Royal Flying Doctor Service Research Articles

The impacts of withdrawal and replacement of general practitioner services on aeromedical service trends: a 13-year interrupted time-series study in Tennant Creek, Northern Territory

BackgroundThe Royal Flying Doctor Service (RFDS) provides aeromedical care to patients during fixed-wing transport over vast distances to healthcare unavailable in rural or remote communities. This study examined the relationship between changes in local accessibility to primary healthcare services and rates of aeromedical service use over time.MethodsThis was a 13-year interrupted time-series study (1999–2012) in Tennant Creek, Northern Territory. Quarterly aeromedical service use for primary care sensitive conditions were calculated and exposure to general practice (GP) services was characterised over time with events modelled as intervention variables: (a) GP service withdrawal (Nov-2004); and (b) GP service replacement (Dec-2006). Intervention effects were estimated using PROC ARIMA in SAS after examination of the time-series structure.ResultsGP withdrawal resulted in an immediate and sustained doubling in quarterly aeromedical service use (+11.8 services per quarter) and GP service replacement had no significant effect.DiscussionLarge and immediate increases in aeromedical service use result from the loss of local GPservices yet, in this case, replacement with a new GP service, 2-years hence, did not ameliorate that effect after six years.ConclusionsThese findings demonstrate the immediate impact of GP-service loss on the rates ofaeromedical transfer of patients from this remote community and lend caution to expectations about thetimeline over which newly implemented primary health care services in such contexts can mitigate the impact of such a loss.

E-Health readiness in outback communities: an exploratory study

E-health has been a recurrent topic in health reform, yet its implementation, ultimate role and feasibility are yet to be clearly defined. Organisations such as the Royal Flying Doctor Service South East Section (RFDS SE) are in a position to utilise technology to enhance the effectiveness of existing clinical services for remote communities. The study aim was to explore the readiness of the remote population of far-west New South Wales, Australia, and RFDS SE as a monopoly service provider to take up e-health innovations. A convenience sample of patients sequentially attending 15 remote fly-in clinics conducted by RFDS SE medical officers were invited to participate in a semi-structured telephone survey using an established survey tool to gather quantitative and qualitative data. RFDS SE health staff and managers were also surveyed. The overall core-readiness to embrace new e-health technologies was at a moderate level; barriers were mainly technical competence and technology availability. Enablers were willingness to learn and engage. The majority of patients did not feel isolated and had their health needs met; albeit there was interest in change if this improved outcomes. Video consultations for mental health and access to specialists were particularly welcome, although responses also indicated concern that video links might replace existing face-to-face services. Health staff saw the need for new technology to assist in healthcare provision but technology availability and support were flagged as key points. Organisational views as elicited from managers identified internal needs for workplace readiness to assist with adoption of new technology. Patients, healthcare providers and RFDS SE as an organisation are interested in engaging in e-health to improve the level of healthcare delivery. There are challenges around the technical capacity and the structural and organisational support for an e-health venture in an outback setting. Specific patient, healthcare provider and organisational needs have been identified and allow for the development of a tailor-made implementation strategy particularly to overcome technical challenges.

Effect of telestroke on emergent stroke care and stroke outcomes.

The delivery of medical care through telecommunication has been available in one form or another for ≈100 years. In the early 1900s, people living in remote areas of Australia used 2-way radios (powered by dynamos and bicycle pedals) to communicate with the Australian Royal Flying Doctor Service. The first direct reference to telemedicine in the literature was in the 1950s, with the transmission of radiological images by telephone in Philadelphia, closely followed by the teleradiology system established in Montreal, Canada.1 Telemedicine by video communication was first implemented by the University of Nebraska in the 1960s to allow clinicians to service remote populations.1 Jumping forward to the 21st century, there are now ≥55 telestroke programs in 27 states of the United States that deliver stroke services to ≥350 spoke hospitals.2 To justify the use of telestroke, there is a need for evidence of benefit. However, evaluating the outcomes of a telestroke program is complex because clinical outcomes from treating patients with acute stroke and wider health system and financial metrics need to be captured. The purpose of this review is to provide an overview of the various outcomes of stroke telemedicine and to outline the new paradigms evolving for systems of care, research, and education, as well as financial considerations. Stroke telemedicine (or telestroke) is the practice of clinical stroke care via telecommunication and came into its own with the era of stroke thrombolysis in the late 1990s. A key driver was to ensure better equity for patients in accessing this time-critical therapy in metropolitan and rural hospitals. Our knowledge base on the benefits of stroke thrombolysis continues to develop. The totality of evidence through pooled data analysis indicates that the therapeutic benefit of recombinant tissue-type plasminogen activator (tPA) is time dependent and is greatest when given early …

A 3-Year Retrospective Audit of the Use of Noninvasive Positive Pressure Ventilation via the Oxylog 3000 Transport Ventilator During Air Medical Retrievals

IntroductionThe purpose of this study was to describe the safety profile of noninvasive positive pressure ventilation (NIPPV) using the Oxylog 3000 transport ventilator (Drager Medical, Lübeck, Germany) by air medical retrieval teams from the Queensland Section of the Royal Flying Doctor Service of Australia. MethodsOver a 3-year period, patients identified in clinical transport records to have NIPPV via the Oxylog 3000 transport ventilator during air medical transfer were systematically reviewed on the clinical indication and adverse effects. ResultsA total of 29 patients were identified to have had treatment with NIPPV during air medical retrieval. Three patients suffered serious adverse effects of cardiorespiratory arrest during treatment. The main reported adverse event was intolerance of the facemask. There were no documented episodes of vomiting or hypotension. ConclusionThe use of NIPPV via the Oxylog 3000 transport ventilator during air medical retrieval requires careful patient selection. The application and management do not differ from standard hospital-based practice.

Endotracheal Tube Cuff Pressure before, during, and after Fixed-Wing Air Medical Retrieval

Background. Increased endotracheal tube (ETT) cuff pressure is associated with compromised tracheal mucosal perfusion and injuries. No published data are available for Australia on pressures in the fixed-wing air medical retrieval setting. Objective. After introduction of a cuff pressure manometer (Mallinckrodt, Hennef, Germany) at the Royal Flying Doctor Service (RFDS) Base in Dubbo, New South Wales (NSW), Australia, we assessed the prevalence of increased cuff pressures before, during, and after air medical retrieval. Methods. This was a retrospective audit in 35 ventilated patients during fixed-wing retrievals by the RFDS in NSW, Australia. Explicit chart review of ventilated patients was performed for cuff pressures and changes during medical retrievals with pressurized aircrafts. Pearson correlation was calculated to determine the relation of ascent and ETT cuff pressure change from ground to flight level. Results. The mean (± standard deviation) of the first ETT cuff pressure measurement on the ground was 44 ± 20 cmH2O. Prior to retrieval in 11 patients, the ETT cuff pressure was >30 cmH2O and in 11 patients >50 cmH2O. After ascent to cruising altitude, the cuff pressure was >30 cmH2O in 22 patients and >50 cmH2O in eight patients. The cuff pressure was reduced 1) in 72% of cases prior to take off and 2) in 85% of cases during flight, and 3) after landing, the cuff pressure increased in 85% of cases. The correlation between ascent in cabin altitude and ETT cuff pressure was r = 0.3901, p = 0.0205. Conclusions. The high prevalence of excessive cuff pressures during air medical retrieval can be avoided by the use of cuff pressure manometers. Key words: cuff pressure; air medical retrieval; prehospital

Aeromedical transfer of women at risk of preterm delivery in remote and rural Western Australia: Why are there no births in flight?

For more than three decades, women at imminent risk of preterm birth (PTB) in Western Australia have been transferred by small aircraft over long distances to the single tertiary level perinatal centre in Perth, with no known case of birth during the flight. We aimed to review recent experience to understand how aircraft travel may delay PTB. Retrospective observational study of 500 consecutive Royal Flying Doctor Service (RFDS) transfers of women at risk of preterm labour to the tertiary referral centre, from September 2007 to December 31, 2009. In-flight delivery, complications associated with transfer and factors associated with delay in preterm delivery. There were no in-flight deliveries or serious complications associated with the aeromedical transfer of these patients. In a multivariable Cox proportional hazards regression analysis, clinical factors in the presentation that were associated with a shorter time from landing to subsequent delivery included cervical dilatation ≥ 4 cm, ruptured membranes, gestational age > 32 weeks and nulliparity. The aircraft reaching an ambient altitude > 14,000 feet, or cabin altitude above zero (sea level), was associated with a delay in time from landing to delivery for women who were not in spontaneous preterm labour. Our findings add to a 30-year experience that women at risk of preterm labour do not deliver during aeromedical transfer. Ambient and cabin altitude of the aircraft were associated with an extension in the time to delivery after arrival. The mechanisms underpinning this effect warrant further investigation.

Major Trauma Patients Transferred From Rural and Remote Western Australia by the Royal Flying Doctor Service

The "golden hour" of trauma care is irrelevant in rural areas. We studied the effect of distance and remoteness on major trauma patients transferred by the Royal Flying Doctor Service from rural and remote Western Australia. The Royal Flying Doctor Service retrieval and Trauma Registry databases were linked for the period of July 1, 1997, to June 30, 2006. Major trauma was defined as Injury Severity Score (ISS) >15. Remoteness was quantified using the Accessibility/Remoteness Index of Australia (ARIA) classes: inner regional, outer regional, remote, and very remote. The primary outcome was death. Among 1328 major trauma transfers to Perth, mean age was 34.2 years ± 18.3 years (range, 0-87 years) and 979 (73.7%) were male. Over half were motor vehicle crashes. Mean transfer time was 11.6 hours (95% confidence interval [CI], 11.2-12.1). The median ISS was 25 (interquartile range [IQR], 18-29), and there were no differences within the ARIA classes for cause and injury patterns. After adjusting for ISS, age, and time, the risk of death increases as remoteness increases: outer regional odds ratio (OR), 2.25 (95% CI, 0.58-8.79); remote, 4.03 (95% CI 1.04-15.62); and very remote, 4.69 (95% CI, 1.23-17.84). Risk increases by 87% for each 1,000 km (OR, 1.87; 95% CI, 1.007-3.48; p = 0.05) flown. Despite long retrieval times, there were no deaths in flight. There is an excess of a fourfold increase in the risk of major trauma death in patients transferred to Perth from remote and very remote Western Australia. Remoteness, as measured by the ARIA, is more important than distance, in the risk of death.

Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval

ObjectiveAeromedical retrieval services face the difficult problem of appropriate levels of sedation for transport of acutely agitated patients to definitive care. This paper describes a technique using ketamine, which is...

Increasing alcohol restrictions and rates of serious injury in four remote Australian Indigenous communities

To document rates of serious injuries in relation to government alcohol restrictions in remote Australian Indigenous communities. An ecological study using Royal Flying Doctor Service injury retrieval data, before and after changes in legal access to alcohol in four remote Australian Indigenous communities, Queensland, 1 January 1996-31 July 2010. Changes in rates of aeromedical retrievals for serious injury, and proportion of retrievals for serious injury, before and after alcohol restrictions. After alcohol restrictions were introduced in 2002-2003, retrieval rates for serious injury dropped initially, and then increased in the 2 years before further restrictions in 2008 (average increase, 2.34 per 1000 per year). This trend reversed in the 2 years after the 2008 restrictions (average decrease, 7.97 per 1000 per year). There was a statistically significant decreasing time trend in serious-injury retrieval rates in each of the four communities for the period 2 years before the 2002-2003 restrictions, 2 years before the 2008 restrictions, and the final 2 years of observations (2009-2010) (P < 0.001 for all four communities combined). Overall, serious-injury retrieval rates dropped from 30 per 1000 in 2008 to 14 per 1000 in 2010, and the proportions of serious-injury retrievals decreased significantly for all four communities. The absolute and the proportional rates of serious-injury retrievals fell significantly as government restrictions on legal access to alcohol increased; they are now at their lowest recorded level in 15 years.

A comparison of metropolitan vs rural major trauma in Western Australia

BackgroundMetropolitan and rural Western Australia (WA) major trauma transport times are extremely different. We compared outcomes from these different systems of care. MethodsMajor trauma (Injury Severity Score, ISS>15) data from the Royal Flying Doctor Service (RFDS) and Trauma Registries, 1 July 1997–30 June 2006. Two groups were studied: Metro (metropolitan major trauma transported directly to a tertiary hospital), and Rural (rural major trauma transferred by the RFDS to a tertiary hospital in Perth). The primary endpoint was death. We used logistic regression and multiple imputation. Results3333 major trauma patients were identified (mean age 40.1±22.6 yrs; Metro=2005, Rural=1328). The rural patients were younger, had a larger proportion of motor vehicle crashes, and higher median ISS (25 vs 24, p<0.001). Mean times to definitive care were 59min versus 11.6h, respectively (p<0.0001). After adjusting for age, injury severity and the effect of time with the initial rural deaths, there was a significantly increased risk of death (OR 2.60, 95% CI 1.05–6.53, p=0.039) in the Rural group. For those rural patients who reached Perth, the adjusted OR for death was 1.10 (95% CI 0.66–1.84, p=0.708). ConclusionThere is more than double the risk of major trauma death in rural and remote WA. However, if a major trauma patient survives to be retrieved to Perth by the RFDS, then mortality outcomes are equivalent to the metropolitan area.

H1N1 09 influenza—An aeromedical perspective

The Royal Flying Doctor Service, Queensland Section is the primary service provider for aeromedical retrieval and transfer within Queensland. During the recent H1N1 09 influenza pandemic the organisation was required to undertake substantial planning as well as revision of existing guidelines in light of a new strain of influenza of unknown transmissibility and virulence and potential increase in workload. This paper provides an overview of the experiences of the organisation during the H1N1 09 influenza pandemic including surge capacity planning, infection control measures unique to the aeromedical environment, caseload data and employee health impacts. The Royal Flying Doctor Service, Queensland Section is the primary service provider for aeromedical retrieval and transfer within Queensland. During the recent H1N1 09 influenza pandemic the organisation was required to undertake substantial planning as well as revision of existing guidelines in light of a new strain of influenza of unknown transmissibility and virulence and potential increase in workload. This paper provides an overview of the experiences of the organisation during the H1N1 09 influenza pandemic including surge capacity planning, infection control measures unique to the aeromedical environment, caseload data and employee health impacts.

The first medical jet aircraft for the Royal Flying Doctor Service

Medical Journal of AustraliaVolume 191, Issue 11-12 p. 609-610 Rural and Remote Health The first medical jet aircraft for the Royal Flying Doctor Service Stephen A Langford, Corresponding Author Stephen A Langford Medical Director stephen.langford@rfdswa.com.au Royal Flying Doctor Service Western Operations, Perth, WA.Correspondence: stephen.langford@rfdswa.com.auSearch for more papers by this author Stephen A Langford, Corresponding Author Stephen A Langford Medical Director stephen.langford@rfdswa.com.au Royal Flying Doctor Service Western Operations, Perth, WA.Correspondence: stephen.langford@rfdswa.com.auSearch for more papers by this author First published: 07 December 2009 https://doi.org/10.5694/j.1326-5377.2009.tb03346.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume191, Issue11-12Christmas issueDecember 2009Pages 609-610 RelatedInformation

Frequent users of the Royal Flying Doctor Service primary clinic and aeromedical services in remote New South Wales: a quality study

To examine activity patterns of the Royal Flying Doctor Service of Australia (RFDS) in far western New South Wales and to determine whether frequent use of RFDS services, particularly emergency evacuations, is a useful indicator of patients who may benefit from care planning and review. We conducted a retrospective audit of the RFDS South Eastern Section's Broken Hill patient database. Patients with a residential address in the study area who had accessed at least one RFDS medical service between 1 July 2000 and 30 June 2005 were included in the study. Number of evacuations, clinic consultations and remote consultations; clinic usage by frequent evacuees; number of primary diagnoses recorded for frequent evacuees; number of frequent users who might benefit from multidisciplinary care or specialist shared care. Between July 2000 and June 2005, the number of residents requiring evacuation or remote consultations declined by 26% and 19%, respectively, and the number of residents accessing clinics declined by 6%. (Over the same period, the population of the study area fell by about 24%.) Of the 78 patients who were identified as frequent users of the evacuation service (> or = 3 evacuations/year), 34 had three or more primary diagnoses recorded; 15 were infrequent or non-users of the clinics (< or = 3 attendances/year); 53 may have benefited from multidisciplinary care, and 41 from specialist shared care. Simple, practical clinical review systems can help health care organisations in rural and remote communities to achieve better outcomes by identifying patients who may benefit from planned care.

The Royal Flying Doctor Service Flies to New Heights: The Journey of Health Information Management.

The Royal Flying Doctor Service (RFDS) of Australia was founded in 1928 by the Reverend John Flynn to deliver health services to the people of the Australian Outback. In this unique environment the RFDS Queensland Section provides both Primary Health Care and Aeromedical services to rural and remote communities throughout Queensland. It provides health services from a hub and spoke model and its clinicians work very closely with other health service providers, such as Queensland Heath, within the communities it visits. Currently, the RFDS' health records are both paper and electronic and clinicians duplicate much of patient information and data between RFDS and non-RFDS health records. Introduction of an off-the-shelf electronic medical record (EMR) would not meet the RFDS' clinical and organisational needs because of complexity, the multidisciplinary nature of the teams and the lack of communication technology in the communities the RFDS visits. This article defines the vision for a health information system designed to meet the requirements of the RFDS, and describes its implementation throughout RFDS Queensland using the PRINCE2 project management methodology.

Australia's flying doctors tackle Third World health issues

Doctors Minh and Shelley Le Cong wanted to do their bit to alleviate suffering in the developing world and were thinking about volunteering abroad. Instead, the Australian couple stayed home and joined the Royal Flying Doctor Service of Australia. “We realized there were serious inequalities in

The Royal Flying Doctor Service primary care skin cancer clinic: a pilot program for remote Australia

The geography and logistics of living in remote Australia provide unique challenges in providing dedicated primary healthcare services to tackle the rising incidence of skin cancer. The aim of this study was to ascertain whether the Royal Flying Doctor Service (RFDS) skin cancer clinic could improve skin cancer health outcomes for the target population while providing care at a level consistent with that documented for metropolitan skin cancer clinics. This retrospective longitudinal report compared historical controls with a dedicated fly-in/fly-out primary care skin cancer outreach clinic provided by the RFDS. The clinic was run concurrently with the regular primary care medical service; the entire focus of this additional service was on skin cancer diagnosis and management. This model was used to minimise the additional costs of providing the service. During the study period a total of 316 people were seen at this skin cancer clinic (29% of the total non-Indigenous population) with 39% of those aged over 50 years seen. There was an average of 1.1 consultations per person (343 consultations in total), with a procedure performed in approximately one-third of consultations. The demographic most likely to have a lesion removed were over 50 year-old males (p<0.0001). The rate of skin cancer detection was 15/1000 adults/year. The number of lesions removed per year increased from 37 to 42 after the intervention, with no statistically significant change in the percentage of excised lesions that were malignant (44%). For over 50 year-old males there was a statistically significant increase in the proportion of excised lesions that were melanomas (chi2 = 6.015; p = 0.013). This corresponded to a four-fold rise in melanoma detection from 0.2/1000 people/year pre-intervention to 2/1000 people/year post-intervention. A comparison of the skin clinic's effectiveness with documented results from other Australian non-specialist skin cancer services demonstrated a low number needed to treat for melanoma which is consistent with high diagnostic accuracy. This is also supported by a relatively high consultation to biopsy ratio. The biopsy treatment ratio and percentage of lesions that were malignant were similar to those seen in other Australian settings. The RFDS skin cancer clinic outcomes were not dissimilar to those seen in metropolitan skin cancer clinics. The small population and consequently low statistical power mitigated against certainty in concluding that clinical outcomes were enhanced. Further studies would assist in the future development of models for skin cancer clinics in remote areas.

The laboratory and quality response to POCT

Point of care testing (POCT) is now a significant part of the provision of diagnostic services. Generally, POCT devices are used in a number of different areas, and they can be broadly classified as one of the following: 1. Mini-pathology laboratory providing a limited range of testing to small hospitals and specialist situations like the Royal Flying Doctor Service and defence forces. 2. Backup analysers in small to medium sized laboratories. 3. Specialised units such as casualty, theatre and high dependency units where blood gases, troponins and potassiums are performed either intra-operatively or during triage. 4. Niche roles such as HbA1c or INR analysers in specialist clinic settings, often involving paediatric or child patients. But there are some situations where POCT is not appropriate, either because of cost or quality requirements, and a request for a POCT device can identify a problem with the existing laboratory service. This presentation will describe the advantages and disadvantages of using POCT in various settings and include examples from various public and private pathology networks and some uses of POCT in community medicine.

Art Therapy: Promoting Wellbeing in Rural and Remote Communities

Art therapy encompasses both preventative and curative activities and aims to improve ways of engaging those who might be reticent in seeking more traditional forms of psychological support offered through 'talking therapies'. The Longreach base of the Royal Flying Doctor Service in Queensland provides mental health support to people living in rural and remote locations in central western Queensland and has been complemented since 2006 by the addition of a full-time art therapist. This paper provides an overview of art therapy and a description of this innovative approach to addressing mental health needs in a rural and remote setting.

Aeromedical Retrieval for Critical Clinical Conditions: 12 Years of Experience with the Royal Flying Doctor Service, Queensland, Australia

Background: The Royal Flying Doctor Service (RFDS) has been providing emergency aeromedical retrieval services in Queensland, Australia since 1928. Study Objectives: This article details service and delivery structure plus a description of 12 years of experience managing patients with critical clinical conditions. Methods: This study is a retrospective longitudinal analysis of the demographics and diagnostic classification of all cases of critical clinical severity conducted March 1, 1994 through February 28, 2006. Results: There were a total of 72,054 retrievals, with trauma the single most common clinical diagnosis. There were 4259 retrievals for patients with critical clinical conditions (6%). The most common categories of clinical diagnosis were: trauma with 1493 (35.1%), respiratory diseases 1386 (32.5%), and circulatory diseases 908 (21.3%). Trauma accounted for 69 of the 90 (77%) primary retrievals from locations without health care facilities. The death rate in transport was 1%, with most of these involving males from locations with minimal health facilities. Conclusion: The RFDS in Queensland is an effective provider of fixed-wing aeromedical retrieval services, operating in an unusual environment with vast distances, low population density, and a high number of Indigenous people.

Royal Flying Doctor Service ‘field days’: A move towards more comprehensive primary health care

To examine the Royal Flying Doctor Service (RFDS) field day program as a means of strengthening community capacity within a primary health care context in remote communities of north Queensland. Qualitative explanatory study using in-depth face-to-face and phone interviews with field day participants, field day coordinators and RFDS staff and a focus group with RFDS staff. Rural and remote communities of north Queensland that participate in RFDS field days. Field days were found to be contributing to building capacity for health in the remote communities that have been involved in field days. Participants reported increased linkages and partnerships; increased participation; improved problem-solving capacity and increased knowledge transfer associated with the conduct of RFDS field days. RFDS field days represent a viable framework for building community capacity for health in remote communities within a primary health care context.