Community Health and Safety
 
Portland Aluminium contributes to healthy communities worldwide by broadening access to healthcare and social services, improving service quality and efficiency, preventing injuries and promoting wellness at every stage of life.  Children and families need knowledge, tools and services to remain healthy and safe at home, in the community and in the workplace.
 
 
Centre for Rural Emergency Medicine (CREM)
In 2007 Alcoa formed a partnership with Deakin University to establish the Centre for Rural Emergency Medicine (CREM) in south-west Victoria. The partnership has also been supported by the Victorian Government Department of Human Services.

Based in Warrnambool (South West Healthcare) and Portland (Portland District Health), the centre aims to enhance the quality of regional medical care and address emergency medical shortages in Victoria’s south-west, and will provide clinical leadership as well as research and training in emergency rural medicine.

The partnership signifies Alcoa’s commitment to the south west region by supporting a sustainable solution to the provision of long term health services in the region.

The CREM is a model for rural Australia in the development and provision of these services. Additionally, it contributes to teaching programs coordinated by Deakin Medical School’s Greater Green Triangle Clinical School based at Warrnambool. The centre also provides emergency medical training for junior and senior medical staff, as well as regional medical practitioners and GPs.

Community support and ownership is achieved by an interactive education process which allows input from the local communities and engages community leaders and other influential members of the community.

The project achievements to-date includes:
 
i) Clinical practice

CREM’s initial task is to improve the safety of patients being treated for medical emergencies in south-west Victoria, especially in smaller hospitals and health services. The centre is constructing a model where emergency medicine specialists set up treatment protocols, train staff and are immediately available for consultation, but local doctors provide the majority of the emergency care.

At Portland District Health, this approach has been successfully introduced to deal with major head and spinal cord injuries, emergency intubations, major paediatric trauma, cardiac arrest and septic shock. The new procedures have been very well received by junior doctors, GPs, nurses and hospital administrators, all of whom have appreciated higher levels of support.

Emergency call criteria
CREM has helped Portland Hospital introduce a ‘track and trigger’ system, which detects patients who need critical care as early as possible. Small hospitals do not have senior staff on site at all times and the junior medical staff who manage the hospital out of hours often find it difficult to know when to call for help. They are very concerned about detecting and managing patients who present with or develop critical illness. The new system tracks and records patients’ symptoms and vital signs  (pulse, blood pressure, blood oxygen levels) and defines triggers (the emergency call criteria) which prompt junior medical staff or nursing staff to consult a medical specialist.  This advice is accessible 24 hours a day.

Currently, about four cases each week trigger the system. A monthly review meeting examines how these cases were treated, leading to changed protocols, purchase or modification of equipment, and education of junior staff in safe patient management.

Liaison with state-wide emergency services
Metropolitan-based specialist services often focus on the needs of the city hospitals receiving transferred patients rather than the needs of rural referring hospitals and their patients. A member of the Barwon South Western Regional Emergency and Critical Care Advisory Committee and the Victorian Cardiac Clinical Network, the Director of CREM is able to represent rural health services. Regular discussions also occur with Ambulance Victoria and the Adult Retrieval Service Victoria, especially about the best use of the new helicopter based in south west Victoria.

Recommencement of ophthalmology virtual services
The South West Alliance of Rural Health Virtual Services Project had previously provided specialised equipment for real time transmission of images of eye diseases from patients at Portland and Warrnambool Emergency Departments to eye specialists at the Royal Victorian Eye and Ear Hospital in Melbourne. Unfortunately this equipment was never used. CREM is assisting in educating local staff to re-establish its use.

ii) Education

Many professional groups other than emergency physicians deal with emergencies in rural areas. One of the key tasks of CREM is to help these groups stay abreast of emergency medicine principles and new techniques.

Medical students
In 2011, the first cohort of students at Deakin’s new medical school will commence their fourth year emergency medicine rotation. The director of CREM has coordinated the development of a curriculum for this rotation for medical students at all Deakin Medical School sites. Much of this work was completed in preparation for an Australian Medical Council accreditation of the medical school in July, 2009.

Hospital medical and nursing staff
Medical and nursing staff at Warrnambool hospital receive two hours of emergency medicine teaching every Friday. The teaching covers procedures, common presentations, case studies and journal articles. Lectures are also given to medical and nursing staff at Portland Hospital.

General practitioners
Requests for teaching from general practitioners are given high priority because they provide most of the emergency care in rural areas. CREM has provided a trainer for the Rural Workforce Agency Victoria’s rural emergency skills training weekend, and a lecturer for the Victorian Medical Postgraduate Foundation country education program.

iii) Research

A key objective for CREM is to address the dearth of research in rural emergency medicine. Rural health and emergency medicine journals are now well established but unfortunately publish very few articles on rural emergency medicine.

Small hospital emergency department database
There is almost no data available or published about small emergency departments in Australia; what resources and staffing they have, what kind of patients they treat, and how well they perform. In contrast, large urban emergency departments record detailed information on every patient seen and every treatment given. Without this data, researchers, clinicians, health departments and communities are blind to what is actually happening in small rural and regional emergency departments and unable to assess which approaches are most effective.

Preparations for this project are well advanced. Twelve months of medical records from every small emergency department in south west Victoria will be reviewed to collect and record the information collected in large emergency departments. This database will allow us to assess who is treated and how, and allow direct comparisons with large emergency departments. It will be possible to integrate our data with data collected by regional ambulance services to give a comprehensive overview of rural emergencies.

An editorial, outlining the need for this research, has been accepted for publication in the Australian Journal of Rural Health.

Emergency management of chest pain 
Heart attack patients who present to hospital early are more likely to survive. Unfortunately, many people living in rural Australia who develop chest pain present late to medical care. This is an important problem because when compared to urban areas, cardiac mortality is more than 20 % higher and survival from out of hospital cardiac arrest is 75 % lower. It is possible that country people present late because they are more used to attending their local doctor than an emergency department - they may be unaware that they should attend an emergency department immediately if they have chest pain, even at night. A questionnaire addressing underlying beliefs about chest pain has already been tested on a pilot group and is now being administered to over 400 farmers in conjunction with the National Centre for Farmer Health.

Head injury 
There is preliminary evidence that the outcome for patients in rural areas with head injuries may not be as good as for urban patients. A collaboration with Professor Peter Cameron, the Director of Research at the Alfred Hospital Emergency Department, will use data from the Victorian State Trauma Outcomes Registry to compare the outcomes 6 months after head injury of rural and urban patients. This project will be undertaken by the PhD student who is awarded the Windermere Foundation Syd Allen Scholarship.

iv) Community Engagement

Community awareness
In recent years there have been many reports of variable quality on the difficulty of treating emergencies in rural areas in local and national media outlets. To improve community understanding, a series of interviews and media releases have been provided by CREM to local newspapers and radio. A talk has also been given to the Portland branch of St John Ambulance.

Advisory board
The CREM Advisory Board has been includes representatives from Alcoa Portland Aluminium, the Department of Human Services Victoria, Deakin University, Warrnambool and Portland hospitals and the local community and meets regularly to review and approve an activities report and a business plan. The board manages and evaluate the Centre’s performance in relation to key performance indicators.
 
For more information about the Centre for Rural Emergency Medicine (CREM), visit http://www.deakin.edu.au/hmnbs/medicine/research/crem.php


2010_PA_CREM_PDHTour

Click image to enlarge.


From left: Alcoa of Australia Managing Director Alan Cransberg, Portland District Health Board Chairman Andy Govanstone, Portland Aluminium Operations Manager John Osborne and CREM Clinical Associate Professor Dr Tim Baker during their tour of Portland District Health on 10 June 2010.