Blackwell Publishing AsiaMelbourne, AustraliaAJRAustralian Journal of Rural Health1038-5282 2006 The Authors; Journal Compilation 2006 National Rural

l Health Alliance Inc.? 2006146270274Original ArticleREMOTE AREA AEROMEDICAL EVACUATIONS

D. PEIRIS ET AL.

Aust. J. Rural Health (2006) 14, 270274

Original Article Aeromedical evacuations from an east Arnhem Land community 20032005: The impact on a primary health care centre
David Peiris,1 Cherryl Wirtanen1 and John Hall2
1

Ngalkanbuy Health Centre, Galiwinku, Elcho Island, Northern Territory, and 2School of Public Health, University of Sydney, New South Wales, Australia

Abstract
Objective: To understand the prole and impact of aeromedical evacuations in remote Indigenous communities. Design: Descriptive study. Setting: A primary health care centre in east Arnhem Land, Northern Territory, Australia. Participants: Four hundred and ten evacuations from a total population of more than 2200 were analysed from February 2003 to August 2005. Main outcome measures: Patient demographics, seasonal variations, diagnostic categories, utilisation of staff resources. Results: On average 6.5% of the community were evacuated to hospital every year with an evacuation occurring every 2.2 days. Children aged under ve years were 3.3-fold overrepresented in evacuations (comprising 37.7% of those evacuated versus 11.3% of the community, P < 0.001). Four diagnostic categories accounted for 61% of evacuations: respiratory disease (21%), obstetric conditions (15%), gastroenteritis (14%) and injury/poisoning (11%). Over the study period four patients required intubation at the clinic. Evacuation rates were higher in the monsoon season. Forty-seven per cent of evacuations occurred after hours. The waiting time for plane arrival ranged from one hour to 21 hours with a median wait-time of three hours. Conclusion: Aeromedical evacuations place a heavy burden on primary health centres. Clinic staff are regularly required to provide hospital-level acute care, often for several hours at a time. Meeting this burden

competes with primary prevention programs and regular clinic duties. The age and diagnostic proles encountered in this study have signicant implications for the range of skills required to provide an adequate acute care service. This study highlights the need for remote area health centres to be well resourced to meet these needs. KEY WORDS: emergency, Indigenous health, prehospital care, remote area nursing, service delivery to Indigenous population.

Introduction
The long-standing and growing health disparity between Indigenous and non-Indigenous Australians has been well described in successive Australian Institute of Health and Welfare and Australian Bureau of Statistics reports.14 One aspect of this disparity is the high rates of Indigenous hospitalisation for most acute conditions. Aside from renal dialysis, the most common reasons for Indigenous hospital separation were pregnancy/puerperium (15.8% of female separations), injury/poisoning (12.3% male, 7.3% female) and respiratory (11.0% male, 7.8% female).5 Although circulatory disease is the greatest contributor to Indigenous adult morbidity and premature mortality,6 it plays a less prominent role in acute hospital admissions accounting for only 4.2% of Indigenous male and 3.2% of Indigenous female hospital separations in 19992000.5 For children, the disparities are similar. Indigenous infants are 1.3-fold more likely to be hospitalised overall and threefold more likely for respiratory, infectious and skin conditions.5 These gures occur, however, in the context of a signicant decline in Indigenous infant mortality over the last two decades.3,7,8 In the Northern Territory (NT) there was an 85% decline in mortality in children aged under ve years between 1966 and 2001.9 Improved quality of health care and accessibility
doi: 10.1111/j.1440-1584.2006.00828.x

Correspondence: Dr David Peiris, Ngalkanbuy Health Centre, PMB 230 Galiwinku community, Elcho Island, Galiwinku Community, Northern Territory 0822, Australia. Email: priyajit@bigpond.com Accepted for publication 22 September 2006.
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What is already known on this subject: Indigenous Australians are hospitalised at higher rates than non-Indigenous Australians with obstetric, injury and respiratory illnesses being the most common reasons. There have been no known studies published to look at the burden of acute illness requiring evacuation to hospital from remote communities.

What this study adds: This study is the rst in Australia to provide a detailed descriptive analysis of aeromedical evacuations to hospital from a remote or rural primary health care setting. Children bear the greatest burden of acute illness requiring evacuation to hospital. Remote health centre resources are considerably stressed to meet the acute care needs of the community.

has been an important factor in this decline. In a study of all admissions in Western Australia for acute gastroenteritis between 1990 and 2000 there were no recorded deaths from this condition compared with 69 deaths of Aboriginal children between 1970 and 1979 and nine deaths between 1980 and 1989.10 Although hospitalisation data are relatively easily accessible a review of several databases failed to nd any descriptive analyses of evacuations to hospital from Australian remote areas. The Royal Flying Doctor Service is the major provider of aeromedical services in Australia with the exception of the Top End of the NT, which is serviced by the NT government through the Northern Territory Aerial Medical Service (NTAMS). In 2003/2004 the Royal Flying Doctor Service performed 3804 primary medical evacuations from rural and remote areas.11 Forty-two per cent of these occurred in the Alice Springs region alone representing an average of more than four evacuations per day. Two studies in Papua New Guinea found obstetric, trauma and respiratory conditions as the leading reasons for evacuation from remote area clinics.12,13 A west-Australian study found a median transfer time to hospital of more than nine hours for 440 trauma patients.14 Aside from these scant facts little else is known. Thus our study is the rst known in Australia to perform a descriptive analysis of aeromedical evacuations to hospital from remote area clinics.

TABLE 1: Age breakdown of an east Arnhem community based on clinic records Age group (years) Under 5 59 1019 2029 3039 4049 5059 60 and older Total No. 412 388 513 538 417 291 150 104 2813 % 14.6 13.8 18.2 19.1 14.8 10.3 5.3 3.7 100 Cumulative % 14.6 28.4 46.6 65.8 80.6 91.0 96.3 100.0

Methods
Setting and participants
The remote Indigenous community is located in east Arnhem Land. Population gures vary from the town council estimate of 2200 to the health centre gures of 2813 regular clients. The former is most likely an underestimate whereas the latter includes clients of the service who do not regularly reside in the community. Table 1 lists the percentage breakdown of age groups in the
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community based on clinic records. This is consistent with Australian Bureau of Statistics 2001 census data, which quote the median age for east Arnhem Land as 22 years with 34.1% of the population under 15 years of age.15 Over the study period the health centre provided 24hour acute care services via six Aboriginal health workers (AHWs), ve Registered Nurses (RNs) and one resident doctor (either a GP or a GP registrar). An AHW is rst on-call for all after-hours presentations and is supported by either an RN or the resident doctor who share the second on-call roster. The resident doctor was therefore not expected to be involved in all evacuations but was available as a third on-call in more extreme emergencies. Patients requiring evacuation travel by plane to either Nhulunbuys Gove District Hospital (45 min ight time) or Royal Darwin Hospital (75 min ight time). The community has a 24-hour accessible, sealed airstrip. Despite this landings can be rendered impossible in the monsoonal season (December March). The NTAMS has three bases in the Top End with Beechcraft Kingair B200C planes on site at Darwin, Katherine and Nhulunbuy. The Nhulunbuy-

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based NTAMS performs the majority of evacuations with a small proportion of ambulant, self-caring patients evacuated to hospital using daytime chartered or routine passenger commercial ights. When an evacuation is contemplated health centre staff consult the District Medical Ofcer at Gove District Hospital who assesses the suitability and priority for evacuation. The NTAMS frequently needs to coordinate evacuations from multiple remote communities and this impacts on the waiting time to pick-up. A ight nurse attends all evacuations and a ight doctor attends more severe cases. Occasionally Darwin-based specialist staff are required, particularly for paediatric and obstetric emergencies.

160 140 Number of evacuations 120 100 80 60 40 20 0 Under 5 59 1019 2029 3039 4049 5059 60 or over

Age group (years)

FIGURE 1: Age distribution of patients evacuated to hospital from an east Arnhem community 20032005.

Data collection and analysis

The health centre routinely records data on aeromedical evacuations. A de-identied version of these existing data was used to undertake this study. No additional data collection or interviews were performed. Written consent to perform the data analysis was obtained from the community council and the health centre management. Analyses were conducted using SPSS version 12.0 statistical software (SPSS Inc., Chicago, IL, USA).

Results
There were 410 aeromedical evacuations recorded between February 2003 and August 2005 representing an average of one evacuation every 2.2 days. Most evacuations (84%) were performed by either the Gove- or Darwin-based NTAMS team with the remainder transported to hospital via either a chartered commercial aircraft or the routine passenger plane. Sixty-eight per cent of evacuations were to Gove District Hospital and 32% to Royal Darwin Hospital. The majority of evacuations (86%) involved the transfer of one patient. The majority (88%) of patients were evacuated only once during the study period. A small number (n = 9) were evacuated three or more times the most common reason being missed renal dialysis. Taking into account patients who were evacuated more than once, on average 6.5% of the community required acute transfer to hospital every year. Gender representation was roughly equal in all adult age groups except for the 2029 years group where 74% of people evacuated were women and in the 3039 years group where 61% evacuated were men. Figure 1 shows the age distribution of the evacuated population. Overall, this population was signicantly different to the non-evacuated population (2 = 189.7 with seven degrees of freedom P < 0.001). Adjusting for people evacuated multiple times, the under ve years age group were 3.3-fold overrepresented in evacuations

FIGURE 2: Seasonal variation in aeromedical evacuations from an east Arnhem community February 2003August 2005.

(comprising 37.7% of all evacuations despite constituting only 11.3% of the community). This overrepresentation was highly signicant (2 = 173.4 with one degree of freedom P < 0.001). The median age for evacuation was 18.3 years. Figure 2 shows that a seasonal trend was observed with an increase in evacuation rates over the monsoonal period from late December to March.

Diagnostic categories
Table 2 below outlines the diagnostic categories for evacuations over the study period. In the respiratory group 53 of the 85 evacuations (12.9% of all diagnoses) were children with bronchiolitis or pneumonia. All children had moderate-to-severe respiratory distress with an oxygen requirement. Adult pneumonia, chronic obstructive pulmonary disease and asthma exacerbations accounted for the remaining 32 cases. In the
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TABLE 2: Diagnostic categories for evacuations to hospital from an east Arnhem community 20032005 Principal diagnostic group Respiratory Obstetric Gastroenteritis/failure to thrive Injury/poisoning Neurological Renal Cardiac Mental health Infectious disease Other GIT Haematological Rheumatological Other Total GIT, gastrointestinal tract illness. Frequency 85 62 59 44 25 18 15 14 13 12 8 8 47 410 % 21 15 14 11 6 4 4 3 3 3 2 2 11 100

place between 17:00 hours and midnight and 16% of cases required care after midnight.

Discussion
The provision of primary health care in remote Australian Indigenous communities presents unique challenges for health practitioners. Wakerman denes remote area practice as one characterised by:
isolation which is geographical, social and professional; a small dispersed and highly mobile population; climatic extremes; high population morbidity and mortality; an extended practice role; a strong multidisciplinary approach and cross cultural issues affecting practice and everyday life. 16

obstetric group 52 of the 62 evacuations were for labour (12.6% of all diagnoses). The majority of these labours (63%) were preterm. Eleven women delivered term babies in the community prior to departure to hospital. In the gastroenteritis and failure to thrive category almost all patients had moderate-to-severe dehydration. Two children required intraosseous needles inserted for uid resuscitation. In the trauma group 17 patients had major trauma with a further 17 having upper limb fractures. Eight patients were evacuated for potential envenomations (either jelly sh stings or snake bites). Over the study period four patients (three adults and one child) were intubated and ventilated at the clinic. The conditions requiring intubation were status epilepticus, myocardial infarction with a ventricular brillation arrest, severe pneumonia and severe bronchiolitis with febrile convulsions.

Utilisation of staff resources

Eighty-ve per cent of evacuations required a combination of staff to provide care to the patient. RNs were involved in 80% of evacuations, doctors in 64% of evacuations and AHWs in 63% of evacuations. Eight per cent required aeromedical or specialist staff to provide care on site prior to evacuation. The waiting time between the decision to evacuate and actual evacuation ranged from one hour to 21 hours with a median wait time of three hours. Sixty-six per cent of evacuations had wait times less than four hours, 28% between four and eight hours and 6% beyond eight hours. In 53% of evacuations the majority of clinical care took place in normal working hours, in 31% of cases some care took
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Aeromedical evacuations in remote settings epitomise these characteristics. With an evacuation occurring just over every two days on average, this study highlights the signicant impact of providing high-level acute care in a remote, primary health care setting. The prominence of respiratory, obstetric, gastrointestinal and injury/poisoning-related conditions in the diagnostic breakdown of our study concurs with the available national data on hospital separations for Indigenous people. Like the national data, cardiovascular conditions accounted for only a small proportion of evacuations despite there being a high burden of these diseases and their risk factors in this community.17,18 Children aged under ve years bore the greatest burden of acute illness requiring hospital admission (especially due to gastroenteritis and bronchiolitis). Our study supports national ndings that young Indigenous children are hospitalised at higher rates than non-Indigenous children. Although the high childhood evacuation rates might appear grim news it might be one of the most signicant contributions to reductions in Indigenous infant mortality. Prompt treatment and evacuation of children with gastroenteritis now makes deaths from this condition exceedingly rare. As gastroenteritis and bronchiolitis tends to occur in outbreaks, primary health centres need to be adequately equipped and staff appropriately trained during these times. Staff in this study can expect to see at least one child present with life-threatening respiratory distress or gastroenteritis every year. Anticipation of these occasions can greatly alleviate the stress of providing care in extreme circumstances. Similarly clinic staff at this community can expect to be regularly providing care for women in labour (particularly preterm labour) and the delivery of around four babies each year. This occurs despite NT health department policy to evacuate all antenatal women to hospital for delivery. Once again this has implications for staff training. Over the study period the community was fortunate to have excellent health cen-

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tre staff with the necessary skills to provide a high level of acute care. Low staff turnover rates, weekly scenariobased education sessions, regular in-services in Darwin and Nhulunbuy and a health centre policy that requires a midwife to be available at all times have been factors that contributed to this high level of care. This study showed the NTAMS to be prompt in responding to patient needs with two-thirds of requests for evacuation responded to in less than four hours. Despite this, staff must be prepared to manage acute illness for many hours at a time especially for the 47% of evacuations that occurred after hours when there was less staff support and waiting times were longer. This high after-hours utilisation of staff has a signicant impact on planning and allocating resources for other clinic activities. Although the study period was only two and a half years a seasonal trend was observed that could also be useful for health centre planning. Staff can expect to be busier in the monsoon season months and consequently might recruit extra staff and/or downscale other clinic activities during these months. Similarly the drier months might be more opportune for expanding other clinical programs or allowing more staff to take leave. This study is the rst known in Australia to look at the impact of evacuations to hospital on a remote primary health centre. More work is required to see if the observations and trends highlighted here remain consistent over time. Comparison with other communities would also provide a more comprehensive picture. Several factors have been raised that can be useful for health centre planners to meet the considerable burden of acute care in similar settings.

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Acknowledgements
Sincere thanks to the staff at Ngalkanbuy Health Centre. Statistical advice was given by Dr Petra Macaskill and Mr Kevin McGeechan. Jane Ryan and Tony Parsons from the RACGP library assisted with the literature review. Drs John Setchell and Didier Palmer provided valuable information on aeromedical services research in the Northern Territory.
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References
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2006 The Authors Journal Compilation 2006 National Rural Health Alliance Inc.