Emergency care “out there”: lessons from the RERN

AMBULANCE services are the undisputed experts in pre-hospital care. However, in rural and remote Australia, services are often constrained by resources and scope of practice of largely volunteer-based crews.

Crews are sometimes responsible for a critically ill patient for many hours before a retrieval team can take over care. Therefore, a window of time exists when an appropriately trained and equipped rural generalist may “value add” at critical incidents, particularly, in areas such as advanced airway skills, intravenous access, and analgesia. In 2012, rural GP-anaesthetists reported already occupying this role ad hoc in their communities.

South Australia is the only state with a developed system to formally incorporate the skillset of rural generalists into the pre-hospital system. Since 2008, the SA Rural Emergency Responder Network (RERN) tasks suitable trained and equipped rural generalist clinicians to pre-hospital emergencies in rural communities.

RERN is run by the Steering Committee, which, within the study period, sat within the broader Rural Support Service branch of SA Health. RERN is a voluntary service and the members are reimbursed for their time and procedures performed at the incident. Reimbursement is based on the SA Medical Schedule of Fees. Each RERN member completes a clinical record of the call and submits to the Rural Support Service for payment.

Calls are assigned to RERN rural generalists through the SA Ambulance Service (SAAS) Emergency Operations Centre (EOC), where they maybe tasked to incidents by the extended care paramedics on duty. RERN members are tasked by the SAAS EOC by both pager and text via mobile phone. As it is a voluntary service, RERN members are not obliged to attend each call. As rural generalists, they could already be in clinic or involved in a clinical situation at the hospital. Alternatively, they may not be available due to a private obligation. RERN doctors notify the EOC if they are available and arrangement is made to either be picked up by the ambulance crew or to drive to the scene themselves.

As part of the Flinders University Doctor of Medicine program, Dr Tim Leeuwenburg and I undertook a retrospective quality improvement study of RERN (unpublished data). This project examined the casemix of the RERN model between 2010 and 2020 to better inform future training, equipment and other needs, as well as to provide meaningful data for other states to establish similar networks.

Over the study period of 2010–2020, 477 clinical record forms were submitted that met the study criteria. To be included, the clinical record form had to have a date and start and finish times. Not all clinical record forms contained all study variables, so the sample size varies for each study variable. Data were collected from de-identified clinical record forms.

The RERN doctors claimed a mean time of 60 minutes (σ_M = 2.8 minutes; range, 3–373 minutes) per assigned task, which was used as a surrogate marker for duration of an assigned task. This was important for understanding how long a rural generalist could expect to be away from their other clinical duties.

RERN clinicians were most often attending to a single patient (88%, n = 476) as an additional responder supporting existing emergency services (83%, n = 372). For the most part, allocated tasks were for trauma (58%, n = 476), road trauma, farm accidents and workplace incidents.

At an incident, the most likely outcome of RERN attendance was that they performed a clinical intervention of some kind (65%, n = 476; Table 1). Interventions included obtaining intravenous access and fluids, advanced airway skills, ventilation and providing analgesia. Providing intravenous access was important as it is beyond the scope of practice for volunteer ambulance services in South Australia. Analgesia was important as, at the time of the study, the volunteer service was unable to offer opioid analgesia without senior support. Only recently has intranasal fentanyl been available, even for serious trauma.

In some instances, RERN clinicians were stood down prior to arrival (5.3%; Table 1) the reason for which was sometimes recorded, such as the patient was deceased (4.0%; Table 1) or the RERN doctor was diverted to their local hospital (1.5%; Table 1).

Frequently, the RERN doctor was recorded as taking more of an assessment and triage role (24%; Table 1), suggesting that in bringing “soft skills” to an incident, RERN doctors could also add value to clinical care at critical incidents. These included decisions to cease active resuscitation, for example. These “soft skills” were not as reported on in the other key articles (here and here) on this topic.

Table 1. Outcome of RERN tasking 2010–2020

What other states could learn

The results of the study indicated that RERN clinicians during the study period (2010–2020) were reporting attending mostly trauma incidents, attending to a single patient, and performing a clinical intervention of some kind (eg, cannulation or administering medication).

There have been some grumblings of interest in similar network from other states in Australia. It is important to know that rural generalists are already undertaking this role in an informal capacity across Australia. There are also comparable networks in the United Kingdom (British Association for Immediate Care) and New Zealand (Primary Response in Medical Emergencies).

These clinicians are not replacing existing ambulance resources as first responders, but rather, are supporting the existing agencies. At an incident, rural generalists are performing a limited suite of meaningful interventions. They are performing the basics well, which agrees with the position statements of industry bodies – the Australian Medical Association and the Rural Doctors Association of Australia in conjunction with the Australian College of Rural and Remote Medicine.

From a logistical perspective, this study provides an estimate of the average time investment of an RERN clinician per incident as well as an estimate of the number of incidents per year. This could be integrated into cost analysis. The average cost per annum for all RERN taskings is under $50 000. However, this is anticipated to be proportionate to the number of taskings per year (RERN Project Officer, personal communication). Costing analysis was not within the scope of this project but represents an area for future research.

From a workforce perspective, formalising the network – by making it government-funded, by connecting rural generalists who perform this role with each other, and creating a committee that oversees accreditation, equipment and training – allows rural generalists to be equipped, trained, and reimbursed for this kind of clinical work. In equipping and training people, it could improve clinical outcomes and, at the very least, can offer an increased awareness of scene safety. Mackenzie noted that pre-hospital emergency medicine was recognised as its own subspecialty by the General Medical Council in the United Kingdom in 2011, reflecting the unique challenges of this area of practice. This holds true for the rural generalists who are keen to help their communities in any way they can but some may lack the skills and/or training to translate skills to the pre-hospital environment.

We can see from this study that there is a real demand for RERN presence at critical incidents in South Australia. However, this evolved as the network aged. It would be expected that we would see a similar trend should other states adopt this model.

Using skills of appropriately trained and equipped rural doctors can “value add”, especially in locations where ambulance resources are limited (available assets and/or treatment ceilings). The rural generalist clinician can also deliver early, meaningful interventions well before the arrival of specialist retrieval teams, which is of vital importance in Australia where the tyranny of distance is a factor, such as in South Australia.

A recent study by Maclure and colleagues found that of a cohort of 337 patients treated by a pre-hospital retrieval medicine team in South Australia, only 37% of trauma patients received pre-hospital emergency anaesthesia within 45 minutes of team activation. To a RERN clinician, this may represent 45 minutes or so where they may “value add” to patient care, assisting their community emergency response. It is the opinion of retrieval physicians that a well trained clinician can provide timely, effective clinical interventions in the pre-hospital environment. The last thing we want is for rural generalists to risk their own safety regularly in this environment.

The benefit of specialist pre-hospital retrieval teams, particularly to rural trauma patients, is well established. It is challenging to demonstrate a benefit of RERN in the same way, as the network is small and resources are limited. Exploring the benefit of RERN involvement at critical incidents from a morbidity and mortality perspective represents a significant area for future research. By interrogating the utilisation of RERN through this project, it was hoped that the academic community could be convinced to investigate this remarkable entity further.

It is now time for other states to adopt similar models. As a bottom-up approach, rural doctors in other states are forming networks supported by the Sandpiper Australia charity, ensuring suitably trained clinicians have a standardised kit: the Sandpiper bag. With the appropriate training and the Sandpiper bag, RERN clinicians are not just impromptu responders, but skilled, prepared responders. They are poised to attend incidents as they happen within their communities. But they need a formal network, such as RERN, to support and compensate them for their time.

Involvement with the project on RERN has solidified my interested in critical care disciplines and reaffirmed my desire to practise outside of metropolitan areas. Since starting my medical school journey, my rural year remains the enduring highlight. It emphasised for me that leaving the hospital environment did not mean leaving behind clinical challenge.

Personally, clinical challenge and variety have rated highly as priorities when reflecting on my future career choice. I get to achieve this professional and academic fulfilment in inclusive, welcoming communities in places of exceptional natural beauty, through rural practice.

Caitlin Skinner is a final year medical student at Flinders University in South Australia. She is interested in critical care medicine, particularly within the rural context.

I wish to acknowledge the Rural Emergency Responder Network in South Australia Steering Committee for their support of this project and myself.

For questions regarding RERN itself:
Jennifer Smith RN – Nurse Consultant, Senior Project Officer for RERN
Jennifer.Smith@sa.gov.au

Dr Trevor Burchall – RERN Clinician
Trevor.Burchall@sa.gov.au

For questions regarding the project:
Skin0087@flinders.edu.au
timleeuwenburg@gmail.com

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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