If 40 per cent of trauma patients initially present there – even for an hour for life-saving intervention and stabilising before they get transported – it’s important that clinicians at these centres get adequate exposure and experience,” he said.

The paper, published recently in Emergency Medicine Australasia, surveyed 30 emergency trauma clinicians from the three major hospitals and 108 from non-trauma hospitals including rural, regional and some suburban hospitals. All were practising FACEMs (Fellows of the Australasian College for Emergency Medicine).

Respondents were asked how often they performed a number of skills pertaining to airway, breathing and circulation, and how confident they felt about doing this. The study found that emergency physicians outside the major trauma centres performed relatively few trauma-related critical procedures and that their confidence in key elements of trauma care was relatively low.

The researchers found that the more exposure to trauma situations, the more confidence increased. They conducted multivariant analyses to find factors that could raise confidence in trauma management and found that doing a shift per fortnight in a major centre could be sufficient, Dr Olaussen said.

Previous experience helped too, even if it had been some time ago, he said.

“It’s surprisingly easy to raise clinicians’ confidence in dealing with trauma, you’ve just got to have seen it a few times and been part of it – you don’t have to work seven days a week doing it.”

Other methods suggested for closing the gap included a combination of increased exposure, targeted education focussing on trauma, and a revision of the fellowship trauma requirements.

First author on the paper was Dr Mark Putland, then on sabbatical at The Alfred and who previously worked at Bendigo Health, and who is now Director of Emergency Medicine at the Royal Melbourne Hospital. Monash University Professor Mark Fitzgerald, Director of the National Trauma Research Institute, was senior author.

Reference
Putland M, Noonan M, Olaussen A, Cameron P, Fitzgerald M. Low major trauma confidence among emergency physicians working outside major trauma services: Inevitable result of a centralised trauma system or evidence for change? Emerg Med Australas. 2018 Jul 28. doi: 10.1111/1742-6723.13135. [Epub ahead of print]