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Background: Linked datasets for trauma system monitoring should ideally follow patients from the prehospital scene to hospital admission and post-discharge. Having a well-defined cohort when using administrative datasets is essential because they must capture the representative population. Unlike hospital electronic health records (EHR), ambulance patient-care records lack access to sources beyond immediate clinical notes. Relying on a limited set of variables to define a study population might result in missed patient inclusion. We aimed to compare two methods of identifying prehospital trauma patients: one using only those documented under a trauma protocol and another incorporating additional data elements from ambulance patient care records., Methods: We analyzed data from six routinely collected administrative datasets from 2015 to 2018, including ambulance patient-care records, aeromedical data, emergency department visits, hospitalizations, rehabilitation outcomes, and death records. Three prehospital trauma cohorts were created: an Extended-T-protocol cohort (patients transported under a trauma protocol and/or patients with prespecified criteria from structured data fields), T-protocol cohort (only patients documented as transported under a trauma protocol) and non-T-protocol (extended-T-protocol population not in the T-protocol cohort). Patient-encounter characteristics, mortality, clinical and post-hospital discharge outcomes were compared. A conservative p-value of 0.01 was considered significant RESULTS: Of 1 038 263 patient-encounters included in the extended-T-population 814 729 (78.5 %) were transported, with 438 893 (53.9 %) documented as a T-protocol patient. Half (49.6 %) of the non-T-protocol sub-cohort had an International Classification of Disease 10th edition injury or external cause code, indicating 79644 missed patients when a T-protocol-only definition was used. The non-T-protocol sub-cohort also identified additional patients with intubation, prehospital blood transfusion and positive eFAST. A higher proportion of non-T protocol patients than T-protocol patients were admitted to the ICU (4.6% vs 3.6 %), ventilated (1.8% vs 1.3 %), received in-hospital transfusion (7.9 vs 6.8 %) or died (1.8% vs 1.3 %). Urgent trauma surgery was similar between groups (1.3% vs 1.4 %)., Conclusion: The extended-T-population definition identified 50 % more admitted patients with an ICD-10-AM code consistent with an injury, including patients with severe trauma. Developing an EHR phenotype incorporating multiple data fields of ambulance-transported trauma patients for use with linked data may avoid missing these patients., Competing Interests: Declaration of competing interest Matthew Miller reports financial support was provided by New South Wales Institute for Trauma and Injury Management (ITIM). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Matthew Miller is supported in his PhD by an Australian Commonwealth Government Research Training Program (RTP) scholarship., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: COVID-19 has left no healthcare system untouched. In New South Wales (NSW), the most populous state in Australia, COVID-19 case numbers have to date been relatively low. However, that does not mean the state's healthcare system has been unaffected. Preparations to create sufficient capacity to accommodate a COVID-19 surge resulted in widespread deferment of scheduled medical procedures and appointments. Patterns of healthcare-seeking behaviour changed, with a reluctance to visit healthcare settings. The aim of this study was to quantify the changes in activity seen in the NSW health system in the first half of 2020., Methods: Healthcare data were drawn from multiple sources, including primary care, ambulance, emergency departments and inpatient settings. Volumes of healthcare activity in 2020, overall, by urgency of cases and by reasons for care were compared with the figures for the same period in 2019. Changes in the modality of care provision were also examined., Results: In March to June 2020, compared with the same period in 2019, primary care face-to-face consultations decreased by 22.1%, breast screening activity by 51.5%, ambulance incidents by 7.2%, emergency department visits by 13.9%, public hospital inpatient episodes by 14.3%, and public hospital planned surgical activity by 32.6%., Conclusion: There were substantial declines in a wide range of healthcare activities across the NSW health system between March and June 2020 due to the impact of the COVID-19 pandemic. Although activity levels were recovering by September 2020, they had not yet returned to 'normal'. The implications of these changes - and the indirect impact of COVID-19 - require further study., Competing Interests: None declared

Background: To describe the diagnoses of people who present to the emergency department (ED) with low back pain (LBP), the proportion of people with a lumbar spine condition who arrived by ambulance, received imaging, opioids and were admitted to hospital; and to explore factors associated with these four outcomes., Methods: In this retrospective study, we analysed electronic medical records for all adults presenting with LBP at three Australian EDs from January 2016 to June 2018. Outcomes included discharge diagnoses and key aspects of care (ambulance transport, lumbar spine imaging, provision of opioids, admission). We explored factors associated with these care outcomes using multilevel mixed-effects logistic regression models and reported data as ORs., Results: There were 14 024 presentations with a 'visit reason' for low back pain, of which 6393 (45.6%) had a diagnosis of a lumbar spine condition. Of these, 31.4% arrived by ambulance, 23.6% received lumbar imaging, 69.6% received opioids and 17.6% were admitted to hospital. Older patients (OR 1.79, 95% CI 1.56 to 2.04) were more likely to be imaged. Opioids were less used during working hours (OR 0.81, 95% CI 0.67 to 0.98) and in patients with non-serious LBP compared with patients with serious spinal pathology (OR 1.65, 95% CI 1.07 to 2.55). Hospital admission was more likely to occur during working hours (OR 1.74, 95% CI 1.48 to 2.05) and for those who arrived by ambulance (OR 2.98, 95% CI 2.53 to 3.51)., Conclusion: Many ED presentations of LBP were not due to a lumbar spine condition. Of those that were, we noted relatively high rates of lumbar imaging, opioid use and hospital admission., Competing Interests: Competing interests: C-WCL and CGM were investigators on the PRECISE study, an investigator-initiated trial evaluating pregabalin for sciatica, funded by the National Health and Medical Research Council of Australia with in-kind research support from Pfizer (ACTRN12613000530729). CN received fees for the provision of education seminars for the SHaPED trial, a stepped-wedge cluster randomised trial evaluating the implementation of a model of care for patients with low back pain presenting to emergency departments (ACTRN 12617001160325). All other authors declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Periods of successive extreme heat and cold temperature have major effects on human health and increase rates of health service utilisation. The severity of these events varies between geographic locations and populations. This study aimed to estimate the effects of heat waves and cold waves on health service utilisation across urban, regional and remote areas in New South Wales (NSW), Australia, during the 10-year study period 2005-2015. We divided the state into three regions and used 24 over-dispersed or zero-inflated Poisson time-series regression models to estimate the effect of heat waves and cold waves, of three levels of severity, on the rates of ambulance call-outs, emergency department (ED) presentations and mortality. We defined heat waves and cold waves using excess heat factor (EHF) and excess cold factor (ECF) metrics, respectively. Heat waves generally resulted in increased rates of ambulance call-outs, ED presentations and mortality across the three regions and the entire state. For all of NSW, very intense heat waves resulted in an increase of 10.8% (95% confidence interval (CI) 4.5, 17.4%) in mortality, 3.4% (95% CI 0.8, 7.8%) in ED presentations and 10.9% (95% CI 7.7, 14.2%) in ambulance call-outs. Cold waves were shown to have significant effects on ED presentations (9.3% increase for intense events, 95% CI 8.0-10.6%) and mortality (8.8% increase for intense events, 95% CI 2.1-15.9%) in outer regional and remote areas. There was little evidence for an effect from cold waves on health service utilisation in major cities and inner regional areas. Heat waves have a large impact on health service utilisation in NSW in both urban and rural settings. Cold waves also have significant effects in outer regional and remote areas. EHF is a good predictor of health service utilisation for heat waves, although service needs may differ between urban and rural areas.

Background and Purpose: The National Stroke Foundation of Australia has run 12 public awareness campaigns since 2004. Campaign exposure and funding has varied annually and regionally during this time. The aim of this study was to measure the effect of campaigns on calls to ambulance for stroke across Australia in exposed regions (paid or pro bono advertising)., Methods: All ambulance services in Australia provided monthly ambulance dispatch data between January 2003 and June 2014. We performed multivariable regression to measure the effect of campaign exposure on the volume of stroke-related emergency calls, after controlling for confounders., Results: The final model indicated that 11 of the 12 National Stroke Foundation campaigns were associated with increases in the volume of stroke-related calls (varying between 1% and 9.9%) in regions with exposure to advertising. This increase lasted ≈3 months, with an additional 10.2% relative increase in the volume of the calls in regions with paid advertising. We found no significant additional effect of the campaigns on stroke calls where ambulance services are publicly funded., Conclusions: The National Stroke Foundation stroke awareness campaigns are associated with increases to calls to ambulance for stroke in regions receiving advertising and promotion. Research is now required to examine whether this increased use in ambulance is for appropriate emergencies., (© 2015 American Heart Association, Inc.)

This study has two aims: 1) to describe linkage rates between ambulance data and external datasets for "episodes of care" and "patient only" linkages in New South Wales (NSW), Australia; and 2) to detect and report any systematic issues with linkage that relate to patients, and operational or clinical variables that may introduce bias in subsequent studies if not adequately addressed. During 2010-11, the Centre for Health Record Linkage (CHeReL) in NSW, linked the records for patients attended by NSW Ambulance paramedics for the period July 2006 to June 2009, with four external datasets: Emergency Department Data Collection; Admitted Patient Data Collection; NSW Registry of Births, Deaths and Marriages death registration data; and the Australian Bureau of Statistics mortality data. This study reports linkage rates in terms of those "expected" to link and those who were "not expected" to link with external databases within 24 hours of paramedic attendance. Following thorough data preparation processes, 2,041,728 NSW Ambulance care episodes for 1,116,509 patients fulfilled the inclusion criteria. The overall episode-specific hospital linkage rate was 97.2%. Where a patient was not transported to hospital following paramedic care, 8.6% of these episodes resulted in an emergency department attendance within 24 hours. For all care episodes, 5.2% linked to a death record at some time within the 3-year period, with 2.4% of all death episodes occurring within 7 days of a paramedic encounter. For NSW Ambulance episodes of care that were expected to link to an external dataset but did not, nonlinkage to hospital admission records tended to decrease with age. For all other variables, issues relating to rates of linkage and nonlinkage were more indiscriminate. This quantification of the limitations of this large linked dataset will underpin the interpretation and results of ensuing studies that will inform future clinical and operational policies and practices at NSW Ambulance.

Objectives: To identify patient, clinical, and operational factors associated with nontransport of older people who have fallen and received ambulance care; and to develop a nontransport prediction tool that could be utilized during the dispatch process to rationalize allocation of emergency ambulance resources., Methods: The study was a planned subanalysis using data collected during a prospective observational cohort study of nonconsecutive emergency responses to older people aged 65 years or more who had fallen between October 1, 2010 and June 30, 2011. The data consisted of routinely collected ambulance dispatch and clinical records, combined with prospectively collected fall-specific information. Missing data were managed using multiple imputation. Multivariate logistic regression modeling was undertaken to identify predictors of nontransport. Results are described for original and imputated data sets, presented as odds ratios (OR) with 95%CI (confidence interval). Receiver operating curve (ROC) statistics were generated, with model discrimination determined by the area under the curve (AUC)., Results: There were 1,484 cases eligible for this subanalysis of which 419 (28.2%) were recorded as nontransport. Multivariate regression including dispatch and clinical variables identified a 6-item final model. Younger age group, nonurgent response priority, and presence of a personal alarm were predictors of nontransport, along with clinical variables, including normal vital signs, absence of injury, and unchanged functional status post-fall. The AUC was 0.88 (95% CI 0.86-0.90; p < 0.0001) (imputed data AUC 0.86 (95% CI 0.84-0.88)). Multivariate modeling of dispatch variables only identified a 3-item final model, which included response nonurgent response priority, younger age, and the presence of a personal alarm. The AUC was 0.68 (95% CI 0.64-0.71; p < 0.0001) (imputed data AUC 0.69 (95% CI 0.66-0.72))., Conclusion: In this population of confirmed older fallers attended to by paramedics, determination of the prehospital transport outcome is greatly influenced by on-scene findings resulting from paramedic assessment. The presence of new pain, abnormal physiology, and altered function post-fall were strongly associated with increased odds of transport. Conversely the presence of a personal alarm and allocation of a nonurgent dispatch priority increased the odds of nontransport. Accurate discrimination between older fallers who were and were not transported using dispatch data only was not possible.

Objective: Each year, the Newborn and Paediatric Emergency Transport Service (NETS) receives over 3600 calls from health professionals regarding the management and transportation of critically ill children across New South Wales, with toxicological emergencies making up 1.5% of these calls. The aim of the present study is to describe the characteristics of patients transported for toxicological emergencies and their retrieval management., Methods: A retrospective review of patients referred for management of a toxicological emergency between 2007 and 2011. Extracted data included patient demographics, substances involved, consultation with toxicological expertise, interventions performed and major adverse outcomes., Results: Two hundred and thirty patients, with 307 toxicological exposures, were referred to NETS, of whom 169 (73.5%) were subsequently transported. Pharmaceutical poisonings (223, 72.6%) were the most common, followed by non-pharmaceutical poisonings (61, 19.9%) and envenomation (23, 7.5%). Psychotropics, analgesics and chemicals were the most frequently ingested substances. The most common source of accidentally ingested pharmaceuticals was a family member. The most frequently given therapies were specific antidotes, in particular naloxone and N-acetylcysteine. Nearly half (43.2%) of transported children required only non-invasive monitoring. There was one death during the retrieval process., Conclusions: Many children with toxicological emergencies require only non-invasive monitoring, which could be provided by trained ambulance crews in select scenarios. Involvement of a toxicologist in the initial consultation to identify these patients might reduce retrieval numbers and costs. Children on regular medication and those living with family members on psychotropic or cardiac drugs were identified as high-risk groups that should be targeted for medication safety education., (© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Aim: To quantify the size and scope of the operational burden for a large ambulance service arising from older people who have fallen and to describe this population., Methods: Retrospective analysis of ambulance records from New South Wales, Australia for emergency calls classified as 'falls' in the period 1 July 2008 to 30 June 2009., Results: There were 42 331 responses to people aged 65 years or older, constituting 5.1% of total emergency workload. The median age of patients was 83 (interquartile range 76-87) and 62% were women. The transport rate was 76%. Transport to hospital was more likely during the day (odds ratio (OR) 1.8, 95% confidence interval (CI) 1.7-1.9) and on weekends (OR 1.06, 95%CI 1.0-1.1)., Conclusion: Falls by older people constitute approximately 5% of all emergency responses, of which one quarter are not transported to emergency department (ED) after paramedic assessment. Increasing the sophistication of ambulance dispatch processes to older people who have fallen, and continuing with the development of new models of care aimed at decreasing unnecessary transports to the EDs, should be a priority when planning ambulance service delivery for older people who have fallen., (© 2012 The Authors. Australasian Journal on Ageing © 2012 ACOTA.)

Objectives: Delays in the clinical handover of patient care from emergency medical services (EMS) to the ED because of ED crowding are a substantial problem for many EMS systems. This study was conducted to quantify handover delays experienced by the Ambulance Service of New South Wales (ASNSW), and to investigate patient and system factors associated with handover delay., Methods: A retrospective study of EMS dispatch and ambulance patient care records was conducted for all patients transported by ASNSW in January/April/July/October 2009. Patient characteristics and time intervals were summarised using descriptive statistics, with handover delay categorised as <30 min, 30-60 min and ≥60 min. Times are reported as HH:MM:SS. Partial proportional odds models were used to investigate factors associated with delays., Results: Of 141 381 transports, 12.5% of patients experienced a handover delay of 30-60 min, and 5% a delay of ≥60 min. The median handover interval was 00:15:46 (IQR 00:08:58-00:24:52, maximum 08:43:13). Patients transported to large hospitals were more likely to experience a delay of ≥30 min (odds ratio [OR] 14.57, 95% CI 11.41-18.60) or ≥60 min (OR 15.75, 95% CI 12.27-20.23) than those transported to small hospitals. Patients in major cities were more likely to experience delays than those in other areas, and patients ≥65 years were more likely to experience delays than those <16 years. Delays were most likely in winter. Cardiac and major trauma patients had the lowest likelihood of experiencing delays., Conclusions: Handover delays are relatively common at the EMS/ED interface in New South Wales, and are most pronounced at large hospitals, in urban areas and during winter., (© 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Background: Pre-hospital triage protocols are an important component in the treatment of injured patients. The aim was to determine the level of, and factors associated with, adherence to the pre-hospital trauma triage criteria for urban patients transported in New South Wales, Australia., Method: This retrospective study included patients injured in urban areas who were transported by road for the treatment of traumatic injuries in the period 1 July 2006 to 30 June 2007., Results: Of the 57,775 transported to hospital due to traumatic injury, 9344 (16%) met one or more of the pre-hospital triage criteria. Of these, 74% were transported to a protocol adherent major or regional trauma centre. Adherence rates differed by triage criteria met and was lowest for patients meeting physiologic-only criteria (63.5%) and highest for patients meeting all three triage criteria of physiology, mechanism and injury (85.4%). Female gender, increasing patient age, patients classified as having had a fall, the qualification level of treating officer and patients transported between midday to 18:00 (relative to those transported between midnight to 06:00) were factors associated with significantly lower levels of protocol adherence with respect to hospital destination. Minimal time differences were evident between patients transported to protocol adherent and non-adherent destinations., Conclusion: Based on the post hoc evaluation of triage status, adherence to the triage protocol was 74%. Analysis of patient destinations for protocol non-adherence appears to indicate that paramedic interpretation and discretion played a role in determining hospital choice. There was a marginal time difference between those transported to protocol adherent and non-adherent destinations. Future research needs to determine whether deviations from protocol are associated with differential mortality., (Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.)

Aims: Supervised injecting facilities (SIFs) are effective in reducing the harms associated with injecting drug use among their clientele, but do SIFs ease the burden on ambulance services of attending to overdoses in the community? This study addresses this question, which is yet to be answered, in the growing body of international evidence supporting SIFs efficacy., Design: Ecological study of patterns in ambulance attendances at opioid-related overdoses, before and after the opening of a SIF in Sydney, Australia., Setting: A SIF opened as a pilot in Sydney's 'red light' district with the aim of accommodating a high throughput of injecting drug users (IDUs) for supervised injecting episodes, recovery and the management of overdoses., Measurements: A total of 20,409 ambulance attendances at opioid-related overdoses before and after the opening of the Sydney SIF. Average monthly ambulance attendances at suspected opioid-related overdoses, before (36 months) and after (60 months) the opening of the Sydney Medically Supervised Injecting Centre (MSIC), in the vicinity of the centre and in the rest of New South Wales (NSW)., Results: The burden on ambulance services of attending to opioid-related overdoses declined significantly in the vicinity of the Sydney SIF after it opened, compared to the rest of NSW. This effect was greatest during operating hours and in the immediate MSIC area, suggesting that SIFs may be most effective in reducing the impact of opioid-related overdose in their immediate vicinity., Conclusions: By providing environments in which IDUs receive supervised injection and overdose management and education SIF can reduce the demand for ambulance services, thereby freeing them to attend other medical emergencies within the community.

Objective: To profile a helicopter emergency medical service in rural Australia. To assess patient injury severities and outcomes. To compare missions involving ambulance officers with physicians. To determine any time advantage of the aircraft over ground transfer., Methods: Intention-to-treat analysis using retrospective case note review of all helicopter emergency medical service trauma patients from January 2004 to November 2006. Global positioning system mapping technology was used to compare one-way road transfer times with two-way helicopter retrieval., Results: Two hundred and twenty-two missions were identified from the helicopter log. Forty missions were aborted in flight. Of 182 patients transported, 11 records were incomplete, leaving 171 for analysis. Fifty (29%) patients transported had an Injury Severity Score (ISS) > 15; the average ISS was 12.30 (standard error of the mean 0.82). The average calculated distance flown was 160.4 nautical miles (standard error of the mean 5.29; range 28-360 nautical miles). There was no significant difference in ISS between ambulance officers and physician groups (t = -1.17, P = 0.25, 95% CI -7.37-1.91). There was no difference in the incidence of severe injury (ISS > 15, P = 0.39) or mortality (P = 0.33) when the groups were compared. Air transport was significantly faster beyond 100 km, with a mean difference of 48 min (P = 0.00)., Conclusion: We could not identify a significant survival benefit attributable to the addition of a doctor, although numbers for this comparison were small. Predicting missions where flight physicians might provide benefit remain imprecise and should be a priority area for prospective evaluation. We have demonstrated that in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care.

Objective: To explore the association between daily patient numbers, sociodemographic, clinical and system characteristics and walkout rates of patients from New South Wales (NSW) public hospital ED (without seeing a medical officer)., Methods: This was a secondary analysis of the NSW Emergency Department Data Collection, between 1 January 1999 and 31 December 2001, with a total of 4 356 323 ED attendances. Bivariate and multiple logistic regression analyses were performed to explore the relationship of walkout from ED and explanatory variables., Results: About 5.7% of the patients attending in NSW public hospital ED left without seeing a doctor. The results from bivariate and multivariate analyses revealed that walkout rates significantly varied by sociodemographic and clinical characteristics of the patients. Patient groups that more likely to walk out were those aged 15-44 years, from a non-English-speaking background, Aboriginal, with lower socioeconomic status, with no private health insurance coverage and longer waiting times for triage. Patient volume in the ED showed a significant positive association with walkout rates., Conclusions: After adjusting for triage category (urgency of presentation) and triage time, patients from lower socioeconomic backgrounds and those without private health insurance coverage were more likely to leave ED without treatment. These results have important implications for Health Services. Future strategies aimed at minimizing walkouts from public hospital ED should prioritize and target factors identified in the present study.

A review of trauma statistics in metropolitan Sydney over a three-year period was undertaken. Data were obtained from the NSW Department of Health on hospital separations for trauma diagnoses for the two financial years 1985-1986 and 1988-1989 and from the Roads and Traffic Authority of New South Wales and the NSW Ambulance Service. Marked differences emerged in the pattern of overall trauma between the 1985-1986 and 1988-1989 periods, the most noteworthy being the reduction of teaching hospital separations both for total trauma and for transport related trauma which is responsible for the majority of serious injuries. The implementation of a State-wide policy for trauma services in New South Wales is now occurring. The information obtained from this study indicates that much of the baseline data used in formulating that policy were misleading. The policy of concentrating major trauma resources (level 3 trauma centres) in the eastern half of the city is found to be at odds with the finding of a high morbidity and mortality from transport related trauma in the western half of the city and the lack of such resources in that area.