Edited by Charlotte Evans, Anne Creaton and Marcus Kennedy, the first edition of this text is now in production, for release in September 2016. This is the first text of its type and draws on the work of many experts in the area of Retrieval Medicine in Australia and the UK.
Retrieval medicine has existed in various guises for many decades however in recent years has become more systematised as an area of specialist clinical practice and an area of clinical medicine which requires its own body of literature, educational systems, qualifications and recognition.
The days are gone where retrieval was critical care transfer by junior staff, with ad hoc equipment and monitoring, non specialised transport platforms, all enveloped by a clinical governance void!
In contradistinction, around the world we now have specialist training systems that are established or developing, formal qualifications and defined standards and accreditation in many settings. University courses and qualifications in aeromedical, prehospital and retrieval medicine have emerged, and research activity is progressing positively. In addition, governance systems, regulation, accreditation, data sharing and benchmarking are also appearing worldwide.
This progress is however not uniform, and indeed retrieval medicine is practised in a vast range of models around the world.
We have approached this textbook from the perspective that there is international commonality at the core of this discipline, and that systems of patient care and clinical retrieval medicine are similar in many countries. We have consulted widely with international colleagues and adopted generic approaches where possible, and feel confident that the contents of this work will be of value and relevance to all retrieval practitioners – from those working in high volume critical care retrieval services to those who are ‘occasional retrievalists’ or need to maintain low volume patient transfer capability.
It is our aim to add to the knowledge that drives standards of patient care and the quality of clinical outcomes. Each of us has seen the difference between non-systematised patient transfer, and the transfer of patients via professional retrieval services who deploy well trained, educated and supported staff. We hope that this work will contribute further to these systems, this quality of retrieval care, and the health of our communities.
Impact of the Introduction of an Integrated Adult Retrieval Service on Major Trauma Outcomes
Kennedy, Marcus P, Gabbe, Belinda J, McKenzie, Ben A
Emergency Medicine Journal (BMJ), 2015
The primary aim of this study was to examine the impact of the introduction of an integrated adult critical care patient retrieval system in Victoria, Australia on early clinical outcomes for major trauma patients who undergo inter-hospital transfer. The secondary aims were to examine the impact on quality and process measures for inter-hospital transfers in this population, and on longer term patient-reported outcomes. Method: This is a cohort study utilising data contained in the Victorian State Trauma Registry (VSTR) for major trauma patients >18 years of age between 2009 and 2013 who had undergone inter-hospital transfer. For eligible patients, data items were extracted from the VSTR for analysis: demographic, injury details, hospital details, transfer details, Adult Retrieval Victoria (ARV) coordination indicator and transfer indicator, key clinical observations and outcomes. Results: There were 3,009 major trauma inter-hospital transfers in the state with a transfer time less than 24 hours. ARV was contacted for 1,174 (39.0%) transfers. ARV coordinated metropolitan transfers demonstrated lower adjusted odds of in-hospital mortality compared to metropolitan transfers occurring without ARV coordination (OR 0.39, 0.15-0.97). Adjusting for destination hospital type demonstrates that this impact was principally due to ARV facilitation of a Major Trauma Service as the destination for transferred patients (OR 0.41, 0.16-1.02). The median time spent at the referral hospital was lower for ARV coordinated transfers: 5.4 hours (3.8-7.5) vs 6.1 (4.2-9.2), p<0.0001. Conclusion: In a mature trauma system, an effective retrieval service can further reduce mortality and improve long-term outcomes.
The Retrieval Rapid Emergency Medical Score in Retrieval Medicine
Kennedy, Marcus P, Wilson, Krystle, Gabbe, Belinda J, Straney, Lahn, Michael Bailey
Emergency Medicine Australasia, 2015
Objective: Prognostic models are commonly used in the clinical setting. The objective of the study is to evaluate the prognostic accuracy of the Rapid Emergency Medical Score (REMS) or alternate models.
Methods: A retrospective cohort study of critical care patients who underwent retrieval service transfer to an Intensive Care Unit (ICU) in a single state-wide service in Victoria, Australia. All patients aged 18 years and over transferred to an ICU between 01/1/2010 and 30/6/2013. Retrieval and ICU datasets were probabilistically linked. Multivariable logistic regression modelling was used to investigate the capacity of physiological markers and patient characteristics to predict in hospital mortality in the ICU population. The prediction performance was evaluated using measures of discrimination (C-statistic) and calibration (Hosmer-Lemeshow (H-L statistic)).
Results: There were 1776 ICU patients who were transferred and 1749 (98.5%) had complete data. Of the 1749 patients with complete data, 257 (14.7%) died in-hospital. The REMS calculated at the time of retrieval referral demonstrated borderline predictive capability (C-statistic 0.69, 95% CI 0.62-0.76). Following logistic regression analysis of the REMS components, final variables included in the Retrieval REMS model were age, mean arterial pressure and Glasgow Coma Score. This model demonstrated acceptable predictive capability (C-statistic 0.72 95% CI 0.64-0.79). The median (IQR) Retrieval REMS for survivors and non-survivors respectively was 7 (5,10) and 9 (7,11) p<0.01.
Conclusions: The availability of a validated tool such as Retrieval REMS assists recognition of high risk patients and consideration of this risk in retrieval mission planning and response.
Civilian aeromedical retrievals (the Australian experience)
R Ramadas, S Hendel, A MacKillop
BJA Education, 2015, 1–5
Retrieval medicine is the process by which suitably qualiﬁed and trained personnel utilize appropriate equipment and transport platforms to clinically manage and safely transport a patient from one location to another.
Retrievals can be subclassiﬁed into primary, secondary, and tertiary. Primary retrieval is the transport of patients to their initial hospital reception. This may be their nearest hospital, or directly to a larger and more distant centre such as a designated trauma centre.
Secondary retrievals move patients from a non- specialized hospital to a higher level of clinical care such as for neurosurgery, interventional cardiology, complex obstetrics, or paediatrics. Tertiary retrievals transport patients between two similarly specialized hospitals.
In ‘modiﬁed primary retrievals’, an injured or unwell patient has already been taken to an initial health facility that has minimal capacity to increase the level of care to that provided in the prehospital environment. In these circumstances, the retrieval team apply similar practices to a true primary retrieval, albeit in a more controlled clinical environment.
In Australia, owing to the large land mass and relatively low population density, specialized medical services are clustered mostly in coastal urban centres. Therefore, many referrals are from rural and remote areas where access to specialist medical services is limited.
Journeys range from a few kilometres and a few minutes in major capital cities to several thousand kilometres over many hours from isolated rural communities. While distance might not be limiting, other access issues such as terrain and weather extremes play roles in the structure of services.
Most retrieval occurs within state health system jurisdictions or within state boundaries. If there is need to transfer patients interstate or internationally, pre-existing agreements between the relevant authorities are important to safely facilitate transfer. These patients have often received initial medical care at the place of presentation. With the increased ease and popularity of travel, particularly to developing nations with limited healthcare capacity, international retrievals/repatriations are becoming common. They bring with them unique logistic and cultural issues for the retrieval team, in addition to the challenges of medical retrieval.
Philip Visser, Marcus Kennedy, Linton R Harriss, Graeme K Hart, Megan Bohensky, Lalitha Sundaresan
The study aimed to determine factors related to ICU mortality in critically ill patients transferred by Adult Retrieval Victoria (ARV) medical staff. Patients who died in ICU after interhospital transfer were compared against those who survived.
This was a retrospective cohort study of ARV cases between 1 January 2009 and 30 June 2010. Retrieval data were linked with data from the ANZICS CORE APD (Australia and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database). Victoria Data Linkage (VDL) performed linkage of data. Data included demographic and clinical data obtained during transfer and clinical data recorded in ICU.
Of the 601 cases transferred by ARV during the study period, 549 cases were eligible for linkage to 25 543 ANZICS APD case records for the same period. VDL matched 460 of these cases (83.8%). Mortality rate in the matched sample was 13.9%. Variables associated with mortality were: advanced age (odds ratios [OR] 1.02, 95% conﬁdence interval [CI] 1.00–1.04, P = 0.02), principal referral problem cardiac (OR 1.84, 95%CI 1.02–3.32, P = 0.04), lower mean arterial blood pressure (OR 0.97, 95% CI 0.95–0.99, P = 0.005) and tachycardia (OR 1.02, 95% CI 1.00–1.03, P = 0.008) on arrival at destination hospital.
Advanced age, lower mean arterial blood pressure and tachycardia towards the completion of transfer were associated with increased ICU mortality in this population. Clinicians should be aware of the additional risk for cardiac patients.