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| Journal of the New Zealand Medical Association,
21-January-2011, Vol 124 No 1328
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Approximately 10% of New Zealanders live within the
catchment of a rural hospital.1 Over 40% of
admissions to hospital of these patients can be managed at a generalist
level.2 Most of the rest are likely at some
point to be transferred to a larger hospital.
Much of the published information in the medical literature
about interhospital transfers relates to larger countries that contain more
remote populations such as Australia,3-5
Canada,6,7 or the
USA.8-12 The majority of the
articles4,5,7,13,14 deal exclusively with
transport by air.
Many of the
studies5,10–12 relate to trauma,
specifically transfer of patients with other surgical
emergencies,2 and patients in
labour.8,15 Two
papers7,15 deal mainly with social and
emotional factors.
Ironically, one of three published New Zealand
papers13 describes transfers out of an urban
hospital, including some to rural hospitals, during a nurses’ strike in
Christchurch. The others are both from Northland: one a useful review of
helicopter transfers in and out of Whangarei14
from the perspective of the retrieval team, the
other16 a highly relevant audit of transfers
out of Rawene Hospital.
We aimed to canvass a wider range of New Zealand rural
hospital doctors and make some recommendations by combining the experience of
these doctors with published information.
MethodAs part of the assessment for the Rural Hospital
Clinical Practice paper for the Diploma in Rural and Provincial Hospital
Practice taught by the University of Otago in 2008, the students were required
to submit an assignment on transfers from their hospital (Box 1). They were
advised at the start of the course that the information from this might be
submitted for publication and, after the assignments were marked, the ten
doctors who completed the paper gave their permission for the information from
them to be used as the basis for this paper, for their words to be quoted if
necessary, and to have their identities acknowledged.
Box 1. Transfer project
The information from the assignments was grouped into
themes, which arose from the issues that each doctor had chosen to cover (Box
2), for analysis and reporting.
Box 2. Issues mentioned by rural hospital
doctors
Note: (number of doctors mentioning
each issue in brackets).
ResultsAll of the doctors described working in isolation, at a
distance from their base hospital. “The area is large but the population
is small”. Many doctors rely on nurses to help with decision making.
“Rural transfers often happen as a team process.” Several mentioned
the need for education, of themselves and of the rest of the team. Lack of
availability of diagnostic investigations was seen as a problem that sometimes
necessitated transfer.
There were a variety of clinical conditions mentioned as
examples where transfer had been required. Trauma, bowel obstructions and acute
coronary syndromes were the ones most frequently mentioned.
Factors influencing the transfer were explained mainly in
general terms ”Transfer is appropriate when better care can be provided
elsewhere”. or “when specialist care is not available”.
“To await events in a doubtful situation in rural New Zealand and not
transfer is a recipe for regret.” Where further investigation and
treatment were likely to be futile, there was support for the idea that people
should be allowed to die near where they lived rather than be transferred out.
Air transfers (mainly by helicopter, though fixed-wing
aircraft were seen as an option for longer flights) were preferred in
emergencies.
Helicopters were not always available, mainly because of bad
weather. There was a general feeling that the helicopter should not be overused.
Not all transfers are for emergencies. “By far the majority of ...
transfers are conducted by road ambulance.” Ambulances were often not
available when they were needed. “Our ambulance crews are almost all made
up of volunteers and we rely on these volunteers heavily.”
Occasionally there were communication problems within the
team at the rural hospital. More commonly, the doctors reported communication
difficulties with base hospital specialists. Several doctors were critical of
the poor feedback from the base hospital about patients who had been
transferred.
Both registrars and consultants were perceived as sometimes
obstructive, giving conflicting advice, not passing on information to the
receiving team, causing delays, and generally having a lack of understanding of
the rural facility and what was available. “Arguing with them takes time;
time better spent stabilizing an ill patient.” “There is a
perception in some quarters that, in some way, specialist treatment in a large
hospital is intrinsically superior to anything that goes on at the
periphery.”
Most doctors thought that it was best to discuss the
proposed transfer with a base hospital consultant, rather than more junior staff
.Several doctors mentioned the importance of gaining the trust of specialists
within the base hospital and working together on protocols for transfers. One
doctor wrote of the need to “advocate against a system trying not to use
resources”.
There were also instances described where communication had
gone well. “The above emergency and transfer that took place went smoothly
only due to the well coordinated effort of staff and telephone communication
between our hospital and the staff of the other involved hospitals.
There was mention of the need to provide treatments before
and during transport. There was recognition of the vulnerability of the patient
during transport, and the need for early detection of things going wrong.
“It is about keeping the patient safe”.
Several doctors expressed frustration at the difficulty of
by-passing the nearest provincial hospital when they knew that only a tertiary
hospital would be able to provide the definitive care that the patient required.
“The overriding principle in ... in medical and surgical emergencies is
timely arrival of the sufferer in a hospital with sufficient facilities and
expertise to provide ... definitive care.”
In many cases definitive care could have been provided at
the rural hospital with better facilities for diagnosis and treatment, and
better-trained staff. The system for patient care was seen ideally as an
extended team, which was “only as strong as its weakest link”.
DiscussionAs these examples illustrate, transfer to other hospitals is
a reality of rural medicine.6 Around the world,
rural areas have disproportionately high death rates from
trauma5,10 A similar situation seems to exist
within New Zealand with cardiology services, where patients admitted initially
to some peripheral hospitals receive fewer interventions and have poorer
outcomes than patients admitted to the receiving tertiary
hospitals.17
Deciding which patients can be managed in rural hospitals is
a constant dilemma for health workers in rural
areas.18 The number of patients requiring
transfer is likely to vary depending upon the resources
available.6 Transport will become necessary
when the care needs, or potential care needs, of the patient are beyond the
scope of the facility at which the patient is receiving
care.8 This is especially relevant for rural
patients.4
An expert opinion in a recent case before the Health and
Disability Commissioner, 19 where there had
been doubt about the advisability of transferring a patient, stated:
“Smaller hospitals require a system of support and back-up where
potentially unstable patients can be easily transferred to the larger centre ...
[and] medical officers have a right to the ability to transfer patients to the
larger centres if they feel this is required.”
In the audit from Rawene, the primary reason for transport
to an outside facility was to achieve definitive treatment for a defined medical
condition.16 The doctors in our study felt that
some transfers could have been avoided by better access to imaging, up-skilling
of rural generalist doctors, and improved access to specialist advice.
The arrangement of the transfer can be frustrating to the
attending physician and can actually become more stressful than the patient
care.6 Decisions on transfers should always be
regarded as mutual ones between the two hospitals
17. Good communication between referring and
receiving medical and nursing staff is
imperative.20
Futile transfers, as some of the doctors in our study
emphasise, should be avoided. Patient transfer should only occur if it there is
a reasonable likelihood of it improving the patient’s clinical
outcome.20
Closer liaison between referring and receiving clinicians
may avoid unnecessary transfers in some cases.4
In a 2002 audit at Dunstan hospital in Central Otago of patients surviving after
an acute coronary syndrome, there was documented consultation with a specialist
in 60% of cases.18 Only 24.3% at that time were
transferred to the base hospital.
Education for all categories of staff was seen by the
doctors in our study as essential. Training of staff and the resources available
at the hospital, will impact on the care
provided.2
There is now an opportunity to generate the skilled
generalist medical workforce New Zealand rural hospitals need with the
recognition of rural hospital medicine as a new scope of
practice.21 There is a strong emphasis on the
skills necessary to appropriately and safely transfer
patients.21 To remain vocationally registered
in rural hospital medicine, doctors have to meet a number of requirements,
including passing specified courses in resuscitation and trauma
care.22,23
To practise safely across a broad scope, doctors need strong
and healthy relationships with their specialist
colleagues.21 Trust and “knowing the
person you are talking to” are important elements of effective and
satisfactory communication.3 Maintenance of
professional standards will include requiring rural hospital doctors to spend
some time each year working in the base
hospital.23
For trauma patients, regionalized systems of care have been
shown to improve mortality.10 The purpose of
organised trauma systems is to ensure the expeditious transfer of seriously
injured patients to the facility best equipped to care for their
injuries.12 There a need in New Zealand for
staff at different levels to continue to work together in the development of
similar systems for all categories of patients.
To summarise, we have listed the elements of what we
consider to be the ideal emergency transfer from a rural hospital in New
Zealand:
Author information:
Katharina Blattner, General Practitioner, Rawene Hospital, Hokianga Health
Enterprise Trust, Kaikohe, Northland; Garry Nixon, Medical Officer, Dunstan
Hospital, Clyde, Central Otago
Acknowledgements: This paper is based on
the written assignments completed by the following doctors: Tom Barry,
Greymouth; Jim Corbett, Raetihi; Mohe Sierra Gonzalez, Dannevirke; Alison
McAlwee, Kaeo; Steve Main, Rawene; Stuart Mologne, Westport; Alan Murray,
Kawakawa; Cornelius van Dorp, Kaitaia; Rafik Wanis, Wairoa; and Eric Wegener,
Roxburgh.
Correspondence: Trevor Lloyd, Medical
Officer, Dunstan Hospital, PO Box 30, Clyde, Central Otago, New Zealand. Email:
trevor.lloyd@cohealth.co.nz
References:
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