Small rural emergency departments are not simply cut-down large urban emergency departments

Abstract

It is important to understand how small rural emergency departments work. They are a significant fraction of a state's medical system. Although they each see only a few thousand patients a year, as a group they are likely to treat more emergency patients than the largest city hospital. It is a myth that they only deal with minor ailments. Many isolated rural hospitals receive ambulances because ambulance services are reluctant to send their only local ambulance out of area. In addition, many patients with serious illness come directly to the emergency department without calling an ambulance. Small rural emergency departments are not simply cut-down versions of large emergency departments. They face different challenges. They cannot be judged by the same criteria. The impact of distance from specialty services is shared with many areas of rural health. What is less well understood is the impact of seeing far fewer patients than urban emergency departments, but attendances still being spread over 24 hours a day and 365 days a year. Few small hospitals receive enough patients each shift to employ even junior doctors onsite. Nurses are the key staff members here. They must be quite independent. In the small rural hospital described in this issue,1 over 50% of emergency patients were not seen by a doctor before discharge. Nurses managed category 1 patients alone for 6 min on average before other help arrived, and managed 8% of category 2 patients alone until morning. They fill a role similar to that of junior medical officers in urban hospitals. Their responsibilities have not been properly recognised. Their scope of practice should be defined and suitable training made available. General practitioners then function more as consultants. They have their own practices to keep running. They provide advice by telephone, or arrange for patients to see them later in their rooms. They attend the hospital mainly for emergencies and procedures. It is inaccurate to use the time taken for the patient to be seen by the doctor, as suggested by the Australasian triage scale,2 to indicate when medical assessment starts. More suitable measures for small rural hospitals would be the time taken until medical advice is received by telephone, and the time taken for the doctor to attend when requested. Preparing for the rare but random life-threatening illnesses and injuries that happen in a small town is challenging. At the hospital in this issue, 11 category 1 patients arrived in a year; often enough to require a prepared response but not often enough to easily justify the cost of having doctors with advanced airway, critical care and trauma skills available at all times, even if such doctors could be recruited. Alternatives include letting paramedics with advanced training transport critical patients directly to larger centres, improving the critical care skills of nurses or relying on medical retrieval services based in larger centres. There is no evidence yet to prove which approach is best, but it is likely that different solutions will suit different locations. Fortunately, it is now possible to gather enough data from small hospitals to investigate these questions. Large emergency departments record comprehensive data on every patient they see and treatment they give. As small hospitals become linked with larger regional centres, they share the same computer systems and can also collect this information. It should be collated in a way that shows the unique nature of rural emergency medicine, the challenges faced and the best way forward.