Table 6 Changes—Summary of rural clinicians’ experience and example quotes

Changes

Patient

Supporting patients in their hospital journey

the indigenous folk in the Northern Territory always were allowed an escort, which I thought was fantastic – certainly for the elderly patients… you need that support. To have somebody flown in with you and supported while you’re in hospital. RN1

I can’t imagine anything worse than, the last thing you remember you’re in a car accident and then you wake up in this place where, you’re sore and you don’t know what’s going on. The best thing for delirium is something that means something to you, the awareness of something familiar..,. [having] a next of kin readily available, a surrogate decision maker for that person that’s accessible. DR9

Enabling discussions on advanced care planning

In our community, we don’t have good discussions about ceiling of care of elderly patients. A lot of people in nursing homes are scared to do that because they think they’ll get no care. I think there’s a lot of confusion around the language of that and it’s often left to junior doctors… to have those conversations. DR10

A good discussion early about how this might change their life… to have a clear understanding of the pathway that might occur in hospital and also involving families. RN1

Having a discussion… once you get to the first smaller hospital in conjunction with the treating specialists at the receiving hospitals. That way, informed decisions about trajectories can be made and patient’s wishes or the patient’s proxies can be assessed. DR9

It takes a long time. It’s time consuming in a time poor environment. But they get to stay at home and they die at home or in their own town. A lot of the rural doctors don’t want to make those decisions because they live there and they’ll see them at the shops or the pub. Having other people come in and help make those decisions is really important. DR4

Maybe we’ve got to put in place some trigger, when somebody is a trauma and they are over a certain age, there’s a prompt to ask, Do they have an ARP (acute resuscitation plan)? [DR4]

Staff

Multidisciplinary and coordinated care as standard of care

In old people, it’s not so much the injury because the bone gets treated the same way in a 90 year-old as it gets in a 40 year-old… So the ideal situation would be to have this system where we have a shared treatment or a surgeon geriatrician [DR5]

You need a generalist… for a small hospital, a good, general physician is invaluable. In a smaller hospital, you have to get on a bit more. Bigger hospitals can sometimes be a lot harder to have relationship building. If you’re a smaller centre, if you’ve got a way of having a joint care model that has a general physician and your surgeon working together, then that’s a good model for those patients.DR2

A coordinator for in-patient and post-acute care

They gone from seeing us twice a day, making sure everything is working to now being by themselves, not really sure about the medications they’re meant to take, when they’re meant to come back in. DR7

Someone who actually telephones them and checks they’re okay would go a long way to making sure that we avoid complications and that they’re either not overdosing themselves on analgesia we’ve given them, or underdosing themselves. DR9

A trauma nurse navigator post-discharge, would be very valuable in the older person. This is that link between the hospital and the person’s home because once they’re discharged and go back to the GP, they might miss the outpatient clinic because they didn’t have it coordinated for them. DR10

A nurse practitioner fills that gap between discharge and GP, especially with regards to analgesia, doing chest x-rays, wound care and lots of other psychological support [DR6]

Enabling the training of rural clinicians in older trauma care

A stronger emphasis on the types of cases we actually see frequently, regularly rather than the higher acuity cases. It’s this paradox. We train for something we might do once a year, but the elderly faller gets maybe a couple of hours of training [PM1]

To have your radar up; awareness and greater focus and management of the smaller things, that if not done properly, lead to somebody who might have been leading an independent life, to be nursing home-bound or wheelchair-bound, for injuries that in a younger person wouldn’t necessarily lead to that outcome [DR5]

Education has to be in the rural hospital because they’re so understaffed, they can’t take the time off… that’s the only thing that’s sustainable. And you need to tailor it to their needs. It doesn’t make sense to do rural trauma education and talk about REBOA. DR5

We should be going a week every couple of years, through one of the big trauma centres and just doing trauma [education]. The skills are really heavily concentrated down there. DR2

System

Improving integration within the health system

It’s better to get them into the right place at the right time, but then you don’t want to overwhelm the system. How do you put the line for when you’re going to pull the trigger? DR1

To use each facility to the capacity they can for as long as they can, but recognising early on, if they do need a tertiary level care, bringing them down to the place they need. [DR6]

Accessibility to a universal medical record, would be handy. All you need on it is comorbidities or recent medications and next of kin. That’s just good care, not only patient centric care but telling next of kin that their loved one has been involved in a car accident. DR10

The problem is we are funded at individual sites and so there is no financial benefit for thinking bigger and broader. So how do you get the administrative side of things to understand the clinical benefit is if we all talk together. DR1

Care protocols and standardized referral pathways

Whether or not we should have different criteria for older people. Do you do it on age? Do you do it on frailty? Other factors? DR1

However it’s incorporated, it needs to be in a way that is rapidly assessable, by paramedics or pre-hospital clinicians. You’ve got this information overload and you’ve got to add another layer of information. DR7

A documented pathway of care that emphasises the risk related with geriatric trauma, deciding who goes home, who stays and who goes to [the city]… some guidance on who to image. DR2

Flowcharts and straightforward evidence-based contemporary, ‘this is what you do in this case’ without it being a bible. DR9

For the multi trauma patient, it’s an ad hoc, phone call to phone call. There’s no point a rural generalist with 20 years’ experience, trying to get advice from one of our junior doctor. DR1

A system whereby there can be early access to a senior clinician at subspecialty level… for particular injury patterns or severity or important decision making, that would go straight to a fellow or consultant level [DR4]

A trauma lead that you can just ring as a single point of contact for trauma. When you’re not sure what speciality teams need to be involved or you don’t want to do that hour and a half ring around to all the teams who need to do something but none of them want to admit the patient… that could be helpful… DR2

Supporting and expanding the use of telehealth

When it’s set up properly, you can set the cameras… [to see] the monitor, where the vital signs were and the other side, I could look at the patient. It’s like a chameleon [DR9]

With telehealth, how much of an overreach do you have to support versus guide versus tell. It’s often more of a senior clinician that just needs a bit of a handhold and advice as opposed to direct supervision. DR10