THE EMERGENCY CARE

OF

ROAD CRASI"I VICTIMS

P. D. Clark, M.8.,, B.S. (Adelaide, 1967)

A Thesls presented for the degree of Doctor of Medlcineln the Universlty of Adelalde, based on a sfudy conducted

in the Departmenf of Social and Preventive Mediclne,Monash Universlty, Melbourne, Vicforla, and supporled by

the National Health and Medical Research Counci I of Austral ia.

SubmíTted May, 1972

CONTENTS

tt

Page

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lx

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1

33

1216l62328

63646467676969737475767980

Summary

Dec larat ion

Acknow I edgements

Chapter I INTRODUCTION

Chapter 2

Chapter 5

HISTORICAL OUTLINE AND REVIEI,ll OF THE LITERATUREThe Development of Emergency ServlcesCrash lnjury Studies in AustraliaSludies of Emergency Servlces

Ambu I ance ServicesHospital Casualty DepartmentsEmergency Care System Studles

THE STUDY BACKGROUND

Stafement of the ProblemThe Emergency Care Sysfem ln Melbourne

Obj ecf i vesE I ements

The General PublicTowi ng ServicesPol iceThe Fire BrigadeThe Ambulance Servíce

Descriptlve Model

THE STUDY OEJECTIVES

THE STUDY METHOD

The Study Design: Phase OneEmergencies in MelbourneThe Sample AreaThe Sampl ing ScheduleSelection of lhe CrashesOperatlon of the Research Team

The Study Design: Phase TwoThe Samp I i ng Schedu leSelectîon of Sludy PatientsData Col lection Methods

Data Recording and ProcessingDefínitions

393941

4243434343444452

61Chapler 4

Chapter 5

ilt

85Chapter 6

Chapler 7

THE CRASHES, THE PATIENTS AI.ID THEIR INJURIESPhase One:

The CrashesThe PatientsPatterns of lnjurySeat BeltsAlcohol

Phase Two:The PatlentsPatlerns of I nJurySeal BelfsAlcoholThe CrashesVal idity of the SampleThe Quesfionnaire Sample

OPERATION OF THE EMERGENCY CARE SYSTEM IN I,4ELBOURNEThe Communications Subsystem:

Crash Detection and NotífícatlonAmbulance DispatchCommunications during Ambulance ServiceCommunications between Hospitals and lhe

Ambulance ServlceCommunications withi n Hospifa I

The Transport Subsystem:Response of fhe Emergency ServicesProtection al the Crash SceneAmbulance TransporfLift¡ng and Moving fhe lnjuredTime Delays during Ambulance Service

Trave I T imeTlme at SconeTransport TlmeAmbu lance Response TimeTrealmenf and Transport TimeAmbulance Service Time

The Treatment Subsystem:Care beforo Hospital

First Aid at the SceneAmbu lance Care

Care in CasualtyTr i ageIreatment ProceduresIreatmenl De I ays

Reception TlmeNursing Assessmenf DelayWaifing Time to See a Medical

0ff i cerX-Ray Service TlmeObservation and Treatment TimeTolal Casualty Treafment Time

B989919292939B

101

83858687B8

101103105

110113

n5118120121123124124125126127128

129129130134134135139140140

141143145146

Chapter 7 (Contd. )

The Documentatlon Subsystem:Crash Data CollectionAmbu lance RecordsCasua I ty Documental i on

Chapler I EVALUATION OF THE EMERGENCY CARE SYSTEMOutcomes of CareThe Slrucfure of CareThe Care Process

Time Delays in the Emergency Care System:The Significance of Tíme DelaysThe Observed Time DelaysWaifíng Times in Hospltal Casualty

DepartmentsThe Effects of Alternative Patterns of

Ambulance Servíce on Time Delays

The Qual îty of Emergency Medical Care:Standa rdsThe Method of EvaluationThe Quality of Care for the Phase One

Paf i entsThe Qual ify of Care for the Phase Two

Patients - comprising:Ihe Histony and PhysieaT EnønínøtionIhe Tneahnent Penformed:

Int ensío e Re sus eitationfntnauenous IhetapyFnaettpe MannganentWounå Manngement

Ihe SuaLitA of CasuaLty CaneReLíabiLíta of the AssessmentePatients' Attítttdee to CareSwrmaz,y

An Analysis of Patterns of Casualfy Servlcefor Road Crash Victlms

ïhe Technique of Simulated Sampl ingSimulaÌion of fhe Observed Sysïem

A lms of the S imu laf ionThe S imu lat ion Mode I

D i scuss ionConclusions

CONCLUS IONS AND RECOÍ\4MENDAT IONSCommunicationsTransportDocumentaf ionTreatmentSumma ry

iv

148t48152

155155158162163163164

166

168

171172

174

17A179

185187192195202205206212

212213215219219225225

228229231233235238

Chapter 9

Appendix 1 TABLES

Appendix 2 AMBULANCE EQUIPMENT LtST

Appendix 3 EMERGENCY CARE SysTEJvt sTUDy coDEs

Appendix 4 QUESTIONNAIRE

Bibl iography

Appendix 5 TREATMENT DELAYS BY TIME 0F I,rIEEK

v

239

251

25t

268

270

286

V¡

SUMMARY

The lhesis describes the findings of a study conducted by a

research team, consisting of Dr. G. A. Ryan and lhe author, from fheDepartmenl of Social and Preventive Medicine, Monash Universíty,l4elbourne. The aim of the study u¡as to descrlbe and evaluate theopenation of the emergency care system in Melbourno.

The study was conducted ín two distinct phases. ln fhe firsfphase the research feam attended the scene of 100 road crashes ln a

selected metropol itan area. Delai ls of fhe crashes, the operatíon ofthe omergency services, and the care provided for the 310 persons

involved in fhe crashes, wore observed and recorded by the fwo

researchers. Pallenls who required hospital trealment were fol lowed

to the hospital and observed untll their dlscharge from fhe casualtydepartment. ln the second phase, the author observed the care pro-vided Íor 328 crash victims during fheir frealment in lhe casualfydepartment of a major Melbourne feaching hospífal. This phaso of thestudy was designed to investigate in greater detai I the performance

of emergency care within the casualty department.

ln the thesis a systems approach is used to describe theemergency services and the care provided at the crash scene, duringambulance care, and in the hospital casualty department. Care beforehospital is compared with that provlded in the casualfy department,

using the time delays ln the varlous freatment phases and the qualityof the treafment performed as varíables for evaluafing performance inthe omergency care system.

Deficiencies dotocted in the system included poor communication

betwoen ambulance and casualty staff members, the lack of an effectlvedocumentation subsysfem for recording posf-crash dafa, and defects lnthe provisions for patient safety and comfort during transport.

vi¡

Ïhe major time delays during treatment occurred within fhehospltal casualty department. lt was observed that the median elapsedtime for ambulances to reach the crash scene affer the service was

notif ied was 12 minutes with a median delay oÍ 25 minutes from receiptof thc notification cal I untî I patients reached hospital. Afterarriving in hospital the median waiting time to see a doctor was 17

minutes, just eight minutes less than-lhe total elapsed tlme duringlhe ambulance cal l. 0n the average, study patients spenf approximatelythree hours in receiving casualfy treatment.

Deficiencies were found in the qual ity of the lreatmenfprovided in the casualfy deparfmenT. Major discrepancies were observed

belween the care provided and fhat expected on the basis of fhenormative standards for the managemenf of road traffic casualtiesdefined by the Royal Ausfralasian Col lege of Surgeons. Less than

21, oÍ patients received care commensurable wlih these standards.Ïhirfeen per cenf of patients were assessed by the observers as receivlngunsatisfactory casualty treatment. ln contrasf, the differences befween

the standards for ambulance care and the care acfually performed were

less marked, wifh approximately 6% of patienfs receîving care thaf was

assessed as unsatisfactory.

Many of the emergency care sysfem problems are problems oforganization and managemenf. As such, they lend themselves to operationsresearch analysís and, in the f inal section of the thesis, a simulationmodel is used to demonstrate the applicability of these lechniques tothe problems under study. Data collected during the study are used as

inpufs for the model and the cffects of two changes in casualty depart-menf operafions are examined.

The study, which is lhe first of its kind fo be conducted inAustral ia, contributes to knowledge by descríbing and documentíng the

vl¡l

operat¡on of the emergency care system and demonstrating the confrlb-utions of fhe separafe omergency services to the overalr systemperformance. The major conclusion drawn is that important deflclenciesin the emergency care system occur durlng care wilhin hospital casualtydepartments. lt is recommended that planners of emergency servlcesshould consider care within the casualty department when plannlng changes

in fhe exlsting system.

ix

DECLARAT ION

This thesis is my own composition and fho work thereln

has nof been presented for the award of any other Degree in this

or any other University.

P. D. CLARK

X

ACKNOWLEDGEMENTS

The firsf phase.of Ìhis study was planned and direcled byDr. G. A. Ryan who, as leader of fhe research team, assis-led wifh thecollection and analysis of the data. H¡s advice, guldance andsupervlsion were invaluable throughout bofh phases of the sÌudy.

Professor B. S. Hetzel and o1'her members of the Departmentof Social and Preventive Medicine. Monash University, gave help andadvice on many occasions. Dr. Tony McMichael wrote many of thecomputer programs and Dr, Graeme 0l iver advised on statistical andprogramming problems. Mr. Steven Lazarus, of the Department ofEconomics, Monash University, derived lhe model used in the simulafionsludy and assisted with the calculations and analysis of the results.

The study could not have been performed without the co-operatlonof the Hospitals and Charilies Commission of Vicforia and the boards ofmanagement and employees of the Victorian CÌvi I Ambulance Service,Alf red llospital, Prince Henryrs Hospilal and the Box Hi ll and DistrictHospital. ln particular, I am indebted to Mr. Gordon Ortmann, thechief executive officer of the Vicforian Civi I Ambulance Service, forhis help on meny occasions and to the many staff members of the casualtydeparlments of the hospitals who lolerated a redundant docfor wilhoutreal ly understanding what he was doing.

Mrs. Dorothy Chappel l, Dr. Gabor Kovacs and Mr. Shane Fennessyassisted on many occasions wilh preparation of lhe research matorial.Sandra, ffiy wife, assisted with preparalion of the manuscript and sufferedlhe rigorous sampl ing schedules used in lhe study.

The study was supported by fhe National Healfh and MedicalResearch Council of Ausfralia, with the aulhor wcrking as a postgraduatescholar of -lhe Council.

Finally, I wish lo acknowledge the assistance of Dr. David Dqntand Dr. Tony Ryan, who read and criticised -lhe manuscripl.

xl

,The

adequnte eare(1)

(2)

(3)

(4)

abiT.ity of any ønbuLanee sertsiee to giue pronpt and.to and transportation of the iraju.t,ed depends on:-Effieient eo¡nrntnícatíon beü¡een eontrol anå. ønbuLances.

Suffieient ønbuLanees positioned ín eueh a,lnaA that onLyshort distanees mtst be eoüeyed from eaLL to píek up.Adequate nwtbens of traíned staff to deal uíth theaecídent uictíms.Effíeient first aíd en route. I

(4. Howard Toyne, President,Victorlan Civi I Ambulance Service, 1970)

tThe Casunlty Departrnent nendere a seyuiee to the eomnunítyoultase funetion may be diuided into a series of separate actiuities:-

(1) Ebornpt reeeption, doeumentation and, transfer of patientsfrom the qnbu\anees and uaLking entnanees to theirappnopríat e destinøtíon.

( 2) Pnoyp-t eæønination, app"opz.íate speeíaL inuestigationsand díagnosis of the eondit.ion oi eondítions.

(3) Pronpt and adequate treatment uheyaobsen)atíon if neeessqrA and speedyrequåned destination.

appnopriate,díspateh to the

Ihe department shouLd be regæded as a uard of the hospí,taL. l

( I nsfructions for Casua lty Resl denfs,Alf red Hospital, Melbourne, 1969)

O,t¡

Chapfer 1

I NTRODUCT ION

A steady lncrease in the number of víolent and accidentaldeafhs in recent years, combined with an ahrareness of fheir causes and

cosfs, has led many people to express concern about the adequacy ofemergency services and their faci I lties. An important factor con-tributing to this sítuation has been the prevalence and severlty oflosses due to motor vehlcle crashes.

ln 1969, 31502 people dled on Ausfralian roads as a resulf ofnotor vehicle crashes and a further 87,864 were injured. ln theMelbourne statlstical divlsion, one area of which was studied in thisresearch project, 548 persons wore killed and 16,196 injured in 11,739casualty accldenfs in the same perlod. (Commonwealth Bureau of Census

and Statislics, 1970.)

The load which fhis epidemic of traumatic injury places upon

The emorgency care syslem is one of many factors whlch have caused

concern over the operation of the sysfem in general, and ambulance

servlces and hospital casualfy departments in particular. Cases ofrunnecessary? death at the roadside, delay in ambulance service, and

deficiencies ln lroatment have received comment in fhe public press and,occasionally, f rom medical personnel. ln Australia, the problems ofhospítal casualfy departments have remained comparatively free from

crilical investigation. The population tends lo accept the long waitlngtimes and discomfort, which accompany casualty and outpatient care lnhospltals, as an inevitable part of receiving what is often lhought tobo the best medícal care.

ln 1959 fhere were 15,266 casualty admisslons to fhe AlfredHospltal in Melbourne, of which 1,458 were traf f ic crash victlms.(Hocking, 1962.) By 1969 +hls figure had risen to 46,997 adnisslons

")

2

tv¡th f,788 crash víctlms (Alfred Hospltal, 197ü. An important aspectof this growth in fhe overall numbers of caeualty attendances has been

the use of the department by non-emergency patienfs seeklng prlmarymedical care. This addif ional load has major lmplicallons for- theemergency services. The consumers of emergency medical cane, fhepafients, are confronted wlth increased waiting and treatment timeswhich, apart from the inconvenience they generate, may affect theirconditíon and treatment. Administraflve and sfaffing problems arecreated by the overloading of avallable f acil¡+les, and the abi lity ofthe avaí lable staff to handle the work load decreases proportfonately.

Several authors have suggested thaf deficiencies in emergency

services may exist, but there have been relatively few atfempts toidentify and evaluate those deflcîencies. Vlews have been expressed on

the desirability of improvements in patienf care from the scene of fhecrash to and through the casualty department. Standards for ambulance

vehîcles, their equlpment and operaf lon, ancj the operation, f aci litíesand staffing of casualty departments have been examined by commitfeesin the uniled Kingdom and the u.s.A. ln Australia, the managemenl ofroad traffic casualties was fhe subJect of a seminar held by the Royal

Australasian college of surgeons in 1969. ln 1971, the Expert Group on

Road Safety of the commonwealth Department of shipping and Transportincluded a review of emergency services in a detailed investlgatlon ofthe state of road safety in Australia. There has been li+fle workdocumenting what actually happens at the scene of the crash and durlngsubsequent emergency care, to define the exisfing system and ldentifythose areas of it which may warrant closer investigation and subsequent

npdification.

This lhesis relates the findíngs of a study which was designedto descrlbe the operation of the emergency care system in an area ofMelbourne and lo evaluate the quality of care provided for a group ofroad crash victims,

3

Chapter 2

HISTORICAL OUTLINE AND REVIEI{ OF THE LITERATURE

THE DEVELOPI4EN.T OF EMERGENCY Í\4EDIC,qL SERVICES

Among 'the earl iest recorded descrlpf ions of organized medical

services are those relating fo Roman milîlary medicine. ln Roman times

a syslem of emergency cðre evolved with medici providing firsl ald forwounded in the field. (Nutton, 1969.) Severoly injured victims wero

evacuated to ualetu&inaria, the hospilals which were establ ished in

stralegic positions as the armies advanced. Expeditionary armies

returned lo Rome carrying their sick and wounded and if became a mark

of palriolism among lady patricians to establ ish temporary hospitalsln fhelr houses, in which casualties were nursed and treated.

With the decline of lhe Roman Empire and the spread ofChristianity, thescr houses opened their doors to lhe sick and suffering,and tho system of Christian hospiTals evolved. Ihe hospitals were

staffed by i-he various monastic and other Orders which sprang up during

the mediaeval period. (Poynter & Keele, 1961.) Among these Orders was

a group of Benedictlne monks who served în hospìlals ín Jerusalem. This

Order treated many of the Crusaders and, after the capture of Jerusalem

in 1099, acquired the monastery of St. John fhe Baptîst in Jerusalem.

St. John was adopted as lhe Patron Saint of the Order, which was recog-

nized by the Pope in 1113. Subsequently throughoul the succession ofholy wars between Chris'fians and Moslems, the activities of tho hosplt-allers of the Order were closely associaled with charilable and nursing

functions. An English tongue of the Order developed in London, buf fhe

dissolulion of the monasleries which fol lowed the quarrel between Henry

Vlll and the Pope saw the end of the activities of the Order in England

in 1540. (Ronwick & hlilliams, 1969.)

Religious wars in the sixteenth an<j seventeenlh centuriesprovided surgeons of the time with ample experience in wound treafmenT.

Notable advances in techniques of surgical repair and the alleviaffon of

t\

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I II

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Larrey's 'Flyi ng Ambul ance ' (tlgZ)

4

suffering fol lowed the work of such surgeons as Ambrose Paré. Neverfhe-

less, developments in lhe organizalion of emergency servlces were few and

were restricted to lhe bafllefiolds. (Singer & Underwood, 1962.)

One of the greafesf mi I itary surgeons was Dominique Jean

Larrey who, after his appointment as a surgeon major ln lhe Army of the

Rhine in 1792, introduced the use of I ighf-weight, horse-drawn ambul-

ances to evacuale the wounded from -lhe battlefield. The Baron Percy, a

contemporary of Larrey in Napoleonts army, lrained a corps of lifterbearers who gathered patients from the front lines and transported them

to surgical aid posts. (McKenny, 1967,)

Other armies were slow to recognize the developments in

emergency service¡s initiated by the French. ln the United States, forexample, there was no effecf ive system for handling casualties at the¡

outbreak of the Civil frlar in 1861 . ln late 1862, Major Jonathan

Letterman, a medical officer in the Army of the Potomac, devised a plan

for an organized ambulance corps which was so practical that it has

formed the b¿¡sis for subsequent ar,'ny f ield medical services lhroughout

the world. Leltermanrs complete syslem was first employed at Fredericks-

burg on December 13, 1862. Approximately ten lhousand wounded were re-moved from the battlefield and shellered within twelve hours. (Key,

1968. ) Ambulances were used duríng thís war, initial ly two and four

wheeled horse-drawn types and, later, the I ight-weight Rosencrans ambul-

ance, capable of carrying either len seated patients or two sitling and

two rec I i n i ng pat i ents. (McKenny, 1967 . )

Significant advances in care of lhe wounded fol lowed the work

of iJenri Dunant, v,/ho, appalled by the suf fering he wifnessed at the

Batlle of Sclferino in 1859, was responsible for the foundation of the

Red Cross and the organizalion of lhe Geneva Convention of 1864. Ïhe

St. John Organization had been revived in England in 1831 but it was not

until the 1870ts that the first aid work of lhe Order recommenced. ln

5

Europe, Friedrlch von Esmarch foundod the Samarltan Movement, and

Jarom i r Fre i herr von lrlundy the V iennese Vo I untary Rescue Soc iety.( Fi scher-Homberger, 1 971 . )

The development of these services was the result of several

faclors. The pressures of war and its effects, 1'he humanitarian approach

of particular individuals and the social and spirifual climate of the

lime all conÌribuled to the cJevelopmenl of civilian hospltal and

emergency care services.

Systems of care evolved according to the patlerns of health

and hospÌtal service in the separate countries. ln Europe, first aid

and rescue Services were regarded as an additional duty for lhe Fire

Brigade and as early as 1877 fire fighting organieations included firstaid as parl of lheir service in Germany and Switzerland. ln Germany in

the lBBOts insurance organizatlons establ ished a network of remergency

stationsr for the treatment of insured and non-insured citizens' This

development led, preclictably, to clashes, based on pol itical, economlc

and ethical grounds, with The medlcal profession which, fortunately,wero soon resolved. The present system of Accident Hospital s ln Austria

was founded by Bôhler in conjunction with the compulsory accident insur-ance company in 1925. (Böhler, 1965.)

The first accldent service in Britain was organized by Robert

Jones during lhe bui lding of fhe Manchester Ship Canal. The service

consisled of a chain of f irst aid stations with fhree base hospitals

strategically placed along thc waterway. The importanl feature of thisunif ied organization was that it became possible to treat the ln.jured

v¡ithout undue delay. (Platt, .l969. ) Ambulance services in Britaindeveloped under the auspices of the St. John and St. Andrewfs Ambulance

Associations, staffecJ mainly by voluntary workers, who provided treat-ment for lhe sick and injured before fransporting them to the major

hospitals which had developed.

6

Throughoul the twenlíelh century significant developments in

lhe management of trauma have conlinued to follow medical experience in

war. The Flrst World War saw advances in wound care associated with thedevelopment of plastic surgery and the acceptance of the principles ofsplInling fraclures at the scene. Little atfention hacl been paid to themanagemenl of shock t¡efore the war but the value of blood transf uslon

was established al that lime. (Cave, 1968. ) ln Vlorld War ll lhe valueof resuscilaTion ín the r.ìanagement of shock was recognized and methods

of trealing major injuries were refined. Further improvemenfs in

surgical techniques resulted from experience in Korea and Vietnam.

A marked improvemenl in tho methods of providing care for theinjured has been assoclated with these improvemenfs in surgical tech-nlques. The following Table from a paper by Mitchell (1968) demon-

strates the correlation befween the shorter tlmes in which patientswere brought to definitive surgery and the improvement in case fatalityrates for various wars.

Table l/1

PERCENTAGE OF U.S. WOUNDËDX DYING OF WOUNDS(Mitchell, ,l968)

War Yea rs Average Timoto Definítive

Surgery

,l

?

12 - 18 hours

6-12 tl

2- 4 'l{ I â lltT - ¿

15 - 20 minules

?

6.7

8.1

4.5

2.5

1.0

0. 36

14,9

14. I

3,400

318,200

1 ,600

1 53,000

598,000

1,568

1 846*48

1861 -65

1 B9B

19r4-i81941 -45

1950-52

1e65-

( 1 965-66 )

Mex i can

Ci vi I War

Span i sh-Amer i can

Worl d War I

World VJar I I

Korea

V i efnam

( Exper i ment )

CaseFata I i ty

Rate

Numbe rlllounded

*Excludes kil led in action cafegory

7

lmprovemenls în surgical expertise undoubtedly accounled formuch of the improvemenf ín fatal ity rates demonstrated. Nevertheless,

it is generally acknovrledged lhat the ef f iciency of the militaryemergency care syslem în bringing rapicl, ski I led treatment to the

palient has made a substantial contribution to the observed improvement

rales. (Howard , 1956; Eiseman , 1967; I'leel , 1968; Haacker , 1969,)

The mi I itary emergency care system is characterized by llsconstant preparedness for the treatment of the injured. An extenslve

communications system is supported by transport faci I ltíes, notably

helicopfens, which ensure that injured victims receive prornpt lreatment

on fhe batf lef leld f rom ski I led personnel . Subsequontly, victims are

rapidly evacualed to triage centres and base hospitals where medícal

and surgical teams are ready to províde definitive treaTment.

ln contrasl lo the improvements in the mi I ltary emêrgoncy

care system, civi I ian systems have been extnemely slow to develop.

Surgical lessons learnt during war have been adopted rapidly by the

med ical profession, but, unti I recenl years, there have been f a:w

attempts to adopt the supporting techniques which have proved effectivein war zones. Thís sifuafion is anomalous in thaf, sínce the advent and

universal acceptance of the motor car as a transport vehicle, lhe major

source of trauma in this century has moved from the military battlefieldto 1'he civi I ian road.

The firsl motor car accident death is believed to have occurred

in 1895 but it was nol until the 1920ts that the significance of the

motor car as a cause of lrauma was recognized in the medical literature.(Ryan, 1965,) Further references to motor vehicle frauma arppeared

sporadically during the 1930ts and 1940ts but only during lho last

twenty years has a scientific approach been adopted in sludying crashes

and thei r epidemiology.

B

Th,: importance of lhe motor car as a cause of death and injuryneeds no subsfantiation, but the comparison betwêen civi I ian and mi I lt-ary lrauma is demonstrated by Austral ian Army statislics relafing toarmy personncl killed or wounded in Vietnam and Australía. ln the periodfrom May 1, 1966, to May 28, 1911, the Ausfralian Army suffered 2,439Battle Casualties - 369 men ki lled and 2,070 injured. ln the same

period; 324 soldiers were killed and 2,7Q8 injured in non-battle accid-enls, many of which involved motor vohicles. (Derpt. of Army, 1971.)

ln the same period, 17,483 civilians were ki lled on Australlan roads.(Commonwealth Bureau of Census and Slatislics, 1971.)

ln summary, the developmenf of services and techniques for thetreatment of the injured throughout history has fol lowed the fortunes ofwar. ln this cenlury, the road has replaced fhe bafllefield as themajor source of traumatic injury. ln spile of this fransposition,civillan emergency services have evolved slowly in comparison with Ìhemi I itary system, a situation which reflects many influences, among themost important of which is the general apalhy of the corrnunity towards

lhe problems of road safefy.

THE DEVELOFI4ENT OF EI4ERGENCY MEDICAL SERVICES IN VICTORIA

(a) Casua lty Departments

The first hospital in Victoría was the Melbourne Hospital,founded in 1848 as a voluntary hospilal to cater for the needs of thesick and injured of the cify. The hospifal was financed by a government

grant from ils inception and relied upon grants and donations from ilspatrons and supporters for additÍonal supporf. By 1865 the hospitalwôs ln an unsanitary stale and was unable to cope with fhe numbers ofpatients who required admission. Hence, following the shooting ofPrince Alfred in Sydney in 1868, the Prince Alfred Memorial Fund, which

hacj been set up as a loken of thanksgivlng thaf the Prince had not been

killed, was used fo build the f irs't two pavilion style units of the

. ,...ii-¡ .4.7

h,*¡' l

The first horse-drown ombulonce, outside the Eostern Hill Fire Stotion'

t

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9

Alfred Hcspital. The hospi'fal accepted its f irst outpatients in March

1871. (Milchel l, ,l970.)

A number of hospitals ancl charilable inslitutions were erectedin Victoria during lhe l860ts and 1B7Ots, a situation which has been

ascribed to the humanitarian spiri-l- abroad in the community in thoseyears. These large public hospilals l"raVê ôlways constituted ono of theStaters main responsibilities to the sick and seriously lnjured and theprovision of emergency medical care has been centred on them. Successive

Eovernmenfs con'f inued fo combine with charltable institutions to f lnancethe hospilals, fhus avoiding the more fînancial ly unpalatable alter-native of direct responsibi I ity for hospital services. (Mitchel l, 1972,)Whi ls'l the founding and financlng of lhese institutions fostered thenotion of fhe sick poor, fhe hospitals have always catered for allsectlons of the community, and, lo this day, these hospitals provicletroafment for the majority of road crash vicfims and many other emergencypat i ents.

(b) Ambulance Services

The revival of the St. John Organization in the United Kingdom

was followed by the formalîon of a Victorian Branch of the st. John

Ambulance Association in 1883. The branch began with the objectives ofteaching f irst aid and home nursíng, minimizing fhe careless handlingof accidenl casos and helping lo al leviate suffering. (phelan, 1971.)ln 1BB7 a group of lhese volunfary workers raised sufficient funds topurchase six tAshford Littersr which were placed at the Melbourne policesfations. The pol ice officers were responsible for pushing the I itterand providing first aid. ln 1896 one of the litters was lransferred tothe Easfern Hill Firc stalion and the firemen temporarily took overresponsibi I ¡ty for manning lhe service.

The first horsc+-drawn ambulance was brought into service ini899. The fire brîgade continuod fo man the service unfil 1907, when

:&..::

The first motor ombulonce wos put into operotion on July 25, I9l0'

l0

a privale contractor was appoinl'ed. ln 19lO'ihe f irst mofor ambulance

was purchased. Subsequenl expansion of fhe service fol lowed terminatíonof the agreement with the private conlractor and resumption of fullcontrol by the St. John Association.

Financial difficulties plagued lhe servico throughout itsearly years and lt was totally dependenf on voluntary donations for ltsrunning cosls. The state governmenl was unwi I I ing fo provide funds,conlending fhat the ?police would convey injured persons by cabs and

lifters and that the ambulance would not bo requiredr. (Anon., 1963.)Nevertheless, the St. John Council were convinced of the value of theirservice and continued to flnance ¡t. lt was not until 1914 that theVíctorien Government made its first grant towards the cosl of ambulance

ope rat i ons .

ln 1916 a new company, The Victorian Civi I Ambulance Service,was registered to fake over thc service. The Government remained

reluctanf to assist wi+h f inancing, a situaf ion which persistecj untl I

1936 when the servîce went into voluntary liquid¿¡tion and was rogisteredas a charitable society. By lhis lime the service had expanded wlth theopening of a country cllvision in 1924, The consequent proliferaf ion ofservices and vehicles saw the esfablishmenl of 23 branches and 68 firstaid stalions ín country centres.

ln 1947 a Hospitals and Charities Act was broughl down by theVictorian Parl iament and al I ambulance services in Victoria were placed

under the contro I of the l-losp ita I s and Char it ies Comm i ss ion. The Statewas divided into sixteen regions and the Victorian Civi l Ambulance

Service was made responsible for the provision of services in the melro-pol itan area. After a lmost sixty years of ambu lance operaf ions, theState Government assumed financial responsib¡ I ity for the provision ofambulance services. The improved financial slatus of the service whichresulted from this act has permitted the development of fhe present

11

organizatlon and resulted in the standards of care and operation whichare described in this thesis.

ln conclusion, casualty departments and ambulance services inVictoria, although parls of fhe same emergency care system, have devel-opecl incJependently. A lthough both services hacj charitab le orig lns, theambulance services suffered considerable f inancial d¡ff iculties duringtheir development which reînforcod the¡ir spi rit of independence. More-over, the lack of interest shown by medical praclitioners ln the problemsof emergency care has compoundecj the divislon belween fhe two services.Despite the assumption of overal I responsibi I ity for both services bythe Hospilals and Charities Commissîon ln 1948, lndependent operationshave continued with comparatively little communication and overallplanning between individual hospitals and the ambulance services. Thissitueltion has imporlant implications for lhe operation of the emergencycaro system which wi I I be discussed in this thesls.

REVIEW OF THE LITE RATURE

scientiflc study of crash injuries, their prevention andamelioration ls a comparatively recent development in the field of roadsafety. Durlng the f lrst half of this century, the t¡elief that injuriesmusl necessarily result from road crashes led to the concontratlon oncrash prevention which has been, and still is, characlerisflc of moslroad safety programmes.

The work of De Haven (1942) and subsequent studîes by workersín the crash injury research project of Cornel I University demonstratedsome of the patterns and causes of injury and proved that injury prevent-ion was possible by means other Ìhan preventing lho occurrence ofcrashes. (Ryan, 1 965. )

Additional understanding of the crash injury problem fol lowed

12

the applícalion of epidemiological prlnciples to the study of crashes by

Gordon (1949), McFarIand and Mocrc (962) and Haddon (1963). Man, as

the host, was relaled to lhe energy exchanged in the crash as the agent,with the crash environment completing the epidemiologlcal triarJ.

Haddon (1968, 1970) described an extenslon of this epidemiolog-ical approach in which emphasis was placed on aetirclogical factors intrauma. The primary objeclive of the road safety system was seen to be

reductlon of the losses, in terms of personal injury and propertydamage, caused by crashes. Crash events were cafegorized ln fhreephases'- pre-crash, crash and pos'f-crash - and identified as eitherhuman, vehicle, or environmental in origîn. By comparing these phases

and factors, a matrix was developed which is of considerable value forcafegorizing the various road safety phenomena.

The use of an epidemiological approach for investigating crash

injury requires that the'tyoes and causes of injury should first be

defíned. Many studies havo been undertaken in differenf countries todelermine the patterns of road crash injury. The following secf ion

reviews the major studies performeci in Austral ia.

CRASH INJURY STUDIES IN AUSTRALIA

One of the eerliesl studies of crash injury in Australia was

reported by Hodge (1962)" He reviewed a series of 174 aufopsies per-formed ¡:n victims of road crashcs which occurred in and around theAdelaide metropol ilan area over a lwo year period. The analysis included

descripfions c'¡f the types anci time distribufion of lhe crashes, the age

and sex distribution of lhe victims, and the types of injury sustained.Elevatod blood alcohol levels were detected in 38ß of drivers.

A second study based on aufopsy findings was reported from

Brisbane by Tonge et al, (1964). The resulls of 2,214 post mortem

13

examlnatîons performed between 1935 and 1963 were reviewed and theinjury patterns of the victims analysed. This series was much largerthan that observed by Hodge. lt included 90$ of all deaths from 1958-

1963. The study prrcv i decj descr i pt ions of the patterns of crash i nj ury

and demonstrated changes ín the patterns of injury over fhe periodstud i ed.

A sludy by Jamlesorr and Tail (1966) used hospital admission

records to detecl 1,000 consecutive victims of crashes in Brisbane.Patients who were; treated in hsopital were examined and their injuriesrecorded. A ful I autopsy was performed on the 1BB viclims who died.Detai ls of the crashes were col lected, whenever posslble, by inter-viewing patients and pol ice officers and by lnspectlng the crashed

vehicles. Approximalely one quarter of the patienls Q62) had sufferedminor lnjuries,416 had major injuries of one body region and 322 had

major injuries To more than one body area. The study extended the know-

ledge of injury patterns, lhe management of injuries and provided

limited information on fhe causes of injury for a population of victimswho received hospital treatment.

A different melhod for studying crashes was introduced by

Robertson and his co-workers in Adelaide in 1963-64. An ton-therspotf

study used the ambulance service to delect crashes in which persons

had been injured. A research team consisting of a doctor and an

engineer atlended the scene of 408 mefropol itan road crashes, rcpresent-ing a 12.3 per cent sample of all crashes attended by ambulances duríng

thcl sample period. The patterns of injury of 1,029 car occupants,82 pedestrians, 44 pedal cycl isfs and 74 motor cycl ists were documented.

Crash mechanisms were studied and injuries were relaled lo lhe parts ofthevehicle which had caused lhem. Although lhe study concentrated on crash

injury, lhc numbers of palienls J'aken to hospital, their trea-lment and

duration of stay were among the post-crash events recorded. A defect

14

in the study method was the sampling bias caused by the omission ofcnashes occurring during lhe late night hours on Fridays and Saturdays.

A second ron-the-spo'tt study was performed in Brisbane. Agaln

the ambulance service was used as a means of detecting crashes and a

team consisting of a doctor, social worker and an engineer atlended thecrash scene within 15 minutr:s of the collision. Findings of the previous

studies on the patterns and mechanisms of injury were confirmed. Parfic-ular attenlion t,las paid to elucidaTing the effects of the ejectlon ofvictims from vehicles and it was suggested that, when most of the energy

of collisîon had been expended in fhe collision, ojectlon was a relative-ly unimportant cause of injury. Sociological and psychological facforslrlere examined by fhe social worker in the team. Drivers were classifledas reckless, negl lgent or involved by chance. The characteristics ofeach group in lerms of their social, occupational and financial back-grounds were described. lt was fcund that 25 per cent of driversinvolved in single vehlcle crashes to which an ambulance was called were

known to police because of a previous criminal rocord. The experience ofthe Adelaide sfudy was available fo lhe workers and thus statisticaldesign of the sampling melhod r:nsured thaf lhe sample of crashes repres-ented fhe patfern of crashes in all areas of Brisbane at all hours ofthe week. (Jamieson et a I . , 1911 .)

A s'ludy of rural crashes was performed by Adams (1967) using

a questionnaire sent lo 56 general praclilioners in country areas. The

doctors \¡/ere requested to complete the questíonnairos for road crashes

occurring in the country ôreas surrounding thoír practice. Data was

analysed fron 320 of a fotal of 359 queslionnaires returned to therecorder. Single vehicle and rol l-over crashes were found to be common

and the aulhor concluded lhat high impact speeds wilh correspondinglyhigh degrees of injury were responsible for the high dealh rales ob-served. 0f particular importance for the emergency care system vÌas thefinding that a large number of deaths occurred during extra-hospítal

15

care. Delay in the provision of adequate medical care was suggesfed as

a causalive faclor. The sample was probably biased towards severecrashes. Nevertheless, the 'lypes and patterns of injury differed from

lhose observed in tha previous studies of urban crashes.

The imporlance of time de|ays In the survivaI of crash victimswas discussed by Robertson and Tonge (1968), who studied survival timesby comparing data from aufopsy studies in A<Jelaide and Brisbane. ltwas found that 50Í of fatally injured victims were dead within one hour,B0É in a day, goiÅ in a week, and tess than 4Í líved beyond a month. The

authors strongly recommended the adoption of a thirty day cuf off periodfor the defínitlon of road crash Ceaths for statistical purposes. The

influence on survival of such factors as agê, sex and type of involve-ment were compared for the victims. ll was found that the main facforsinfluencíng survival for severely injured pedestrians from the lwocities were.; the nafure, degree and dístribution of their injuríes.

More recenf injury studies in Austral ia include a review offhe crashes involving heavy vehlcles ln New South frlales by Henderson(1970) and a study of the mcchanisms of pedestrian injury by vaughan(1971), The Royal Aus'tralasian C<¡ll¡'.;ge of Surgeons is conducting a

pattern of injur^y survey in Victoria, results of which are, as ye-|-,

unpublished.

As a resull of 1'hese studies, patterns of crash injury inAustralia have been delineate¡d, particularly for urban crashos. Furtherinvesllgalion of rural crashes would be desirable to expand knowledge

of the palterns and mechanisms of crash injury in the counfry areas.Moreover,although research has defined many of the problems in the crashand pre-crash phascs of the epiderniological matrix, there have been few

invesfigations of post-crash avents. Emergency services, which help loamel iorale the effecls of crashes and crash injury, are importanfelemenfs of fhe post-crash phase. The dearlh of studies of these

16

services in Austral ia reflecls a simi lar lack in overseas countries.Sludies which have contribul'ecJ lo knowledge in this ¿:rea will be dis-cussed ín the fol lowing secfion.

STUDIES OF EMERGENCY SERVICËS

Most studies of emergency serrvices have concentrated on

either ambulance services or hospital casualfy departments withoufrelating each to the ofher as importanl elements of the emergency caresystem. Neverlheless, as a resull of lhe increasing attention whichhas been paid to emergency services in the last five years, many papershave been publ ished which describe exisling services and suggest methods

of improving them. The studios fal I into three broad categories accord-ing to the area of emergency care which forms theír main focus. These

categories are:(a) Studies of Ambulance Services(b) Studies of Hospital Casualty Deparfmenls(c) Emergency Care System studiesThe fol lowi ng review wi I I considor the publ i shed I iterafure

in these three categories.

(a) Ambulance Servicos

Several papers l-rave described existing ambuf¿lnce servÍces inlocal areas by using data gathered from questionnoire surveys. Hampton(1960) reported one of ther earliest such surveys in the United Slates.A questionnaire designed to gather information on patterns of ambulance

service was mailed to 1,560 cilîes. Replies f rom 865 cilies describedthe number and types of ambulance vehicles used, the sfaffing patternsof the sf:r-vice, training standards, legal con-lrols of service, and theagencios responsi ble for ambu lance service. Oiher i nvestigators used

quest ionna í i-e and i nterv iew methocjs lo descr i be ambu I ance serv i ces i n

several local areas in tne United States (Lehman & Hollingsworth, 1960;

cadmus, 1965; t4aine De¡rartment of Hearlth and welfare, 1966; owens, 1965,

17

1966; Cooper, 1968. ) The studles provided invenlories of ambulance

faci I ities which were used for eval uating existing services and re-commending changes lo improve them.

Olher aufhors have analysed servict: records or introduced

special recording forms as methods of gathelring operational data tocomplement avai lable invcntory data and permit assessments of perform-

ance to be made. Caldwell (1961) usod such forms to gather data on

the elapsed times during the phases of the ambulance call, the injuriessustaîned by victims, and the trealment performed for fhose injuries,for an Ont¡¡rio ambulance service. He concluded that substantialdeficiencies existed in all aspects of the servic;e and recommended thata major reorganization of ambulance services should be undertaken.

Vlallc-r (1966) examinecJ trip records for 923 ambulance runs performed by

a service in rural Cal ifornia, supplemonting the ambulance Cefa wifhadditional material gathered from hospilal records. Thc populafion

using the service was delineated and census tracts were used to delermine

utilization rates. A gross annual utillzation rate of 29.6 trips per

1,0C0 members of 'the resîdeinl oopulation was noted. Heavy uti lizationby elclerly persons was found and types of illnesses for which ambul-

ances were used were determined. Traffic crashes accounted for 33.1

per cenl of the tnips and 23.6 per cent of the fafalities attended.

In the Uniled Kingciom, Boughey (I968) reviewed dala coI lected

by ambulance of f icers in Portsmouth. A card lvas completed for each of1,612 paf ients of whom 597 ß71,) were crash victims. Thc adequacy ofthe lrealmcnt performed was ¿rssessed and rç:laled to lhe availabilityof equipment and olher faci I ities. Allhough the criteria and methods

of assessment of lhe adequacy c.rf treatment were not def i ned i n thepaper, the author concluded thaf morlal ity and morbidity from accldentsrcould be appreciably reduced by better training, equipment and improved

communicatíons befween the ambulance service and hospîtalsr.

1B

Ambulance services in European countries vary în several

respecfs frorn those described in the Llnited States. A description ofseveral services is contained în a World Health Organization report ofresuscilation and casualty sorvices iri Europe. (W.l-1.0., 1968. ) Kimball(1967) also describes features of several Ëuropean services in reporlingobservations made during a study tour of Europe. Emergency ambulances,

especial ly equipped for resuscitation and infensive care a-l- the scene,

are widely used. (Gregorieva, 1967; Böhler, 1970; Bourrel, 1971; Storey

& Rothr 1971.) ln most countries thcse arnbulances are manned by skilledmedical or para-medical personnel. Their use in Germany has been des-

cribed in many papers, although Few data are avai lable f rom which theírI ife saving potential and cosl-effectiveness may be evaluated.

Frledhoff (1959) discussed the use of such an ambulance in Cologne,

detailing the types of treatment used and lhe particular value of the

un i -l' f or 579 emergency cases. An extens i vo rev iew of emergency serv i ces

i n Germ¿:ny (Gog ler, 1969) inc I uded data f rom He ide I berg, where a doctor

travels ïo the scene of incídents, meeting lhe ambulance on arrival.For J'he period under review, 1,666 patlenls f rom 1,300 incidents had

been lreated (an averagc. of 300 irrciden-ls per year); 517 paf ients ß1%)

were dangerously il l, of whom l83 ß5/") were rsavedr. (Brechmann, 1969.)

The {'avourable descriptions of the use of these vehicles have

led to the adoption of similar services in other countries, parlicularlyas mobilo cnronary care unils. (l'lagel, 1968; Nagel ef a. , 1970; Audette,

1970; Safar, 1971.) Robinson (1970) descríbed the use of such a vehicle

i n Perth, Western Austra I ia.

The demand for emergency ambulances hars grown markedly in

recent years, largely as a result of a widespread feelíng that existingambulance services are inadequate. Nevertheless, there have been few

sfudies evaluating their cosl-effectiveness. ln parficular, the advant-

ages of taking medical care to the scene over those of rapidly carryingpatients Tc; a hospital wilh ef f icient cmergency faci lities have not been

19

demonstraled. l.levertheless, favourable reports of their use, coupled

with fheir undoubted usefulness when injured víctims arc trapped and incertain medical emergencies, suggcsl that they represent a val uable

adjunct fo existing ambulance services.

Alternative suggestions for prcviding medical care at thecrash scene have included the use of Accident Flying Squads. Experiences

wíth the operaf ion of such a squad were <Jescribed by Collins (1966) forthe area surrounding the Derbyshire Royol lnfirmary. ln differenlschemes in Bath (Snc¡ok,1969 (1) & (2);1971) and in Yorkshire (Easton,

1969; 19701, general practilioners join ambulance, police and f ireservices in providing care ¿t the scene. Again lhere is little publisheddata by which the erffectiveness of the schemes may be assessed, but lheservices do marshal I community rcsources and develop publ ic interest inemergency care, as well as enabling docfors to aftend emergencies when

lhey are required.

A sîmi lar community project operates in fhe Tea Gardens areaol' New South Wrrles. (Pacy , 1967.) Bush (1971) dlscussed the merifs ofthese schernes and announced plans for a similar service to be started inthe Me I bo u rne met ropo I i -t an a rea .

The costs ancl difficullies involved in providing and staffingemergency ambulances, coup led with a general awareness of the deficienc-ic;s in cornmunication which exist between ambulances and hospitalcasualty departments, has led several aufhors to investigate thefeasibilily of direct radio links between the ambulance and the hospital.Hal I and Garden ( l9€.¡7) reported the use of such a I ink, which was found't<¡ be cffective in warning the hospi-lal of the ambulancess arrival.Moreover, it provided support for ambulence officers at lhe scene, who

could communicate with the doclor in hospital. Telemetry of physio-logical data is another communications development which has been invest-igated (Nagel ef al., 1910; Safar,19-11) and which may be used in future

20

emergency servi ces.

There have been few publ ished reports of ambulance services inAuslral ia. Gartrel I (1965) revíewed the developments in ambulance trans-port nursing in South Auslralia in describing traíning meì'hods and dis-cussing recent innovations in ambulance treal-ment. He also listed theslandard equi pmenf carri ed on Sc¡ulh Austra I i an ambu l ances. Descri ptionsof ambulance operations in Vicforia were provided by several speakers atthe seminar of lhe Royal Australasian College of Surgeons in 1969.(Roya I Austra I as ian Co I lege of Surgec-:ns, 1970.)

Robr:rtson (1971) stucjied the rural ambulance load in South

Aus-iral ia in 1968 and 1970. Sixly-three ambulance services were sur-veyed using a postai questionnaire direcled to fhe acjministrators ofeach service. Dat¡: w¿:re gathererJ on the numbers and types of emergenciesaltr:ncled, the total mileage travelled and ther number of victims involvedfor the various catr:gories of service. The study documenled ambulance

work loads and operat i ng cha r¿rc-ler î s'f lcs, and represe nts f he on I y rev i ew

of ifs type yel pubI ished for AustraI ian ambuIance services. The

Australîan N4edical Association has commissioned an Ausfralia-wide surveyof ambulance and casually services but the survey is still in progress

and its resulfs to dale are no'l' published. Data f rom this survey will,no doubl, provide an inventory of Australian services upon which fufurep I ann i ng of ambu I ance servi cos may be based.

Many authors concl ude thci r descriptions of exi sli ng ambul ance

services by recommcnding changes -lo improve the quality of service. The

need for standards as operatir¡nal and evalualory quides for ambulance

services has been recognized in many countries. ln the Uniled l(ingdom,

a working party was established in 'the early l960rs to invesf igateambulance services. The resulting report recommended standards forambulanc': operafions, eguipment and trainirrg in that country. (Mi I lar,1966, ) Sfandards for al I aspecfs of ambulance operations in lhe tJnited

21

States were recommended by the American College of Surgeons (1961), theAmerican Society of Anaesthesiologists ( 1968) and the U.S. Dr:parlment ofTransportation ( 1 968) .

ln Austral ia, stancjards vary from service fo service and fromSla-le tc¡ Stale. The re are nc naf iona I standards for an¡bu länce operations.ln Victoria tha Hospilals and Charifies Commission supervíses servicesand publ ishos a handbook r,¡hich prescnibes standards. (Hospifals and

Charities Commission, 1970. )

Ïhe establishment of standards for organizatic'rn and stafftraining provides a means of ímproving and evalua'fing the eff iciencyand effectiveness of ambulance services. Moreover, êQUipment standardsênsure lhal adequate facîl¡fies are available for use by the traineds-laff. Several papers have reported the findings of committees invest-igating vohicle dcsign and equîpment slandards. (Millar, 1966; 0glo,1969; Mackay, 1969; Berry, 1971,) Uniformlty of vehicle an<J equipmentdesign Îs desirable sitrce stretchers and other items of equipmenf need

to be interchangeable belwer¡n vehicles and bctween services. ln spiteof these recommendetions, I ittle progress has been made fowar<Js theach i evemenl of such un i form i ty betwc;en serv i ces.

Further emphasis has bcen plced on'lhe good design of oquip-ment and vehicles because of the effects thaf road transport may have

on the comfort and clinical condition of th¿; palient. This aspect ofambulance care has received I ittle objective study. Although soveralauthors have; e>xpressed concern thaf road transporl'may have an adverseeffecl on a patien'tts condition, no studles have been performed toconfirm these suspicions. Harbison (1969) asserted lhat road transportcoulrJ dol'rimontally affect patients on long country lrips and supportedhis assertion with examples from his personal observations of ruralgeneral practice in Austral ia. ln advocating fhe use of air ambulancos

as a desir¿lble alternative to road transport, he discussed the operations

22

of the Viciorian Air Ambulance Service.

The question of the spss¿ing ambulance, i1-s hazards and

advanlages, is closely related to lhis problem of road transport and

its effects on the patient. Af'l-er studying 2,500 ambulance emergency

calls in Michigan, Curry and Ly-t'tle (19i7 ) ccncluded that speed was

unnecessary in 98.2 per cent of the cases. ln The remaining 'l .B percent íl was concluded thatrexpeditious han<lling was necessary, but a

speeding ambulance could have increased the severity of injuryr.

ln one of lhe most comprehensive studies of fhe effects ofambulence fransporf on patients, west e;t al. (1964) examined over 5,000emergency lrips in Cal ifornia. The primary objecfive was to determinelhe need for, and effects of, speed during ambulance transport. The

allending ambulance and medical slaff were asked to record fheir opiníonson the urgency of the cases ancl the consequenf need for speedy transport.It was c<¡ncluded that speed during transport to hospital may have been

of benef it in B,q' of the côses reviewecl buf was not essential in any ofl¡e cases. l4oreover, the medical observors considercd that speed was

nol !-f-%sry.j¡9. in -any of the cases studied. Nor was there any evi<jencethat the ambulance ride had dclrîme¡nfally affecfcci the patientrs coh-dilion. The mean time saved by exceedirrg the speed limît was 2 minutc:s.I n conc I us ion , i-t' was cons i dered thal tlre i ncreased hazards of spe;ed i ng

were such lha't its use was contra-inclicated in view of the marg inalt i rne-sav i ng i: dvanf ages .

Ro¡;d transport has sr¡vera I obvious I imitalîons and theefficiency of the helicopten as an ambulance verhicle in war zones has

led many people lo advocale its use as an alternative to road ambulances.

Ïhe use of ambulance hel ícopters has been extensively investigated inthe lJnited States (Bordner, 1968- Karthauser et al., 1969; Arizona Slafeuniversîfy, 1970; Turner & EllÍngson, 1g7o; Barflett, I97l) and lhey areused in several European countries. An evaluation of fheir usefulness

23

and opereling costs in an Australian settlng was performed by Berry(1968). Hel icopters have significant operating advantages c¡ver ambul-ances in certain sifuations, notably when road access ls difflculf forany reasoÍ1. However, the costs of operatlons are high and represenfmajrrr restricfions on the use of these vehícles. These cosls can be

modif ied by using the helicop-ters for police, f ire and rescue as wellas ambulance work. Such multi-service usage, howu-ver, restricfs fheavai labi I ity of the aircraft for ambulance purposes.

(b) Hosp i ta I Casua I tv Deoartmenl's

Many aulhors of pðpers describing hospital emergency depart-menls express dissatisfaction with the quality of care provided în thedepartmen'l-s and suggest the need for changes in methods of departmental

organ izat ion. However, mos't reports f ocus on specif ic hosp íta I s orgroups of hospitals and the ir f indings.,are thus.of limíted general

applicåbîlity.

United Kinqdom Studies

The British Orthopaedic Association (1959) described defic-iencies in Accident Services, attributing them to fai lures in organiz-ation, staffing, accommodation and surgical fraining. The Associationcalled for a major nalional reorganization of accident services for theinjured, to remedy the sifuafion. This call was followed by the reportof a commitlee of lhe Nuff ield Provincial Hospitals Trust, who surveyedtwenly casualty departments ar-rd lheir facili-ties in fourtcen areas ofthe United Kingdom. They concluded lhal (a) publ ic dissafisfaction withcasualty services was jusfified; (b) hospital leadership and execufiveaclion were needed to improve service;s; (c) hosp ita ls shou ld be class-if ied and listed according Io their faci lities for accidenf anc,i emergency

care; (d) general practifioner services affect casually department uti l-ization; and (e) there r¡/as a need for detailed surveys of services by

mu lt i -d i sci p I i nary teams compri si ng stati sti ci ans, sociolog i sts and

doctors. (Fry, 1960. )

24

ln Jarruary, 1965, a committee of the lrish tledical Associationinvesfigated hospitals and ambulance services in Dubl in, by requestingpatients who presented fo eleven of the ciÌyts major casualty depart-ments-fo complele survey queslionnaires. The findings of the surveyincluded informalion on the source of pafienl referrals and the patternand nature of casualty workloads. Changes in the organizatîon and sfaff-îng of the departments were recommended as a result of lhe committeersf i ndi ngs. (Corcoran , 1967 ,)

ln London, Fairley and Hewett (1969) surveyed workloads on 126

casualty departments in the Greater London area. ln noting deficíenciesin the organization of serviccs, they commented on the facl that approx-imately 50 per cent of the depantments freated less fhan 5 palients pernight. Non-emergency cases represented o largc proportion of thecasua I ty vrork load.

Jenkins eT al. (1969) review<¡d the medical records of a seriesof 100 emergency pafients who required admission to the resuscitationroom of the Edinburgh Royal lnfîrmary. This group represented 0.45 percent of al I patients admitJ'ed to the casualfy department. Trafficcrashes and drug overdose wene the commonest causes of admission. Two-

fhirds of the injured patlents had susTained multiple injuries. The

sludy doscríbod injury types, lreatmenl mothods and fime delays duringtreafmenl for the observed patienls.

Although these and simi lar studies had described 'the sifualionin casually deparfmenls, several authors nofed that the organization ofaccident services in the U.K. had remained basica I ly unaltered duringthe decade to 1970. (Anon., 1g7O; Sc<¡tt, 1970; London, 1970,)

Studies of Emerqencv Deoarfmenls in the Un ited StalesThe problems of erncrgency departments in the United States

have; been exacerbated by lhe marked increases in usage of fhe depart-ments in recent years. A postal survey of 300 hospital emergency

25

deparTments lhroughout the coun'try revealed a 120 per cent increase inemergency depanfment visíts deom 1944 to 1951. (Skudder & McCarrol l,1961 . ) From 1954 to 1964, vísíts lo emerrgency de;partments increased aT

a rate of 6 per cent annually (American Medical Association, 1966) and

the increase has confinued steadi ly since that time. (webb, 1969.) The

implications of theso changing usage patterns were díscussed by Kennedy(1963) and Skudder and Wade (196Ð.

0ther sTudies have investigatetl workloads on departmenls inaffempting fo def ine the problcrms and suggest solutions lo them. Freyel al. (1970) used the casuírlty department log book to determine work-.

loads on the universîty of Michigan Medical centre during 1960-67,Staffing and edminisfrative arrangements were considered in the I ight oftheir findings, and fhe authors concluded that improvements in recordlngsystems, sÌaff ratios, communications between hospltals and rescueunils, teaching, and quality conÌrol of care were indicatod. A similarmelhod was used by Jacobs et al. (1971) to study hospitals in theRochester, New York aroa. They suggested fhal an integrated primarycare system t,ias needed on a coñìmunity-wide basís fo overcome The problemsof hospital emergency departments.

Patient interviews were useci as a means of determining usage

patterns by White and 0rConnor (1970) and Torrens and Yedvab (1970).

EioJ'h sfudies invesllgaled the types of patients using emergency depart-menls and theír reasons for seeking merdîcal care from the departmentsin preference t<¡ other sources of care. ln the secon,l study it was

noted that 12 per cent of palienis receîved more than half their carefrom emergency departments, with approximately 7 per cent using itexclusively.

Several authors heve considered alternatívo methods ofcasualty department organization as a means of improving the serviceprovided. worman et al. (1962) were highly critical of an accident

26

service in þ1ílwaukes which was separaled from the local general hospital.

The service was considered fo be expensíve, inefficienl, a poor trainingarea for surgical staff, and a freatment service that was detrimental to

the care of lhe trauma patient.

Weinerman el al, (1963; 1965; 1966), after studying the work-'

loads in lhe emergency departmenl of lhe Yale - New Haven hospital,

introduced a system of rtriaget for new patients pre;senting to fhe

emergency department. An area of the department was sef asíde for the

assessment of new patienls and a senior medical officer was appolnted

to.screen patìenïs and refer them lo the appropriate treatment service.

The service proved effective in rectucing waitlng times and the congestion

in the emergency treatment areas. Experiences with this scheme were

reviewed by Beloff (1969). The scheme is effectíve in helplng lo solve

some of the problems of emergency departments, but is not a panacea. The

authors concluded lhat the solution to emergency cleparÌment problems

lies in an inlegratr:d system of emergency care for the whole community.

Austral lan Studies

Although several speakers at the seminar conducted by the

Royal Austr¿:lasian Col loge of Surcleons in 1969 expressed concern about

lhe care provided in casualty departme,.n'is, fhere have been few sfudies

i nvestigatl ng the subject i n Ausfra I ia. Hocki ng (1962) descr i bed the

incidence of various condilions in patienls presenting to fhe casualty

department of the Alfred Hospital in i\4elbourne in 1969. Brand (1971 )

in a series of papcrs discusse<l workloads, waiting times and the eff lc-iency of staffing of several Victorian hospitals, using data gathered

during a spccial survey of lhe departmonls. Grounds (1969) discussed

the needs of accident and emergency services in a general revir¡w of lhe

Australian situalion for the Australian Mr':dical Assoclation Study Group

on l'1ed ica I P lann ing.

27

Standards for Emerqencv Deoartments

ln recognition of these probable deficiencies in emergency

care in hospilals many professional associations have prescribed sfand-ards for al I aspecfs of casualty department operations. (American

l{ospital Associatlon, 1960; 1962; Amorican Medical Assocíation , 1966;American College of Surgeons, 1963; 1964. ) Staf f ing policíes arereviewed in several papers and recommr¡ndatíons made as to lhe numbers

of s'taff members required lo provide adequate care in the dopartments.(Kennedy, 1963; Am<;rican Hospital Association, 1962; 1g66; Gibson,1970.)

Although fhe managemenl of road crash viclims is an area ofparticu!ar concern to those sludying casualty departments, mosl papers

on this subject have been rcstricted to descriptions of fhe clinicalmanagemenT of inj urles. The im¡rorfance of p lanned managemenf in thetreatment of the severely injured is emphasized by Mustard (1961).

Several ¡rapers have discussed tho surgical principles involved lntreating r:rash injurics. (Currie, 1966; Curry et al., 1967; Howell,1967; Pizzi, 1968; Jones & Shires, 1969; Lewin,1969; Royal AustralasianCol I ege of Surgeons. I 970. )

The Quqf ity of Care in Emerqency Departmenfs

It will be apparenl from the studies discussed so far, fhatmany researchers have described r;xisting servlces and discussed stand-ards for care in casualty deparlments. Few, however, have aftempted toeva luate the qual lfy of the rnedical care provided by matchíng the careperformcd with the establ is;hed standards. Nevertheless, the recentupsurge of interest in med ìca I care reser-rrch genera I ly has led to stud lesbeing underfaken to investígafe methods of evaluating the qual ity ofemergency care.

t'or example, Helfer (1967) examined the performance of internsin a paediatric emergency room using a charf review technique. A panel

of paediatricians defined sfandards for the trealmenf cf cerfaln diseases

28

in the emergcncy roorn. These standards were fhen used to evaluate thec:rre performed by interns as recorded in the medical assessmenf chartfor each paf ient. The interns were raled for prof iciency, ef'f lciencr¡

and competence. After an inilial assessment period, the interns were

made aware that fhe chart review was being performed. Subsequently'the records, and, prcJsumably, the quality of care, were observed foimprove. Chart review was then introduced lo the department as an

on-going process clesigned lo maintain'lhe improvement.

Brook of al , (1970) ev¡¡luatc+d the quality of care provided

for patients in an emorgency room in Ballimore by reviewing the medical

records of 141 patients who presented wi'lh gastro-intestinal disease.

Qual ity was assessed by examining Ìhe relaÌionship between the adequacy

of lhe diagnostic and therapeulic processes employed by the doctor and

the outcome of the disr:ase episodc. The methodology of the study in-volved both charf roviews and oatienl inlerviews. The qual ily of the

medical care was assessed as both inadequafe and ineff icien1- by every

criterion used.

A prel iminary report of a survey beíng conducted ín lheemergoncy departmenf of the Albany l.4edical Cenlre included reviews oflhe care provided for 4,029 trauma vicfims, 514 of whom were from road

crashes. (Carfer, 1971. ) 'Ihe¡ sludy involved colla'tion of data obtained

f rom ambu I ance reports, eme rgency dt> ¡,.artment records, hosp ita I records

and fol low-up patient interviews. A 1.7 per cenf diagnostic error rafewas reported for the roed crash vici-ims; none of lhese mis-diagnoses

werc fatal. The survey was felt -lo be extromely valuable for staf f ln

providing continuing evaluation and feedback of the results of theirwork.

(c) Emerqencv tlare Syslem Studies

ln recent yeôrs, lhe real ization thal the objectíve of high

qual ify emergency care requircs co-ordination between the separate

29

emergency services ôs well as eff iciency of operation wifhin each

service has led reseorchers to use a systems approach for sludyíngemBrgency care problems. ln the case of road crashes, the services pro-viding emergency care may be considerecl as elemen-ls of a system which

intoracl in pursuil of rhe common objcctive of reducing the losses, interms of injury and properfy danrage, resulting from the crashes.

The systems approach involves defining objectives and ident-ifying the critical factors ope;rating in a given situation, so thatalternative methods of achieving ttie stafed objectives may be evaluatedand related to the operation ol the total system under study. Severalsteps are involvecJ in such an approach. Firstly, the objectives ofthe system must be consídered ancl sfated in sufficiently operationalterms lo allow the development of mcasures of performance of the system.

Secondly, alternative methods of saïisfying lhe objectives must be

defined, and, thirdly, these alternatives must bc; evaluaterd to cletermine

the contribution crach could make lo the sfated objective. Finally, lhecosl of each alternatîve should be measured" (Boodman, 1967.)

t¡/ade (1964) was cne of the f irst aufhors to <Jiscuss the need

for an examination of emergency services whích would include servicesoperating at the crash scene as well as the hospital casualty depart-ment. ln 1965, Drye and Hyde clescribecl a system for providing emergency

care in Louisvi I le, Kcntucky. They discussed freatmenf at the crashscene and in hospilal and sta'teC that injured patíeni's receivedrcompef-ent first aid af fhe scene within 5 to 15 rninutes of the crash and were

in hospÍfal within 3C minuTc,.sr. Few data were presented to supportlhese claims.

The passage of the National t"lighway Safety Act by the 89th

Congress of ihe United States in 1966 provided lhc stimulus for wide-spread invesligaTion of emergency services. Several sludies of emergency

caro syslems were commenced under the auspices of.the National Highway

30

Safely Bureau of tho U.S. Deparfment of Transportation.

Particular emphasis was placed on the design of methods forthe analysis and evaluation of services. (Owen (1966, 1967) describeddetailed check lists which coulcJ be used by local authorities to clocument

êmergency s+rvíce workloads. Ir4ancgolC and Silver (1967 ) discussed theconcept of an Êmergency care system which íncluded - as system elemenfs -f irst aid, communícation, transporf and medical facilities. principalproblems in existing systerns were deemed to be the delays in the varioustrealment phases and inadequacies in the quality of the freatment pro-vided. The authors saw the solution to these problems in better educ-ation, comprehenslve planning, accreditation and control of services,and research into the various elemenls of .the syslem.

The commiftee on acufe medicine of the American Society ofAnaesthes iolog ísts -(

I 968) recommended community-wi <Je organ ization ofemergency care. The goal of hígh qualÍty emergency care was seen torequire ma.lor improvements in services af the scene, during ambulance

carÉ), ancJ in the hosp ita I emergency deparfmenf . Starrdards for the organ-ization, sfaffíng and equipment of ambulance servicr¡s and casualtydepartments were stated. l4edical staffing of ambulance was considereddesirable and recommenda'tions wcre made for the catogorlzation ofemergency deparfments accorrli ng to thei r size, faci I ilies and staffavailabîlity.

King and Sox (961) reported one of the f irst studios fo use a

systems approach in gathering data on emergency service operations.Report forms wcìre completod by ambulance drivers, casualty receivingnurses and admitting medical offlcers who treated emergency patlents inthe San Francisco emergency senvice area. The characteristlcs of theemergency services systom and the workloads on the varíous faci I itieswûre recorded by analysing the data containr¡d in 3,431 reports on

ambulance palients and 7,894 reports on non-ambulance patients from the

31

part¡cipating hospitals. Defails c''n the management of palients, lhetypes of care; providr:d and i-l-s effect on the patienfs were recorded,

along with The total times spenf irr receiving casualty care. Although

The findings were specific fo the local situation, lhe authors suggested

that the data may bo useful in subscquent simulalion studies, or for thederivation of ô genere I predicf ive mathema-licel model. The study didnot involve defined populalion and thus iis general appl icabi I ity was

I imited. ln a later paper King dcscribed the approaches lhal are

necessary in formulating plans for systems studies of emergency care.(King, 19ti8.) ln this paper he emphasized lhe difficulties inherent in

measuring fhe quality of emergëncy care and suggested the need for more

sensitive, prcferably time based, criteria for assessing care.

Several studies commissioned bry the National Highway Safety

Bureau tJevised morJels for the analysis of emergency care systems and

designed data systems for L¡se as recording and evalua-lion instrumentsby emc:rgency services. (Borclner, 1968; Dunlap, 1968; SfanforcJ Research

lnstifute, 1968. ) The studies predominantly focusscd on the provisionof servict s outside the hospital. A program for the analysls and sub-

sc':quent improvement of omergency services throughoul'the United Staleswas developed from the findings of such sludieE. (U,S. Deparlment ofTransporfation, 1969. ) The achievcment of emergency cere system object-Îves, as defined, would requirc individual slates to undertake compre-

hensive planning and development programs. Guidel ines for such programs

were suggested.

Th¿ Yalo lrauma survey (Keggi et al. 1970) was designed foexploro the re:lationships belween lhe communications, lreatmenf and

transport componenls of lhe emcrqency care system by using a cenlraltrauma registry. Adinitting nurses used specia I data forms to col lectinformalion from injurod palienls admitted to the Yale - Now Haven

Hospitolfs emergency cJepartmenf. Tho dala related to =l I phases of thepalientst emergency care and documenled demands on several areas of the

32

syslem as well ôs providing such assessments of performance as tlmedelays and treatment procedures used.

ln Austral ia, a: survey conducted by Hughes (1970) investigatedthe availabilify of acciclenJ and emergcncy servîces in the Melbourne

metnopol ilan arca. Questionnaires were used to determino the workloads

and response cðpacitles of N4elbourners casua lty departmcnts and ambulance

services. The findings were related to the clemographic characferisticsof the Melbourne metropol itan ereð. The author concluded lhat the number

of casualfy services in Mr:Ibourne was adequate, but that their distrib-ution in the metropol itan area was unsatisfactory.

Two comprehensive studies in the Uniled States used a systems

approach to evaluate problems of -l'he emergency care syslem in Baltimoreand Chícago. Webb (1969) investigated the patterns of staffing and

uti I izalion of emergency departments in Baltimore and compared the usage

patterns wilh those of 7-25 privately practising physicians. The studywas designed to investígate lhe faclors influencing lhe increasing use

of emergency clepartments by palients seeking primary care. Components ofthe emergency medical care sys-tem which wcre investigaterd included ambul-artce services, poison conf rol centres, prival'e physicians and emergency

deparlments. The steady increase in emergency department usage by non-urgent patients was found to have a weak negafive correlation wiihgeneral practitioner avai labi I ity. Greal variabi I ity in types ofphysician staffing of t;merqency rooms was found, although mosf depart-ments wr-'re staf f ed by i nterns and res i cJcnts. Pat ients wa i-led longer i n

hospitals staffed by housemen, who look longer fo treat patients and

ordered more diagnostic'tesfs. T¡me delays during ambulance care were

deferminecl from records, and the ambulance service tlme was found to be

22.8 ninutes. The mean f ime spent in waif ing for freatment in hospitalwas 42.5 minutes, with a mean tolal system'fine of 121 minufes.

A detai led analysîs of emergcncy servîces in the Chicago area

33

was performed by Gibson et al. (1970) '¡¿ho used a variety of techniques

to collect data about patienl's using J'he various emergency services.Ambulance services and hospital rèmergency de;partments were studied, and

a systems approach was used'to describe the transporl freatmenl, commun-

ications and documentation subsysfems. ln documenÌing changes in

pal-lerns of emergency servíce usage, the study bof h descr i bed a ncj eva I -!_dg!_ lhe opera-l i on of the emergency serv i ces . Ambu la nce serv i ces were

found to be def lclent in terms of their numbers and availability foruse, and standards of service varied widely between the differentservíces. lìecommendations for improving communications lncluded the

inlroduction of an emergency telephone numbcr and cenlral dispatching

faci I ifies. The survoy of' hospital emergency departmenfs in lhe Chicago

area suggesfed lhat the hospitals compared favourably with those in

other meÌropol itan areas and compl ied substantial ly with the relevanfstandards. Fînal ly, the survey investígafed the characferistics ofpatients trealed at hospilaI emergency dr:partments and reviewed the

cos'ts of lhis -l-reatment.

Thes,l 'l-wo studies are among the; most comprehensive reports ofemergency care syslems yet pubi ished. ln addiTion fc describing the

operation of the system in lwo major melropolifan areas, the authors

evalualed fhe performance of tlie system by consideríng the ínteractionsand perfoflflânctl of the various conrponent services.

Melhods of evaluating the performance of emergency care are

poorly defined and relafively unsophisticafed and have thus presented a

major stumbl ing-block to morc wîdespread eva luations of lhe qual ity ofcare. Andrews (1969) saw a necd for a genêral evaluatory model ofemergency care syslems which would take into ¿:ccount the occurrence of

emergency and emergency-l íke incidents, the outcome of those incidents,the operational characferistics of tho system, and fhe total cost ofoperating lhe system. He stated tha-t lhe u ltimale crìf eria for assossing

emergency care should be -

34

(a)

(b)

(c)

MedicaI oufcomes.

Reduction of sufferi ng.

l'ota I cosf .

Cosf is the only one of these lhree criferia which may be

âssrrssed objectively with presen-l rnefhodology, although even this isdiff¡cult because of lhe large number of hiddon cosfs involved. Never-

theless, cost htls, until recently, rarely been usecj as a measurc ofmedical care. Medical oulcomes are extremely difficult to predlct and

measure, and consequently death has been the outcome moasure mosf

common I y used.

lrr tl"re absence of adequate oulcome measurês, operalional cri-feria and nof ultimate criteria must be used to evaluate qualfty.Andrews suggested fhat time delays during freatment would be an appro-priate surrogatr: for fhe reducTion of suffering and thaf operationalcriteria fr:r the quality r:f omergency care were needed lo permit meanlng-

f ul evaluations of the systemrs performance. Simi larly, Nahum (1971),

in advocaling the use of a syslems approach for studying emorgency care,sfaled that functional analyses of lhe sysfem were Fequired. He con-

sidered that such analyses slrould include descriptions of the system

components and evalualion of their operating characterlsllcs, notably-iime delays and the qualily of the care provided.

Severa I stud les have desc¡-ibed tofa I t ime de lays i n e ílherambulance service or casualty core, bul only three - the systems sfudiesby King (967), Webb (1969) and Gibson et al. (1970) - have systematic-ally sturJiod the time delays experienced by patienfs in the variousphases of emergency care by recording delays in ambulance care and

de I ays i n recei vi ng freatment i n hosp ita I .

An important local study by membors of the Austral lan

lnsllfute of Hospital Adminisfrators examincd the waiTing and treatment

35

t îmes exper îenced by ¡ral ients i n scvera I hosp ita I c¿i sua I 'f y depa rfments

in Victoria. A recording fornr was complete<j for patients as theypassed through lhe; several stagcs of lheir casually treatment and

delays werr.: noted. Visits of 4,125 pa'fir>n1's'to eleven hospifals were

documented. Subscquent analysis of the recorded data showed thatpatients w¿riled considerable limes in the various treafmenf phases.

(Brand el al., 1971, (1), (2), (3).) ln a subse;quent paper standards

for waifing times were suggested (Brand,1971, (4).) and the offects ofa mc,thod of ensuring that thr: standarrls were recognízed by attending

staff were discussed. lt was founcj that improvements in waiting limesoccurred as a result of enforcirrg an adrninis;trative instruction thatall patienls should be secn r¡ri-fhin 45 minutes of arriving in casualty.

The use of time cjr:lays as a substitute for reduction ofsuffenirrg presupposes lhat the provision of care în tho shortestpossible time is likely to be a sig.¡nif icant faclor in reducing

morbidity and mortalîty. I'ievertheless, lhe relalionship befween treaf-menf delays and thc development of morbidil'y is difficult to define inmosl silualions and is a ma.jor reason for lhe facl lhat precise standards

for delays have never been suggesfed beyond the usual and somewhat

ncbulous eshorlest possible? delay. More precise definitíon of reason-

able time inÌervals ís of some importance for planncrs of emergency

care sys-lerns, however, sinco many of the major recommended changes loexisting services are based on the assumption thal adequate treatmentis _¡ç.!._ being provided ín reasonable tîme. For examplc, one importanl

advantagr: quolod Lry thosc: who ¿¡dvocate Ìhe replacement of road ambul-

ances by hc-.licopters is lhs recJuction of lhe time delays which accompany

road transport. Unless lime delays in'j-he existinçl system, and the i rsiqnif icance, are known , such measures as the introductíon of hel icoptersmay nol have the effects desired and expecled of lhem.

Several authors have investigaled lhe importance of time

delays in emergency carr: by reviewing the f indings of autopsies on road

36

crash victims. Roberfson and Tonge (1968) and Ruffel-Smith (1970) exam-

ined'lhe duration of survival of victims af-ler crashes. lt was estimated

that approxÍmately two-thirds of'all the dealhs in lhe second study

occurred within the first 25 minutes after The crash and that, if the

ambulance response tlme could have been halved, only 1.5 per cent ofthoso persons rvho diecJ within lhe firsl twelve hours mighl have been

saved.

Frey ef al. (1969) estimated thal 2B (18fr) of 159 persons who

died afier fatal crashes in Michigan could have survlved had oarlier oralternative Ireatment been avai lable. lf was noted, however, thatresuscilation of these patients would have required the ski I ls ofpersons well versed in intravenous fluid therapy and airway control.Furthermore, this lreatment wculd have been required at the crash scene

and within minutes of the cr¿:sh for 15 of the victims, during transportlo hospifal for 11, and in hospilal 'for 2 paf íents.

Furfhcr evidence in supporf of the importance of delays in

receiving emergency treatmenf is provided by the di fferenccs in fafal ityrates cbserved belween rural and urban crashes. Wal ler (1964) attributedthese differences fo problems in crash detection, delays in providing

care, poor communications between personnel at the scene and back-up

medical staff, and the inexperience anci lesser availability of staff in

rural areas. Victims were ob,si:rved to die sooner, morê commonly at Ìhc

scene, and of less severe injuries in rural than in urban crashes.

Adams (1961) made similar observations in his study of rural cr¿islles in

Ausfra I ia.

Mi I ler and Page ( 1968), however, €XP lorc¡d f he ef f ects of

delays ín receiving emergency medical care on the probabi I ity of

survival, given thal patienls had rsurvived Ìhe initial col lisionr.Time delays during ambulance care for 275 crash viclims in Louisiana

wero calculated from data in police f iles and the patientrs injuries

37

vlere classified by sevcrity. LiTl'le difference existed befween the

fatal ancl non-fatal groups arrcJ if was not possible to relate the delay

before. treatmt-.nt to lhe ultimate outcome f'or the paTicnls studied.

Van Wagoner (196i ) investigaled the meCical records of 606

male soldiers who died from traumalic injury in the United Stafes. He

found thatlspeed in reerching medic;:l altention did not seem to be a

primary facfor in survival of the injuredl and noled lhaf one-sixth of

lhe patienls had received inadcquate trealment in hospifal which had

contributetl to lheir death. This lack of proper care was a.tf ributed to

a combinaf ion of faulty díagnosis and inaclequate therapy by'the attend-

ing surgeons. The author wenl on to suggest that, rwhile proper trans-portatÌon, physical facilitîos, blood, X-ra'ys and laboralory tests havr>

all been pointcd ouT as important facÌors in the proper care of the

injured, perhaps the weake.:st I ink is the doctor hirnself | .

Lougheed (1965) report':rd the quality of the e:mergency care

received by a group of rr:ad crash vicfims in er paper which discussed fhe

arrangemen-ls for treating crash injury ín Tennessee. Although the

criteria of adequacy of carc and fhe methocls of assessment were not

defined in the paper, it was slatcd thal only 5 per cent of 616 patients

had received adequale f irst aid befor-e admission to hospita l.

Such evidence reinfcrces the need for studies evaluating the

qual ily of care. Assessments of qual ify have proved exlremely difficultin all areas of medical care becausi: of the limitations of available

mt:thocJology. Nevertl¡eless, s-tudîes have been underfaken to investigate

:issessin(rnt methods. These represenl a large f ield of modical care

rcsearch i n the ir own right., ancJ are comprehens lve ly rev iewed by

Donabedian (1966; 1969) ancj Peterson (1963;1966).

One of fhe reasons that deta relating lo the porformance of

care and its effects on the patienÌ havc rarely been obfained, is that

38

i+ is exlremely diff icull to Ce-t'ermine retrospectively wl'relher or not

proper care h¿rs been given by ambulance officers and rnedical personnel.

It is one-thirrg fo examîne fhe potential lreafment thaT personnel

should be able to deliver; it is another lo de'i'ermine how lhey actuallyperform.

DirecT observatic¡n of physician perfcrm¿lnce has boen used fo

overcorne lh is prob lern in othcr tneclica I care areas, notab ly in the

sludies of gr.jneral practice conducted by PeTerson ef al. (1956), Clute(1963) and .Jungfer and Last (1965). Whi lst such studies have the

obvious aCvantages of diroct observation in any scientific investigat-ion, fhey are ¡:lso accompanied by problems of sampling, observer bias,

cost and re¡rroducibi I ity. Direct observation, as a sludy method, has

not been used in any of fhe reported studies of emergency care.

ln recent vears, wÎclespread use has been made of operations

rc:search lechniques in tl're stucJy of queue Ìng and resource allocationproblems and as aids'to admÍnistrative decision making in industry. 'Ihe

application of fhese techniques lo road safeÌy and emergency care pro-

blems is, however, a comparalively recent development. (Little, 1966l'

Leinirìgor, 1968. ) Bonner (1966) used waif ing time data in a simulation

sludy of hosp ita I outpal ienf and emergr,\ncy services. Savas (1969 ) used

a compuler s imu I at ion fr: ana I yse the poss ib le.: improvements f hat wou ld

result from proposed changcs in lhe nunrber and locatîon of ambulances in

New York City. The cosf-.effcr:'tivoness of several alTernatives ivas eval-

ualed and the advantages of a <lispersed ambulance system wifh central

dispalching faci I it¡es was demons'trated. Kel ler (1971 ) reported the

results of a simulation sf u<1y which investigated service and detection

syslems on freeways. lt w¿rs found that-l-he combinafion of discretecommunication terminals along lhe freeway, monitored at a central clis-

patching system, with station¿:l pol ice and mechanical service unlts

werc the most cost-effectîve operotions. The usefulness of fhese tech-

niques as administrative aids suggests that They will be of consideratrle

benefit in planning future modificalions c¡f emergency care systems.

39

Chapter 3

THE STUDY BACKGROUND

STAÏEMENT OF 'IHE PROBLE¡4

The review of the publ ished I iterature shows that stuclles ofroad crash epidemiology in Austral la have concentratecJ on fhe causesand patterns of crash injury. consequenfly I ittle information has

been available from which the performance of post-crash events can be

assessed. ln particular, I iÌtle has been known abouf the care pro-vided by emergency services a-t lhe scene of the crash, durlng ambul-ance treatment, and in fhe hospltal casualty department. Nevertheless,a general awareness lhat lmprovements ln emergency services may be

desirable has meant thaf planners and administrators are under pressurefrom many seclions of the community to infroduce changes in existingservices. For example, tlre use of helicopters and emergency careambulances has been suggestecl as a means whereby the consequences ofroad crashes and other medical emergencies may be reduced. The lack ofdata on existing operations makes the raflonal planning of services and

evaluation of such a lfernative patferns of operation extremely dif f icult,

As the review of the literature has shown, Ausfralla is notalone in thls need for emergency care sTudies, although fhe increaslngatlention being paid to €mergency care problems is reflected in thegrowing number of studies being reported f rom overseas cenlres. f,4ore-

over, further studíes of emergency care systems are sfi I I required.These needs were well summarised by Frey who, in discussing the dlrect-ions further research in fhe united sfates shourd take, sfated:

'There muet be a systems analyaís of the openation of theemegeneA medieal senùíce" from the seene of the aeeident untíL lospí,taLdiselwnge. Eaeh eLement inuoLued ín patí,ent eare (transpont" eonnmtnie-atíon" training the neeeue worken, in-hospital treabnent of the patienta,nd vøspitaL staffing) mtst be eæønined, in oyder to d.etect a?ea,B ohiehneed improuement. t (Frey, 1971,)

40

The systems approach for studying emergency care was brieflydiscussed in lhe preceding chapter. The use of such an approach re-quires that elements of lhe system should be examinecJ in the contextof thc+ overall system, that syslem objecf ives should be def îned, and

that alternafive means of achieving those objectives should be eval-uated in the lighl of their possible effects on the overall system.ln this study a systems approach is used whereby the separate servicesinvolved in providing emergency care are regardeci as elements of an

emergency care system.

ln fhe pas-|, most studies of emergency care have concentratedon the operalion of emergency services oulside the hospital withoutrelating fhe care provided by'these services to events whlch occurwlthin'the hosoital. The importance of each soparate phase i n fhemanagement of an injured pa'tient ls diff lcult lo def ine, since medlcalcare is a conlinuous process which commences soon after a pafíontreceives his injury and continues through his deflnitive freatment.Nevertheless, for practical reasons, cut-off poinls for each of fhevarious phases of care must be used. Traditional ly emergency care has

been considered as ending with the arrival of the patient at the hospitalemergency department. ln contradistinction, th¡s study wi l l argue thatstudies of the emergency care system should include consideration of thecare provided wilhin lhe hospital casualty rlepartment.

There are several reasons why such an epproach should be used.

Firsf, al-lhough the patientrs arrival at the casualfy departmenf usual lyrepresenfs lhe beginning of his medical treatment, lhe care providedfor patients with severe ínjuries is usually limited lo resuscitatlonand stabilization of their condition before they are admitfed fordefinltive freatment. As such l't is probably most appropriately des-cribed as emerqency medical care. secondly, projecfed changes in theoperation of one ôrea of the system musf be viewed in the overall system

context. For example, time delays în bringing medical care to the

41

pat¡enl (or the potierrt to medical care) are often quoted as reasons formodîficalions to lho transport and treatment subsystems. Time saved in

transport, whi lsl it may bc¡ of cri tícal value, musl be viewed against

The background of time spenl stabilizing lhe condition of the patlenlaf the crash scenê and, more parficularly, againsl the time delays in-volved in receiving medical carc after arrival in casualty deparlments.

It is worth noting In fhis regard that the Task Force on

Emergency Medical Services of the National Hlghway Safety Bureau in the

Uníted Stales recordcd lhe fol lowing observatlon at lhe Highway Safety

Program Priorities Seminar in July, 1969,

'ALtlnugh in the work of N,H,S,B. ue ¡'haLtedrt mo?e or Less atthe TrcspitaL door, the emengeneA ?oom and the medical eare requined

uhen the oietin reaehee that faeiLity, makes this phase of the aystem a

uitaT element of the totaL Ernerge-ney MedícaL Servíees System, and one

in uhích eonsídepabLe upgnadíng is requined. rf ilnt' faeility ispoonLy staffed or badly deficðent - as ís often the ease - then írnpnou-

íng othen eLements of the system outside the emez'gency ?oom uiLL ob-

uiousLy not produee paA offs.'

THE EMERGENCY CARE SYSTENî IN MELBOURNE

Extensive use wÌ I I be made throughout +his thesis of an

analytical model which describes the emergency care sysiem in terms of

four functional subsystems - communications, transport, treatment and

documentation. The mode i t'ras de ve loped by the Frank I I n I nsf iluteResearch Laborafories (Bordner, 1968) to describe lhe services providing

care before pafients reached hospital. ln lhis study the model is

adapted and expanded to includo care within the hospifal casualty

department.

ln lhe fol lowlng two sectlons fhe objeclives of the emergency

care system are stated and the services which comprise the elements of

42

the sysfem for road crashes in MelLrourne are dÌscussed. These servicesinclude the general publ ic, pol ice, fire, fowing and ambulance services,and lhe casually departments of the major metropol ltan hospitals. ln

the th ird sect ion, the mocle I is described. ln a laler sect lon(Chapter 7) the model will be used to discuss the performance of emerg-

ency care within the system as it was observed in Melt¡ourne.

(a) Emerqencv Care Svstem 0biectivesThe primary objective of the emergency care system, as ¡t

operates for road crash victims, is to reduce the losses due tc injury,death and property damage incurred as a result of road crashes. ln

functlonal lerms, this objective impl ies fhat a comprehensive emergency

care system should ber capable of:1. Providing prompt idenliflcation and response lo crashes

under a range of emergency conditions.2. Suslaining and prolonging I ife through proper first ald

and resuscitation measures, both at lhe scene, duringtransport and in the hospital casualty department.

3. Providing fhe co-ordination, lransport and communicalions

necessary to bring fhe injured person and definitivemedical care 1'ogether in the shortest praclicable tlme,wilhoui simultaneously crcating additional hazards.

(U.S. Dept. of Transporfation, 1969.)

The achlevement of these objectives would ensure that crash

vicf lms received prompt and adequate ernergency care. The followlnganalysis aims to determine to what exten'l such cbjectives are mef by

the existing system, and to provide a data base from which performance

standarcJs can be developed, system defects determined and appropriatemod i f icalions p lanned.

43

(b) Elements of the Emerqency Care Svstem

The fol lowing groups and services are normal ly involved lnprovlding care for road crash victims in Melbourne:

( I ) Memtrers of the Genera I Pub I lc(2) Towing Scrvices(5) Pol ice(4) The Fire Brigade(5) Ambu lance Services(6) Publ ic Hospilal Casual ty Deparfments

(1 ) The General Publ icMembers of fhe public are usually the first to arrive af fhe

scene of a road crash. They frequently provide first aid for the

injured, undertake traffic control and, most importanfly, notify the

formal emergency servicos thaf fhe incidenl has occurred. Hence fhey

play an important role ln the early post-crash phase.

(2) -low i nq Serv lces

Towing services are usually the f lrst c¡f the formal emergency

services to reach the scene of road crashes in f,lelbourner ê situationwhich results parfly from the competitive nature of the towing business

and partly from lhe fact that cach service works within a relativelysmall geographical area. Theîr primary role is to remove vehicles and

debris from the crash scene. They rarely provide first ald for the

i nj ured.

(l) Pol lce

Police play an importanl role: in lhe post-crash phase. Thelrresponsîbi I ities include protection of the crash scene, maintenance oftraff ic f low, and crash investigation. They collect informaf ion forofficial recording purposes, assist communicafion between the separate

emergency services, notify the next of kin of the injured and conduct

44

fol low-up investlgations to assess and apportion blame. This is an

extremely complex and time-consuming role.

First aid skills may be required by police in a wide range ofemergency siluations. Police in Victoria receive f irst aid instruclionduring their basic training on joining the force. Any further first aid

trainíng is undertaken on a voluntary basis.

(4) The_ Life Briqade

The f ire brigade a-ltends road crashes in response to speclal

requests from ambulance or police officers at the scene. As the omerg-

ency service equipped with the heavy duty povrer tools occasionally ro-quired for extrícating Trapped viclîms, fhe brigade is summoned when

such equipment is needod. They also altend crashes when the risk ofpost-crash firo is high, nc¡tably when fuel line rupture results in

pefrol spi I lage.

ln Victoria, firemen do nol receive first aid instruclion as

a roufine part of their trainlng. Some firemen attend firsf aid courses

of the St. John Ambulance Association on a voluntary basis.

( 5 ) Ambu lance Serv ice i n t''le I bourne

The ambulance service is fhe major provider of emergency care

at the scene of road crashes in Melbourne. Ambulance treatmenl and

transport facilities in the metro¡rolitan area are provided by the

Victorian Civil Ambulanco Servlce (V.C.A.S. ) which operates oul of 10

ambulance stafions in the city and surrounding suburbs. The service isgovernmenl subs i d i zed and depends on vo I untary subscr i pt i ons, donaf ions

and the collection of fees for service for the remainder of its income.

Fourteen other ambulance services operate in outer urban and rural areas

of thc Sfate of Victorla, each wilh a defined area of operaTion and

simi lar arrangementsfor financing, equipmenl and personnel training.Overall control of ambulance services in lhe Stale of Victoria is

45

maintained by the Viclorian Hospitals and Charities Commission.

ln addition to treatment and transport for emergency cases,

the Victorlan Civi I Ambulance Service provides routine transport forsick patients befween hospilals and belween home and hospltal. Whi lsta tClinic Carr service provides facil¡t¡es for the rouline fransport ofnon-stretcher patlents, the majorily of ambulance runs are made forpatienf transfer cases, with emergency cal ls forming approximately l0Íof al I calls aftendod by the ambulance service. 0f the emergency callsapproximately 501 are i'o the scene of road crashes. (V.C.4.S., 1970.)

This pattern of operafion has evolved as an apparently efficlentand economicaI melhod of servicÌng fhe demands on lhe st:rvlce, althoughthe efficiency and economy of the operation has never been fhoroughlyinvestigated. ln particular it is worth noting that there is no system

of emergency ambulances staffed with ski I led medical or paramedical

personnel providing care in emergencies. The use of such ambulances has

been suggested in view of the claims made for their effectiveness inEuropean counÌnies and in the U.S.A. and a unif is currently being testedin an experimenTal project conducted jointly by the V.C.A.S. and theRoyal Melbourne Hospital. Evaluation of fhe effectiveness of such

units in the light of the present crpera'tion of the emergency care system

wi I I be referred to later in this study.

Ambulance Staffln 1969/70 the V.C.A.S. employed a slaff of 285 persons of

whon 2?.5 were directly associated with ambulance operaf ions. A def inifecareer structure exisls for ambulance officers within the service. Pro-mofion through fhe ranks of Ambulance Officer Grades I - lll, two grades

of Slatlon Officer, two gracles of Divisíonal Officer, fo executive staffpositions is dependent on experîence, seniority, attendance at resident-ial fraining schools and successful complefion of correspondence coursesconducted by the Victorian Hospítals and Charifîes Commission Ambulance

46

Training School. 0f the lB7 Ambulance Officers employed by the serviceat the end of the 1969/70 fiscal year, 4of were of Ambulance officerGrade lll rank, 50% Grade ll and lOÍ Grade l. (V.C.4.S., 1970.) Con-

difíons of service for these men are governed by a determination under

the V íctor ian Lat¡our and I ndustry Act.

Staff Recruilment

Standards for the recruitment of officers to the service areunder conÌinual review. At the time of lhis sfudy the only prerequisitefor joining the service was the possession of a current driverrs licence.Applicants who possess a f irst ¿:id certif icate from the St. John Assoc-iation or some similar volunfary society are preferred. A recruit was

required to present a medical ccrtif icato to af f irm his suil'ability forambulance work, bul recenl modîfìcations to service pol icy have meant

that recruits are now examined by lhe servicers own Medical Officerbefore lhey are employe,.d. The general level of education of recruits islow and less than 5% nold the Victorian lntermediafe Certîficafe or ílsequivalenf. This fact presents some diff iculty urith the dosign oftrainíne courses. (tierry & Toyne, 1970,) Nevertheless, recruitingsultable off icers is not a problem for thesorvice and, a't present,approximately 7 app I icants are i ntervicwed for each man emp loyed.(Ortmann , 1971.)

Staff TrainingTraining procedures irr the service also undergo conlinuing

review. Soveral changes in training methods took place during the sfudyperiod ancj the fol lowîng descriplîon of tra ín ing courses represcntsthose applying at the end of 1971.

0n joining thc service, V.C.A.S. recruifs atfernd a fhroe¡ week

course which includes instruction in basic anatomy, physiology, firslaid, the fundamenfals of ambulance transport nursing.and demonstrations

of the r:se of ambulance equipment.

47

Visits are arranged during this period to fhe casualty departmenl of a

major city toaching hospital, the city mortuary and lhe recovery and

intensive-: care warC of a teaciiîng hospifal. After completing this basic

lraining lhe; officcr is roslerod for normal ambulance duty. For the

f irst four weel.ls of such dufy, a recruit is p laced under the supervision

of an Aml¡ulance Of f icer Gradr,: lll. After this period of supervised

scrvice ttre officer joins tl¡c normal roster, but e servicc regulation

stipulafes that no ambulance should be manned by fwo Ambulance Officersof Gr¿:de I standard. Anothcr administralive instruction requires thatthe senior officer manning an ambulance should be responsible forpa1-ient care.

Tho Victorian Hospit¡¡ls and Charifies Commission conducts a

training school for Ambulance Cfficers which is attended by offìcorsf rom all 16 of 1'he Victoriar¡ Ambulance services. All ambulance off icers

musf apply for such lrainîng wilhin twclve months of joining a service

and promotion through the separal-c grades of Ambulance 0ff icer, Sfafion

Off icer, Divisional 0ff icer and Superintenden-t is conditional on success

in lhese courses as well as expcrience and seniority in the service.

The subjecf material of the courses covers all aspects of ambulance

service and lectures and practical materÎal are presented by oxperts

in the separate fields.

Affer compleTing lhe necerssary courses, an Arnbulance Officer

Grade ll should be competont to lre¿¡l the unconscious patient, maintain

ef feclive airway confrol, ventili-:'te the patienl using mouth to moulh

lechniques or a Lrag and mask, and be able fo diagnose the need for and

perform ex'ternal cardiac mossage. As well as these life-saving procod-

ures he should be conrpetent in minor firsT aicl pror:edLtFersr and be able

to control haemorrhage, apply spl ints, anil perform aPpropriate exlric-ation and I ¡ft¡ng manoeuvres.

St¿rndards for ambulance officer training in Victoria are

48

commensurable with the slandards and guidel lnes laid down by several

overseôs aufhorities. (American Col loge of Surgeons, 1967; American

SocÍety of Anaesthesiologlsts, 1968; World Health Organization, 1968;

l,lillar, 1966. )

Amt¡ulance Vehicles

Ambulances in Melbourno are designed to carry fwo permanent

stretchers, with faci l it¡es for an additional two slretchers in a

fdouble-deckert configuralion should lhey ber reguired' Vohicles used

lnclude a specially designed cabin based on a Ford Galaxie chassis and

Ìhe Hartnetl General Purpose Ambulance which was designed and builf for

service in Austral ian conditions. (Berry , 1971,) The latter vehlcle

meefs mosf of lhe specifications for ambulance deslgn recornmended by

invesf igatory committees in Britain and the United Stales' (U'S' Dept'

of Transportation, 1968; Millar, 1966; Ogle, 1969.) lf is built on a

light truck chassis, with modífied suspension, has adequate room in the

cabin for an ambulance attendant to work between lhe two permanent

stretchers, carries stanclard oquipmenf and is air-conditîoned' ln

1969/70 lhe servlce was equlpped with 88 vehicles of which two were

Hartnett ambulances. ln l97O/71 the number of vehicles had increased fo

90, of which 12 were lhe Harfnett fype.

fur¡bu I ance Eou i omenf

Each ambulance is equipped with lwo permanent stretchers and

two folding sfretchers, two-¡,ay radio, siren ancl flashing I ight' Llght

rescue equ ipment i s carri<;d on each veh ic le.

Medical equipment carried includes first aid matorial, band-

ages, airways, suction, portable oxygen and pos¡tive pressure venti lation

apparatus. The ambulances carry two bottles of stable plasma prolein

solulíon with infusion sets for use by medical praclitioners at the

scene of an emergency. Hayward-Bul't inha lers for trichlorethylene

administration are available on each ambulance'

lr- ,È irrri: -1i '-\,Þ ,

,- .-

Load'ing the Hartnett Ambul ance.

49

A complete equipmcnt I lst is included in Appendix 2-

Ambulance stretchers in Melbourne are made of iubular steel

and aluminium wilh plastic coated sponge mattresses. Slretchors are

porlable and arc notrself-loedingt in that two men are normally re-

quired to lift the s'lrotchcr into fhe ambulance. Stretchers lock into

posilion in the ambulance cabin and are fixed to lhe cabin floor during

transporf.

Ambul ance Commun í cationslndividual ambulances are I inked wiTh a communications centre

in the central ambulancc station by two-way radio. The V.C.A.S. uses

lwo radic frequencies to provide a cover of the metropolitan area.

Those arcjas north and south of fhe Fìiver Yarra form separate areas of

service operation" each of which is controlled lhrough a separate radio

frerquoncy. The radio dispatchers are locafed in the one communications

cenlre al lhe.service headquarters in La Trobe Street, Melbourne.

Peripheral ambulance stations have direct telephone conneclions wifh The

communications centre and a I I ambulance dispafching¡ is undertal<on f rorn

fhis centre. Al the time of the study direct lelephone lines connected

the control centre with several of fhe major metropol itan hospitals.

Communication with other hospitals was môintained thrc¡ugh conventional

telephone channels. A remodellirrg of the communicalions centre wðs com-

pleted in June,1971. lncluded in lhe modern equipment installed was a

P.A.B.X. telephone system which provides direct dialling facil¡ties Ioal I branch stations and al I major rnetropol itan hospitals.

Peak communication loads on the service occur during dayl ight

hours. Telephonists man lhe switchboards during usual office hours,

receiving both ambulance,and general business calls. Relevanl inform-

ation ¡s ¡s66rdecl on cards which are relayed to the dispatcher who main-

lainE radio control over the ambulance fleet. At night, dlspatchers

fi I I the duel roles of felephonisl ancl fleet control ler.

T*

I, _ _4L- t

a

t

)

\r

I

I

.oiJ

r'iìl ..,

bi lb\L5b5l.bbù,:t:ùcooÔÔse

Lltlrbb\\baaaaaaaaaaaçtrccc G

\êO

-t\ t,z

dÅlJ

The V.C.A.S. Commuilícalfons Centre at the Tirne of the Study.

¿aôððé )a¿ccddd d d ó ó ó o ô ¡ ó e o ó

.)a8a.aco oaa9a€

I

¡,

¡,

50

Dispatchers are senlor ambulance personnel, usual ly of SJation

Offlcer rank and above, who have had considerable training and experience

in ambulanc<; work on the road as well as special training in the radlo

and olher procedures associated with fleel control. The control room lsmanned lhroughout the day by af least tr,¿o dispatchers and a supervisory

divlsional off icer who is responslb,le for overall control of the f leet.

( 6 ) l-losp i ta I Casua lty Dep¿rrtmenls

Victims of road crashes in Melbourne usual ly receive emergency

medical care in the casualTy department of major public hospitals. Two

of these hospltals in lhe area of Melbourne under sfudy are teaching

hospitals and the lhird, on fhe periphery of the study area, is a rnajor

district hospítal. Each is equippeld fo handle medlcal emergencies of

al I types. The distribution of major hospitals in the Melbourne mefro-

politan area was invesligated by Hughes (970) and found to be unsatis-

factory. That study was conducted at the same time as this and his con-

clusions and recommendalions are thus germane to the present discussíon.

Those interested in fhin problem are roferred to Hughesf thesis.

Med i ca I Staff i nq Patterns

At the time of fhe s'l'udy each of fhe casualty departments was

manned throughoul the day by junior resident medical offlcers (flrstyear gradua'tes in medicine). Their immediate supervision \,úas provided

by senior resident medîcal officers. These are usual ly doctors in theirsecond post-graduate year. Administrative responsibi I ity for the depart-

menl lies with fhe medical superinlendent, or his deputy, and casualty

surgeons were ¿ìppointed, on a half-time basis, to oversee casualfy

services. Ofher medical supporf was provided by members of the in-paticnt meclical staff .

Nurs I nq StaffNursing care in fhe deparlments is provided by both lralned

and trainee nursing staff. At the timc¡ of the study frained staff were

51

read¡ ly avai lable for casually dulies during the morning, afternoon and

evening shifts, bul'slaff ratios fell off markedly during the night

shift. One sisfer and three or four trainee nurses were normal ly

rostered for night duty in the Alfred Hospitalfs deparfment. A senior

nursing sisler was responsiblo for supervising casualty nursing services

and was present in lhe departmenl during normal workíng hours. During

the night hours, the cenfral nursing administration assumed administrat-ive responsibi I ity for nursing services in casualty.

Anci I larv Staff and Services

Casualty clerks normally inferview patienls on admission and

perform the necessary recording and documontafion procedures. The

medical reccrds library is located clc¡s¡; to lhe casuälty clepartment in

lhe hospifals studied, particularly fhe Alf red Hospital, whero the

casual'ly department is relatively modern and wel I equipped, having beon

opened in 1966.

ln keeping wi-fh its modern design and facilities, the Alf red

Hospilal has an X-ray machine anC 90 seconcj film processor in the casual-

fy department. Radiographers ere rostered for dut'y in the deparlment

throughout the day. The X-ray deparlrnent is conveniently located ln

lhe Box l.lill HospiTal, t¡ut in Prince Henryrs is several f loors removeC

from the casualty department in the same wing of the building. ln the

lalter hospital, at the time of the sÌudy, a radiographer was rostered

on call during the night hours, but was nol required to bo present in

the deparfment - or even within the hospiial confines.

Other casua lly staff members i ncl ude medical orderl ies,

nurslng aides and domeslic sfaff.

52

(c) A Model for ribino the Emeroencv Care Svstem

The Emerqencv Care Cycle

It is useful to consider the events which occur during emerg-

ency care in lerms of flow pattorns in the system. After a road crash,

several emergency services are involved in the various care phases.

The flow of events is, to some oxtent, sequential and each stage is

described as an cperational stage of the Emergency Care Cycle.

CRASH

An incídcnt occurs with patient injury and property damage.

DETECT I ON

Members of the publ ic, who are usual ly the firsl helping

personnel on the scene, detect fhe crash and may Perform

important emergency procedures (e.9. first ald, protectlon

of the scene, extrication of victims).

NOTIFICATION

The emergency services are alertod and thelr resources

mobi I ized.

D I SPATCH

Emergency si¡rv ice veh ic les â Fê srîñ't to lhe scene.

5. TRAVEL TO THE SCËNE

The emergency services travel to the scene with al I reason-

able haste. The relalive localions of the ambulance and the

incident and lhe accessib¡ I ify of the site are important

factors in delermining time delays ln ambulance response.

TR I AGE

The injured are assessed to determine priori'l-ies forfreatment.

2

3

4

6

7

B

53

TREATMENT

First aîd is performed, the paf ientrs condilion is slabil-ized and preparations mado for transport.

TRANSPORT

The injured are laken to hospital for definilive medical

care.

9. TREATMENT IN 'I-RANSIT

Sk¡ l led treatment may be required to maintain the patienttscond it ion.

.IO. TRANSFER TO CASUALTY CARE

The events associated with del ivery of the patient tomedical care inclucle fhe transfer of the patient from the

ambulance to the casualty department and the fransmission,

from th<l ambulance officers to lhe casualty staff, of al I

relevant informalion rela'f ing fo the patientrs condition

and lreatment before admission.

1 1. AMBULANCE RETURN TO READINESS

The ambulance personnel prepare fhe vehicle for another

cal I and notify the dispalcher of their readiness for such

a call.

12. CASUALTY RECEPT ION

Personal detai ls are recorded, the patienfis medical record

is generated, and lhe pallent is admitled to the casualty

assessment area.

13. TRIAGE

Examination and assessment of patient injury is undertaken

by the nursing and medical staff.

54

14. EMERGENCY TREATMENT

Emergency procedures are carrled out (e.9. artlficialresp íralion, intravenous therapy).

15. SPECIAL INVESTIGATION

lndlcated investigafions (e.9. X-rays, blood grouping and

matching, E.C.G.) are performed.

I6. TREATMENT

Deflnltive treatment is performed for those patients who

do not require ln-pallent care.

17. OBSERVAT ION

The patienfrs condífion is monitored for the duraflon ofhis stay in the casualty department.

18. DISCHARGE

The patient is dischargod from the emergency department.

The seriously injured are admltted to hospital. Those who

do not requlre admission are referred fo out-patlentcl inics or some alternative medical care source forfo I I ow-up.

A flow chart depictlng The relalionships befween theseoperational stages ls shown in Flg. 3.1.

CYCLE

DI SCHARGE

OBSERVATION

TREATMENT

SPECIAL INVESTIGATION

EI4ERGENCY TREATMENT

TRIAGE

RECEPTI ON

DISPATCH

NOTI FI CATION

DETECTION

CRASH

CYCLE

CYCLE

RETURN TO

READINESS

TRANSFER TO

CASUALTY CARE

TREATI'IENT INIT

TRANSPORT

TREATMENT

TRIAGE

TRAVEL TO SCENE

Ambul ancePa ti ent

Fig.3.1 The Emerge'ncy Care CYcle

55

Subsvstems of the :Emerooncv Care System

The emergency care system may be described in terms of four

functlona I subsystems.

1. A transport subsvslem which provides rapid access to the

scene of the incident and includes a convenient and com-

forlable means of carrying the patient to and through

definitive medical care in the shortest possible tlme.

2 . A communicafions subsystem which permits lhe prompl

acquisition of information about the crash, ready dlspatch

of emergency services and co-ordination between the

separafe servicos lhroughout their operations.

3. A treatment subsvstem which provides ski I led treatmenl at

the scene, during tra¡sport, and in the hospifal casualty

depa rtment .

4. A rlocumgntation subsvg!_em which ensures fhat all lmportant

dala relating to the incident and the palienl?s condition

are recorded from the scene of the crash until he leaves

the hosp Ì ta I casua I ty departmenl.

Posf-crash events are relafed lo cach of the four subsystems

in tho fol lowing description of lhe various subsystems. Each subsyslem

is idenfífied by an alphabetic character

Commun i cat lons - C

Transporl - T

TreafmenT - M

Documentation - D

and each evenl is coded according to ifs order of occurrence lvlthin the

relovant subsyslem.

\

CRASH

S ITETI

OTHER

E14ERGENCY

SERVI CES

A,I4zuLANCE

LOCATION

COI4I'IUNICAÏIONS

CENTRE

CASUALTY

RECEPTION

ASSESS¡.IENT

AND

TREATT'.IENÏ

SPECIAL

PROCEDURES

IÎ{PATIEIIT/OUTPATIEI{T

CARE

Fig. 3.2 The TransPort SubsYstem.

THE TRANSPORT SUBSYSTEM -

CODE

T1

r2

r3

14

T5

T6

T7

TB

T10

56

Fig.3.2,

EVENT

Ambulance travels lo crash scene.

Other emergency servlces travel to scene.

The patient is extricated, placed on a

stretcher and I lfled into fhe ambulance.

Ambulance transport to hosPital.Patienf lransferred to casualty receptiott -(a ) Li fted from ambu I ance

(b) Transferred from ambulance strefcher

to hospital barouche.

Ambulance refurns to servlce.Patíent taken to casualfy assessment cublcle.

Palienl taken for special invesligatlons(usual ly X-ray) and returned to assessment

area after ínvesllgation.Patient taken lo treatmenl area (e.9. dresslng

cubicle, thealre) and returned lo assessment

cubi cle afler treatment.

Discharge from emergency care.

T9

CRASH

SITE

OTHEREMERGENCY

SERVICES

AMBULANCE

LOCATION

coÈll'IuNI CATt 0NS

CENTRE

CASUALTY

RECEPTIONAND

TREATMEl{T

ASSESSMENT

cl 2-l

SPECI AL

PROCEDURES

INPATIENT/OT'TPATIENT

CARE

Fig. 3.3 The Communications Subsystem

,57THE COi4MUN ICAT lONg SUBSYSTEM - F ig , 3.3

CODE EVENT

Cl Deloclion of lhe crash

CZ Notification of inciclent to communications

cenlre.C3 Emergency services dispatch (pol ice, tow

truck, f i re).C4 Arnbulance dispatch. CommunicatÌon between

ambulance officers at the scene, lhe dis-patcher, and the hospitaI casualty staffprovides control of ambulance response:-

C5 ln transil.C6 Al the scene

C7 Duri ng fransPort.CB Ambulance officers provide patient detai ls

for casua I ty documenlat i on c I erks.

C9 Ambu I ance off ícers report deta i I s of the

palientts condition fo-the casualty sfaff .

Cl O Ambu lance of f icers no't if y d ispatcher of 'the

complelion of service.

Cl1 Patient interviowed by Documentation Clerk'

Clz Patienl intr¿rviewed by the receivlng Nurse'

Cl3Patieni.hÎstoryobfainedbyMedicalOfficer.Cl4 DefaiIs of the pafienff s contlitlon and plan

of treatment i rlvo I ve commun ical ion belween :

(a) casualtY staff members

(b) casualtY staff and Patienl(c) casua ltY staff and relatives.

Cl 5 Med i ca I consLl I lat i on bertween casua lÌy and

consùltanf staff.C16 Discharge from emergency care involves

commun i caf ion between :

(a) casualtY slaff and the Patient(b) casualtY staff and relatives(c) casuölty and in-patient staff.

CRASH

SITE

OTHER

EMERGENCY

SERVICES

CASUALTY

RECEPTION

ASSESSI,IE¡lTAND

TREATI,IENT

SPECIAI

PROCEfN'RES

INPATIENT/ü,TP¡TIENT

CAREAI'IBULANCE

LOCATION

COIO4UNICATIONS

CENTRE

Fig. 3.4 The Treatment SubsYstem'

58

THE TREA1ï4ENT SUBSYSTEM - Fig. 3,4.

CODE

M1

tú2

M3

M4

M5

lvl6

M7

MB

M9

EVENT

First aid from members of the publ ic.Tríage of the injured by lhe ambulance

officers.Firs't aid at lhe scene.

Treatmenl duri ng ambu lance transport.Treatment during transfer to casualty care.

Assessment by receiving Nurse -(a) History(b) Exami nation(c) Undressing tho patient.Nursing care -(a) Wound cleansing(b) Wound dressings(c) 0bservation.Med i ca I assessmenf -(a) History(b) Examination(c) Consu ltation(d) Referral for special investigation

(e.9. X-ray, E.C.G., Echogram).

Medical Treatment -(a) Resuscitation( b ) Sufure(c) Dressi ng

(d) Fracture immobi lizalion(e) Special procedures (e.9. fracture

reducl í on )

(f) fleferral (¡) ln-palient care( i i ) Out-patient fol low-up.

Dischargo from cmergency care.M10

OTHER

EI.IERGENCY

SE RV I CES

CRASH

SITE

AMBULANCE

LOCATION

COII4UN ICAT IONS

CENTRE

CASUALTY

RECTPTION

ASSESSÌVIENT

AND

TREATMENT

{sÞ{)}'

SPECIAL

PROCEDURES

I ¡tPAlIEr{t/OI'T?ATIEIfI

CARE

Fig. 3.5 The DocurrpntatÍon Subsystem'

59

THE DOCUMENTATION SUBSYSTËM - Fig. 3.5.

CODE

DI

D6

D7

EVENT

Tlre ambu I ance d lspalcher records serv ice

dafa during the various phases of the ambul-

ance côll on the record of the initlal callan<J on the d i spatch record.

The ambulance crew record servlce data at thetimc of dispatch, a't the scene and on complet-

ion of the cal l, on the case docket. -

An Ambulance Report Form which lncludes a

record of the petientrs injuries, cl lnicalcondition, initial treafment and treatment

during transport, is comploted for each

pafient by the aftending ambulance officer.Ambulance Report Form lodged with casuallysta ff .

Hospital medical record generated -(a) Palient Ídentificafion data is recorded(b) Previous arJmlssion records are procured

(c) Casually record ls started.Hoad injury chart is'begun (if lndicaled).Casualty history charl is commenced by

Medical 0fficer.'Speclal oxamination request ls generated.

Casua lty hÌstory, discharge and referraldocuments are completed by the Medical

Off i cer.Discharge or admission documentation com-

ple'ted by lhe casualty sfaff .

D2

D3

D4

D5

DB

D9

010

SUBSYSTEM

TRANSPORT

COII4UNI CATI ONS

TREATI4ENT

DOCUMENTATION

tDETECTION

cl

c2

M]

DISPATCH

c3

c4

D1

TRAVELTO

SCENE

TI

12

c5

D2

ûTRIAGE

T3

c6

M2

M3

D1

æ

D3

TRANSPORT

T4

c7

t44

D3

TRANSFER

T5

c8

M5

RECEPTION

T6

T7

ao

cl0

c11

M6

DI

D2

D4

D5

ü

TRIAGE

ctz

c13

t17

r'18

D7

EI.IERGENCY

TREATI'IENT

c14

t{/

M9

SPECIALIGATI

T8

c14

D8

&TREATI,IEI{T

T9

cI4

c15

M7

M9

D9

DISCHARGE

OPERATIOI{AL STAGE

T10

c16

M10

Dl0

Fig. 3.6 The Emergency Care Matrix'

60

A matrix relating the four subsystems and lheir events tothe operatíonal stages of the emergency care cycle is shown in Fig. 3.6.Entries in indlvidual cells of the matrix rarpresent fhe subsystem eventswhich occur during each stage of'lhe cycle. The matrlx thus depictsthe interactions between the elements of fhe emergency care sysfem.

For example, during transport to -lhe hospiTal, communications (C7)

between fhe ambulance ancl the clispalcher and subsequenfly belwoon thedlspatcher and'lhe hospital provide advance warnlng of the lmminent

arrival of a seríously injured pa'lient. Al 1'he same time necessaryresuscitalion and Trealment (M4) is performed by the ambulance officerfo onsure the stabilization of the patienf rs condition. S¡gnif icantevents relatlng to lhe patientes injuries, condition, and managemeht

arê recorded by the ambulance officer on lhe ambulance report form (D5).

ln addition lo shot^ring the relationships betwu.en the operaf-ional stages and subsystem events in diagrammatic form, the mafrixdemonstrates the interfaces between the separate subsystems. A selectionof these interfaces are described ín Flg. 3.7.

DETECTION

NOII FlCATION

OISPATCH

OPIRATIONALSfAGI

TRAVEL TO

SCENE

AT SCENE

TRÁVEL TO

HOSPITAL

TR,ANSFIR fO

CASIJALfY CARE

CASUALTY

TREAT14EIfI

DISCHARCE

TRANSPORT

Provide readiìY available

adequ¿tely equi PPed ambulance

and erergency servlces.

Rapjd response and travel with

maximum safety. Driving skills

Assure safetY and Protection of

scene. txtrication and liftingproceduæs; transfer toambul ance.

Anbulance transPort with

âttention to P¿tient confort's afetY.

Trônsfer Prccedures. Liftingpatient frcn anbulance and

transfer to casualtY care.

Moverent of gatient as required

\rithin the erergencY departrent'

e g to X-R¿Y depÀrtrent and

return.

Tr¿¡sfer of Datient to inpatient

c¿re or for outpatient foì low-

U¡

COI4I,IIJNICAT¡ONS

comunications during travel

Exercise controì; relaY

additìonal infomation re

incident

Provìde ready access to

noti fi cati on devi ces.l'lai nt¿in

effective control and assured

resPonse to erergency cal I s

Notify patient's condition to

dispatcher RelaY details of

patient' s condi tion to hosPi tal

Notify need for additional or

al ternôti ve emergencY servl ces ,

Alert cðsualtY departnent of

iminent arrival of Patient.control ômbulance destinetion

Notify dispatcher of

completion of service

status of casualtY depôrtment

arri valt.,:r.

Rela-v of infornation between

a CasualtY staff rembers

b. Staff and Patientc Staff and relativesd. Staff and inpðtient staff

Referrðl ðnd advice for oatienton follow-uÞ and futurenanôgeænt.

fREAT14ENT

Provide qual jfied Personnel

to man anbulance servjces.

Trjage, first aid, redic¿l

treatrent and use ofemrgency equi prent.

liajntâin patíent's condition

and comfort Treatrent and

resuscitation as required.

Treatrent continued until Patient

receives nursing & mdical care.

Resuscitation and erergencY

redical treatrent as requíredi

observation of Datient

throughout casualty cðre.

Ensure comfort ànd

staÈilizà!ion of patient's

condi ti on.

TI'IERCENCY CARE SUBSYSTEI¡ INTERFACES

l0cu,4il{fAfi 0N

Stàrt ambulance record:

includes diso¿tch tires'mi leðge readi ngs.l ocàtion

and other service dàta.

Stðri disoatch record

includinç data reì¿ting to

site ¿nd t-vDe of incident'

urgency of.all and tìæintervals.

Record arrival tiÉ : colmnce

record of pôtient iniuríes,condition, treatrent etc.Record service dàt¿ in

ànbulance records.

RÊcord depðrture ti@spatient condition and

tÉatrent.

Casu¿l ty æcord comnced.Ambulance reoort fom lodæd

Record detaiìs of o¿tient'shi story,exômi nôti on ànd

treatænt in case record.

Record cì i ni cal condi ti on on

a continuing basìs.

Complete cèsuèì ty docurent-

àtion ànd Éferraì notes-

Fig. 3.7 Emergency Care System Events.

61

Chapfer 4

THE STUDY OBJECTIVES

An lmporïant stlmulus to the planning and dosign of lhisstudy was the dearth of information avai lable fo administrators and

planners of emergency services. Al the time the study was commenced,

lhe only operationaI dala normaI ly reported by fhe ambulance service

were fhe number of ambulance trips performed annually and the pro-

porlion of emergency and non-emergency trips within lhat group. No

details were available on the types of emergencies atlended and llttleinformation was ava í lab le on such importanf operaf ional characteristlcsas the elapsed times in the various phases of the ambulance call. Much

basic service information was not avai lable to administration. ( ltshould be said, however, lhaf recording procedures have since been

upgraded and many of these data are now recorded. ) Simi larly, hospitalrecords did nol provide detaîled breal<downs of the lypes of cases

treateo in casualty, although the inforrna'tion cculd be determined by

special studies of existing medical records. Many detai ls of patient care

in casualty were, and sti I I are, unavai lable from existing records.

Hence, in early 1969, tltis study was undertaken wilh lhe aim

of gathering data relal-ing to the i:mergency care of road crash victimsin the Melbr:urne metropolitan arÉ)a. This thesis records fhe study

findings and provides an analysis of the available data, with the

fo I low ing ob.iect ives.

The first and major objective ls to describe the emergency

care system as il operales for road crash viclims in an area of Melbourne.

The services involved and fheir inleractions were discussed in the pre-

ceding chapter and the performance and contributiorr of each to the over-all system operations will be reviewed in detail in a later sectlon.

The second objeclive is to describe the patterns of injurysustalncrd by víclims of a sample of metropolifan crashes and to discuss

62

the care provided for those patienfs from the scene of the crash untilthe completion of thelr emergency treatment.

A third aim is to evaluate tho qualily of the firsf aid and

emergency medical care provlded for fhe crash victims, by relating the

care performed to the standards of care expec'fed of ambulance and

casualty servlces in Melbourne.

The fourth objoctive is lo determine the time delays exper-

lenced by patlenfs during the various phases of emergency care and to

relate fhese <Je lays in the sc;parate treatment phases 'io the totalsystem times. To complemont this descriplion, a slmulatlon model willbe used to study fhe possiblo effecls of certain organizational changes

on time delays during patienf flow through lhe hospital casualty

depa rtment.

The f inal objective of fhe sfucly is to ideni-ify def iciencies

in presenl operations, to recommend methods of overcoming these defic-iencies, and to examlne the probable effecfs of these changes on the

emergency care system.

63

Chapter 5

THE STUDY I"IETHOD

ln plannlng this study, it was declcled to observe the care

provided for a sample of road crash vicfims al the scene of the crash

and dur i ng ambu I ance and casua I ty trr:atrnent. D i rect observat ion by

physicîan observers v¡as choserr as the method of sludy because of the

need, as d¡scussed in Chapter 2 of this thesis, for evaluatíons of fhe

quality of emergency care using operational criferia. Measurernenfs of

time delays during the various phases of care are nol available from

existing ambulance ancJ hospital records and Thus specÎal study was

necessary to oblain this imporlant data. Furthermore, the dirr-'ct

observation method permits evaluation of the appropriateness and

qualify of lhe care provided for the injured. Although several of the

disa<Jvantages of this me'thod of s1'udy wcre inevifably involved - small

sample popula'l ions, possible observer bias, questions as to the¡ valldity,rel iabi I ify and reproducibi I ity of the observations - lhe advantages,

notably the accurafe recc.rrding of 'lime data and the use of operational

criferia for the assessrnenl' of quality, were felt to far outwelgh any

dísadvanlages of the methocl. Moreover, by wor^king in close contact with

the various emcrgency services, it was possible for the observers togain aclditional insight and exporience of 1'he problems facing each ofthe services in providing emerqency care.

Dala were qalherecl on two sample potulafions during two

dislincl study phases.

Phase one. lhe on-scenc sfudy, involved the attendance of a

research team, consisfing of Dr. G. A. Ryan and lhe author, at fhe

scenc of a sample of 100 road crashes in an area of Melbourne. These

crashes were attended between August 4,. i969 and February 7, 1970.

Phase fwo of lhe study involved a more intensive examination

of the medical care provided for crash victims within lhe casualfy

64

deparlmenl of tho Alfred Hospilal. The study was performed by the

author, as sole observer, between itay 25, 1970 and December 12, 1970.

The sampl ing methods varied between the separate phases and

thus each study phase is considered separalely in the following cliscuss-

lon of thr: study methocj and sampl ing procedures.

THE STUDY DESIGN: PHASE ONE

(l) Emerqencies in M¿+lbourne

ln order fo determine the pattern of ambulance emergency

cal ls, and 'thus the patfern of occurrence of injury-producing crashes

in Melbourne, the records of tho Vîctorian Civi I Ambulance Servlce(V.C.A.S. ) for the months January fo Apri I 1968 were analysed. Unfort-unately, the V.C.A.S. records for lhis period dld not differentiateroad crash calls from other Êmergency calls made on the ambulance

service. Thus drug overdosôge, drowning, d<¡mestic accidents, and

rnedical conditions such as myocardial inf'arction which require urgent

ambulance attendance, were inclucled with the road crashes in a general

omergency category for ambulancc recording purposes. Each emergency

call could be identif ied from the records. lnformation on the time ofnolif ication of each call, the localion of the incidenl, and lhe hospital

to which the persons involved were subsequently taken was recorded.

During the period under revicrw there were 3,701 such emergency

calls in fhe area def ined by the Sands and MacDougall Postc<¡de l4ap ofMelbourne and Suburbs. These accidenfs werè plotted on tlre rnap and each

vvas given co-ordinates locating it lo a map area of { square mile. ln

addition tho time of occurrence of each emergency by hour of day and

day of week was recorded, along with the hospital to which the injured

victims were laken. Thîs coded informafion was punched on B0 column

cards, verified and anaIysed, usirrg lhe CDC 3200 Computer at the Monash

University Computi ng Centre.

01 ()2 A3 04 ¿r5 dd 07 0B 0g 10 11 12 1s 14 16 18 1?

ù1

o2

03

o5

Ò7

o8

o9

10

11

13

14

16

17

18

19

20

24

27

28

29

30

34

38

40

41

42

PORT PHILIP BAY

No. EíErgencles/ ! Mlìe Square

Fig. 5.1 Ambulance Emergencies 'in

Melbourne: January - APrÍl ' 1968.

I

3

2

4

12

6

8

5

3

7

t0

4

4

2

2

12

B

't7

l91l

t2

lìI6

7 ì061l1 4

7

7

2

34

75

't0

21

l724 I

2

't8

l0

352832528

12't4

?

6

4

6

3

1

4

4

7

3

4

3

43

4

2

'I

2

?

2

4

533

36

224

6

1t

'ì

5o 3 4

5bl1?

10

9

l8

I9

7

'Iì6

'ì8

26

?8

Il?2

7

6

6

'tl

ll812

40

56

ô¿

2

I

ì

3

,l

6

5

3

2+

5

4 ll

43

28

ll4

I

2

3 5

6

4

2

1l

2

I 6

6

I

37

'ì3

78

53 I

I

2

3

5

t3

20

29

6

7

3

3

5

I6

6

I

2

.-3

r6l35

4

724l88]s 12

4

65

The data were used lo examíne lhe distribution of V.C.A.S.

emergency calls in time and space, and determine fhe pattern of accidentoccurrence as a pre-requisite to the derivation of a suifable sampling

plan. The computer map of these 3,701 accidonts is shown in Fig. 5.1.The map demonstrates lhe concenlralîon of emergency calls ín the cenfralcity aroa, with a gradient of decreasing frequency extending from fheinner urban areas to thc; outer suburbs. Concentrations of emergency

calls were noted along the lines of major highways, presumably reflecf-ing lhe signif icant contributic¡n of road frauma lo the tofal number ofemergency cal ls. Simi lar maps were produced to relate the site ofoccurrence of each ernergency to the hospital to which the patients were

transported, and a geographical twatorshedt arêa was demonstrated foreach hospilal. This, no cJoubt, reflectod tho result of lhe ambulance

service policy which required that each patient should be taken lo thenearest publ ic hospital for emerqency care.

The distrlbution of these emergencies by hour of day of week

is shown in Table 5/1 (see p.66). The concenTration of emergencles

during the daytime hours and particularly during peak road crash periods

in the evening hours on week nights, and the late night and early morn-

ing hours on Friday, Saturday arrd Sunday confirm the lmportanf contrlb-ution of road crashes to this group in addltÌon to reflecting thepaftern of road crash occurrence which has been demonstrated by ofherstudies in Austral ia. (Robertson et al., 1966; Jamieson et al., 1971.,

A sampling plan for uso during the on-scene study was derived

f rom this analysis of V.C.A.S. emergency calls. The following sectionsdescribo the choice of the study area, Ìhe sampling schedule, and the

method of operatíon of the research team"

66

431724604527447499469TOTAL

39

52

26

18

6

5

I6

5

3

16

25

l6l026

14

23

29

31

12

20

l5

15

tl

31

15

1B

16

4

6

Illl4

l8

41

34

37

33

30

38

44

45

45

56

44

32

48

56

22

B

6

7

6

4

I12

26

15

22

24

24

l9

30

36

37

3B

35

51

37

49

55

33

13

9

4

2

0

2

3

13

26

21

21

?.6

29

20

27

20

37

39

33

40

33

26

52

31

5

5

2

2

3

4

-Q

11

17

17

15

16

20

33

33

23

39

49

22

3l

31

16

25

19

10

I4

1

1

1

5

20

31

22

25

32

23

35

24

28

3B

42

33

19

22

30

33

12

13

5

5

6

1

6

6

1B

26

24

17

24

31

23

50

29

35

32

19

31

23

22

29

14

00..00.59

01-01.59

02-02.59

03-03.59

04-04.59

05-05. 59

06-06,59

07-07.59

08-08. 59

09-09. 59

1 0-1 0.59

11-11.59

12-12.59

13-13.59

1 4-1 4 .59

1 5-1 5.59

16-16.59

17-17.59

1B-1 8.59

19-19.59

20-20.59

21-21 .59

22-22.59

23-23.59

Sun.Sat.Fri.Thur.WedTues.MonHour of Day

TOTAL NTMBER 0F EMERGENC I ES z 3,7O1

fable 5/1

vlcTORlAN CIVIL AMBULANCE SERVICE EMETENC|ES: Jan. - April, 1968

NUMBER OF EMERGENC IES PER HOI.IR OF DAY OF WEEK

67

Q) The Sample Area

The study method requ i red the observers to be present at fhe

crash scene to view fhe firsf aid and emergency care provided forvîctims, and thus limited lhe area of the city whlch could L¡e covered

by the research team. After analysis of the ambulance records it was

decided lo study crashes occurring ln an area bounded by the Yarra

River, Gardinerrs Creek, Toorak Road easf of its junctlon wlth

Gardinerfs Creek, Huntingdale Road, North Road, V,larrlgal Road and Bay

Sfreet, to rejoln tho coast of Port Ph¡llip Bay at Beach Road,

Sandri ngham.

This area was selected for the fol lowing reasons:-

1. The study area lay wholly within one of the V.C.A.S.

operational divlsions. Thus only one radio frequency

required monltoring.2. The area encompassed al I types of urban traffic situations

and included areas of varying demographic characteristics.3. The Alfred Hospifal and Princo Henryts Hospilal, both of

which are teaching hospitals for the Monash Medical School,

receive crash victims from the-area. lnjured persons from

crashes occurring near lhe eastern boundary of tho area

may be taken lo lhe Box Hi I I and Distrlct Hospital.

These hospitals, the area concerned, and the dlslribution of

the 100 sample accidents within that area are shown in Fig. 5.2.

(3) The Sampl inq Schedule

The distribution of emergencies in time and space, which was

dervied from fhe analysis of ambulance records, allowed fhe design of a

pilot s'tudy in which the research team were able to test and develop

lhe proposed study plan. The fol lowing woekly shifts were worked during

this period. Crashes were attended in Week 1 from 0800 lo 1300 hours,

in Week 2 Íron 1300 to 1900 hours and in Week 3 from 1900 to 2400 hours

Og TO LL t2 L3 14 L5 L8 L7

0t t2 t3 j'4 )s c6 07 08

OL

t2.

t4

tea7

o8

o9

LO

LL

L3

L5

Lb

L7

L8

20

2L

24

26

27

28

29

30

3L

34

35

38

39

40

4l

PORf PHILIP

BAY

IIo. OF CRASHES/å I:ILE SQUARE

STUDY AREA

A - ALFRED HOSPITAL

P. PRINCE HENRY'5 HOSPITAL

B - 8O)( HILL HOSPITAL

.l-ã-l

Fi g. 5.2 The D'i stri buti on of the

Study Crashes in the SamPle Area'

II¡III

2

2

2

IIII

-J

4

6l

@

6B

on lvlonday to Thursday. ln Week 3lhe evening perlod on Friday and

Saturday was extended to 0300 hours lhe nexl morning. This schedule was

designed to maximise the number of crashes investlgated and t<¡ ref lectthe pattern of crash occurrence for the area under study. At the com-

pletlon of the pilot study, lt was decided lo aller the working schedule,

since lhe number of crashes attended was less than had been expocted.

Only 15 had been studied, an average of less than one crash per study

per iod .

A new sampling schedule was used, with periods from 0800 hours

lo 17û0 hours daily excluding Sunday, and evening periods from 1700 to2400 hours on l.londay To Saturday. The evening periods on Friday and

Saturday nights were extended to 0200 hours 'the following morning.

Alternate wecks of night and day shifts were: worked. Sundays and one

other weekday which cycled from l4onday through Thursday vvere rostered

as days off duty. Every Friday and Saturday was worked. These schedules

were rnaintained from Augusl 4, 1969 to February 7,1970, spannÎng wintor,spring and summer months in Victoria and including the holiday Chrisltnas/

New Year period. The days and shif-l-s worked during the period are shown

in Table 5/7-.

Table 5/2

DAYS AND TIMES WORKED DURING THE SAMPLE PERIOD 4/8/69 - 7/2/70

Tota I

70

59

12926261BIB1922TOTAL

l4

12

14

12

10

B

10

I

il

B

11

ll

'Day0800 - I 659

Night1700 - 24001700 - 0200

Sat.Thur. Frí.WedTues.Mon.

69

(4) Seleclion of the Crashes

An essential feature of the sample plan was that the team

should attend the first crash which occurred duríng the sample periodwithin lhe area under study. Thus, since fhe nature of the crash was

nol known before arrival at the scene, the sample of crashes obtainedshould be represenlative of lhe range of types and severity of crashesoccu rr i ng .

lf the in'¡estigation of a crash was completed before the end

of a study period, the team awailed fhe occurrence of lhe next crashwithin lhat period. ln practlce, due to the long delays involved infol lowing the viclims during their stay ln hospifal, it was not possîbleto investigate more than fwo crashes in any single study period. lnpractice, fhe number of crashes studied in each working period averaged0.8 over the entire study period.

(5) Operation of the Research Team

The method chosen for the sfudy required that the team shoutdlravel lo the scene of a sample of injury-producing crashes in a seloctedarea of Melbourne. For the purpose of the study an injury-producingcrash was defíned as any road crash to v¡hich an ambulance was calledwithin the study area during the time fhe team was on duty. whilst fheco-operation of the ambulance service was essential for the me"thod

chosen, it was considered importanf'lhaf the team should not be depend-ent on that service for transport to the crashes. llence, to make indep-endent travel possíble, the Department of Social and Preventive Medicinepurchased a car equipped wilh a two-way raclio tuned to the ambulancefrequency. The car was equipped with warning devices (a flashlng I ightand reflecting lriangles for protection at fhe scene), a f irst aid kit,photographic equipment, sphygmomanometer and cJata recording forms.

During the times on duty, as dofermíned by the sampling plan,f he team rnon itored lhe arnbu I a nce rad i o conÌ i nuous I y. To ensure lhat

70

the response time to calls was as small as possible, the team wailed inor near the car, which was kept slraiteglcally placed within the study

area whilst nol actually invesligating a crash. ln this way the prob-

abilify of the team reaching the site of a crash before the ambulance

was increased. lt was arranged with the ambulance service that the

controller should dlspalch lhe rcsearch vehlcle at the same time as

he sent the ambulance to a crash. The feam arrived at fhe scene bofore

the ambulance on 25{. of occasíons, at lhe same lime in 14fi of callsand after lhe ambulance in thc remairrlng 6l#. lrrespective of the

separaì'e arrival patterns of the team and ambulance, if was a require-

ment for sludy of a case lhat the team should Lre able to vlew f lrstaid anc] palient care at tho scene. Thus even in those cases where the

team arrived aflor The ambulance, the llme differencos were minimal

ancl did not preclude inclusion of the case in the sludy.

There were occasions whe¡n the team arrived at fhe scene too

late to observe firsl ald and emergency caro and lhese cases were

excluded from the sample. No detailed record was kept of the frequency

with which lhese cases occurred, their type or the severity of fhe

injuries of those involved. lt is eslimated that less than 5 per cent

of crashes were discarded for such reasons and that those discarded

were predominantly minor crashes involving minor injury. This exclusion

policy wes nof considerc¡d to be a major source of bias in fhe sample.

At lhe sconc of the crash one member of the team was respons-

ible for gathering data on the mechanisms of injury and the crash con-

f iguration as well as obtaining informa'tion from bystanders, Police and

other emergoncy service personnel. The second obsorver v/as thus free

to concentrate on lhe first aid an<l emergency care provided for the mosl

seriously injured victims. Neither observer was directly involved in

the provision of medícal care at the scene and observer interference

with the work carried out by emergency services personnel was kept to a

min imum. ln add it ion lo observing the emergency care of injured vlctlms,

à tfI Þ a a

(,k

3 'ì¡

1

a

\ì

ta I l-

\ ,).

__.{¡¿

ç,,.r;-4 J-.

.. --t.l

.,,\'.- d" .-- '.;-$..* þ-.:

gperat.ion 0f tire Research Tearn : Examining a Victjln at the Cra.sh Scene.

71

measures of pulse, blood pressure, pupl I lary reactions and state ofconsciousness were obfained for each victim at the scene, usually afterthe ambulance officors had completed their initlal assessment of fhe

v i ct ims.

ln practice it was possible for such observations to be made

wilhout ínferfering with the work of fhe ambulance and first aldpersonnel. The ambulance offîcois were aware of the survey as belng a

study of crash injury, lts causes and its effects on fhe patient, and

were aware that if was not the observerrs intention to partlclpate inproviding medlcal care at the scene. 0n two occasions the obsorvers

were obllged to assist when no other help was available. Vlhllst thereis always the posslb¡l¡ty that the presence of the observer ls lik.ely lolnfluence the practlces under observafion, ln fhe busy sltuallons thatare usual at the scene of crashes, observer influence on the system

was felt to be smal l.

All persons involved in the crash were inlervlewed at the

scene. The observed populafion thus included fhose wlth no or mlnor

inJury, as well as fhose whose injuries were sufficienfly severe fowarrant their being laken lo hospttal by ambulance. After first ald atthe scene had been comploted and the victlms placed ln the ambulance

for transport to hospital, fhe team followed the ambulance fo the

casua I ty deparl'ment.

It was not possible for a member of the research team toaccompany tl're patienl to hospital ln the ambulance. The board of the

V.C.A.S. preferred lo have the obsc¡rvers travel lndependently of the

ambulance at al I limos. Hence the procoss of ambulance care during

transport and the effect of the ambulance ride on the patient could not

be assessed.

After arrlving at fhe hospilal, the team observed tho

72

procedures associated with the patientfs transfer fo the casualty

department and continued to observe the patient throughout his medical

care in the department.

A detai led physical examinalion was performed by one of fheobservers after the pationt had been admltted lo tha casualty depart-ment, to complement the roadside dlagnosls and complete the injurydescrlpllon for each patienf.

Significanl events were recorded in each phase of treatmentas they occurred. The patienlfs conditlon was monitored with quarter-hourly estimalions of pulse rate, blood pressure, pupillary reactlonsand state of consciousness.

All evc¿nfs rrJere recorded on work sheets, using a time base

for al I lmportanf treafment events. Time intervals befween the varloustreatment phases h,ere recordod during bolh ambulance and casualty care.It was fhus possible to build up a picture of llme delays ln the variousstages of the emergency care cycle, and to relafe them fo the overallsystem. Simultaneously, judgements on the appropriateness of the care

and the performance of the professionals providing it were made by theobservers.

Each palient was observed until his medical care in the cas-

ualty department was completed. The research team was then free toatlend anofher crash should it occur durlng the remalnder of lhe dutyperlod. Those victlms of crashes which occurred towards the end of theduty periods were obsorved unli I their dlscharge, whether this event

fell vrilhín lhe samplo period or not. Thus, if a crash was attended af0145 hours on a Saturday morning, lhe patients concorned were observed

durlng the course of their emergency care although lhis lnvariablyextended well beyond lhe end of lhe sampling period at 0200 hours.

73

THE ST DESIGN: PHASE TV'IO

(1) I ntroduct i on

Analysis of lhe data col lected during the on-scene study of

crash operations indicated lhal lhe care provided for patients within

hospital casualty deparfments warranted more intenslve investigalion'

The major anphasis of the first study was directed at lhe

investigation of emergency care outside the hospifal and the operafion

of emergency Services at the scene of the crash. Slnce an lmporfant

objective of lhe study was to obtain an overview of the emergency care

syslem, il was logical lhat the focus of thls second phase of fhe study

should be fhe care provided within lhe hospltal emergency department'

A further stimulus for this more intenslve study was the teamrs impress-

ion, backed by a preliminary analysis of the data collected during lhe

on-scene study, that dsficiencies in care within hospital casualty

departmenls had important implications for lhe oporalion of the emerg"

ency care system as a whole, and pa¡ticular relevance for lhe plannlng

of any changes in fhe systom which may be undertaken. Hence if was

decided thaf lhe author should undertake a more detalled analysis of

lhe care of a sample of road crash victims during their treatment in the

casualty deparlment of the Alfred Hospifal '

The Alfred Hospital was chosen as the site for this more

intensive sfudy for several reasons. First, lt is the maJor toaching

hospilal for the trealmenf of road crash vlcfims in the area chosen for

the earl ier, on-scene study. secondly, the analysis of v.c.A.s. emerg-

encìes which was conclucted during Phase one of lhe study showed fhat

more emergency patients werej'aken to the Alfred Hospital than to any

other hospital in the clly. Furfhermore, the Alfred is renowned for the

busyness of lts casualty deparfment, and for the large numbers of roacJ

accident victims who are treated in lhat department (and, subsequently'

as in-palients in the hospital). Thirdly, the casualTy department of

the hospital is relatively new, having been buí lt ancl equipped as part

74

of an extenslve rebuilding of the hospital which is still in progress.

The department thus has the advantages over fhe other deparfmenfs

studîed in Phase One of being well equipped, of modern design and

compact. A patient admitted to the Alf red Hospital fol lowing a road

crash receives all phases of his emergency medical care within fhe

casualty department before being admitfed to lhe wards for elective

treatment. ,Moreover, the ambulance bay, clerical documentation section,

admitting office and X-ray department are built around a cenlral cas-

ualty lreatment area, and it was thus possible lo maintain close sur-

vei I lance of more than one patienï concurrently.

Q) The Samp I i nq Schedu le

Experience in Phase One of the sfudy combined with a review

of the casualty admission records of the Alfred Hospital resulted in the

use of a sampllng plan similar to fhaf used in the on-scene sfudy.

Sundays were included as sampllng days in thls study to permil analysls

of casually operations throughout the week. Sampl ing limes used during

each day of the week were similar fo thoso worked during the on-scene

study, with the addítÎon of fhe Sunday periods as shown'

DAY SHI FT

MONDAY-SATURDAY:0800hoursto1700hoursSUNDAY: 1000 hours to lB00 hours

N IGHT SH I FT

MONDAY-THURSDAY:1700hoursto2400hoursFRIOAY/SAT. - SAT,/SUN.: 1700 hours to 0200 hours

SUNDAY: 1800 hours to 24OO hours

As in lhe on-scene study, evêry Friday and salurday were

worked. Two days were rostered off duty each vJeek, rotafing from Sunday

through Thursday. Allernate weeks of day and night shifts were worked

throughoul the studY Perlod.

The samplÍng period extended f rom l4ay 25, 1970 unlll Augusf 12

and from September 1B unlll December 12,1970. The numbers of days and

75

nights worked during this period are shown in Table 5/3.

lable 5/3

DAYS AND SHIFTS WORKED DURING THE SAI4PLE PERIOD 25/5/70 - 12/12/70

11914242413l41614Tota I

59

60

B

6

12

12

1'2

12

6

7

6

B

B

I7

7

Day Sh i ftNight Sh ¡ fl

Tota ISun.Fri. SatThu r.Wed.Tues.Mon.

(3) Selecfion of Study PatientsPatferns of arrlval of road crash victims in the casualty

department of the Alf red llospital were obtained by analysis of tho cas-

ualty admission record. This pattern, coupled with experíence from the

first phase of the study, resulted in the decision being taken foobserve al I crash vlctims admitted during the study hours.

The observer vlas present in casually throughout the duty

periods to await the arrival of road crash vicfims. The first victimto arrive in the department after the beginning of a dufy period was

identlfied on arrival and his subsequent nlanagemenl observed. Crash

pafients who were already in lhe department at the tíme a study perlod

commenced were nol included in the sample. Al I subsequent crash victimswho arrived during the duty period were included in the sample and ob-

served unti I their emergency care was complele. Occasional ly, several

patienls arrlved simultaneously. Whilsl this situation made observatlon

difficult, it was found that concurrent observalion of several victlmswas feasible because of the compacf design of the casualty deparfment.

Nevertheless there were rare occasions, parlicularly late on Friday and

Saturday nights, when it was not possible to observe all the pafients who

were admitted. 0n these occasions il was found lhat a maxÌmum of three

pafienfs could be observed concurrently.

76

Three hundred and twenty-elght victlms were admitted to the

casualty department during the study perlod; an average of 2.8 patlentsper duty period worked.

(4) Dala Col lecf ion Methods

This phase of the study was considereC complementary to the

first phase and dlrect observatlon of the care provided for a sample ofpatients was selected as the method for col lectlng data. The author

acfed as the sole observer, recordlng the patientst lniuries, cllnicalcondltion and managemenf throughouf their casualty care. Slnce the

observer had no other clinical responsibllities if was possible for hlm

to be present whilsf the patient was being admitted lo the department by

lhe nursing staff, examined and treated by fhe docfor on duty, and trans-ported between the various areas of the departmenl by the medlcal order-

lles. Patients were also observed whilst receiving X-ray and other

díagnostic and treatment procedures.

A plan of management has evolved for all patients admltted fothe casualty department for dlagnosls and frealrnenl. Since crash

victims form a sub-set of this larger group, ll was posslble for the

observer fo document the various slgnificanl evenfs whlch occurred

during the patientrs care ln a structured manner withouf interferingwith fhe medical or nursing staff who were actually looking after him.

This sysfem of management is described in detail ln a later chapter.

Mosf patients who are admltfed to casualfy departments exper-

ience waitlng times of variable lengfhs between the various stages of

lheir care. During these tfmes it was possíble for fhe observer to

obtain a history and perform clinical examlnatlons on the study vlcflms.

The history obfained from the patlent was supplemented by interviews

with tho ambulance officers who had brought the patlent fo hospital.

Consequently informatîon about the type of crash, its sife, the condlt-

lon of lhe patienl and treatmenf provided bofh at the scene and duning

77

transport was galhered. Whenever possible, conlact was made wíth

relatives or other persons who may have accompanied the pafient to

hospitol, and the políce, who f requently înterview victims in hospital.

As a resull.of these enquirios it was possible lo obtain a

piclure of both the crash and the emergency care provided outsíde the

hospilal, to supplement lhe observations made wi-lhln the hospital.

As in Phase one of lhis study, the problems associated wlth

direcl observation of care were presenl in thís Phase. ln this regard

the observer was fortunate in that tho second study followed closely on

the first. Casualty staff, who were acquainted with the study from our

previous contacts, regarrJed the observer as another membor of staff and

thus accepled his presence.

lndividual patíerrls were observed in a manner similar to fhat

describcd for thc casualty care section of the first phase. A continuing

rocord was kepl-, at approximately 15 minute inlervals, of each patienfis

pulse, bloorj pressure, slate of consciousness, and pupi I lary reactions.

Olher relevant infonnation relating to the patientrs injuries, condifion

and treafment was notecj.

Procedures and signifîcanl events were recorded on a Time base

and informatlon relating to specific aspects of departmental operation

was col lected and codcd in pre-designated categories. The waiting and

service tlmr:s withín the department, the numbers of sfaff in attendance'

the numbers cf patients receiving and awaiting treatment, work loads on

the respective services, and the equipment and facililies used in troat-ment were recorded.

Particular emphasis was placed in lhís second phase on record-

ing the time spenl in the various lreatment stages by each patient and

on assessing the quality of the care provided for each patient.

78

The observer assessed the qual ity of emergency care by compar-

ing the care actually performed by the casualty staff with that expected

of provlders of emergency care as defined by fhe Alfred Hospitalrs pro-

cedure manual I lnstructions for Casualty Residentsr, and the standards

for the management of road traffic casualtîes defined by the Royal

Australasian Col lege of Surgeons (1970), The performance of each treat-ment procedure was assessed according to predetermined criteria(Appendix 5) based on the melhods used by Peferson (1956) and Clute(1963).

As an oufcome measure of the qual ity of care, 313 of the 328

patients who were observed during this phase of the study wore invitedfo complete a postal questionnaire designed to assess their attitudesto fhe care they had received in casualty (Appendix 4).

Fifteen of the patients were not included in thls sample,

either because they had died as a result of their inJuries or because

their postal addresses could not be determined from study or hospital

records.

Three hundred and thirleen questionnalres were posfed at the

end of January 1971, two months after the lasf sampling day and approx-

imately eight months from the beginning of the sample perÎod. One

hundred and thirty replies were received fo thls firsÌ malling. At fhe

end of March a second mailing wes performed in whlch fhe non-respondents

were invited to complete an identlcal questionnaire. A further 53

replies were received, making a tofal of 183 respondents - a 5B/' overall

response rate.

Each patientrs questlonnalre was identified try lhe five digitpatient identlflcafion number and thus repondents could be identified.Date from fho questionnaire were added to the data file for each paflent

and il was thus possible to compare questionnaire dafa wifh other data

gathered during the direct observatlon study.

79

DATA RECORDING AND PROCESSING

Record i nq Forms

Data were rocorded on pre-codod forms i n each phase of thestudy. Scparate data forms were used for crash and pa'l'ient data duringthe first phase. Tho crash data form recorded data relatlng to each

crash and thrs performance of the emergency services at the scene. A

patient record form was completed for each person involved ln fhecrash and included data describing the patient, his injuries and thecare provided for lhose injuries from the scene of fhe crash until fhetime of the patientrs discharge from fhe hospital casually department.

ln the second phase, a palient data form was compleled foreach new road crash vicfim admitted to the casualty department. The

form was similar to thal used in the first phase of the study wíthmodifícations to allow fho recording in greater detail of fhe qualityof the care provided for the patient.

Data Process i nq

Data from fhe first phase uiere coded and recorded sfraighton to computer disc files. The recorded data were veriflod by compar-

ison with the original dala. The disc f lles were¡ transferred to magnef ictape and these tape files were uscd for subsequent data procêssing and

analysis. A card deck was punched by the compuler from the tape file,to provide a hard copy for minor sorting and security purposes.

Data from Phase Two were coded and punched on to B0 col umn

cards. The cards were verified and punchÌng errors corrected aften com-

parison of the output with the oríginal data. Tho coded data were

transferred to magnetic tape fi les for data processing.

All sortlng and analysls of the data was undertaken usîng thefaci I ities of the Monash Universíty Computing Centre, predominantly theRemofe Terminal Monitor sysfem I inked with the Centrers CDC i200

80

computer. The programs used were writfen by members of the Departmenf

of Social and Preventive Mediclne.

DEFINI TIONS USED IN THE STUDY

I n.i u ry C l._a_ss i f icat ion

An important variable, which wll I be used frequently in the

following analysis, is the degree of injury sustained by each crash

victim. A scale of impact ínjury, based on the classlf ication used by

The Automofive Crash lnjury Rosearch section of fhe Cornel I Aeronautical

Laboratory lnc., and modified by Robertson ef al. (1966), was used to

assess the severity of injury for each patient. The scale and corres-

ponding lypes and degrees of injury are I isted below'

I n iury Type

1

2

No I n iurv

Uj norlniuries

Ug!_era+e.ln iuries

(1)

Q)

(3)

(4)

(5)

Contusions and abrasions in any area(s) of the

body, superf icial lacerations.

Spralns, fractures, dislocations of fingers,

loes or nose.

Mild concussion wifh no loss of consciousness'

Teeth loosened, broken or knocked out.

Whiplash (unqual if ied).

3(1)

(2)

rDoepr or tdisf igurl ngt laceratlons.

Sprains of sfralns of joints or spine;

I i gaments.

Simple fraclures of bones other than

(a) skull(b) spine(c) pelvis(d) fingers, toes and nose.

I n.iuj^yDeqree of

(3)

torn

Deoree ollniury

3. Moderate

81

I n.iury ïype

Concussion wifh unconsciousness not exceeding

f i ve m i nutes . No ev i dence of other i ntra-cranial injury.

Stra i n or spra i n of neck musc I es.

Compound, comminuled fractures of fingêrs, toes

or nose.

Extensive laceratlons wlthout dangerous

haemorrhage.

Compound, comminutecJ, or simple fractures with

displacement of bones other than(a) skul I

(b) spine(c) fingers, toes or nose.

Disloci:tion of extremif ies (arms, shoulders,

legs, pelvis).Fracture of transverse and/or spinous processes

of spine without evidence of spinal cord

damage; sprain or strain of splnal I igaments.

Simple fractures of verfebral bodies of dorsal

and/or lumbar spine without evidence of

spinal cord damage.

Compression fraclures of L3, 4 or 5.

Skul I fracture without evidence of concussion

or other intracranial injurY.

Al I pelvlc fractures.Loss of eyo.

Concussion with loss of consciousness from

5 to 50 mlnutes wifh no evidence of lntra-cranial damage.

Amputation or crushing of fingers and/or toes.

lnjur.ig-(cont. )

(4)

(1)

Q)

(5)

(6)

4

nof endanqer-inq life

(3)

(4)

(5)

(6)

(7)

(B)

(9)

(10)

(11)

I n iury TypeDeqree ofI n.iurv

5, Very SevereJn.iury

(1)

(2)

82

Lacerations with dangerous haemorrhage.

Fractures of vertebral bodies or of the

cervical spine.

Compression fractures of vertebral bodies of

dorsal spine andlor of Ll and 12,

Crushing of exfremilíes (not fingers or toes).

Evidence of intra-thoraclc or intra-abdominal

i nj ury.Skul I fracture with concussion as ovidenced by

loss of consciousness of 5 mlnutes fo 2 hours.

Concussion as evidenced by loss of conscious-

ness from 30 minutos to 2 hours without

evldence of other intracranial injury.Depressed fractures of skul l.Amputation of majcr extremities.Evidence of critical intra-cranial damage.

= Nol significanl= gignificant at the 5É lovel

- Signíficant at the 1Í level

= $ignif icant at the 0.1tÚ level.

(3)

(6)

(4)

(5)

(7)

(B)

(9)

( 10)

6 Fafa I Deqreesof lniurv -

(fafal wlthin30 days)

Slati sti ca I S iqni f icance

The fol lowing symbols are used fhroughout the fext to denofe

level s of statistical significance.

N.S.******

83

Chapter 6

TI]E CRASHES, THE PAT I ENTS AND TIjE I R INJ UR I ES

PHASE ONE

l. The Sample Crashes

Between Augus't 4, 1969 and February 7, 1970, 100 crashes

involvîng 310 persons an<J 174 vehicles were sfudîed. Ambulance records

showed that, during the same period, 2,501 emergencies occurred withinthe study area, of which 803 occurred during fhe lime the research feam

was on duty. These records did not differentiate the lype of emorgency

attended but an estimate of the proportion of road crashes among these

emergencies was obtained from a special study conducted by the ambulance

authorities <Juring one month in 1969. (V.C.A. S. , 1970, ) lf was found

in that sludy 1'hat road crashes formed approximately a0% of all emerg-

ency cal ls on Mondays, 50f" of the cal ls on Tuesdays, Wednesdays,

Thursdays, Fridays and Surrdays and 607l of emergency cal ls on Saturdays.

Thus, by adjusting the above figures, it was estimated that 1,264 crashes

occurred in the tolal population of 2,501 emergencies and thal 410

crashes occurred during the lime in which the study team was on duty.

The proportion of crashes studied was thus approximately 25% of allthose which occurred during the study poriod.

Table 6/1 (Appendix 1) shows the distribution of those emerg-

encies and estimated crashes by tíme of day and day of week. fable 6/2(Appendix 1 ) shows the dislribution of emergencies and eslimated crashes

during the sarnpl ing perîods. Table 6/3 (see p.B4) depicts fhe distrib-tribution of lhe sample crashes by four hourly periods for each day ofthe week worked. More crashes were observecl on Fridays and Saturdays as

a rcsult of the fact fhat more of fhese days were worked lo reflect thepaftern of crash occurrence whích peaks on these days. Tablo 6/4(Appendix 1) shows the time disÌribution of the study cases as a pro-

portion of the eslimated crashes occurring during the sfudy period. ltcan be seen that thcrc is variation from day fo day and hour to hour

with an overall 24fi sanple. The large variation betwet:n time periods is

84

due to the small number of cases in the sample. lt was orlginally ln-tended that the study should conflnue over a 12 month period and encom-

pass ovor 200 crashes. llowever, aftor preliminary analysis of the data,

it was decided lo terminate this phase of lhe study and concenfrate on

those areils of the system which had been revealed as warranting intensive

i nvest igat ion.

Iable 6/3

NUMBER OF CRASHES STUDIED

By Time of Day and Day of Week

429211391212TOTAL

7

17

18

33

25

43

4

7

5

10

2

1

9

9

4

3

4

2

2

2

3

2

2

3

6

1

3

2

6

0000

0400

0800

1 200

1 600

2000

0359

0759

1 15e

1 559

1959

2359

Tola ISat. Sun.Fri.Thu r.Wed.Tues.T ime Mon.

100

The distribution of lhe types of crash studied is shown ln

Table 6/5, There have been few sludies with which thls crash pattern may

be compared. The proportion of crashes involving motor cars only $1ß),Ïable 6/5

TYPES OF CRASH OBSERVED

100Tota I

44

1

4

1

2

7

7

I

2

22

Ca r/Ca rCarlTruckTruck/Truck

Ca r/Tram

Single Car

l4ultiple Car

Motor Cycle

Pedal Cycle

Pedestr i an

85

pedeslrians (22ß) and motor cycles U1%) are comparable wifh those

obsorved in an on-scene study of crashes conducted in Adelaíde in 1966

(Robertson ef al. (1966) but pedal cycle and 'lruck accldents are

relaliVely under-represented in comparison wifh the Adelaide experience.

A limiled comparison may be drawn be'l'ween lhe observed crashes and

f igures which are now available from the Viclorian Civi I Ambulance

Service. From the beginning of 1971 , a moc!if ication of V.C.A.S. record-

ing procedures made it possit¡le for road crashes to be idenfified frorn

the records. A special sludy revêaled thaf during the first three

months of 1971,2,284 road crash cells were attended by the service, of

which 577 (16.9%) were pcdestrian accldents. The only further sub-

division by type of crash in this analysis was the number of hoax callsQ..3fi) and calls in which the ¿rmbulance was nol required Q5.0Ð,Comparing these figures with those observed during the study, it can be

seen in lhe fcllowing Table that the proportions are similar for each

of the comparable categories and that lhe differences arê not statistlc-ally sif¡nif icanf .

Table 6/6

1 ,985399To1'a I s

100

2,284

7B

1 ,907

22

377

Study Crashes1969/70

V.C.A. S. Study1971

Tota IAl I OtherAcc i dents

Pedeslr i an

2,384

X 2.075, D.F. 1, N.S.

2. The PatientsThree hundred and len people were involved in fhe study

crashes, of whom 256 ß3í') were car occupantso 11 ß.51) truck occup-

ants, 13 ø.2%) no'ror cyclists including 2 pillion passengers, 2 (0,6fi)

pedal cyclists and 26 ß,4f ) were pedestrlans. Two tram drivers, bofh

2

B6

of whom were uninjured, complefed the sample of vehicle occupanfs. The

age and sex distríbulion for these persons is shown ln Table 6/7(Appendlx 1). Car occupants form Ìhe largest group, with males under 30

predomlnating. There were more females involved than males as frontseat passengers, rear seat passengers and pedestrians. With one except-ion, a female nr¡tor-cyclisf , motor and pedal cyclîsts were males. The

majority of car drivers were male.

3 . Pafferns of I n.iury'The

i nj ur i es of 1 9 of the 310 persons i nvo lved were notdocumented because they had left the scene and did not require treat-ment. 0f fhe remaîning 291 persons, 183 were injured. lnjurles were

classified by severify as descrîbed in the previous Chapfer. The over-all degree of injury for each maJor group of persons is shown ln Table6/8. Alnpst 100Í of motor cycl isls, pedal cycl ists and pedestrianswere injured compared with 601 of car occupants.

Table 6/8

DEGREE 0F INJ URY T0 THOSE PERSOI'|S

INVOLVED FOR EACH VEHICLE TYPE

Persons lnvolved fr:r Each Vehiclo Type

2262256

Tota I

108

131

28

16

1

4

19

1

t

13

I

7

4

I

1

1

1

5

4

3

4

7

102

105

23

6

3

17

N¡I

Minor

l4cderafe

Severe

Very Severe

Fata I

Not known

TramPeda I

CyclePedes-trian

MotorCycle

Truck

Degree ofI nj ury Car

TOTAL 11 13 310

Table 6/9 shows lhe frequency of injury toOf fhe 183 persons injured 7Ol' received head and 6Bf

The next most frequently ínjured body areas were fhe

thorax 24%, and neck Bf . 'Ihe average of 2.2 injuredinjured person is a paltern typical of crash injury.

B7

each body area.

lower I imb i nj ur ies.

upper I lmbs 38Í,body areas for each

Table 6/9

DEGREE OF INJURY TO EACH BODY AREA

Body Area M inor

No. of Porsons lnjured = l8jTotal No. of lnjured Body Areas = 405

Average No. of ln.jured Body Areas Per lnjured Person = 2.2

Thero were four deaths in fhis serles; al I were pedesfrians,

One sma I I boy who ran on to the road from between parked cars was sfruck

by a fruck. He was decapitated and clied instantly. ln the ofher case

three women were struck by one car lravelllng at high speed. They alldied at the scone and were found at post morlem to have sustained brain

lacerations, cervical spine fraclures with fransection of lhe spinal

cord, and mulfiple skeletal fractures among other lnjurles.

4. Seaf Be I tsThe seated poslTion of the car occupants involved in the

crashes is shown in Table 6/7 (Appendix 1). Seat belts were fitted in

128

14

43

2(,

70

124

3

3

5

2

6

3

1

4

I

3

7

30

2

7

4

4

87

7

30

19

63

107

Head

Neck

Thorax

Abdomen

Upper L imb

Lower Limb

No. I nJ urectBody Areas

Fata IVerySevere

Modorate Severe

Degree of lnjury

BB

92 oÍ the sealed positlons occupied, although only 10 people were wear-

ing'lheir belts at the time of the crash. None of those wearing belfs

sustained moro than minor injury. This study was conducted in 1969/70

before lhe inlroduction of the Victorian legislation in late 1970 which

requîred seat belts J'o be worn by all persons occupying sea'ts for whlch

belts were fitted. None of the vehicles involved in lhis seríes had

belts f ilted in the rear seats. Of the belts f itled 16$ were lap belts,75% were three; point bel'ts and 9dp wcre sash belts.

5. Alcohol

Assessments of the amounts of a I coho I consumed by those i n-

volved in a sludy such as lhis are diff icult. A combination of direclquestioning and observation of clinical signs was adopted as a meihod

of assessment folthe folloviing reasons. First, the team was dependernt

on the co-operation of thc patients for other dala relating to fhe

crash and their subsequenÌ care, and found that the legal overtones which

accompany quanlifalive investigations for the presence of alcohol

prejudiced lheir rc--lalionship with lhe patients. Secondly, such invtrst-

igations take more time than was available for such procedures within

the present siudy.Usi ng these criteria 32% of those i nvol ved had been dri nki ng

prior to lhe crash, including S4dp of drivers (Table 6/10). As expected,

alcohol was involved in more crashes during The evening hours and on

Fr i day and Sa-lurclay n i ghfs.

Table 6/10

ALCOHOL AND CRASH VICTIMS

Alcohol

28B27178B3Tota I s

34.1

30. 1

23.0

160

102

26

22

5

91

67

20

41

30

6

Dr i vers

Other vehicleoccupa nts

Pedestr i ans

þ Drt nKr ngwhere known

Tota INol KnownNo-l PresentPresernt

31 .8

89

PHASË ThIO

l. The Sample PatientsThree hundred and twenty-eighf road crash victims were ob-

served during the second study. Their pattern of arrival af thecasualty department for each hour of the day of the week is shown inTable 6/11 (Appendix 1).

Two hundred and sixteen (65.91,) of those examlned were caroccupanl's, 24 (7.31,) motor cyclisi's, 15 G.6%) pedal cyclists and 71

Q1 .6%) pedes-f'rians. One boy who fell f rom a trailer and one uncon-scious patien-t'for whom the fype of involvement could not be deter-m i ned comp I eted the samp I e. The age and sex cI í stri but ion of -lhese

victims is shown in Table 6/12 (Appendix 1). As in fhe Phase One

study, car occupants formed the largest group and were predominanflymale. Pedestrians were nepresented in almost idenfical proportions inboth samp I es.

2., Paflerns of ln iurvl-hree hundred and twenty-two of the 328 pationts had been

injurecl. The frequency of injury to each body area for the totalpopu I at ion i s shown î n Tab le 6/13,

Table 6/11I]EGRËE OF INJURY TO EACH BODY AREA

Body Area

Tota I Number of Persons I nj ured = 327-

Tofal Number of lnjured Body Areas = 684

Average Number of I njured Body Areas per Person = 2.1

245

22

60

44

131

182

4

1

1

4

4

2

?_

9

1

1

10

4

14

93

1

t1

24

12

135

20

43

3l

103

154

HearJ

Neck

ïhoraxAbdomen

Upper L imb

Lower Limb

Degree of lnjuryFatal i No. lnjured

I ao¿y Areas

90

It can be seen thaf the average number of injured body areas

per person is similar to thal observed during lhe first phase of the

study (2.2). The proporfions of pafients receiving injuries to the

various body areas are compared with lhose observed during the Phase

Ono s-ludy i n the fo I low i ng Tab I e.

Tab le 6/l 4

A COMPARISON OF INJURY PATTERNS IN THE TWO STUDY PHASES

dþ

76

7

19

14

42

57

dþ

70

B

24

l438

6B

Hoad

Neck

Thorax

Al¡domen

Upper Limb

Lower Limb

Phase TwoPhase One

Body AreaI nj ured

Percentage of Patients ReceivingI njuries

ln addition lo Ìhe degrees of injury to each body area, the

lhree major types of injury suslained by each patient were noted, along

with the body area affected. Analysis of fhis data gives an indlcafionof the frequency of the various types of lnjury occurring to each body

area for road crash viclims. The types of injury observed are lisled lnTable 6/15 (Appendlx 1).

Bruises and abrasíons of the lower limbs were the mosf common

types of injury. Scalp and facíal laceratlons accounted for 75l of al I

lacerations recorded. Wounds in these categories accounled for over

60Í of the injuries recorded. One hundred and Ten patients (34%) were

treafed for concussion. One hundred and throe fractures werê recorded,

52 $O%) of them involving long bones of the upper or lovrer limb.

9l

Two patienfs died from lheir injuries during casualty care.

Another died within 24 hours of admission to hospital. Three patientsdiod within seven days of admission and one died affer 28 days in

hospital.

3. Seat BeltsCa:r occupants and motor cyc I i sls were asked whether they had

been wearing seat belts or helmets at the time of the crash. Helmets

were compulsory for motor cycliEts at fhe time of the study anrJ allmotor cycl ists claimed to have been wearing them.

ln contrasf only 10 car occupants clalmed lo have been wearing

a safety bell. Seventy-five persons sfated that lhey were not wearlng

belts which were fitted in lhe appropriate seatlng position. N¡nefy-

eight patienfs staled that a bell was not filted in the relevant seatingposition. lt was not possible to delermlne whether belfs were eitherv/orn or f ilted for the remaining 33 car occupants.

The types of seat belt f ittecl were described as follows:--lable 6/ l6

SEAT BELT WEARING BY CAR OCCUPANTS

7510Tola I

l071

3

1

't0

61

3

1

10

Lap

3 Poi ntSash

Fu I I Harness

Tota IBelt Nol WornBelt WornBelt Type

No. of Patients

85

92

4, Alcohol

As ln Phase One, the presence of alcohol was determlned by a

combination of direct questloning and clinical observetion. Ninety-one

patîents were assessed as having been drinking before admission. The

pattern of drinking for the major groups involved is shown ln lhe

fol lowi ng Tab le.

'fable 6/17

ALCOHOL AhID CRASI.I VICTIMS

6. The Crashes

lnformation was gathered about the fype and location of the

crash in which lhe sample patients were involved. The 328 patients came

fron 257 crashes, an average of 1.3 patienls per crash. One hundrod and

fifty-six patients (47.6%) were injured in crashes between two cars,

34 (10.41,) in single vohicle crashes and 6 (,8Ð in crashes involving

moro than two vehicles. Fourtoen Q.3%) of patienls were injured incrashes belween a car and a truck; none of them Were lruck occupants.

There was one person injurod following a collision between a car and a

lram.

The locaTion cf the crash was delermined for each palient and

plotted on a map of the l,4elbourne melropolitan area. ll had beon shown

in lhe Phase One study that patients were brought to the Alfred Hospital

40,4

35.2

21 ,0

35.0

32.03284419391Tota I

Popu I at ion

lr9

97

71

24

20

9

9

4

59

57

49

13

40

31

13

7

Dr i vers

Other vehicleoccupan'ls

Pedestr i ans

Molor Cycl isfs

% Drinkingwhere known

Tota INot KnownNot PresentPresent

Alcohol

93

from a reasonably wel I defined area. This observation was supporfed by

the findings in this Phase. Patlents who had been lransferred from theMornington Feninsula were recorded separately. The locations were

characterized by fheir occurrence within areas measured by their radlaldistance f rom the Alf red llospital. The distribuf ion of the crashes interms of their distance from the hospifal is shown in Table 6/18.

TaLrle 6/18

DISTANCE OF CRASH SITES FROM THE ALFRÊD HOSPITAL

1 00.0257ToTa I

30.0

21 .B

1 0.9

14.8

5.1

4.3

3,5

1.9

7.8

77

56

2B

5B

13

11

9

5

20

0 - 1.99 mî les

2-3.gg il

4-5,99 l'

6 - 7.gg rt

8 - g.gg rr

10 - 11.99 ,,

12 + ïi

Peninsula

Not known

No. of CrashesRadial Dislance fromfhe Al fred Hosp ita I

dþ

Two hundred and ninefy-four patienfs (89.6%) were broughtdireclly to the Alfred Hospilal from the crash site. Eight Q.4ft) were

transferred from other hospilals. The remaining 24 0.3%) were patienlswho presented some time (up to three days) after sustaining their crash

injurles.

7 . Va t 'l O itv o+ +ne Samp le

Data oxtracted from the casualty admisslon records of theAlfred llospilal allowed the pattern of admission of road crash victimsduring the tolal sample period to be determined.

94

A casualty admlssion regisler is maintained in the hospitalwhich records the name¡ âge, sex, time of admission, admission diagnosísand approximate duration of stay ín the casuâlty department for each

patient seen in fhal deparTment. Road crash victims receive specialnotation in this record and can fhus be readily identif ied fro¡n ¡1.

This admission register is kept for the convenience of casualty sfaffand inaccuracies occasional ly occur in the detai ls relating fo each

patient (due largely fo lhe facl that the information is recorded by

different members of staff at different times during the patientrs stayin the department). I'levertheless, if was possible lo positively identifylhe records of 324 of the 328 persons observed, and fo compare characf-eristics of the study populaTion wifh those road crash vicfims who were

admitted buf not seen durîng the duty periods. The numbor of road crash

victims admitted during the total sample period was also identifiedfrom lhe record.

Durlng the total sample period of 170 days, 26,236 pat ientswere frealed in the casualty departmenÌ of the Alfred Hospifal, of whom

1,382 $.3%) were vlctims of road crashes. The distrlbution of fhe times

of arrival of these crash patients at the casualty department is shown in

Table 6/19 (Appendix 1).

The toTa I numbe.¡r of crash pat ient arr iva I s at the casua ltydepartment during the limes the observer was on duty were also deter-mined from the admission record. Three hundred and ninety-four patientswere admi-lfed during these duly periods. The observed population thus

represented an 83ß sample of all patients admitted cf uring the duty

periods and a 241" sanple of the road crash patients treated in the cas-

ualty department during lhe total study per¡od. ln Íable 6/20(Appendix 1) the dîsfribulion of the observed patients is compared wifhthal of -lhe tc'tal population admitted during dufy periods.

The number of palients seen during each throe hourly period of

95

the week is expressed as a proportion of the total number of crash

vicf ims admitted to the department in Table 6/21 (Appendix I ). lt can

be seen tha't the proporfion of patients seen varies from time period to

time period fhroughout the week, with an overal I 24fi sanple.

ln 'the fol lowlng discussion, data obtained from fhe casualty

admission records are used lo compare the observed population with those

admitted bul not seen during the duty periods and wi'fh fhe crash popul-

atlon admifted during the folal sample perlod. Age, sex, to+al time

spent in casualty and discharge patterns are usecl for comparing the

three pop u I arl ions .

Table 6/22 (Appendix l) shows the age and sex distrÎbutlon of

the three populations. Comparing the sex distributions, the difference

between those observerl and those admitted duríng duty periods bu'|" not

otrserved is not slatislically signif icant. Similarly, comParison of

fhose observed wilh those not observed bul admitfed during the totalsanrple period reveals lhaf fhe differences between lhe fwo populations

are not slatistical ly sigttificant.

Comparison of the three populations by age in 10 year groups

shows that the observed dlfferences are, once again, not statistical lysignificant, (Observed versus not observed during duty periods

x2 = 6.177; D.F. = 7; N.s.; observed versus not observed during the

tolal sample Period X2 = 12,042; D.F. = 7; lrl.S. )

Since lhe presence of the observer is a potenfial source of

interference in lhe system under study, it is imporfant lhaf an assess*

ment of thls influencc should be obtained. This is of part¡cular import-

ance in this study, where elapsed times in the various -treatrnent phases

are amorìg the major variables under examination.

96

The casualty admission register contaíns a record of the time

of admission and the approximate time of discharge for most of thepatients admit'ted to the department. From these times if was possible

to calculate the fotal tlme spent in casualty by many of the pafients.Thís measure of the tolal system time is used fo compare the threepopulations and obtain an assessment of possible observer lnfluence on

the observed syslem, thus testing the assertion, made earlier ln the

fhesis, that lhis influence was smal l. The distributions of the totalfimes spent in the department for the three groups are shown ln

Table 6/23.

Table 6/23

TOTAL TIME SPENT IN CASUALTY BY CRASH PATIENTS

A vs.

A vs.

2B: X

C: X

= 3.050;

= 1.385;2D. F.

D. F. - z.N. S.

N. S.

lf may be seen from the Table that, for those cases where

times were recorded, the differences between the total times spent incasualty by the observed palients and lhose spenl by persons not observed

during lhe duty periods are not statistically sígnlf icant. Similarly,the differences between the observed population and those not observed

during lhe fotal sample period are not statistically signif icant.

138299266324Tota I

542

374

260

121

85

381

264

186

90

71

50

15

9

7

5

131

95

65

24

I

0 - t hr.59 rnin.

2-3hr.59min.4-5hr.59min.6 hours *Nol Recorded

Tota I CrashAdmisslons

Adm i tted Dur i ngTimes of f Duty

cNot 0bserved

B

0bservedA

Duration of Stayin Casualty

(in 2 hr. groups)

Admltted Duri ngDuty Periods

Number of Crash Patlenls

97

Another data itern by whích the lhree groups may be compared

was the discharge or referral patfern for lhe patients. Admission and

discharge diagnoses were recorded in the casualty register for most

victims. The discharge destinaflon qives a rough apProximation of

severity of injury for lhe patienfs involved, in that most patlents who

are admitted lo hospital are likely to have been more severely injured

than those treated and referred to out-pafients or discharged completely

from medical care. Somo patients were discharged to the care of a local

doclor and a smal I proportion absconded from casualty before theirtreatmenl was comp leted. The d I stri but ir:,n of these d i scharge dest I n-

ations for the lhree groups is shown in Table 6/24.

rable 6/24

DISCHARGE PATTERN FOR CRASH VICTIMS

138299266324Tota I

302

723

33

247

26

50

221

522

19

169

16

45

71

171

13

57

7

rì

10

31

1

21

5

Adm. to Ward

0ulpat i entReferra I

Referred to LMO

Disch. from Care

Absconded fromCasua I fyNof Recorded

Tota I

AdmissionsAdmitled Duri ng

Duty PeriodsI Admitted During

Times of f Duty

Not ObservedB c

D i schargo/Referra I

Arrangoments

Numbor of Patienfs

2 = 9,173; D.F. = 4; N.S.

= 4,596; D.F. = 4; N.S.

A vs. B; X

A vs. C: X2

Oncu again the cbserved differences beTween lhe fhree groups

are not slalislical ly signiflcant.

These comparisons are summarised in tabular form below.

98

Di schargeArrangemenfs

x2 = 4,596

D,F. = 4

N.S.

It can be seen that, with respect to these four criterla, the

observed populallon lvas rêpresentatlve of crash patients admitfed to the

casualfy deparfment of the Alfred Hospifal during the study period.

8. The Questîonna i ro Samp I e

Postal questlonnalres were sent to 313 of fhe 328 crash

vicfims observed, ln order to determine their opinions of the emergency

care fhey had receivod. ln Tables 6/25 to 6/28 lhe respondents to the

quesÌionnaire are compared wifh fhe non-respondents in the observed pop-

ulation. The variables chosen for comparing the lwo populations are age

in ten year groups, sex, degree of injury and the lotal tlmes spenf ln

casualty. The result of X2 lests on each of fhe Tables show that, on

the basls of these criferia, the clifferences between The two populallons

are not statistical ly significant. The questionnaire respondenfs may

thus be considered as representative of the observed population of crash

vlcflms.

x2 = 1.385

D.F. = 3

N. S.

X2 = 0. 183

D.F. = I

N.S

x2 12.042

D. F. 7

N.S

Observed vs.Crash victimsnot observeddurl ng thefotal sampleper i od

x2 9.173

D. F. 4

N.S

X2 = 3.050

D.F. = 3

N.S.

X2 = O.939

D.F. = 1

N.S.

x2 6.177

D. F.

N.S.

7

0bserved vs.Those admittedduri ng dufyperiods butnof observed

Durat ion ofStay i n Cas.

SexAge in 10 yr.Groups

Popu lat ion

Table 6/25

sEX 0F QUESTIoNNAIRE RESPoNDENTS

2X = 1.546; D.F. = 1i N.S.

lable 6/26

TIME SPËNT IN CASUALTY BY QUESTIONNAIRE RESPONDENTS

2X = 5.280; D.F. = B; N.S.

lablø 6/27

AGE OF QUESTIONNAIRE RESPONDENTS

X

99

183

145

328

328150198Tota I

183

145

78

52

105

93

Response

No Response

Response toQuest ionna i re

Sex

Ma le Ferna le Tota I

91283B3430509552Tota I

3

6

7

5

4

4

21

17

IB

16

14

16

28

2?_

60

35

Response

No Response

28

24

Tota IN.K7+6-6.59

5-5.59

44 59

3-3.59

2-2.59

1-I .59

0-0. 59

Response toQ/aire

Elapsed Time in Hours

32861720242427929028Tofa I

183

145

3

3

10

7

15

5

14

10

13

11

13

14

44

48

53

37

1B

l0Responso

No Response

Tota IN. K.70+60-69

50-59

40-49

20-29

3039

10 -19

0-<)

Response toQ/a i re

Age in 10 yr. GrouPs

2 = 7.400; D.F. = B; N.S.

100

Table 6/28

INJURY SEVERITY OF QUESTIONNAIRE RESPONDENTS

2X = 6.608; D.F. = 4; N.S.

3281928981776Tota I

183

145

6

13

19

I53

45

102

75

3

3

Response

No Response

Tota IVerySevere

ModerateMinorNilRcsponse toQ/a i re

lot \.,ìi )j

1ii'i,r(:. "OPERATION OF THE ET4ERGENCY CARE SYSTEM

I N MELBOURNE

The fol lowing discussion of fhe study findings uses the

emergency care system modc-;l (see Chapler 3) lo descríbe the emergency

servîces provided for road crash victims in lerms of the fourfuncfional systems:

(a) Commun i cat ions(b) T'ransporf(c) Treatment(C ) Documentat lon.

TIIE COMNIUN ICAT IONS SUBSYSTEM

(a ) Crash De tecf ion and l,'lot i f icat ion

The firsf helping porsonnel to arrive on the scene of a crash

are usually members of the -c¡eneral public. From observation of fhe

study crashes it seems lhat most crashes in metropolitan aroas are

detected and notified to the ernergency services oromptly.

ll was dîfficull lo determine -lhe length of the notificationdolays for the sludy crashes but bystanders at lhe crash scene were

questioned in an attempt to determine which emergency service was

summorred and by whom. These enquiries were supplemented by examination

of the ambu lance ca I I record kept in lhe ambu lance commun ications cen-tre,

which records the origin of lhe nofification cal I when thls is known.

The origin of the call was delermined for forty of Ìhe

crashes. Thirfy-elght Í were nofified to the ambulance servlce from

the universal omergency number i000t , 16'/" were relayed by the policecommunÎcafions centre and 16Í by taxi radio control lers. The remaining

30Í were nolif ied by direct felephone calls to the ambulance sorvice

from persons al lhe crash scene.

Chapler 7at

l02

The emergency telephone number t000u ls avai lable fhroughout

Ausfral ia for al I major trunk exchanges of the Postmaster Generalrs

Department. Emergency cal ls may be made through this exchange and are

directed to the appropriate emergency service. ln 12 months fo June 50,

1971,397,757 calls were made on the number ln Vlctoria, of which

120,039 were connected fo the fol lovring servlces:

Pol lce

FireAmbu I ance

83,627

10,322

?6,090(Austral ian Post Office, 1971,)

A critical factor which affects the response of the emergency

servlco is the quality of the information fransmitted in the notifyingcal l. lnformafion on the number of persons injured, the nalure oftheir injuries and the slte of the crash allows the dlspatcher loassess 1'he needs and send several ambulances lf necessary. Volce

communication between fhe person notifying the cal I and lhe dispatcher

is the only satisfactory method of ensuring fhat this lnformatlon isavailable. ln practico most notif icaf ions are recelved by telephone

and the dispalcher is fhus al¡le fo exfract the relevant informationf rom fhe caller. ln addif ion lo holping the dlspatcher assign prlorlt-ies, the abilily fo discuss the incident with fhe caller assists him

to assess the seriousness of the incident. lf also helps to reduce

the number of hoax cal ls on the service.

Several authors have commented on the importance of thisinifial call and have suggested methods of improving lhe quality ofthe information transmitted ln ¡f. (Archer,1970; Pacy, l97l;Berry, 1972.,

102A

Communi cations Belween Emerqencv Servlces

Each emergency servÎce has an independenf communicatlons

network with central dispatching faci I ities. Two-way radio and

telephone equipment is used to mainlain confact belween services and

between the vehicles in each servíce. Since towing services are

privately run and competitlve, fhere is no system of central dlspatch

or rational ized operation of low trucks. The olher services - pol lce,

ambulance and fire - have control centres which are linked by telephone

during normal operations. StanCby connections are available formajor emergencies.

ln metropol itan areas, road crashes usual ly result ln several

notlf icatlon calls to the relevant emergency services. A call of any

one of the.services may be relayed to the other services, bul fhis does

not necessarily occur unless members of the Service at the scene

specifical ly request the attendance of another service. For example,

ambulance officers at fhe crash scene will ask for police to be nollfiedif lhey are required and vice versa. The conlrol ler lhen notlflesthe other service, uslng lhe direct telephone line which connects the

lwo services. A sirnî lar procedure is used lo summon flre appl iances.,

Communi cations Equ i pment

The Victorian Civi I Ambulance Service has recently remodel led

its communicafions cenfre, lnstal led modern telephone sysfems and modif-

ied operating procedures within lhe centre. The Victoria Police

communications centre is reported to be severely taxed by current

pol ico operafions and recommendations have been made that the centre

and lts oquipment shoul d be moderni zed. (St. Johnston, 1971.)

Electronic systems which provide data processing and recording

facilîf ies in addition to co-ordinaling emergency service operations

103

have been descrlbed for several overseas contres. (Storey, 1971;

Phel an , 191 1; W.H.0. , 1 968. ) Liftl e consi deration has apparentl y been

given to the instal lation of such equipment in Melbourne. Ambulance

communications are adequate for present operations but more sophisticated

communications and data systems could be expected to contribute signif*icantly to improving the efflciency of the servíce.

It may be opportune, if pol ice co¡nmunications are to be

upgraded by the i nsta I lat ion of ccmputer i zed data syslems, for the

ambulônce Service lo investlgate concurrenf use of the faci I ilies.These systems may be used in solvíng such ambulance servlce problems as

planning ambulance locations and routine fransport schedules, as wel I

as thelr obvious usefulness for accounfing and data processing purposes.

(b) Ambulance Disoatch

Aflor receiving the notification cal l, the ambulance control ler

dlspatches an ambulance to the crash. This usual ly involves sênding the

nearest available vehicle. Allernatively a standby vehicle is sent

from the nearest base station. During daylight hours, when mosf of the

ambulances are involved in lhe routine transport of sick patlents, fhe

control ler may re-route an ambulance from a non-emergency cal l. Durlng

off-peak hcurs and at night, proporlionately more ambulances are on

sland-by in base stations. Dispatching ls usual ly performed by radio,

allhough ambulances in base stations may be cal led out by lelephone.

ln dispatching the ambulance, the control ler transmits inform-

atlon relating to lhe site and nature of the incldent as well as service

data which is required for recording and accounting purposes. ln emerg-

ency calls to road crashes this information includes:

Se¡rvice Data:- DailY Job Number

Time of Day

Crash Data:- Sife of the lncídent

Type of Crash (if known)

Urgency of the Ca I I .

CRASH - DETECTION - NOTIFICATION -AMBULANCE

DISPATCH

AMBULANCE

- A¡|BULANCE

ARRIVES LEAVES

AT SCENE

SCENE

TII1E AT THE SCENE

AÎ'.IBULANCE SERVICT ÏIIIE

AI1BULANCE AMBULANCE

ARRIVES AT CALLHOSPITAL COHPLETE

RETURN TO

READINESS

NOTI FICATIONTIME

DISPATCHTIME

TRAVET

TII4E

TRANS PORT

TII4E

DELIVERY

TII'IE

AMBULANCE RESPONSE TII''IE TREATI4ENT AND TRANSPORT TIME

Fig. 7.1 Sequence of Events During an

Arnbul ance Cal I , Showi ng Time Rel ati onshi ps '

CYCLE

NOTIFICATIONPROCEDT'RES

DISPATCHPROCEruRES

TRAVEL fO THE SCENE

TRIAGE E

FIRSl AIDAT THESCENE

TRANSPORT TO HOSPITAL

DELIVERYTO

MEDI CAL

CARE

104

The ambulance officers on the vehicle conflrm recelpt of fhe

instrucïions and relay their service numbers fc the dispatcher, who in

turn records them on his dai ly work sheet. Specifîc formats are

followed durirrg radio communícations. At the time of this study,

verbal descriplions of the degree of urgency and nature of cases were

used and were sonewhat informal. A change in raclio procedures since

that time has meant that the common lypes of incident are now described

by code names (e.g. Signal B = Emergency call; proceed to scene usíng

warn i ng dev I ces ) .

Di soatch De I avs

The dispatch fime is defined as fhe elapsed time from roceiptof fhe notiflcation call untll lhe ambulance is dispatched to thc'

scene. (Fig. 7.1,)

ll was possible to observe lhe length of these delays for the

sample acciclents by comparing lhe dispatch fimes, which were recorded

al the time lhey were transmitted by the controller, with the notif ic-atlon times recorded on the ambulance cal I records. D¡spatch delays

could be determined for 97 of fhe 100 crashes aftended and were dislrlb-uted as fol lows.

Table 7/1

DISPATCH TIME

Range:

Mean Time:

1 - 20 minutes

2.6 ninutes

62

Ã?o

63.9

3

3.1

80.4

5

5.2

77,3

6

8.2

72.1

6

6.2

99.0

12

12.4

92.8

1

.l.0

100.0

97

I 00.0

)0-1 43 10-195-9 20+ Tota I

Elapsed Time in Mlnutes

No. of Crashes

Percentage

Cumu I at ive $

S.D. 4.1 minufes

t05

It may be seen lhat dispatch times are usually short, with a

median delay of one minute. Nevertheless, on 7% of occasions the delay

vras greater lhan '10 minutes. During peak hours the availabilify ofambulances for emergency calls irr a given area is a complex queuelng

and schedul ing problem. Ihe ambulance dispatcher must balanco the

desirabi I lty of sending a given ambulance against the estimated work

loads facing the service and the availability of other ambulances in

the area. Such ollrer variables as knowledge of the site of the incident,d¡ff¡culties of access, roacJ condilions and traffic densities at the

time of dispafch complicafe the fask. He is frequently faced with the

decision as to whether to r¿rail for a nearby ambulance to complete a

case or dispatch anofher ambulance from a more remote site. The

decision involves balancing a dispatch tirne of indeterminafe (but

presumably short) length against a relatively long travel lime from the

remote site. The solulion of lhese dispalching problems could be

assistcd by elocfronic syslems whích record vehicle locaïíons and

incorporate visual displays. Such systoms have been described foroverseas centres where lhey are used as mefhods of keeping the dis-p¡rtchor informed on the whereabouts and status of hís fleet and provid-

ing solutions to the probabilify decisions involved in lhe various

di spatch i ng a lternaf ives.

(c) Communications duri nq Ambulance Service

Rad io con'f act is ma inla i ned belween the cen-lra I d ispalcherand lhe ambulance cr€rw throughout each ambulance ca I I . Relevant

information may thus be passed between conlrol ler and crew, ensuring

overal I control of ambulance operalions. During travel to the scene,

details of the localion of the crash, redirection of the ambulance or

even cancellation of the call may be reasons for additional radio

c'ontacts. The crew notífy tlre controller of their arrival at lhe

scene and assess the crash, after which they may request additionalaid íf such ls requíred. þJhen the injured have been treated and placed

in the ambulance the driver reports lheir condition, the type and

106

severify of their injuries, and notifies his intention of faking fhepatients to a partlcular hospital.

Current service pol icy requires that crash víctims should be

fakcn to the nearest publ ic hospital casualty department. Occasional lypatients are taken elsewhere for medical care. For example, a doctor

al the scens may wish To manage a palîc-.nt privafely and will direclthat he be takon to a particular hospilal. Occasionally the ambulance

control lcr may suggest thal' palienl's should be taken to an a lternativehospiTal Ìf their clinical conclítion permits the diversion and he knows

that the nearest hospifal is overloaded. Normal ly, however, the choice

of hosp ita I is leff To 'the atnbu lance of f icers at the scene, and they

usually elecT lo take the patient to fhe nearest hospital. This policyis based on the legitimate essumption that fhe ambulance officer in

atfendance is the person besi'equipped to assess the patientrs conditionand need for urgent care. Although this prc+mise is sound, the pol icy

has ímportant impl ications for the operation of the emergency care

system in thaf it affects lhe distribution of paTients between hospitals,which, in lurn, affects palient waiting times and care within fhose

hospitals. This situafion wi I I be discussed laler in this chapter.

During transport to hospifal the crew may provide the con-

lroller with progress reports on the condifion of the injured and

request that lhe hospital be nolified of their impending arrival. There

is, at present, no facility for dîrect cornmunication belwoen the ambul-

ance of f îcers at the scene and cloctors in lhe receiving hospltal.Particular advantages of these I inks which have been described include:

(1) Early warning of lhe patientes condition and impending

arrival allows lhe-- casualfy staff to prepare fhe

necessany faci I itiesQ) The I i nk prov i dos back-up med ica I adv ice f or ambu I ance

officers al the scene.

ß) V ita I phys io log i ca I pa rameters may be transm itted f or

107

interpretation by the hospital staff.(4 ) Hosp i-f'a I based f I y i ng squads may be summoned to lhe

scene. (Hall & Garden, 1967; Nagel el al., 1968.)

ln the existing system in Melbourne, the ambulance service and

the separate metropol iTan hospilals are connecled by direct telephone

lines. lnformation f low, before lhe ambulancers arrival at hospital,is normal ly restricted to telephone communications beïween the ambulance

conïrol lers and members of the hospital staff. The member of the

hospifal staff who receives The incoming cal I under this arrangement

varies f rom hospital to hospi'lal. ln the Alfred Hospital calls on the

direct line are usually taken by a hospifal medical orderly who then

relays fhe informalion lo the casually sistcr. ln cases where patienls

wifh I ife-threatening injuries are being transporled, the confrol lerusually altempls to nof ify the admílting medical off icer, thus alelrtingthe medical staff directly. The present communication system has

several defocTs. Firsl, lhe introduction of the ambulance conlrol lerand a casualty medical orderly into the line of communication between

ambulance offlcers af thc scene and receivíng medical and nursing slaffis undesirablo in lhat the advanlages of direct communicalion are

mitigated or lost. Secondly, it was occasional ly observed that the

ambulance servicets notíficatiorìs w€re ignored because of a rwait and

seer altitude on the part of fhe casually s1-aff . Thirdly, although the

existing system has lhe capacily for providing advanced warning ofpalient arrivals, 'these warnirìgs are not always heeded. As one example

of this, the admiïting officer of one of the study hospilals was advised

by the ambulance conlroller thal a severely înjured crash vicf im would

arrive in casualty wiThin five minutes. The admilting off icer was not

in fhe deparTment at the time he received the telephone call. He did

nol nolify the casualty staff and they were thus not prepared to receive

the pat i enf, who requ i red i ntens i ve resusc i fat i on.

The advantages of direcl ambulance lo hospital radio I inks as

l0B

outl lned previously are consîderable, but several observaf ions made

during the study suggest lhat these advantages may nol be readilyachieved by their introduction into the exisling system. Flrsf,casualty medical sfaf f are usua I ly busy and thus may no'f be readi ly

available for radio consultation. Secondly, fhey are usually iuniormembers of the mec1ical staff who are roslered for relafively briefterms of casu¿¡lty duty and are thus unlikely lo be experienced in radio-

diagnosis and consultation. Thirdly, in busy departments, fhe responslb-

ilily for manning and moni'toring radio equipment is likely to be dele-

gatc:d fo a junior staff memberr or even, as is the case wilh the present

telephone connecf ions, a medical orderly. Finally, in a large cify wilhseveral hospitals receiving casualties, the duplication of facllitíesnecessary to provide links to all of the required hospilals may be a

relatively inefficient way of providing fhe service. An alternativemethod of achieving the objectives will be suggested in a later section.

0n reaching the hospil'al the ambulance crev'' notify theirarrival lo the dispalcher. After removing the patienl from tho vehicle

and transferring him to the casLlôlTy stretcher one member of the ambulance

crew usually accompanies the palient into -lhe casualty receiving area,

while the sec;ond ambulance off icer provides details of the paf ienl fortho'casu¡:lty documentation clerks. Ambulance off icers continue fo main-

tain patien't care unlil responsibilify for this care is fransferred tolhe casualty nursing and medical staff. Al lhe time of transferring the

patient, the ambulance officer normally provides a brief history of the

patientrs injurics and clinical condí-lion during lransport fo a member

of tho casualty staff. lf an ambulance report form has been completed

for thr.; palient, il is lodged with the slaff member at fhis tlme.

A further breakdown in communicalions can occur af fhis point.Arnbulance off icers are usually the only para-medical personnel to have

observed lhe patienl durlng the early post-crash phase. They thus have

information relating lo thc+ patientts injuries and clinical condltion

109

bcfore hospilal, which may be important for the doctorrs assessmenf and

subsequent treatmenl. This ìnformalion is often lost because of poor

communication belween the various staff members. Frequently the cas-

ualty slaff who receive the patient may not be fhose who finally assess

him. lr'loreover, casua lty staf f are of ten indif ferent to the infornlatlonprovided by the ambul¡nce off icers, wlio consequently feel rebuffcd. To

some extent, arnbulance off icers feel ô sense of professional isolationwilhin lho departments which is reflecled in fheir attempts lo communic-

ate with the medlcal sfaff.

A record was kepf of the communications befween lhe ambulance

and casualty sfaff for 176 of the 269 patienfs who were brought tohospital by ambulance during the second study phase. l-he patferns

observed are shown in Tablo 7/2,

Table 7/2

COMMUNICATION BETWEEN AI'4BULANCE OFFICERS AND CASUALTY STAFF

176 100.083 100.093 100.0Tota I

n dþ

18 10.2

129 73,3

29 16.9

n %

13 15.7

5B 69.8

12 14.4

n tr

5 5.4

11 76.3

17 18. 3

Ambu lance o'f f icersrelated history tomed i ca I or sen iornursing sfaffBrief hisl'ory relatedlo any member ofcasua I ty sfaffNo communlcalion betweenAmbulance officers andCasualty staff

Mod. lo FatalNil & Minor

DEGREE OF INJURY TO PATIENTTota I

Eighty-three of lhe '176 crash victims had sustalned moderate

or greater injuries. Communicalions between fhe alnbulance staff and the

110

medical and nursing staff who managed I'he patient occurred for onlV 16Í,

of these patients. The situatíon wherein ambu lance of f icers describe a

brief hislory fo a member of the casualty slaff on arriving in thedeparfment îs oftcn unsalisfacl'cry in that, often, the member of staffis not presenf when the patient is assessed by the medical officer. An

awareness by i:mbulanco aufhorities of the d¡ff iculfies associaled vrith

this communications problem led to the development of the Ambulanco

Report Form as a tangible record ol a patientrs ambulance tneatmenf.

The use of ihis dc)cumen't will l¡e discussecl in a later secfion. Paflernsof crash injury are, to scrme extcrnt." pre<Jiclable, and much useful dia-gnostic materlal c¿rn be gained by knowing whether lhe pafienf was, forexample, a pedes-trian or a vchiclL- occupant. ln many cases, lheireating medîcal officers did not have such basic informaticn nt lher

fime c¡f examination and, on occasions, were not even aware that thei nj u rod person had been i nvr-¡ | ved i n ¡: road crash .

After the patienl'has been fransferred lo casualty care, theambulance officers relurn to their vehicle, prepare it for a subsequent

trip and notify the dispatcher of th<¡ir refurn to readiness by radio,or by direct telephone call from fhe hospítal. This final radio contacfcould be used as a means of providirrg the ambulance controller with an

estimale of the loads on lhe crersualty dc-:partmenl so that distribution ofemergency calls between casualty deparfmenfs could be facililated. ln

pracfice this feedback raroly occurs.

(d) Communications between Hosoit¿:ls and belween the Ambulance Service

and Hosp i ta I s

Several areas of communication between hospitals and between

the ambulance service and hospitals warrant commenl in view of observ-

alions made during lhe sfudy. The dis-i'ribution of palients between the

separate hospital emergency departments in Melbourne is a problem whîch

affects severôl areas of pa-l'ien-l care. As menfioned previously, thedecisic¡n as lo which a hospíta I a patient should be taken after a crash

111

is normally lefl to the ambulance off icer at fhe scene. ln 'the absence

of any cenfral confrol of emergency deparl-ments or accident servicebeds, this policy dlrectly af fects fhe number of patients waif ing forcare in the separate departmenÌs. During peak periods, one department

may be overloadod whilst a second department as liltle as one or two

miles away is relatively f rcr-i of w¡¡iting pa-l'ienfs. E¡ght major publichospitals in the Melbourne metropol îtan area receive road crash victimsand 1-here is a need for an effectîve system for recording casualtydepartmenl loads and emergency bed occupanc)', lo ensure fhe distributionof pal i ents between these hosp i ta I s.

ln an atlempt to r¡vercome this problem in patient distrit¡ufiona fbed bureauf co-ordinated by fhe ambulance service has been in oper-ation in Melbourne for several years. Several fimes each day theambulance conlrol ler contacts lhe admifting offlcen at every Melbourne

public hospilal to de'termine the bed stafe of his hospital. This inform-ation is galhered in an attempt lo ensure the distribufion of ambulance

cases befween lhe major hospi lals. Each hospital is autonomous wifhrespect lo ils admitting policies and it has become the practice c.¡f

admifling offîcers to under-report the number of empty beds in theirrespective hospi-fals. This practice has lod to the breakdown of the

bure¿:u with consequenl effects on the distribufion of palients between

hospitals. Furlher inefficiencies result from the fai lure of this system,

since patienls who are admitted to the casualfy deparlments of hospitalswhich genuinely have no beds must be placed ín other hospitals. Thisplacement requires consultation between the separa"le hospital admittingoff icers. As a rcsull, valuable medical off icer lime is wasted and

furlher ambulance services are involverl în Ìransfcrring patients between

ho.sp ita I s.

Much of the responsibi I ity for this breakdown in communicalions

between fhe ambulence conÌrol centre and lhe hospilal casuälty depart-ment can be allributed lo poor inferpr of essiona I cornmunication. The

112

relatively junior medical staff who act as hospital admilting off icersin Melbourne hospilals have I itlle appreciation of the importance ofthe bed bureau for patienl care. Equal ly, ambulance control lers have

Iittle comprehensíon of the dÌf f iculties facing admitting of f icers inmanaglng the few unoccupied be<Js wilhin fheir hospitals. These cornmunic-

ations diff iculties are likely -lo persist for as long as casualtydeparlments are manned by rclal'ively junior medical staff and ambulance

off icers are trained outside the hospital environment. With existingorganizational arrangemenls there are few opportunities for hospital and

ambulance staff to develop mutual uirderstanding and respect for each

olherts lasks within lhe emergency care system.

These breakdowns i n commun i cat ions have sevena I imp I i cat ions

for lhe ernergency care of road crash v ict ims. An uneven d i slr i but íon

of patients belween casualty departments occurs commonly, particularlyduring such peak periods as'the laTe night hours on Friday and Safurday

nights. As a resull, crash,¡ictims experience long delays in receívingcare and fhe pressures of Ìhe heavy work loads on the attending medical

staff make mistakes ln diagrrosis and trealment more likely. These

problems could be alleviated if the work loads were distribulecJ more

evenly between the avai lable departments.

The introducfion of a sysfem whereby ambulance officers, inconjunction with the hospita I ca!ìualty staf f , provided some feedback tothe ambulance confroller on casualty patient loads would help to resolvethis problem.

A more efficìent means cf ensuring distribution may be a

system of accident or emerqcncy units within hospilals with centralcontrol over admissions to their cmergency beds. Such systems have

boen descr i bed for cerfa i n European countr ies. (1,4u I , 1 956; Storey

& Rofh, 1971,) There has been considerable debate between members ofthe medical profession about the desirabi I ity of accident or trauma

113

un¡ls to undertakæ the man¿rgemcnt of lrauma patíents. Whilsl thisproblem is related to the overall problem of management of crash victims,it may be regarded as a separate issue from that relating fo lhe avail-ability, dislribuf ion, and control of admissions to, emergency beds in

hospitals. Central control of such beds could help to reduce lime

delays in casualfy departmenTs and increase the overal I efficiency of

emergency care sysÌem operalions.

A first step in the developmenf of such a system would be the

appointment of a medical officer to the ambulance control centre. This

officer could assume respons¡bilify for the bed bureau and would be well

placed to discuss admission pric¡rlties with the separate hospital

admitling officers. As a frained medical officer he should be able tc>

overcome many of the difficulties in communicalion which beset the

existing sys-t'em. ln addition such a person would be well placed loprovide medical advice for ambulance officers at lhe crash scene and

during transport to hospîtal. ln this capacity he could advise the

conlroller and fhe ambulance crew on the risks lnvolved in by-passing

the nearest hospital department in f¿:vour of a second less-crowded

department. ln the event of telemetry of physiological data becoming

a feasible adjuncf lo ambulance care, such a medical officer would be

well placed to monitor lhe equlpment and advise the crew accordingly.

Considerable savings in manpower, equipment and time should result from

such centra I i zed faci I íti es.

(e ) Commun i cal ions w ilh i n l-losp ita I

Pat i enf-Sf,af f Commun i cat ions

Many pafients who have been ínvolved in road crashes regard

themselves as emergency casos warnanting urgent attention and had

difficulty reconci I ing the long waiting flmes experienced in casualty

deparTments wilh the apparent urgency of their condition. TwenÌy per

cent of patients who were asked lheir opinion of casually waitlng times

before discharge from the department statod that wailing times were too

r14

long. ln response fo a postal ques'l'ionnaire asklng opinions about

several aspects of casualty care,35/ o1 respondents regarded the wáit-ing times in casualty as longer than they had expected.

Patients can be holped lo understand fheir condition, thetroatment whích is being performed and lhe reasons for delays in treal-ment by adequale communication urith lhose members of lhe casualty staffwho are carinE for them. Because casualty departmenls are busy lhere lsa Tendency for staff to regard païients as pathological entitíes to be

processed. Allhough the emphasis in casualty is on prompl díagnosis,-treatment and referral, lhe explanaf ion of a paf ienlf s situation need

not be time consuming and does rnuch to allevia'te anxiely. Twenty-fourper cent of the observed pal'ients were unaware of the reason for theirbeing kept in casualty and displayed anxiety about their condition and

fulure management as a resul'l'. Only 3lí of palíents were kepf informed

of their condition, the reasons for freatmenf delays, and fhe trealmenfbe i ng performed, throuqhoul lhei r stay in the casually deparfment.

Those patienls who do not reqr:ire admission for f urther lreat-ment of i njuries are discharged for oul-palienf fol low-up. Speci ficwritten instructions are issued t<: patients who have undergone such

special procedures as lhe application of a plaster casl or who have been

observed for heacl injuries. ln addition a medical officer, casualtysisfer or senior member of the nursing sfaff explains fhe necessary

steps the palient should take lc, ensure fol low-up cane. Nevertheless,

many patients were confused about lhe arrangements for fheir futuremanagement at the time of discharge. Thirteen (28%) of the 47 patientswho were questioned about errangements for fol low-up care w<;re uncertainas to what arrangernenfs had been made for them and what was required ofthem in fr.rlf illing their future care requirements. This lack of under-

standing no doubt contributes to the fall off in attendance at out-patient accident cl inics.

115

Communicalions between Casuallv Staff and a Patientrs RelativesAn administralive ins-t'rucÌion requires casualty residenf

medical officers in the Alfred Hospital fo give \,vailing rç:lativos a briefsummary of the palientrs condition either directly, or through a member

of the senior nursing staff, affcr his examination is compleled. The

insl'rucf icn requíres that particular attention should be paid to estim-ating the tirnc the patient will be in the department. Moreover, a

summary of the palienlrs contlilion and management instrucf ions should

be given to fhe relalives aT lhe fime of the patientrs discharge. ln

pracf i ce cornmun icat ion betwtl r¡n ll-¡c casua lty staf f and re I at i ves i s

usually lefl to senior nursirrg slz:f f . The lack of an established

rcutine for this procedure meanÌ fhat relatives were often unaware ofthe patientts clinical progross. Hospital siaff conlacted the waitingrelatives of 106 ß6%) of fhe 160 patients for vihom it was possible toobserve this evenl in casual'ty care at least once. Nevertheless,

relatives were rarely kept informed of a patienlfs progress on an

ongoing basîs. Several pafients made particular comment fo this effectin thei r questionna i re respor'rses.

Reassurance of bo1-h pationts and relatives is an imporlant

aspect of tho medical care process which reflects on the quality ofthe care provlded and which markedly influences fhe attitude of the

patients to bolh lhe care and the insfilution providing lhe care. The

sc¡cial dimensions of medical care warrant attentíon from treafmenf

personnel, even though lhey may appear to be of peripheral imporfance

in busy casualty departments.

THE TRANSPORT SUBSYSTEJVI

(a) Response cf the Emerqency Services

Road transport is used by each of lhe services in responding

to emergency cal ls in Melbourne. Ambulance and pol ice vehicles aro

equipped with warníng devices for use during travel to and from the

116

scene. Tow trucks have flashing amber lighfs for use at fhe scene but

are not classed as emergency vehlcles within the meaning of the Road

Traffic Act. Legal ly they do not have emergency priority whi le trav-elling to lhe scene. All the services usually travel to the scene at

speed. The usual pattern of arrival of emergency services for the

crashes sfudied was towing service, ambulance and then pol íce.

(1 ) Towinq Services

The f i rst emergency serv i ces at the scene of a crash i n

Melbourne are uSuAl ly the toiv trucks. Towing companies operate in

limited but overlapping areas and may offer financial reward to a callerwho notifies them of a crash in which they oblain Ìhe tow. The towing

business in Melbourne is fiercely compelitive since the financialrewards for resuscltafing cars are considerable. Several differentsenvices are usually presenl at the scene of each crash. The firsltowing service on the scene has a good chance of obtaining lhe tow and

drivers thus use all measures in lheir atlempls to achieve this end.

Al I of fhese factors assist the early notification and arrival of the

towing services. l4oreover, the possibilify of f lnancial reward may

induce members of the public to call the towing company before the

ambulance or police when first notífying the crash.

Q) Pol ice

ln police operations in Vic1-oria' mossages concerning emerg-

encies are given precedence over all ofher radio messages and dispatch

of police to lhe scene is prompt. (Braybrook, 1970.) This applies inparticular to road crashes where the profection of life and property at

the scene requires pol ice control in co-operation with other emergency

services. (Pol ice attend the scene of lhe majority of injury-producing

road crashes ín Melbourne.) Police had arrived at the scene of 59 of

the 1OO crashes studied by the time the ambulance had left the scene.

117

(3) The Ambu I ance Servi ce

ln responding to en emergency cal I ambulancês use lheírwarning devices and travel at speeds which will ensure their rapidarrival at the scene. Service rules and training programs emphasize

that safel'y is more important than speed in ambulance work. (Hospitals

and Charif ies Commission, 1970,) Road traff ic regulations allowpriority for emerqency vehicles using lheir warning devices, but do notpermît dangerous driving in the course of exercising fhat priority.

The research team was able lo observe the driving pracflcesof ombulance officers during several of the sludy cases and for many

non-sfudy emergencies. 0n most occasions ambulances are driven wilhinthe limits of speed and safety specif íed by Ìhe services. Violationsof this code are difficult to determine, although some measure of itseffectiveness could be gainod from the rate of ambulance crashes duringcmergency cal ls, were these fo be avai lable. There are, however, no

figures available on the numbers and lypos of crashes in which V.C.A.S.

ambulances are involved. A sfudy of crashes for another Vicforianservíce revealed that lhe risk is 4å times greater for ambulances duringemergency calls lhan during transport calls, with a ra'i-e of one crash

for every 629 energency cal ls. (Watson, 1970.) Since the majority ofthese crashos occurred al intersections, speed is probably a less

critical facfor ln ambulance crashes than lhe failure of other motorisfsto delect and heed viarning devices.

Ambulance off icers unclorgo training on recruitment which

acquaints them with the praclical requirements for ambulance drlving toensure patient comfort. There is no specific înstruction in the drivingand handl ing of vehicles at speed. Such instruction should be unnecess-

ary, but for pract i ca I purposes may b,e des i rab I e.

llB

(b) Proteclion of the Crash Scene

Prolection from secondary collislons is an important area ofpost-crash control which warranfs comment in view of observations made

at the scene of sfudy crashes. lrlo dala are available f rom police

records on the incidence of second collisions in Victoria but Braybrook

(197ü, in commenting on this aspoct cf emergency care operations,

stated that'bflen furlher crashos occur resuiting in ser¡ous or fafalinjurics lo essentlal service workers or bysïundersl'

ln one of the study crashes a car collided with one of two

cars involved in an inlersec-fion smash. A tow lruck operalor, who was

examining lhe front chassis of the stationary vehicle, was dragged along

the road beneath tho car for sorne ten yards. He suffered abrasions fohis arms, legs and trunk, without further serious injury. No acfive

measures had been laken by cmergency service personnel to prolect the

scène of lhis crash.

Protectíon of the crash scene may be dlvided lnto two sections:(1 ) Site Prolectícn(2) Personal Protection.

(l ) Sile ProtectionEach of lhe emergency services should be involved in this

lmportanl area of post-crash safety. ln most cases second col I isions

are due fo lhe lnadequate use of warning devices. At mosf crashes,

byslanders or police redirect traffic and thus maintaÎn some degree ofprotecïion. The only other protective measure routinely faken by the

services is lhal emergency vehicles are parked close to the crashed

vehicles. These vehicles are equipped with flashing I ights (red fcrambulances, blue for police and amber for all other emergency sorvfcos)

which offer some warning for oncoming motorisls. Nevertheless, they

are invariably parked close to llre scene, and this limits their usef ul-ness as warning devices.

119

Emergency services in lulelbourne do not use such proven

de,¡ices, as Twitches hatstor ref lecting triangles as a warning for on-

coming motorists. Experience ín the Unifed Kingdom has shown lhat these

devices need to be placecl up to 900 yarcis from the scene (presumably for

motorway crashes). (Anderson, 1969,) Road and other fransport workers

in Victoria use these protective devices and they should be used

routinely by the emergency servîces.

(2) Personal Protection

Ambulance and pol ice officers ln Melbourne wear dark uniforms

during norma I duty and no addltional c¡r alternative clolhing is worn at

lhe scene of crashes. These colours are difficult to distinguish,parlicularly r:f night, and the resultlng lack of visibility adds to the

risk of injury from socondary col I isions. Pol îcemen on point duty at

busy intersections are similarly at risk, although white armlels are

occasionally t,ilorn by lhese off icers. Tow fruck drivers do not use

sfandard for¡ns of dress allhough many wear overalls, some of which are

white or I ighÌ coloured.

Fluorescent orange has been shown fo be an effective colour

for use ln safety clolhíng (lvlichon, 1969) and jackets of this material

are used by Counlry Roads Board workers in Victoria. The use of fhese

dustco¿its or jackets would contribufe to the safety of emergency service

personnel at the Scene. Moreover, the clothing could be expected to

contribule lo the effectiveness of the task of Those involved in trafflccontrol by ensuring that lhey are visible to the oncoming motorist.

The rlsks incurrr¡d by fai lure to use protecting devices are

considerable and demonstrably useful saf'ety measures should be inlro-ducecl and used roulinely by emergency servíce personnel.

120

(c) Ambu I ance Transporf

Patienls are carriecl in the rear cabin of V.C.A.S. ambulances

on stretchers fixed on either side of a central corridor. An ambulance

officer ri<ies in fhe cabir¡ rr,ilh lhe patient and maintains patient care

during lransporl. Patienls wifh minor injuries may be seated on fhese

strelchers or in the Passengerrs seal next to fhe driver. V.C.A.S.

anlbulances are equipoed to load an addìJ'ional two stretcher patienfs in

fhe rear cabin in emengencies. This confíguration Ìs rarely used and

was no-f required for any of the study crashes, ln practice lhe con-

trollers usually dispal-ch ¿: strcond ambularrce when rnore than fwc stretcher

patients need transport from any ono inciden'|.

One hunclrecl and t'lenfy-one injured victims f rom the 100 study

crashes were transporled to hospÎtal by ambulance. EÌghty-six of fhese

persons were stretcher palients carried lying in the rear cabin. The

remainîng fhirty-five patienls were sealed in either lhe rear cabin or

in the front passenger seat of the vehicle. Ambulances frequently

carrîc;d several victims from the same crash. Two victims were trans-

ported fron 21 of the stu<iy crashes and lhree or morÈ patients from 9

of thE: crashes. The ambulanc€) was not roquired for transporT in 16

cases. Tw i ce pat i ents were la kc-.n lo hosp îla I i n pr i ,¿ate ca rs bef ore

the ambulance arriveci. Orr bolh occasions lhe hospital was nearby, the

patíentst injuries were minor ancJ they were laken to hospifal by

bysta n de rs .

Seat Belts în Ambulances

At lhc time of thc s'lucly arnbulances were not f ítted wilh

devices to restrain patients in 'the event of a collision. All ambulance

stretchr:rs ar(? now f illed wilh yir,-bbing harness to restrain stretcher

paticrnts. Seat bells are fittod in lhe fronf seats of vehicles bul

fhere arü no restraining mechanisms for those; palienls who sit in the

rear cabin during transport. A signifîcant proportion of the 35 patienls

who were carried as silling pa-fîenfs, were seated in the rear cabin and

121

were thus unprolected in the event of a crash.

Road TransoorT and its Effocts on the Patient

As was menlíoned in the revisw of the I iterafure, several

authors have commented on the possible effects of road transport on fhe

injured palient and have related experiences of lhe discomfort felt by

patients during ambulance 'lrips. Since it was nof possiblo for the

observer lo ride in the ambulance wífh the patients, observations ofpatientsr condition wcre linriled to lhose which were obtained lmmediafely

before the ambulance leff the scene and on arrival af the hospital.These íncluded measuroments of pulso rate and blood pressure and observ-

ations of pupillary reacf ions, colour, state of consciousness, as

îndicalîons of the patienlts cl inical condition. lf was not posslble todemonstrate any changes i n pa'fi ent cond it ion wh i ch cou I d be attr I buted

to the ambulance ride. ln particular, there wero no marked changes in

pulsc or blood pressure associaled wìlh ambulance transport for those

patients with moderafe or greatcr injuries. Nor was it possible todemonstrate marked changes in the clinical condi-lion of these patienls

affer ambulance transport.

After arriving in the casualty department, study patients

were asked

whether the ambulancer ride had made them feel sick;whether The ambulance ride had increascd the pain from

their injurit=;s.

(i)(¡i)

lnvariably the patients responded to these dlrect questions lnlhe negalive. Several pationts did comment, however, on the pain assoc-

ialed with lîf+îng nìanoeuvres during fhe various phases of their caro.

(d) Liftinq and Movinq lhe lniuredtion of C h Vic-t'ims f V

Forty-four of lhe 310 persons involved in the study crashes

(uorlecUlxa oroJaq 6ai pe;nllerJ ol pol¡dde 1u'rlds r'!'V:0+0hl)'rutlo!A pã.rnçu1 up 6u!1PrlJxxl sroslJJg aouPInquy

-Ê---

a

tI

laÐ )

122

were sti I I inside their vehicles when the ambulance officers arrivedat lhe scL'ane. Twelve of fheso patients were either unconscious or had

suffered limb fracfures ancJ had to be lifted from the vehicle. One

patienf was trappelC in an overturned car and a power saw was used toassisÌ wíth extricating him. Overal l, the methods uscd to extricalevictims were considerod satisfactory. Eight of these viclims had

sustained limb fracturcs, of whom'lhree were rèmoved from the vehiclebefore theír f ractures were splinted, when splints could and should

havo been applie:d before moving them.

Liftin<l and Movinq Patients durinq Emerqencv Care

Ambulanc,r of f icers ¿:re trained Ìn methods of lifting and

extrica'ling injured patîents and are thus more ski I led lhan most

bystanders (including most mcdical practitionors) in lhese procedures.

They were observed to perforrr these manoeuvres satisfactori ly for the

study patîents. Lifting movements arc often painful for the injuredpatients and may cause fur-lher in.jury in certain situalions. lt thusfollows that pafienfs should be lifted and moved as liltle as possible.ldeally, once a patient is placcd on a stretcher it should not be

necessary to move him f rom J'l-rat s-lrelcher until he is 1'ransferred to a

hospital bed.

ln practicel, paticnls are moved from the strelcher several

f imes during emergency care. 0n ¿:rriving a1' the casualty deparfment

patients are usual ly transferred from the ambulance stretcher to a

hospital barouche. This transfer is made because changeover ambul-ance strelchcrs are n,;-f ava i lab le in the casua lty departmenf s,

Frequently lhe patient îs liftod manually from lhe stretcher on to thebarouche allhough canv¿)s s-lretchcrs ârc occasionally used for -lhis pro-ceCure. The procedure is of-len painful for lhe patient and represenlsan avoidable source of discomfort"

Nlos-l patients are lransferred f rom fhc barouche af le¿:st once

123

more dur¡ng emergency care. Those patients -r.rho require X-ray are

lifted from tho barouche lo lhe X-ray table and back. Most barouches

are equipped wilh a canvas which may be convertecl into a stretcher by

mêans of two poles with melal spreaders to tension fhe cÐnvas. Occasion-

al ly staf f members were obsc:rved tc I ift patients without using the

metal spreaders. Thls resultcrd ín unnecessary pain and discomfort forthe patient.

Changeover stretchers, which al low the patient to remain on

the one stretcher throughout emergency care, are used in other AustrallanStates and eliminalo lhe need for multlple patient lifts. A recent

invenfion which promises to solve somc of lhe problems associated wilh

change;over stretchers is the Jordan I ¡ f ting f rame. ([3erry ' 1972., The

davice is light, compact, clreap, simple to operafe and may be used atthe crash scene or in hospifals. lt overcomes many of the dísadvanfages

of changeover slretchors slnce it is easily stored, is radio-lucent and

fits on exisfing stretchers and barouches. lts particular advantage

for emergency care lies ín fho fact that the patienf, once placed on ¡lat lhe crash scene, remains on -l-he frame until lifted into the hospítal

bed.

(e) Time Delavs durinq Ambulance Service

The sequenc(r and time¡ relationships of evenfs occurring

durlng the various phases of an ambulance call are shown in Fig. 7,1.

ln lhe first phase of the study, fime delays during these phases were

measured for the majority of the sludy cases. ln some cases it was

nelth--r possible nor appropriate to record elapsed times during allphases of the ambulance cal l. For example, ambulance transport was not

requlred for patients from 16 of the 100 study crashes and thus lreatment

and transirort times were noI recorded for those paf ients. 0n anolher

c)ccäsion a patient was taken to a privafe doctorrs surgery and sub-

sequently to a private hospital for care. Since this represented an

a-lypical situation, da-l-a from this crash were also precluded from

the analysis"

124

Trave I T lme

The ambulance lravel lime is defined as the elapsed time from

dispatch unti I the ambulance arrive¡s al fhe crash scene. The distrib-ution of travel limes for the study crashes is shown in the following

Tab I e.

Table 7/3

AMBI.JLANCE TRAVEL T II'"{E

1

1.2

I 00.0

4

4.8

98. B

19

22.9

94. 0

40

48.2

71 .1

19

22.9

22.9

No. of Crashes

Percentaç¡c

Cumulative f

Tota I20+1 5-1910-145-90-4

Elapsecl Time in Minufes

83

1 00.0

Ra nge :

Mean Time:

1 - 20 minutes

7 .6 ninutes S. D. 4.3 ni nutes

The meCian fravel time to the scene of the sludy crashes was

7 minulcs and in 7O% of cases the ambulance had reached lhe scone within

10 minutes. lvlany factors inf luence thc speecl with which ambulances

reach the scene, among the most important of whích are the distance of

the vehicle frt:lm the site at the time of dispatch, the traffic densltles,

and roacj and envlronmental conditions. As has been mentioned, drivers

use emergency priority cn route lo the scene of crashes and lhe observed

limes thus approach the minimum possible travel times under existing

condifions of road transPort.

Time at the Scene

The time at lhe scene ls defined as lhe elapseC time from the

arrival of the ambulance at the scene until it leaves to take fhe

injured to hospital. lt depen<1s on the numbers of patienls involved,

lhc severily of lheir injuries, anri the trealmeni-procedures that are

required. The emphasis in freafmenl at the scene is on speedy cliagnosis

125

and emergency treatment before lransporf. 'Ihe median time spent inexamining patients, provídirrg f irst aid and loading them into the

ambulance was 7 minutes. ln both of lhe cases in which the ambulance

spent longer than 25 minutes al fhe scene, trapped patients had to be

extricaled from damaged cars.

fable 7/4

TIME AT THE CRASH SCENE

81

1 00.0

2

?_.5

1 00.0

z)3.7

97.5

1t

13,6

93,8

43

53.O

80.2

22

27.2

27,2

No. of Crashes

Percentage

Cumul ative %

Tota I

Elapsed Time in Minutes

Range:

Mean Time:

2 - 27 minutes

7 ,2 n inutes S. D. 4.9 ni nutes

Transport Time

The transport time is cJefined as the lime takeír by the

ambulance to reach the hospital after leaving fhe crash scene. The

duration of this lime period depends on the distance of lhe crash from

the hospilal, prevai I ing traffic, road and wealhen condíllons and the

urgency of the case.

Al though ambu lances use emergency Pr ior i fy i n trave I I I ng to

the crash scene, such urgency is rarely required on lhe refurn trip lohospital. Among fhe medical indicalions for emergency return tripsare cases of asphyxia and dangerous haemorrhage, bolh of which may resultfrom road trauma. Such emergencies occur rarely and thus, in the

majority of cases, ambulance officers are able to drive ln a manner

which provides for the safety and comforf of the injured patient. Emerg-

ency transport to hospital was nof required for any of the study patients.

126

Iable 7/5

TRANSPORT T IME

Tota I

82

I 00.0

1

1,2

1 00.0

3

3.7

98. I

7

8.5

95.1

30

36

B6

6

6

41

50. 0

50.0

No. of Crashes

Percentage

Cumulative fl

40-49 50-5930*3920-29l0-190-9

Elapsed Tíme in Minufes

llange:

Mean 'f ime:

2 - 50 mlnutes

12.0 n inutes S.D. 8.9 minutes

The distribution of transport times reflecls the dfstributionof the study crashes within the study area. Two crashes occurred at

intersections within a quarter of a mile of otre of lhe sfudy hospifals

and lhe patients had reachecl the hospital within 2 minutes of leaving

the scene. On another occasion, an ambulance was diverted to atlend a

qecond crash after leaving'l-he scene of a crash at the poriphery of the

study area. Two pafients with minor Injuries were being carried tohospital from the firsf inciderrT and a third, seriously ¡niured, was

trealed and carried from the scene of the second crash. ln this case

the transport lime for lhe study patients from the first crash was 50

minutes, The other extreme of fhe range of transport times.

Ambulance Resoonse Time

The ambulance response tíme represents the delay between the

time the notif ication call is received by the ambulance service anC

the arrival of fhe ambulance at the crash scene, and thus includes the

dispatch delay and the lravol time for- each crash. The distribufion ofobservod ambulance r-esponse times Îs shown in Table 7/6.

127

-lable 7/6

AMBULANCE RESPONSE TIMES

Rangez 2-31 minutes

MeanTime: l0.Bminules S.D. 5.Tminufes

The median response for the study crashes was 12 mínutes and

lhe ambulance arrived at lhe scene wilhin 10 minufes of notif ication inqA% of the calls and wilhin 15 minutes in 76% of casos.

Treatment and Transporf Time

This delay is definecl as the elapsed time befween fhe arrivalof the ambulance al the crash sccne and the time of arrlval af the

hosp ita I casua l-ly depa rtment.

f able 7 /7

TRËATMENT AND TRANSPORT TIMES

B2

100.0

1

1.2

1 00.0

1

1.2

98. B

2

2.4

97.6

16

19.5

95.1

23

28.0

75,6

31

37.8

47.6

B

9.8

9.8

No. of Crashes

Percenfage

Cumul ative f

Tota I30+25"2920..2415-195-s I ro-t+0-4

Elapsed Tlmos in Minufes

Tota I

72

1 00.0

4

5,6

100.0

2

2.8

94,4

2

2.8

91 .7

6

8.3

BB.9

14

19.4

80.5

17

23.6

6i .1

16

22.2

37.5

11

15.3

15.30.0

No, ofCrashes

Percentago

Cumul. É

40+35-39

t0-34

25-29

20-24

15-19

10-14

5-90-4

Elapsed Time in Mînules

Ra nge :

Mean Time:

5 - 55 mirrutes

lB.B minutes S.D. 10.0 minutes

128

The average time spent in providing Treatment af the scene and

Ìransport to hospil'al was 1B.B minutes. Fifteen per cent of patients

reached hospital wi'l'hin 10 minutes ancl 81'Á within 7-5 tninutes of tiroambulance reaching the crash scene.

bulance Service Ti

The distribulion of ambulance service tlmes describes the

observed limes between receipt of the notification call al the ambulance

conlro I cenlre and the arr i va I of the ambu lance a't the hosp ita I

casualty departmenf.

Iablct 7/B

TOTAL AMBULANCE SERVICE T IES

B2

I 00.0

1

1.2

100.0

0

0

3

3,6

96.3

2

2.5

98. B

11

13.4

92.7

1e'

19.5

79.3

l0

36.6'

59. B

18

22.0

23.2

1

1 2

21

Tota I

Elapse.d Tilne in MinutosB0-

B9

No. ofCrashes

Percentage

Cumul. Í

Ra nge :

Mean Time:

B - 86 minutes

30.0 m i nutes S.D. 13.9 minutes

The median ambulance service lime follhe observed crashes

was 25 minules. ln 23fr of cases the patient was in hospl-lal wilhin 20

minutes of lhe call being receiveC and BOf of patients had arrivedwilhin 40 minutes.

1?9

THE TREATI'4ENÏ SUBSYSTEM

Treafment subsystem elemenls include lhe various measures used

in providlng care from the scene of lhe crash until the time of dlscharge

from emergency caro. They may be broadly divlded inlo two groups:(a) care before casualty, and (b) care within fhe casualty department.

Care Before Hospifal(a) Firsl Aid at lhe Scene

First aid had been performed by members of the public forpersons lnvolved in 23 of the study crashes. V¡cfims from 12 crashes

had been taken to nearby houses or buildings where they were made com-

fortable whi lst awaiting the ambulance. There were three instancos oftowels or other makeshift dressings being used to staunch blood flow

from lacerations. Only once u/as ð first aid kit used by a bystander.

A motorist stopped after witnessing the crash and used materlals from

a kit he carried in his car fo bandage a head laceration. There were

no casos in which first aid provided by members of the public lvas detri-mental to the patient?s conCition.

Tow truck drivers occasional ly assisted fhe injured before

the ambulance service arríved and helped with the exlricalion of Trapped

persons. Some truck operators are genuinely interesfed ln first aid and

carry first aid equipment in lheir trucks. (Murcott, 1971. ) Neverthe-

less, lheir job is to obtain lhe towing rlghts and this takes precedence

over fîrst aid. Some ambulance drfvers acf as tow truck drivers durlng

off-duty periods and openly admit that fhey rarely perform first ald

because They have to compete with other services for ïhe towing rights.(Kovacs, 1971.)

Police were not involved in the provision of f f rst aid at lhescene of any of tho study crashes. They altend to the imporlant tasks

of site prolection and traff ic control and this llmits their avail-abllity as flrst aid personnel.

t50

None c¡f the vehicles lnvolved in the study crashes caught

fire, allhough the flre brigade altended two crashes to hose spiltpetrol from fhe road and maínlain general surveillance in case firebroke ouf. 0n one occasion the brigaders salvage van was called foassist with the exTricatíon of a lrapped victim.

Doctors were present at the scene of 3 of fhe 100 crashes

studied. One of the patients treeted by a doctor at the scene was

subsequently managed privately by that practifíoner. These observations

support previous stafements that doctors in urban areas rarely attend

the scene.¡f road crashes and even more rarely confinue to manage the

patients after providing emergency care. (Bush, 1971; Royal Austral-asian Col lege of Surgeons, 1970. )

(b) Ambulance Care

Ambulance c¡fficers are frained to provide f lrst aid, withparlicular emphasis on speedy díagnosis and correct emergency lreatment.0n arrivîng af the scene they assess the condition of the injured,delermino treatment priorities and porform necessary first ald before

loading patients into the ¿rmbulance for transport to hospital.

Trlaqo at the Sceno

Three hundred and ten persons were involved in the

crashes, of whom 183 wore injured. One hundred and forty-seven (80Í)

of the injurecl were treated by ambulance officers. Those injured but

not treated had sustained minor injurles and ln most cases did not

requlre treatment. Overal I the ambulance offlcers were thorough in

their altempts to locate and assess the irrjured and friage of those

lnvolved was completed within a short limo of arrival at the crash site.Five victims, who had lacerations requlring suture. or t'lere concussed,

refused ambulance troatment and transporf, despite repeated attempts

by fhe ambulance men lo have them attend hospital.

131

Ambulance cfficers encourage al I palients with a hlsïory,signs, or symptoms suggeslive of concussion to accompany them tohospilal. Many patienls wilh minor injuries (e,9. bruises or abrasions)

who, on questioning, have an incomple-l-e recollection of the crash and

evonls leading up to il, are broughf to hospital wiÌh suspected con-

cussion. These patients with minor injuries contribute signiflcantlyto the loads on casualty departments, particularly in the late night,peak poriods. Nevertheless, fhe cautîon of the ambulance offlcers isjusfified and reflects the current service (and medical ) pol ïcy which

requires lhaT al I palients with possible head injuries should be

assessed by qual ifíed medical personnel before thely are discharged from

emergency care.

Treatment Procedures

Particular importancc^ is placed on the management of the

unconscious patlent with emphasis on the maintenance of the patientrs

airway, breathing and circulation. None of the sample patien'ts required

inlensive resuscilation at the scene, buT the necessary faci I íties,which included suction, oxygen and intravonous infusion equipment, were

available on ambulances if required. The suction equipment was used to

clear blood from the naso-pharynx of ono of the study patlents.

Five of the palients werc unconscious at the crash scene.

Four were managed in the coma position ('three-quartor prone) which is

sfandard practice within the service. The fiflh was a young man' one

of four victims involved in a single vehicle crash in which a car

col I ided with a pole.

cAsE 51 041 An 1B year-old unconscious male was

extricated from the rear seal of a car. Three other viclims in the

crash had been assessed by thc ambulance officers and loaded into the

ambulance be;fore his extrication was completed. A second ambulance was

thus summoned to take him J-o hospital. The f irsl ambulance left the

132

scene before the second had arrived, leaving the unconscious man lyingon his back at the roadside ín lhe care of bystanders. ïhe second

ambulance arrived approximately five minutes later.

This was one of the few cases of unsatisfactory ambulance

care that were observed. The anrbulance officers should have nursed thepafien-f in the coma position and waited for the second ambulance before

leaving lhe crash scene. Triage and treatmenf of several injuredvictims is ciiff icult at tho crash scene and mistakes in priorities are

bound to occur. Nevertheless, it is important that few such mistakes

wore made by ambulance offlcers al lhe sfudy crashes.

Dress i ngs were app I ied 'to 35 vict ims w íth I acerat ions

and abrasions. They were usual ly used to achieve haemostasis. Dressings

are not always applied to op.:n wounds, but there were few occasions on

whlch dressings were not applled when indicated. ln general, the dress-ings used and the technique of applying them were satisfactory.

Seventeen persons required I imb spl ints for fracturss.Air splints are stanclard equipment in thls service and were used forsuspectcrJ fractures in al I cases. Deficlencies in the uso of these

spl ints were noted on three occasions, when ambulance officers removed

victims f rom vehicles before applying splints. 0n another occaslon a

short leg splint was used for a tibial f racture when a long leg splintwas indicated. The re-use of air spl ints, whlch is sfandard practice,makes it important lhat splints should be checked for leaks before they

are repackaged. Sevoral splints were partially def lated by the time

the patienl reached hospital. ln general, the judgement used by

ambulance officers in applying splints for suspected fractures was

sat i sfactory.

Forty-one patients with I imb fraclures were included infhe series of 328 patienfs examined affer admission to casualty in fhe

133

second phase of lhe study. ln 7 cases, splints had nof been appliedby ambulance offîcers when indicated; 1'wice for upper limb fractures,once for a fraclured tibia and fibula and on four occasions for fracturesof the femoral shaft. Each ambulance carries a modifled Thomas Spl intwhlch is narticularly suifable for immobilizing f ractures of fhe femoral

slraft, bul which is rarely used for vicfims of urban cnashes.

ln cases of suspected spinal fraclure, of which fherewere two in Phase One, no special immobilizafion measures were used.

Spinal boards are not carried on Victorian ambulances. Sand bags forsupporting suspected cervical fractures have been introduced as standard

equlpmenf since the lime of lhe study. Ambulance officers are acutelyaware of the dangers of manipulatlng spinal injuries and showed care inmanaging cases in whlch fractures were suspected.

Trichlorethylene is used as an an¿:esthetic for ambulance

purposes and Hayward-Butt inhalers are carried on al I ambulances. An

inhaler was used only once in ihis sample of patients. lts use isparticularly lncJicated when patients are being extricated f rom vehiclesor undergoing procedures which can be expected to be painful, nofablyI ¡ft¡ng movements and lhe appl icatíon of spl ints. Despite iÌs avai l-ability the inhalêr was not used during such procedures. 0n the one

occasion in which lhe inhaler was used, it was offered to the patientafter she had been ex1'ricated and her fraclure spl inted. The operationof the device was inadequately explained and it was thus ineffective.

The fol lowing Table summarizes lhe freatment procedures

carried ouî by ambul¿¡nce officers for the victims of the study crashes.

134

Table 7/9

APIBULANCE PROCEDURES PERFOFMED FOLLOI4IING l OO CRASHES

lll AN AREA 0F Í"|ËLBOURNE

510

lBl147

12

5

5

1

35

17

2

1

121

Total No. of Patients lnvolved

Number of Patients lnjuredTreated by Ambulance 0fficersExfricated from Vehicle

Refused Treafment and Transport

Unconscious Patíents

Airway Cleared (Suction Equipment)

Dress i ngs

Limb SplintsSpinal lmmobilization

Anal gesi a (Tr ich lorethyl ene)

Transported fo Hospital by Ambulance

Proport I onof Total

No. ofPat ie+nts

100.0

59.0

47,4

3.9

1.6

1.6

0.3

11.3

5.5

0.6

0.339.0

Care in Casualtv

Fou r hundrecl and f i f ty-e igh't crash v i ct íms who presented tohospital in the two phases of this study u¡ero observed during thelrcasualty care. Crash victims regisler at the casualty admission desk

on arriving in tho departmenÍ and are lhen faken to the assessmënf and

treatment area where initial tr iage and admission procedures are

performed.

(a) Trl.aqe

The initlal assessment of palients was usual ly carr¡ed out

by a momber of the trainee nursing staff. lt was her responsibllitylo assess all new patients and reporl fheir conditlon to the Sister-in-Charge. This nurse, who was usuôlly one of the most junior and lnexper-

ienced members of the casualty staff, was responsible for some of the

135

most important decisions affecting priorities in patient care, since

she was frequently the only member of the casualty staff to see the

patient immediately after admission.

This triage mechanism was unsatisfaclory. Many of the

observed patients wifh severe injuries did not receive apPropriate

priority in the patient queue because they had been inadequately

assossed. Road crash victims were not automatical ly rogarded as

emergency cases requiring urgent care in casualty. Hence they j'oined

the normal patient queue, unless lhe assessmenf by 'fhe triage nurse

or some other staff member suggested lhaf they should be seen more

urgently. The distributîon of waiting tîmes to see the medical officer,described in the next section, supports llre conclusion that the methoo

of Ìriage presently employed is unsuitable and ineffectlve.

Four hunclred and forty-eight of the patients who presenfed

lo thc casually doparfment tliere examined by a medical officer and

subsequenlly received invesligation and treatment of their injuries.Ten patients absconded from the departments before they were seen by a

doctor. The .types and sevority of -ihe injuries susfalned by these

patients was described in Chapter 6. ln lhe fol lowing section fhe

lreatmcnt procedures penformed for them wi I I be described.

(b) Treatment Procedures

There were 110 patients treated for concussion in the second

study phase. They were observed for a pcriod of at least four hours

bofore being allowed to leave lhe casualty department. Thoy received

assessment by a resiclenf medical officer and regular half-hourlyobsorvation by the nursing staff before being discharged from emergency

medical care. These oatienfs are observed in the acute receiving

cubicles in the treatmenl and assessment area.

Unconscious patîeni's were usually admitted to lhe emergency

136

cubicles in 'lhe departmenf and received prompt assessment from members

of the medîcal and nursing staf f . Ten Q.2% ) of fhe patients were

unconscious on admission to lhe casua lty department. l4ost unconscious

palients were nursed supine, which increased the risk of inhalatlon ofsecretions. Several of these patienJ-s had facial fnjuries, with

bleeding from and into the naso-pharynx, or had been drinking heforo

the crash occurred. Active measuros, which incl uded oro-pharyngeal

airways and suction, were used lo clear the alrway of flve pafienfs.

Two patients with multiple severe injuries required intensiveresuscitation, incl uding endotrachea I íntubation, artlf icial respirationand exlernal cardiac massage. Both died in lhe casualfy department.

Twenty pallents G.4%) had inTravenous infusions commenced

in the casualty dopartment. Al I were severely injured and cl inical lyshocked al the time fhe drips were sel up. Seventy of lhe study

patienls had received severe or greater injuries. Doctors in casually

were conservative in lheir use of intravenous lherapy and usually waited

until patients had developed clinical slgns and symptoms of shock before

commencing infusions, Those patients who had intravenous infusions had

blood senl for grouping and matching. 0nly one patienl received a blood

transf usion in the casualty departrnenl. Stable plasma protein solution

was used in those cases where ungent plasma expansion was required.

Thirty-six of the 58 patienfs who had sustained I ímb fractureshad their fracturos imrnobi I ized by spl inTs in casualfy, As was staTed

in an earlier secticn, ambulance officers apply air splints af lhe scene

in lhe majority of cases where fractures are suspectod. ln the hospitals

under study, it is ncrmal practice for lhese splints to be removed soon

after the pafient is admitted. The splint is either replaced by a

wooden splint or, as hap¡;ened in 3B/' of cases where fractures were

present, nol reapplîed at all.

137

Eight patienls were suspected of having spinal injuries at thetime of admission. Three of these were subsequently confirmed as having

fractures of lhe cervical spine, A fourth victim who was admîtted lohospilal for lreatment of multiple pelvic and limb fractures was found

to have an undisplaced fraclure of his seconcl cervícal verfebrae two

days after his admlssion tc¡ lrospital, when he complained of a sore neck.

A furlher two patients had frac'tures of luml¡ar transverse processes.

The adequacy of the communications between ambulance officersand casualty staff is of paramount importance in the management of spinalinjury. 0n onc occasion, poor communicatîon befween fhe ambulance

off icers and members of the casualty s-l'aff at the fime of admission

meant that the oatient was undressed without due care by nurses who were

unaware of the suspecled cervical fnacture. 0n a second occasion nurses

undressed a patient whc had.iust been examined by a doc'tor who suspected

a spînal fracture. ln both cases manipulalion of the pafienlfs head and

neck was involved in removing lhe clotlies. Fortunately, fractures were

not present in either case.

M i nor wounds, bru i ses, abras i ons and I acerat ions ¿:re the

commonest injuries suffered in road crashcs. Abrasions were usual lycleaned and painled wilh mercurochrome by members of lhe nursing s'taff.It4ost laceralions were clcaned a¡rd dressc-:d by nurses before sutures were

insertecl. One hundred and twenty*seven patients received sutures in lhedepartment. Although casualty theatres and procedure rooms were avai l-able for the perfonnance of'these procedures, many of them were performed

i n f he acule rece i v i ng and treatm.-.,nf are¿J.

Two hundred and sixfy-nine patients had casually X-rays

performed, buf few other special diagnostic services were required forthe study patients. One echogram was performed on a pa-fient with a

head injury and suspected întra-cranial lesion.

138

As was mentîoned in an earlier section, senior medlcal

personrìel are on call and may be consulted by casualty sfaff . E¡ght of

fhe 328 patienls seen during the second phase of this study were seen

by the appointed casualfy surgeons. Fifteen patients were examined by

the receiving honorary in-patienf surgeons. A further 63 werr¡ seen by

surgical registrars cr admitling officers, in consultation with the

res i dent med ica I of f icer i,rho was hancl I i ng lhe case. S ixty-two per cent

of the palienls admilted for in-patienl care were seen by the admitting

officer before they were laken to lhe wards.

Patients are eilher admilted for in-patient treafment or

discharged from emergerìcy care after receiving casualty treatment. One

hundred and one Q2Ð of the 458 patients who presented to hospilal

during the two phases of this study wero admitted for in-pationt care.

An edminisfrative inslrucfion of the Alfred Hospilal stafes That Ino

patient shoulcJ be dischargecl frorn medical care while symptoms are stillpresentr. (Alfred Hospital, 1969. ) Thus the majority of crash victims

who are trealed as oul-pafients are referred lo the hospitalfs Accldent

Clinic or lo a local medical officer for fol.low*up. The paTterns of

referral for each of the 328 patients who presented in Phase Ïwo of fhe

study are shown in the following Table.

Table 7/10

No. of Pafientsn

67

2

207

9

]B

5

20.4

0.6

63.?

2.7

11.6

1.5

Tota I

Admitted to Hospital

Referred to Another Hospitalfor Admission

Referred to Accidenl Cl inicReferr+:d lo Local Doclor

No Referra I

Absconded from Care

Referra I

328 100.0

ln summary, treatment procedures carried out for those

patients who were observod in casualty during the two study phases

were -

lable 7/11

CASUALTY TREATMENT PROCI.DURES PERFOFMED

FOR THE OBSERVED ROAD CRASI.I VICTIMS

139

458

448

10

103

2

20

36

B

269

127

101

Crash Viclims Presenling lo Casualty

Examined by Modical OfficersUnconscious on Admi ssion

Dress i ngs

I ntensive Resuscitaf ion (E.C.M./Airway)

I ntravenous Therapy

Limb Fraclures Sp I i nted

Sp ina I lmmob i I lzat ion

Radiography

Suture of Lacerations

Admitfed lo ln-Patient Care

Proporf I onof Tota I

No. ofPat i entsProcedure

I 00.0

97.8

2.2

22,5

0.44,4

7.8

1.7

58.7

27.7

22.1

%

(c) Casualty Treatment Delays

V'lhenever poss ib le, e lapsed times in the separate phases ofcasualty lreatment were recorded for fhose road crash victims who were

observerl during their casualfy troafment. Flg. 7.2 dep icts fhe sequence

of events occurring during casualty care, and i I lustrates fhe time

periods for which delays wene recorded for each of the study patients.

Patient- Regi stratj on-Casual ty bY by

M.0.tbcurentati on Cubi cl e Nurse

Nursingcasualty Reception Assessment

Ti me Del

l,laiting Tine to See

Medical 0fficer

Taken to-Seen-Seen Taken to- Returned -to

Takenfor

speci aìProcedures

Progressreviered - Pati ent

I eave sby Casual ty

doctor

X-RayArri vesat

Hospi taìCubi cle

X-Ray Service Time

-l-otal Casualty Treatnent Time

0bservatìon and Treatnent TireMed'ical officer

Service Time

F'ig. 7.2 Sequence of events during

casualty care, show'ing time relationsh'ips.

CASUALTY RECEPTION TRIAGE

EMERGENCYTREAI},IENT

&

RESUSCITATION

DIAGNOSTI C

PROCEOURESTREATMENT OBSERVAT IOIi

140

Recept ion TÌme

The recepfion time represenls lhe delays experienced by

pafients durirrg transfer to the casualty trealment and assessment area.

This corresponds to the ambulance delivery time (Flg. 7.1.) for those

crash victims brought to hospital by ambulance. ll încludes delays

incurred in transfer from ambulance stretcher to hospifal barouche and

in documentation and registrafion en route fo the assessment and treat-rnent area. Non-emergency patients usual ly complete this lransfer in

less than five minutes. These procedures may be waived for emergency

patients and they are usually lransferred in one or two mlnutes.

Walking patienfs regíster at the casualfy admissions

desk before being faken fo the treafment area. Queues form at thispolnt anC delays depend on the number of patÌents waÎting to reglsÌer,the tlme of day, and the severlty of their injuries. Pallenfs wifh

disabling injuries are usual ly taken straight to the assessment area

where registration and documentation procedures are completed by lho

casualty clerks.

Two hundrecJ and slxty-seven (81Ð of the 328 patienTs

in the second phase of fhe study were broughf to hospltal by ambulance

and avoided the reglstratlon and documentation queue. Many of lhe

remaining 19/ of patients also passed by fhÌs queue because of thelrovert lnjuries.

Nurs i nq Assessment De I ay

It was stated earl ier in

inltlal ly assessed by a receivîng nurse

patientls conditlon and then reports fonursing assessment delay represents thepatientrs arrlval in the assessment and

î s soen by fhe assess i ng nurse.

this chapter that patients are

who gathers deta i I s of the

lhe sister in charge. The

elapsed time befween the

treatment area and the time he

141

The distribufion of the delays observed for patients lnfhe second study phase are shown in Table 7/12.

Table 7/12

NURSING ASSESSMENT DELAY

315

100

Range: 1-l0minutesMean Time: 1.9 minutes S.D. 1.5 minutes

Patienfs were assessed prompfly by the admitting nurse

wlth a median delay of one mlnute. Patients who waifed longer than sixminufes were all walking patients with relatively minor injuries.

Waltinq Time to See a Medical OfficerAfter patients have been assessed by the admitting nurse

and registration and documentalíon procedures are completed, they wait

to see a medlcal officer. The elapsed time befween the arrival of a

patient at the casualty trealment and assessment area and the time ofexamination by a doctor is defined as the waiting time to see a medical

of f i cer.

A doctor was rostered ín the casualty department of fhe

Alfred Hospifal to see all pafienfs wifh severe illness or injury attheir time of arrival. lnevitably, queues form for medical officerservices. Each patientfs name and provisional diagnosis was placed in

the casualty admission register by oither lhe documentation clerk orthe admittlng nurse. The order in whlch a patient was seen was observed

4

1.3

100

6

1.9

98.7

0

96.8

1

0.396.8

I2.5

96.5

l0

3.2

94.O

30

9,5

90. I

95

30.2

Bt .3

161

51 .1

51 .1

No. ofPat i ents

Percentage

Cumulatlve Í

Tota I9+B765432I

Elapsed Time in Minutes

142

lo be dependenl on his posiTîon in the patienl queue as recorded in lhisregister. Êmergency palienls, who had boen identifled as such, were

normal ly seen promptly by an avai lable docfor.

Waiting times were recorded for 416 of the 448 patients

who saw a medical offîcer. E¡ght of the ten patients who absconded from

the departmen't grerl tlred of waiting for a'ltention ancJ signed lhemselves

out. The distribution of waiting times observed is shown in the follow-ing Table.

Tabla 7/13

I¡JAITING TIME TO SEE THE MEDICAL OFFICER

416

100

43

10.5

100

22

5.3

89. 7

31

7.5

84.4

4A

9.6

76.9

65

1 5.6

67.3

96

23.1

51 .1

59

14,?

28.6

60

14.4

14 .4

No. ofPat i enÌs

Percentage

Cumulative É

ïota I60+50-5940-4930-3920-29t0-195-90-4

Elapsed Tíme in Mlnutes

Range:

Mean Time:

1 - 235 minutes

26.0 mi nutes S.D. 22.1 ninutes

Although the median waiting lime was 17 minutes, 32% ofpatienfs waited longor than 30 minules for medical officer examination

and 10f longcr than an hour. l{any factors are involved in producing

these delays and their length is of considerable importance in view ofthe principle thal emergency care shoulrJ be provided in the shortestpossible time.

A corollary of this principle is that paf ients wilhsevere injuries should be seen promptly afler admission. The dlstrib-ution of observed wailing times for patients with varying degrees of

injury is recorded in Table 7/14,

143

Table 7 /14

WAITING TIMES TO i3E SEEN BY A DOCTOR

BY DEGREË OF PATIENT INJURY

Nit

Minor

Moderate

Severe

Very Severe

Fata I

416

Patients wilh severe or greater injuríes waited forshortcr limes than those with minor or moderate injury, but even forthis severoly injurerl group, fhe rnedian waiting time was 7 minutes with

18% of palients waiting longer than 30 minutes to be seen by a doctor.

The range cf waiting¡ times for severely injured pafiente was from 1 to95 m i nules.

X-Ray Service Time

The dis-lribution of times spent in X-ray (Table 7/15)

represents the observed delays between fhe removal of the patients from

the casualfy cubicle and the fime of their return to it affer X-rays

had been-faken. lt include-s tlme spent wailing in fhe queue for X-ray,

time spent receiving lhe service, an<i time spent in (or outside) the

department wai'llng to be returned to the casualty cubicle.

4322314065965960Tota I

10

231

114

41

10

10

2

28

9

4

1

13

6

2

1

21

7

2

31

A

2

1

41

20

3

1

3

50

30

10

3

,)1-

27

1B

10

1

t1

1

20

1 B

B

5

B

Tota I60+50-593o-3s j +o-+s20-2910-190-4 5-9Degree of

I nj ury

Elapsed Tirne ín Minutes

þ_b..te 7/15

X-RAY SERVICE TIME

144

259

100

Range:

Mean Time:

6 - 157 minutes

33.5ninutes S.D. 21 .6minutes

The distribution of waifing times ref lects the loads on

the deparlment. The X-ray department in the Alfred Hospital was close

to the casualty treatment area, and wel I equipped with a rapid fllmprocessor. I n Pr i nce llenryrs Hosp î fa I , where the department was severa I

floors removed from the casually deparfmenf, cJelays in X-ray service

were observed to be longer.

It was observed thal the speed and qua I iÌy of the X-ray

service varied markedly wil'h the racjiographer on duïy. Queues and

waiting times were markecJly reduced when efficient radiographers were

on duty. The numbers of patients awaiting X-ray were recorded at the

time of each crash victîmrs admission and the frequency distríbutionof lhese observalions is shown in Table 1/16 (see p.1a5).

Patients queue for X-ray approximately half the time.

Since lhe time spenl in X-ray conlributes significantly To the delays

in cosualty care, particularly for lhose patients with severe injuries,the casualty X-ray departmr:nt ne¡eds to be slaffecl around the clock by

experienced radiographers who are able to provide rapid, good qual itysorv i ce.

13

5.0

100

4

1.5

95.0

20

7.7

93.4

36

13.9

85.7

55

21 .2

71.8

56

21 .6

50.6

62

23.9

28.9

13

5.0

5.0

No. ofPat i en'ts

Percentage

Cumulative f

Tota I70+60-6950-594A^4930-3920-2910-190-9

Elapsed Time in Minutes

145

lable 7/16

THE SIZE OF THE X-RAY QUEUE AT THE TIMECRASH PAT I ENTS I.i FRE ADÍ\4 ITTËD

150

82

45

21

5

2

23

46.6

25,5

14.0

6.5

1.6

0.6

5.3

328 100.0Tota I

0

1

2

3

4

5

N.K

Frequencyn%

No. of Patientsawaiti X-ray

_Observation and Treatment Time

Afler being examined by lhe medical officor, patienlsspend a variable time undergoinE further observation and trealmenl and

wail for out-patlen'l referra I or in-patlent admission procedures tobe cornpleled. Patients lvho have been X-rayed wait for f urther assess-

ment, treatment and referral by The casualty staff. The treafment and

observation time is defined as the elapsed time from fho examination by

the medical officer for lhose pallents who do not go to X-ray, or the

return to J'he casualfy cubicle from X-ray for those who do, until the

time of their discharge from emergency medÍcal care. The dislribufionof observation and treatment times observeci is shown in Table 7/17 (see

p.146).

The median elapsed time for the combined sludy patients

was 90 minutes and il can be seen that 25% of patients spend longer

than 3 hours ín th is pl'rase of the i r care.

Table 7/17

OBSERVATION AND TREATMENT TIMËS

146

Tota I

411

1 00.0

Range:

l4ean Time:

4 - 1386 minutes

142.0 minutes S. D. 129,0 m i nufes

It was standard practice in the stucjy hospifals forpafients with a history of concussion to be observed for a period offour hours before being discharged from omergency caro. ln the

Alfred Hospital, lhese patients aro observed withín the casualtyreceivîng are-.¡, occupy¡ng acute casualty recoiving cubícles for consider-able periods of time and contributing to the congesfion withln thedepartmenl. An observalion ward is located adjacenl to the casualtydepartment but at the -lime of lhe study was nol used for these patients,ostcnsibly becauser of a lack of staff to man il. ftn observation ward isessenfial for eff icíent cesualty opere.itions, since, in busy casualtydepartmenfs, the long teirm occupatíon of cubicles by patienls who are

bein.o routinely observe..d limits the availabilify of examinaf ion and

trealmenf faci I ities for new patients.

'[ota I Casua I lv Trealmont T ime

The casually treatment time is defined as the elapsed

lime frcm the arrival of the patient in fhe casually assessment area

until lhe time of his discharge frorn thaf area. Patients are discharged

lo eifher in-patîent or ouf-patient care according to the nature and

severify of their injuries. The distribution of the elapsed fimes spent

by the observed patients during lhis phase of lheir care is shown in

13

3.2

1 00.0

1B

4.4

96.8

29

7,1

92.4

44

10.7

85.4

45

10.9

7 4.7

B9

21 .6

63.7

6B

1ô.5

42.1

105

25.5açE

No. ofPaf i ents

Percentage

Cumu I alive $

560+300-359

240-299

1 80-239

120-179

õ,0*119

30..59

0-29

F-lapseci Time in Minutes

the fol lowing Table.

22

5.1

100

147

Tota I

430

100

lable 7/18

TOTAL CASUALTY TREATI4ENT T IME

Range:

Mean T ime:

23 - 1595 minutes

190.0 minutes S,D. 1 53.0 mi nutes

The distribulion shows that the median fime spent inobtaining casua lfy care for the observed rc-:ad crash victims was 150

minutes. Cne hundred and thirly ß0,3%) of the patients spent longerthan four hours in the deparfments. Fifly-five (42Ð of these paTients

were under observation for head injuries and were fhus expecfed to be

in lhe department for at least lhat lime. Thus the delays for approx-imately 60f" of lhe palients who stayed in lhe department for longerlhan four hours mey be allribuled to organizational deficiencies and

not to matters of treatment pol icy.

Pafients who required admission for in-pafienf care

spen-l- a median time of 150 minutes in casualty. 0nly 10ft of these

victims were admitted within an hour of thoir arrival at the department,

The median casualty treatment time for pafients with severe and greaterdegrees of injury was 90 minutes. 0nly 13% of this group were admitfedwiïhi n an hour of arrivi ng I n the casua lty department.

fPrompt treatment and speedy dîspatch (of patienfs) tothe required destinatione are among the sfated objectives of casualty

10

17

94.9

49

11 .4

92.6

49

11 .4

81 .2

4B

11,2

69.1

69

1 6.0

58.6

122

28.4

42.6

61

14.2

14.2

No. ofPat i ents

Percentage

Cumul ative f,

420+360-419

500-359

2.40-299

1 BO-239

120-179

60-119

0-59

Elapsed Time in 14inutes

148

trealment. (Alfred Hospital, 1969.) TreaÌment times as long as those

observed suggest that the present organization of services is not

ach ievi ng the des i red object i ves.

THE DOCUI.4ENTAT ION SUBSYSTEM

The documentation subsys-lem i nc I udes the var ious methods of

recording data describing the crash, the response of the emergency

sorvices,-fhe patienlst injuries and their management.

(a) Crash Data CoI IectionAccidenl invesligation and the collection of crash data for

statistical purposes is undertaken by the V!cforia Police. The VictoriaPolice Accident Report Form con'tains four, closely typewritten, foolscap

pages of question relating to matlers of fact and opinion based on the

pol icemanrs observafions of the incident. Much of the form ls pre-coded

and thus suitable for completion al the scene. The policemanf s role atlhe scene is complex and ir¡volves such important functions as slleprotection and supervision of the olher emergency services. Consequently

lhe form was rarcly filled oul at the scenü and the officers presumably

relied on lheir memory to complete the clata record af a lafer date. ln

many cases pollce were observed to make long-hand notes of their find-îngs, presumably fo assisl with subsequenl completion of lhe reoorlforms. The rel iabi I ity of data recorded under such conditions is opon

to question and, although it is nol appropriate lo comment on the con-

tenÌs or requiremenfs of the polico accidenl record, it may be thal a

review of both recordìng melhods and the content of the record could

procluce more itccurate data for bolh stat ist ica I record i ng and genera I

pol ice purposes.

(b) Ambulanco Records

Ambulance service dala are recorded for each ambulance cal I on

three separale forms. A fourth form records data rolating to the

149

injuries and condition of fhe patient and îs deslgned to be handed tothe casualty staff at fhe time of 'the patientts admission for inclusioni n fhe med i ca I record.

Ambulance Call Record

0n receiving the notif ication call, the lelephonist or ambul-

ance dispatcher comple'tes a case card on which lhe details of the callare listed. lncluded among these details are

1. The time of lhe call;2, The slte of the incident;3, The nature of the incident;4. The name of the cal ler;5. The origin of the call (e.9. police, taxi

company etc. ).This record ls then passed on fo the ambulance dispalcher who

notes the relevant informatíon on lhe díspatch recond.

Di spatch Record

Each dispatcher maintains a dai ly work sheet which provides

a record of the location and distribution of lhe ambulances under hlsconf rol. On receiving the cal I record he notes the tlme of the day,

the timc of dispatch and the site and nafure of the incidenf on the

work sheet. When an ambulance is dispafched he records the ambulance

and crew I denli f i calion numbers.

At lhe time of the sfudy fhe service did not record fimes ofarrival and departure from fhe scene and arrival at hospital. As a

rosult of changes in adminislrative pol icy these significant servicoflmes are now recorded. The dispatcher also records fhe hospital towhich the injured are taken.

Service Docket

The ambulance crew complete a case docket on each ambulance

150

call. Data recorded on lhls docket lnclude1. The name and acldress of the palient;2. The d¿ri ly job number;-5. Di spatch and job cornp I et ion f imes;

4. The site and na.ture of the incident;5. The nurnbcr of patients and their injuries;6. 14ileage dala (from odorneter readings);7. lnformation requîred for bill¡ng and accounting

DUrposes.

This dockel is completed during the approprlate phases of theambulance call: dispatch data at the lime of dispatch, crash data atthe scene, and patient defai ls, accounJ'ing and bi I I ing informafionduring transport to hospital or orì completion of the call.

Ambulance Officerfs Report on a Casualtv

The fourth p iece of ambu l¡rnce service documentation ls thecasualty report form, designed to provide a record of the patientfsinjuries and cl inical condition as observed during ambulance care. A

form should be compleled for each emergency paflent. This form is theonly tangible and permanent record of lhc patientrs condition at the

scene and during transport. As such, il should provide a valuablesource of infr¡rmation for subsequent emergency care in casua lty. The

form, which is divided into six seclions, is used by all Victorianambulance services. ln addition to brie f personal details on thepatienlts name, âgo, sex, it contains thc following observations ofpatient conditîon at fhe scene and durÌng transporf.

Patient Data: Stata of consciousness;

Pupillary reactions;Pu I se;

Resp i rafory rate;Suspecterd injuríes;Other abnormal ities noticed.

151

Trealmenl Performed: Oxygen adminislration;Tri lene admi n istration;Other lreatmenf.

'fhe report form was rarely used for patients carried by theVictorian Civi I Ambulance Servlce. Ten of the ?67 patients brought tohospital by ambulance in the Eecond phase werê accompanied by completed

report forms. Soven of these patients were carriecl by the Peninsula

Anrbulance Servíce which used the fcrms routinely as part of the ambul-

ênce service rocord. Thus approximately lfi of cresh victims carrledby the V.C.A.S. had ambulance report'Éonns completed.

Since the reporf form was fhe only record of the patientf s

condition and treatment before hospllal, the arnbulance of f icersr fai lurefo complete it was reprehensible. Novertheless, it was, to some extenl,understandable. The form is designed to be included in the patient?shospilal record buf, in practice, none of them were subsoquently

included in the hislory. They wone usual ly left lying around thecasualty deparlment or consîgne<J to the waste paper baskel. Ambulance

officers were aware Ìhat casualty medical staff rarely read the reportform and had thus developed thc attitude that completion of fhe form

was a waste of time.

This represents a furfher example of poor communicalion

befween the ambulance and casualty sfaffs which may affecf subsequenf

palienl' care. Although ambulance men usual ly attempt to relate detal lsof a patientts injuries and management to a member of the casualtystaff, the only satisfactory way of ensuring that the relevant inform-ation gets to the medical officer who ultimately assesses the patientis to provide a written history. Equally, fhere is an obligaTion on

the casualty staff to take note of fhe hisfory whlch is provide<1.

152

(c) Casua I ty Documentat ion(1 ) Documentalion Procedures

Casually Documenfation clerks were among the first members oflhç casualty staff to inferview pationts, recording the personal data

necessary to eifhor procure an exísfing medical history or generate a

new hisTory. ln pracfice this procedure was a pre-requislte for exam-

inatíon by a medical officer in all cases except those where seriouslyi njured patients requi red i nfens i ve resuscí tation and care. On comp I et-ion of casualty documentation, paf lents were listed in the casualtyadmission bcok and theircby joinod the queue for examÍnallon.

Documentation delays in casualty were not recorded in thisstudy, buf two of the observed patlents did not receive medical carebecause they had not been docurnenled on admission to the clepartment.ln both cases, affer a delay of an hour, thc¡ observer reporTed theomission to thrs c.:sualty clerks who promptly completed the documontationand the patienfs jcined the queue for medical attention.

P.'tients who require':d admlssion to hospifal wero frequentlydelayed in casualty because of lhc documenfation procedures requiredbefore they were admitted. The admilting medical officor on duly was

required to sign thc medical record and allot lhe palient fo a ward.Often, during evening and nighf hours whan admit'ting officers were

absent from the department, long delays occurred because the document-

ation procedures couId noï be compIeterj. The delays caused by thedocumen-i-ation procedures pûr se were rìegligible in comparison with thedelays cat¡sed by the norì-availability of the admi'l-ting medical off icers.There are good medical reasons why aCmitting officers should be presenfin the deparlment thrcughout their rostc.:rod duty periods, since they arethe personnel who should be available for immediate consultation by thejunior resident staff. Equal ly, fhey should be presonT at al I times To

ensure the rapid admission or discharge of those patients who have com-

p leted thei r casua I ly treatment.

153

Q) The Medical HistorvCasua lly h istory and exam ination sheets tvere comp leted f or

each pat ie¡lt seen i n the clepa r1-ment. Record i ng proc;eclures i n the sludyhospitals followed the traditional patTern whereby medical informationwas noted in long-hand in fhe medical history. structured recordingformafs offer several advantages over the traditional methods ofrecorciing medical cjata. (Weed, 1970; Race, 1972.) Recording forms

have been de.signed especially for trauma victims (Bordner, 1968;

Stanford Research lnstitute, 1968) and evaluafed as an effecfive means

of recording and s.toring clinical and statistical data. (Cashman, 1970).

The existing system has several obvious deficiencies. Firsf,it I eads to lhe record i ng of i ncomp le'l-e ancj, f requent I y, i rre levanfdata. secondly, observations made during'this study suggest that lhemosf severely injurr:d paf ients are often those for whom lhe least datais recorded in the medical hislory. Data recorcling is rightful ly low

in the order of priorities in the l'lurry of aclivity that surrounds fheadmission of these palienls. Nevertheless, data on the early management

of fhe seriously injured may be of consiclerable importance for subsequent

care and relevant signs, symptoms and treatmenf detai ls should be

included in the patîentts history.

The casually medicai records of each of ihe palients admittedduring fhe second phaser of fhis sludy rvere reviewed after the patienfhad been discharged from tho casualty departmenf. Twelve (4/ù of therecords reviewed contalned complete documentation of the patientrshís'lory, examinalion, and subsequent casualty troatment. Two hundred

and forfy-nine ß2%) of the records contaíned a record of the majorf ind ings and treatment performed . ln 44 (4%) of the cases importantinformation on the patienlrs condition ancJ lrealment was omitted from

the casualty record. 'Table 7/19 describes the observed relationshipbetween the qualily of the medical necord and the degnee of injurysustaíned by patlents.

lable 7/19

COMPLETENESS OF THE MEDICAL RECORD FOR DIFFERËNT DEGRËES

OF PATIENT INJURY

154

TOTAL

ndlo

12 3.9

249 81.6

44 14 .4

305 100.0

2A + I vs. C: X = 18.15; D.F. = I tr*x

Significanfly more paf¡ents with severe dêgreès of injuryreceived Incomplote documentafion of their casualfy treatmont than

did fhose wilh minor and modc¡rate degrees of injury.

43 100.091 1 00.0171 1 00.0'Iola I

15 34,913 14.316 9.3C

I ncomp I eferecord. S i g-rrif icant f ind-i ngs and treat-ment omitte<J.

27 62.773 80.2149 87.1B

Major findingsi nc I uded. l.losigníficantdetai lsom i tted

I 2.3

n í

5 5.5

n %

6

n dle

3,5A

Al I posilívofindings andsignifícanfevents í ncl udedi n record

Severe *ModerateNll & Minor

DIGREE OF INJ I.JRYCOI,4PLETENESS OF

T4EDICAL RECORD

155

Chapter I

F THE EM ENCY CARE S

The use of a systems approach for examining emergency servlces

requires that the operations of the existing system should be evaluated

and alternative methods of achlevlng the objecflves of the system con-

sidered in the light of their likely effects on lt. Moreover, fhe

approach implies that the system should be examined as a whole, using

specific criterla to evaluate its various elements.

The problem in evaluating emergency care, as in many olher

areas of medical care, lles malnly in f indlng valid and reliablecrlteria. Few slandards have been defined and thus reference polnts

wilh whlch perfofinance ln the system may be compared are few. Many ofthe criteria that do exist are subjective and assessments based on them

are usually slmilarly subjective.

lnvestlgators of medlcal care have used three main approaches

in studying qual ity. These have been described as

(a) Studies of Care Outcornes;

(b) Studles of the Structure of Care;

(c) Studles of the Process of Care. (Donabedian, 1969.)

(a) OUTCOMES 0F CARE

Assessments of the outcomes of care involve evaluation of the

end results of the care process. Quality ls determined by the extent fo

which fhe results accord wlth curren'l- social and professional expect-

ations. Crlteria used frequently in outcome assessments include case

fatality or disability rates, measures of recovery such as length ofabsenteeism, and patienf attitudes to and satisfaction wlth the care pro-

vided. Outcomes are diffícult to measure and usual ly fai I to provlde

insight into the specific strengths or wraaknesses of the system. They

represent broad measures of perf'ormance and are dependent on the

156

assumption that good results are consequenl on good care. ln Ìheory,

outcome measures provide lhe best measure of quality because they assess

lhe ultimate effectiveness of the process under review. Nevertheless,

the diff iculties wilh def inition limil lheir usefulness and aPplicabil-ity as qual ity measures.

This appl los particularly to fhe assessment of the outcome of

emerqencv care, since emergency care forms the inifial part of a continu-

ous medical care process which lncl udes definifive treatment and rehabi l-llation. The outcomes of care are înfluenced by treatment in all fhe

separate phases and it is extremely difficult to distinguish the parflc-ular significance of any one of these phases for the ultimate result.Thus, for example, the recovery of the severely fnjured patÎent may be

influenced by the rapiclity with which he receives emergency care and the

competence of those who provide it. Bul it is also affected by lhe

compelence of the doclors who provide deflnitlve care, the nurslng care

and many other factors.

Two outcome measures were used in thls study and both were

based on pafientst assessments of the care they had received. As an

outcome measure of recovery frcm crash injury, patlents who responded

lo questionnai re sunvey were asked to make an assessment of the length

of the time between the occurrence of fhe crash and their return fofheir normal activities. The distribution of lhe responses is shown in

Table 8/1. (See p.157.)

The median time for crash vlctims to resumo normal activítleswas approximalely a fortnight with 20% of patienfs laking three months

or more.

157

Tab le B/1

T IME TO REStJfl4E NOFMAL ACT I V IT IESFOR ROAD CRASH VICTIMS

No. of Patlentsnfi

183 1 00,0Tola I

Less than a day

A few days

About a week

About a forfníghtAbout a monfh

About Ihree months

More than three months

No opi nion

Tlme Delay

20

30

27

24

36

15

25

6

I23

17

20

37

29

35

14

10.9

16.4,l4.

B

13. 1

19,7

8.2

13.7

3.3

4.4

12.6

9.310.9

20.2

15.8

19.1

7.7

Resumption of normal activities is one measure of recovery,but pa'i'ienfs often return to work some time before they feel they have

recovered from the lncident completely. Hence patients were invitedfo assess the lime that elapsed belween the crash and the fime that theyfelr they were back to normal health. Their responses are shown lnTable Bl2.

Table B/2

ELAPSED TII"1E FROM THE CRASH UNTIL RETURN

TO NOFMAL HEALTH

183 1 00.0ïota I

Less lhan a day

A few days

About a week

About a fortnightAbouf a month

About three months

More than three months

S+¡ll not recovered

Time Delay No. of Patientsn%

158

The median tîme before patients felf back to normal health was

approximately a month. That morbidity from crash injury ls considerable

is demonstrated by the fact lhaf The distribution is skewed fowards fhe

longer llme intervals" No dat¿: are avai lable with which theso assess-

ments can be compared, and thus the ef'fect of the care provided on thislreatment oulcome cannot be evaluated.

Evaluatlons using outcome measures are cornpl icated by such

variables as lhe characlerlstics of the populafion, the types of injurysuffered, the d¡fficulty in defining the exact measure used, and lhe

lack of comparable criteria as reference points. These facfors al I need

to be considered in making assessmenls and it is oflen d¡fflculf torelate tho outcome fo a specific causo. Thus assessments using less

ultimate criteria must be useC. Such criteria are used in studies of

the slrucfure and process of care.

(b) THË STRUCTURE OF CARE

Assessmenls of the structure of care involve evaluatÎon of the

facilifies used for providing care and examination of such areas as the

administration and organizalion of fhe services, equipment and faci I itiesused, staff qualif ications and availabillty, and the f inancing of the

serv i ces.

Qual ily assessments based on these crileria have the advant-

ages of deal ing wifh objective data. The underlying premises in the

evaluation are that -1. Betler qual ity care is more I ikely to be provided when

, qualif ied staf f , good physical facllities and sound

organizafional sfructures are avai lable.

?-. EnouEh is known to idenfify whaf is good with respect

to these items.

3. A relationship exists between these sfructural elements

159

and The qual ity of care.

Given good structural qual ifies, good care wi I I result.

ln chapter 3 it was shown that the sfrucfure of ambulance

services in Melbourne in lerms of organization, equipmenf, personnol

and staff fraining compared favourably with similar services elsewhero

in Auslralia and wilh the published standards for services in several

overseas countries. The lack of a system of emergency ambulances

staffed uri-t'h rnedical or para-medical personnel, such as ls employed in

several European countries, was noted, although the particular value of

these services in lhe Austral ian setting, partícularly for road crash

victims, has yet to be defined.

Slmí larly, the sfructure of hospital casualty departmenls was

oull ined. Ëxisling departments in Melbourne aro equipped to cater for

all lypes of emergencies although facîlif ies, in ferms of equipmenf and

manpower, are strained by the demancJs placed on lhe system by patients

seeking primary medical care.

ln evaluating struclural aspects of the emergency caro syslem,

'the medical staff ing of hospifal casualty departments warrants particular

comment. Most hospital casualty deparfments ln Melbourne are staffed by

doctors in their firsl year after graduation. These doctors are resPon-

sible for thr: initial aesessment and managoment of injured patients.

Since it is generally acknowledged that the early freatment of injuriesmay be of importance for the outcome of care, it is paradoxical that

emergency care is provided by the most ínexperienced medical personnel.

The casualty departmenl of oach of fhe sfudy hospltals was

manned throughout tho 24 hour's of the day by junior resident medical

officers. ln the casualty departmenl of lhe Alfred Hospital, four of

these doctors were orì duty each weekday morníñ9, With either 2, 3 or 4

docïors at other times and on vleekends between the hc'urs of 0830 hours

4

160

and 2300 hours. One residenl medical officer was on dufy at night tocover the emergency cases presenling between 2300 hours and 0830 hours

the following morning. An additional doctor vras rostered unti I midnight

on Friday and 0300 hours on Sunday morning to help cope with the addition-al workloads which occurred on lhose nights, due largely to the admission

of road crash victims.

Duties are allocaled to each of lhe residents according to hìs

working shift. _The duties required of lhe resident working lhe so-calledrfirst cnf shift included the lmmediate assessment and management ofemergency cases as they arrived in the department. The doctor working

this shift was on duty from 0830 hours until 2300 hours - a 14.5 hour

shift. ln a busy casualty departmenl this involved consfant work under

pressure. The medical officers accepted the long hours which they

worked as a necessary, if undesirable part of lheir training and exper-

ience. Few other professionals work for such long periods under such

constant stress. lt is doubtful whether fhese work patterns are conducive

to maximum efficiency and there can be little doubt that the fatíguewhich most doctors experience affects both their judgement and perform-

ance. The minimum weekly working períod for a casualty resldent medical

officer al the lime of the sfudy was 62.5 hours.

ln these hospitals, immediate supervision of residenl medical

of f icers was provided by 'lhe hospital admitting of f icers, who were

usual ly doctors in their second year afler graduation. Three of these

doctors were rosfered for duTy ín the casualty department of the AlfredHospital during the day. Al night one of them was responslble forhospifal admissions and overseeing the casualty department.

Responsib¡ l ity for the overal l supervision of the deparfment

lay with the medical superintendent or his deputy. ln addition most

hospîfals employed qualified surgeons on a part or full-tlme basis toconduct casually cl înics, supervise in-service trai ning and deparfmental

161

oPeralions, and provide consultanÌ services for the casualty staff. lnlhe Alf red lìospital two cersualty surgeons were employed on a half -'limebasis to provide these supenvisory arrd consultant services. One of them

was rostered for duty in the deparfment each day and on Friday and

salurday evenings. Further t.'ack-up medical support was provided by lhein-patiçnl staff. þledical and surgical registrars were frequently con-su I ted by lhe casuô I ty staff.

lf is thus apparenf that a large number of medical practition-ers witlr varying levels of lraining and experience were pofentiallyavai lable to assist casualty staff. ln praclice these back-up staffwere offen not avaílable for immediate ccnsultation. This situationusual ly arose cluring late nighl' hours when consulting and supervisingstaff were nof presenf in the department and junior sfaff were fhusso le ly respons ib le for the prov ís ion of emergency care. i'vlany road

crash vicl ims we-.re adm itted during these hours, particu larly on Frídayand Safurday nights, and experienced Treatment delays and deficienciesas a nesu I t of the staff i ng def i ci enci es.

Ther.: is a need for f ul l-time supe rvision of casualty depart-ments by trained and experienced medical practitioners. The special istfor this position shculd Lrc cxperiencecJ in resuscitation ancl the manage-

menf of f rauma ancj, above all, be înteresled in fhe organization and

adminîslration of lhe department. Experienccd personnel should be

avai lable in the casualty deparlment on ô round-the-clock basis provid-ing assistance and advice for resident medical officers. Several

hospitals in Melbourne have advertised for ful l -Ìime casualty super-visors in an attompt to remedy some of the deficiencies in casual'lystaffing and orqanization. ln general, it has proved Cifficult to finddoctors 'to f i I I these positions. The compromise arrangement wtrich isadopte<l in many hospítals, of employing two half-f ime pe; rsons, usuallyjunior surgeons, to perform this funcfion is unsatisfacfory. Such

personnel are rarely interesfed in the organizational and supervisory

162

functions which are of prime imporlance for mainlaining and promotlng

thc-, ef f i ci ency of casua I ty operat ions.

The recommendaf ions on caslralty staf f ing prepared by theNew Soulh Wales State Commîttee of the Royal Australasian Col lege of

Surgeons and publ ished by lhe Col lege (Royal Australasian Col lege ofSurgeons, 1970) stafe thal rjunior residents should nof be unsupervised

in a Casualty Departmentr. ln practice, în the hospilals studied, lheywere unsupervised during mosl of fhe night hours on all days of the woek.

Di,l'icienci,¡s in the structural aspects of care are inevitablein any systemn especially when normative Etandards are used as a basls

for evalualion. The particular significance of the structural deficien-cies for fhe operation of fhe system cannot be evaluatcd unless theprocیs_ of ca re i s cons i dered.

(c) THÊ CARE PFOCESS

Assessmenls of the process of care consider the performance ofdoctors and olher professionals in managing pafienls wifhln the system.

The criteria used are the currently accepted standards of praclice as

formulated by leaders of the professions. Qual íty is determined by the

degree to which observed performance matches 'these accepted standards.

lmplicît in the assessments is the assumptîon that particular aspects ofcare are known to be specifically relatod to successful heallh outcomes.

Sludies o'f process have usually involved detailed assessment of theperformance of professionals by direct observation or by record revlew.

The judgements c.rf qualily are based on such faclors as the complefeness

of lhe cl inical history and examinafion, the technical competence dis-played in lhe performance of therapy., the choice of diagnosfic aids and

fhe compleleness of the medical record.

ln considering the process of emergency care additlonal facfors

163

must be laken inlo consideration. The use of the term emengeney lodescribe lhe care syslem has two importanÌ implications for lts function.First, lhe system should have the capabílily to handle serious illness orinjury. Secondly, the def inif ion implies fhat timo or, more partlcularly,time delays are imporTant variables to be considered ln assessíng fhe

systemrs operation.

(1 ) Time Delays in the Emerqency Care System

(a) The Siqnif icance of Time Delays

The assertion that Time delays are important in emergency medical

care neecls litlle substantiation for clinicians who have observed lheeffects of irreversible shock on the sevenely injurod patient. ln extreme

situations, lhe importance of delays in treafment is obvious. The patientwhose airway is occluded will die in minules if that airway is not cleared,The patient bleeding from a severed major arlery will exsanguinate unless

measures are taken promptly to slop the bleeding and resuscitate him.

ln such cases lime delays are critical and the neod for treaTment :

i mmed i ate.

Furfher evidence of this is provided by the experience in war

zones, discussed in Chapter 2 of lhis thesis, where lhe use of an

efficienï emergency care systern has resulted in an improvement in case

falalify rates associated wîlh reduclion of fhe delays ín instltutingtreatment. (1"4ítchell, 1968. ) lrr civilian practlce, coronary care unitshave been infroduced irr hospilals as a means of providing immediate,

skilled treafment for patients in the acule phase of illness, with con-

sequent improvements in mortal îfy rates. Fol lowing on from this,coronary care ambulances have been introduced as a means of gettingsimilar care to patients before they reach hospital. Undoubfedly, the

rapid provislon of skilled care can be lifç.-saving in certaln situaf lons.

The signif icance of time delays for the deve lopment of morbld-

ity is, however, more difficuli to define. The majorily of emergency

164

care is proviclc.tJ for patients with less than critical degrees of injury,wherc thc urgency is less and the effects of treatment are less obvious.

ln these cases, sÌandards for accepfable dolays in instituti'ng therapy

have never bcen sef and the evalualion of tlre importance of a given time

delay is thus d¡fficult. The rela'tionship h.retween time delay and deter-

ioration in clinical condilion îs complex and unprediclable and thls is

one of the main reasons thaf standards for fime delays in lhe provision

of emergency care have nevcr been c1efined beyond the general, somewhat

nebulous, princîple that the best possible care should be provided in

lhe shorlest possible time.

The feeling anrong many sections of the community lhat high

qualily care is not being provídecl witirin a minimum possible time has

lecJ to the suggestion of several allernafives to the established methods

of provi d i ng emergency care. For examp I e, he I i copters have been

suggeslod as allernafives lo road ambulances and emergency care ambul-

ances aro considereci by many lay and professlonal people to be desirable

¡: I tt¡rnali ves or add ít ions lo ex i st i ng ambu lance serv i ces. A case may be

made for the availability of both facililies, since both off-er advant-

ages over normal services in particular situafions. Bofh, however,

represenf .rxpensive additions to the emergency services and their use

and cost-ef fectiveness must therefore bc-. caref ul ly evaluated in fhe lightof the performance of the existing system in the area under sfudy.

(b) The Observed Time Delavs

ln examining the significance of time delays În the emergency

care syslem, one is obliged to examîne the delays in the separate care

phases. By this means lhe ex.lenl to which the rshortest possiblel

criterion is being met can be determined and the areas which need

modification to improve the operation of lhe system identified.

The response times observe<J in lhis study suggesT that delays

in lhe separate phases of the ambulance call are short. Although ¡t

165

ìilas nol possible to determíne notif ication delays for the study crashes,

it seems fronr interviews conducted aJ--ihe crash scene lhat bystanders

notify urban crashes promptly. l'he median time for an ambulance toarrive at the scene of a road crash after lhe notifying call was

received was observed lo be l2ninutes wíth an average response-iime of10.8 minutcs. (Table 7/6, p.1?7.) The modian treatment and transportlime for fhese calls was 17 minutes, as is shown by the time distríb-ution in Table 7/7 þ.127), Furthermore, the ambulance service time

distrîbution (Table 7/8, p.128) indicates that ambulance vicf ims reach

hospital from crashes in the ¿rea sludied in a mean time of 30 minutes

(wîth a median of 25 ninutes).

After arrivirrg in hospil'al patients wait to see the medical

off icer. The average time u¡aited for this service by road crash victimswas 26 minules; just four minules less than the average lotal elapsed

time during ambulance service. Standards for lhis delay have nof been

prescribed for thc study hospiTals, but since this consultation wifh the

medical officcr ís lhe important event in casualty care, ¡t is apparent

that the service provided does not meet the standard implied in the

administrafive inslruclion (Alfred Hospital, 1969) whích stafes thafpatienls should receiv,,: rprompt examination, appropriate special invest-iga-lions and diagnosis of their conditionr.

The mean total lime spe.,nt in the deparTment by the observed

crash victíms was 190 minutes. (Table 7/8, p.128.) Although crash

victims represenf a small proportion of tlre tofal casualty load, they

form a much larger-proportion of the enrergency patienls freated ln the

departmenf. Thus ¡t is of somo concern thal treatmenl tímes are so

long for this patienl group, and, once aga ín, if is reasonable toconclude that the s-i'atr:d objectivc of tprompt f reatmcnf.....andspeedy dc;spalch to the required clestinalion? (Alfred Hospital, 1969)

is not being met.

POST-CRASH EWNT CRASH

OPERATIONAL STAGE

OBSERWD AWRAGE TIMES(Mírwtes )

AMBULANCEDI S PATCH

ARRIVALAT

THE SCENE

ARRIVALAT

HOSP ITAL

PAI I ENT

SEEN BY

M.0.

+ 10.8 *+ .t8.8 26.0

Fig. 8.1 TIME DELAYS DURING EMERGENcY cARE

NOTIFICATIONAMBULANCE

RESPONSE

TREAÏMENTAND

TRANSPORT

CASUALTY RECEPTION

166

The r elationship bet,*een 'lhe important ambulance and casualty

deparlment treatmenT delays is shown in Fî9. 8.1. The lenglh of the

delays for patients waiting to sr¡e the doc'lor suggests thal- many of the

time saving advanlages-tc' be gairred by improved amtrulance transporlsystems may be lost because of the delays involved in casualty freat-mont. (The mean waiting fime for severely injured patients in thiscare phase was seventeen minutes. )

ln summary, the observed time distributiorrs suggest thatcJelays in ambulance service in the area studied are usually small.

Delays in casualty treatment are, howe;\,er, almosl invarlably long ancJ

apply to all phases of tile care. Thu:;, in terms of time-saving in the

emergency care system, 'there i:; more room for improvement i n casua lfydepartment organ i zaliorr and c;pcra:f ions than i n lhe ambu I ance serv ice.

(c) Waitinq Times in Hosoital Casually Departments'fhe waii.ing and lreafmenl lime distribulîons observed in the

study werre derived f rom obse;rvations made in three metropolitan hospitals.Ninety-five per ccnt of the palients observed werr¡ trt'aled in fhe AlfredHospital ancl the observerd waifing antl trcatmenl limes are thus largely

characterisfic of a single hospilr:l and its pattern of operations.

Therefore, it is desirable fhe-l waiting and lreatmenl fimes in other

hospilals should be compared with lhose observed to delermine how lhe

observed pattern correlaters lvith waiting limes in otlrer hospitals.

Tho research committee of 1'he Viclorian Seclion of the Ausfral-ian lnstilule of Hospital Adminislrators reported the resulfs of a

survey irr which the walting and treatmonÌ times in eleven VictorianPublic Hospital casualty depi:r-lments were reviewcd. (Brand et al., 1971

(1), (2), (3).) The sarn¡lle of hospitals íncluded fcur teaching hospitals

but did not include lher Alf rrld llospilal. Dala were collecled on alltypes of casualty attenders incl udi ng, pnesumably, road crash victíms.

167

Time i nterve I s mcasured i ncl uded -(¡) Delay during clerical documentation;

( i i ) Wa it i ng t ime to be seen by a docfor;(¡il) The lengthofthe initial consultation;(iv) The lotal time spent in the casualty deparfmenl.

Observations ln thr¡ second and fourth of these categories may

be compared with those of the F.¡reseñt study. Teaching hospilal figuresf rom the daJ'a are used in drawing fhe comparísons in Table 8/3,

Table 8/3

COMPARISON OF WAITING TIME DATA FROM T\,vO STUDIESOF VICTOFTIAN HOSPITAL CASUALTY DEPARTMENTS

Cateqorv ( ¡i) Waif inq Time to See a Doctor

ttrlaiting Time ln Minutes

Cafeqory ( iv) Tola I Casua ltv Tre¿¡tment T ime

1 380

1 595

132

190

V ictorian Te;ach ingHosp ita I sx

Al fred Hosp ita I

Crash Victims

Max ímumMeran

Waiting'Iime in Minufes

xFrom Brand et a L 1971 ('l ) and (3)

It may be seen that the mean lime spent waiting to see the

medical of f icer in other Melbourne teraching hospitals is similar fo'l'hat observed for road crash viclims within the Alf red Hospital. 0n

203

235

25

26

Victorian TeachingHospifalsx

Alfrod HospilalCrash Vi ctims

Max îmumMean

168

the averacteo crash victinrs spent longor receiving their casualty treat-monf in the Alfr,:d Hospital 'lh¿¡n thei ovcrall leaching hospltal average.

'[oach i ng irosp ita I pat i errts wcjre categor i zed ¿:ccord i ng to whetherthcy wore urgcnt/non*urgent and s-lrctcher or ambulant. The figures used

in J'ile aL;ove comparisons are based on the over¡.¡ll average assossments

whcre these weri) recorrJod. it is worth noting that'lhe mean casualfytreatment li¡ne in the teachíng hospi-lals studled for the urgenf,/stretchergroup (whir:h would re¡rresent rrìore ne¿-ìt ly the populaiion of road crashvictims) was 227 minutes wilh a maximum waiting timc-: of 1380 minutes.

(d) The Effects of Alfr-:rnatívo Patlerns of Ambulance Serviceon Time Delays

llel icopfe;rs have bc.en suggested as alternaf ive ambulance trans-port vehicles as a resulJ'of fl¡eir usc in war zones. particularly inVietnam. ln the existîng systcm in thc. area under stuciy ít is extremelydoublf u I l'ihcthc:r ambu I ance rcsponse t imes cou I d be improved by the use ofhelicoptor services vrere lhese lo be boTh feasible anrj permitted in thebuilt-up melropolitan area. h/ith response times as shorl as thoseobserved, the time advantages of air lransport would be lergely nega'led

by the relativoly lonq turn-around times whîch accompany civilian heli-copter operations. Hc:l icopters Érreì, hcwevcr, admirab ly suited to ambul-ance service in those situations where travel times make a larger con-trîbution 1'o the ove rall ambulance service lirnc. [ffectively, in thel4elbourne eroð, this means ¡ì range of approximafely 20 fo 100 miles f rcm

the cily centre.

Hel icopters have been uscd in operations on the MorningtonPeninsula in Victoria for fransporting emcrgency patients'fo the majormetropolitan hospitals. Their oLìèratíons have been limi'ied and thussorvice routines are relatively unsophîstic¿rtcd. ln particular thecommunications subsystem and procedures fr¡r palienl pick-up and

transfer neecj development. -l-his is demonstrafed by recent observations

169

of patient reception procedurcs at lhe Alfred Hospifal. The hel icopterlands in a park immedialely opposite the hospilal, and it has been

ol¡serveci thal the average time to unload a pationt and lransfer hlrn tolhe casua lly clepartment is between 4 ar¡d 5 m inu-t'es. (Th is representsan improvemenf on the 6 to 7 minule delays which were noled at the time

the service commenced. ) The normal f lyíng time f rorn Frankston isapproximately 11 minutes and compares favouratlly with the road trip time

of 45 mînutes. The aircrafl is an ef f icient means of 'l-ransporf over

lhese dislancers but its efficiency is tempered by the communications and

de livery faci lilies at each enc1 of the f líghl. Moreover, the delays'that patients may experience wilhin hospilal must also t¡e considered.

A second a I fernat î ve -lo ex i sti ng patterns of ambu I ance servi ce

is the use; of emcrgency ambulânccs. Such a service has recently been

commenced as a combíncd project of the Royal l4elbourne Hospital and theV.C.A.S. with the supporl of the llospitals and Charities Commission ofVictoria. Figures based on en evaluation of the first lhree monthst

operat ion of tlre ve h ic le have no-|, as yet, been re leased " The ambu lance

is based at the Royal Mclbourne Hospifal and is staffed by a medical

registrar from the hospital and a senior ambulance offícer who has

recelved speclal tralning in intensive care.

T!'rc ambulance may bc called out by doctors in the case of such

emergencies as cardiac arresl, asphyxia and drowning, whe;n the equipr¡s¡ffor inlensive resuscitation which the vehicle carries is invaluable. lnother situations, including road crashes, fhe vehicle can be called outby ambulance officers or such persons as police or doctors at the scene.

0verall conlrol of lhe servicc lios with the senior ambulance control leron duly. Such a screening mechanism has been lhoughl necessary because

in the case of road crashes, for example, a relatively small proporlion(approximately 10/') of Ìhose injured recoive severe injuries. Further-more, only a small proportion of those severely in.jured are likely torequire inlensive care at the scene, Therefore, it is necessary to have

170

d f iltering ntechanism to ensure lhe eff icient use of tho service.

ln rc¡aci crash si'tuations, fhe current call out policy means

that lhe pcirsc'n summoning the ambulance ís likely to be the ,Ambulance

Officer already in altendance. The ambulance response times observed in

this sludy suggest lhat, in an ideal system, thore may br: more advantage

in terms of time savîng during extra-hospífal care, in rapidly loading

anC lransporf ing -lhe patienl to an ef f icie nt hosp ital casualty department.

Using lhe avcrage elapsed times observed, it can be seen that thc response

timo for the f îrst ambulance is approximately B minutes. To this must be

added a proporl'ion of th+: treatment and assessment time (say 2 minutes)

in which the i:mbulance off icer determines the nature and severity of the

injuries an'C makes radio conlact fo cal I out fhe emargency ambu lance.

The total elapsed time for Ìhe nclification call for the emergency

ambulance is thus in excess of 1O minutes. The emergency ambulance willtake as long tc.'l-ravel lo the scenü as the ambulance al the scene would

take on the relurn trip. The time saving advanfages of the omergency

vehicle during exf ra-hospifal care are thus marginal. This situationrepresenls lhe pessimislic extreme¡ of emergency ambulance operations

and in practice the vehicler should usual ly bc dispatched wilh some tlme

advantage,

lrr the existing systcm, however, the emergency ambulance

hes ber¡n observed lo make signif icant contribu't'ions nol only to lhe care

the ¡Lalients receive, but also J-o-t'he speed with which fhey receive it.Because a senior member of the hospital medical staff is employod on the

ambulance, the hospital is made aware of a scriously ill patienlfsimminent arrival and preparations are madc for his rercepfion. 0n arrívalat the casually department, the pafient is admitted directly to the

appropriate trealmenf service and thus avoids lhe delays which normal ly

accompôny côsua lty trea-tmen-|. Patients are resuscitated earl ier and

reach the in-palient services ln l¡etter cl inical condltion than isnormal ly observed affer casualty admission. Many of the advantages of

171

this emergency ambulance service are thus derived from the effects thalit has on 'the service and p atienf care wifhin hospital.

ln fhose medical si1-uations, for example, hoart cases, drownings

and industrial accidents, where erarly notificalion and rapid response ofthe vehicle providos definilive medical care al the scene for palientswhcse clinical condition is serious, an emcrgency ambulance is of valueand its adoptlon anc1 use is thus warranted. Af the scene of road crashes,

however, lhe value of fhe service should norrnally be limíted to those

cases where seriously injured victims are trapped in vehicles and requireextricalion, cr wherLì several severely injured patienfs make friage and

resuscitation dif f iculf for a síngle ambulance crew.

Q) The Qua I ify of Emerqoncy þled ica I Care

The second important variable lo be considered in examining

the process of emerqency care is thc quallfy of the care provlded. lnpraclice, this rcquires examination and assessment of 'l-he actual servicesrenCered fo those who entr¡r the syslem. The measuremenf is based on the

assumpfion thaf at any time there is a s;cienfific conscnsus among experlson what conslilutes good or high qual ity emergency care" This consensus

should idoal ly be basi.:C on a br:dy of emplrical data and may thus be

relatecJ to actual practice within tho system under study. The extent towhich performance wilhin the sysfom matches standards els defined isregarded as a me¿rsure of the quality of fhe care provided.

Standards

ln practice" standards and criteria have rarely boen definedfor fhc elements of the medical care process and thus reliable and validcriferia which can be used Tr: interpret valid and useful measures ofqual ity are few. Nevertheless, normative standards for the management

of roed crash injury urere def inecl by the Royal Australasian College ofSurgeons (1970) in a book published as a result of a semînar aÌtended by

Ìhe leading surgeons of the country in 1969. ln recording the consensus

172

of surgical opinion exÞressed at the seminar, the book examines in con-sicjerable detail all aspects of the managemenf ol. crash injury and may

thus be accepted as represenfing the normative standards for pracfice inAuslra I i a.

Sfandar,Cs for ambu lance service used in th is sf udy inc I ude theAmbu I ance Handbook of the V i ctor ian l-iosp ila I s and Char if ies Comm i ss ion(1970) and fhe Manual of Ambulance Transport lJursing published by theSl. John Ambulance Brigaclr-r in South Australia (1963). Both of thesepubl ications describe treatmenl methods and ambulance service practiceswhich may be regarded as standards fo be followed in the performance ofambu I ance serv i ce.

Final ly, the standards for patienl management in the casualtydeparlmen'l of the Alfred Hospital are described in fhc hospitalts hand-

bookrlnstructions to Casualty Residentsr issued to all residenls at thetime they commence work in fhe department. (Alfred Hospital, 1969.)

The sfandards described in the relevant sections of these sourcedocumenls are used in evaluatÍng the qualify of lhe emergency care pro-vided for road crash victims in fhis study.

Thc Melhod of EvaluationEven in the presenco of acceptable slandards against which

qualily can be measured, the peirformance in a given situa'lion is diff lcultto assess objecf irre ly, s ince treafment is s ituation dependenl. The pro-cedures and methods employed necd lo be considered in lhe lighf of pre-vailing circumsfances at the time of trealrnent. Even more importanf thanlhe actual procedure performed is the decisíon pafh followed by theprofesslonals in the process of. providlng lroalment. Since individualclinical sítuations are variable and conrplex, it is often diff icult losÌate that a precise form of care should be performed in a given clinicalsituatic,n. For example, the procedure of sp I ínf ing a f racture in a

173

casualty departmenl may be of secondary imporlance in lhe case of a

soverely injured patient who nceds immediate resuscitafion and emorgency

surgery. Moreover, the doc i s ion ma ki ng procoss i n emergency s ituaT íons

is to a large exlont time depcndent, r:nd the time scale within which

trealmenl is performed mus'f be consiclered in assessing fhe appropriate-ness ¡:nd quality of lhaf performance.

The followlng discìussion of the qualî'ty of the care provided

for crash victims is divided into Two secfîons. l-he first section relatesfo the observations made during Phase One of fhe study, when crash

victims were observed at the sceno of lhe crash ancl during casualtycare. The procedures performod during tneatment were enumerafed

previously and, in lhis chapler, the quality of tho performance isassesseri in ther light of fhe d<;f ined standards for ambulance and casualfyca re.

ln the second section a more delailed analysis of fhe qualityof casualty care focusses on specif ic aspec-l-s of fhe cars process as

it was observed for the victims in Phase Two of the study. The qualifyof thc casualty history and physical examination performed, the adequacy

of the performance c'f certain procedures and lhe overall assessment ofthe qualily of care are examined. Finally, tho results of the postal

qucslionnaire, in which patîents recorded their opinions of the care they

received, are; ¿ìnelysed as an outcome measure of the qualit.v of care

provided for these patients.

ln making The qual ity assessments, fhe observers rated lheperformance of care by comparing the observed perfonrrance with the

defined standards. The categories and cri'leria used in makíng fhe

comparisons are I isted in Appendix 3. lnevitably, subjectîve assess-

ments ancl judgements were involved, but fhe effects of these influenceswere conlrolled as much as possible by inlerprefing each element of care

according fo the specific criteria. These críleria were defined before

the sccorrd phase of fhc sludy uias undertaken,

174

The Qual ity of the Emerqency Care Provided for the Victims

of I 00 Road Crashes i n Me I bourne

ln Phase One of the study, fhe quality of the care provided foreach patient was determined by the two observers at the end of the patlentrsambulance and casualty care. Assessments of quality were based on a consen-

sus of opinion befween the two observers based on their observations of fhecare performed for the víclims.

The assessments were subjective and the care for each patlentwas rated as either satisfacfory or unsatisfaclory. Both observers were

medical pracfitioners who were au fait with the prevalling standards forthe management of road crash and trauma victlms, and who had had prevlous

experience of working both in and with ambulance services and hospifalcasualty departments. The detai led criteria descrlbed for the second

phase were not used in this phase.

ln the majority of cases, procedures were performed salisfactori lyduring ambulance care and the ambulance officers showed satisfactoryjudgement in determining treatment prlorities. One hundred and forty-seven patients were lreated by the ambulance officers, of whom lwo (1.4/")

were judged to lrave received unsatísfacfory care. A further elght patients

from four crashes díd not receive examinafion and treatment when such were

indícatcd. Ambulance offîcers drove up to the scene of two of those

crashes and, wîthout al ighting from the vehicle, enquired whether anyone

was injured. 0n receiving a rcply in the negative, they drove off. One

of the victims involved in these crashes had clínícal slgns of rib frac-tures and a second patient had suffered minor lacerations. The injuriesof all eight of these patîents were relatively minor, and the absence

of examination and treatment would not have affected their subsequenl

management sîgnificantly. The overal I incidence of cases of unsafisfactoryambulance freatment was thus I in 16 rc.4%).

The two cases of unsatisfactory care involved inappropriate

175

care of victíms with severe injuries. The case, mentioned in Chapter 7,

of the unconscious man who was left lying on his t¡ack at the roadside in

the care of bystanders was one example. The second was fhe followingca 5e.

CASE 31010 A 20 year old female car passengcr sustained a

compound f racture of her left wris'|., minor abras ions, lacerations and

concussion in an intersection col I ision. She was found at the scene,

sitting in the passengerrs seat of the vehicle. She had fo be liftedfrom the vehicle lo be placed on fhe ambulance stretcher. The ambulance

officers considered spl inling the fracture before removing her from fhe

car - a procedune which could have been simply performed. ln theirhasle to removo lhe woman, they omitted 1-o splint the fracfure and she

suffereC considerable pain from the fraclure sile during exfrica'lion.An air splint was c-¡ventually applied when she had been placed on the

s-lretcher. Thc trichlorethylene inhaler was offere;d fo her, after she

had been removed from the vehicle,, but its operation was not explained

sal isfactori ly and iJ' was thus îrr{-rf fective.

The "iudgemenf

of unsatisfacfory côre was based on the series

of errors involvcd in this u¡o¡n¿rnrs carre. lt was noleworthy that, whÎlsfmi nor def i ci enci es i n the performance of procedures occurred occas iona I I y,

multiple errors were rare and rarely were the palients exposed to the

risk of exacerbarting or compounding injuries as a result of these

erro 15.

A summary of the obsrèrversr assessmenls of lhe quality of care

provided for each patienf by ambulance officers aÌ lhe scene is shown

în Table B/4 (see p.176),

Approximate-;ly 6Í, of patients received unsatisfactory care atthe scene ¿rnd it may be seen from the Table that-the differences between

the two groups by cJegree of injury are not stalistically signif icant.

176

Table B/4

AMBULANCE CARE AT THI CRASI.I SCENE

Quall of Care Observed

x2 .37C D. F. 1 N.S.

One hundred and twenty-one of those palienls were brought tohospital by ambuiance and five of Them absconded from fhe casualty

departmenl before lheir freatmenl was completed. 0nly those patienlswho completed their casl¡alty care were included in the group for whom

qual ify assessments are shown, for dlfferent degrees of pafienf injury,ín Table B/5.

Tab le B/5

QUALITY OF CARE IN CASUALTY

Degree of lnjury Qual ity of Care Observed

x2 B. 40 D. F. 1 xt(

#One patienf with very severe injuries was transported fromone of the sludy crashes by ambulance but her care al thescene was nof observed by fhe research feam. Her care incasualty was observerJ, however, and she is thus includedin lhis group.

155 1 00.010 6.4145 93.6Tota I

1r1

44

I 00

00

0

01

I2

7

4

2

5

103

42

92

95

B

5

Nî I and Minor

Moderate .. Very Severer

Tota I

n oípUnsafi sfactory

n%Sati sfactoryn%

Dogree of lnjury

1 'l 6 100.016.4198t.697Tota I

13

6 8.5

28.9

91 ,5

11.1

64

32

Ni I and Mí nor

Moderate - Very Sovere#

Sati sfacloryn%

1 00.0

1 00.0

Tofa I

%n

71

45

Unsafi sfacloryn%

177

It may be seen thal more severely injured patients received

unsatisfactory care more frequently than those with mlnor degrees ofinjury and that the differencc be'l'ween thr; two groups is slatislicallysignif ican't.

Comparing the asses-smerrl-s of f he care provided by ambu lance

officers with that providod vrithin hospital casualty cJepartmenls, itmay be seen lhat lhe frequency of unsatisfactory care was higher during

casuôlTy than ambulance côre (16% of cases versus 611,) an¿ that the

di fferences befween fhe two are slalistical ly significanf (Tabl e B/6).

Tab I e 8/6

AMBULANCE Vs. CASUALTY CARE

271 1 00.029 10.1242 89.3Tofa I

155

116

I 00.0

1 00.0

10

19

6.416.4

145

97

93.(t

83.6

,tr¡bu lance Care

Casua I ly Care

Tota I

n ollo

Unsatisfactoryn%

Sal i sfactoryn/"

Care PhaseQua I i ty of Care Observed

2X = 6.84 D.F. - I **

These findings, combined with the overal I impressions gained

during fhe first phase of fhe study, led to the intensive examination,

in Phase Two, of the performance of care withínthe hospiTal casualty

departmenl. The findings of this detai led study of lhe qual ity ofcasualty care in the Alf red Hospil-al are discussed in the nexf section.

178

The Oual itv of Casualtv Care in Phase Two

The qualily of the care provided for crash viclims admitted tothe Alfred Hospîtal Casualty Departmenl during Phace Two of the study was

assessed by the author as sole observer.

Experience during the first phase had shcwn that crash victitnsreceive emergency care accorciing to a predictable pattern. Each medical

of f icer should elicit a medical history f rom the paf ient before perform-

ing a detai led physical examînation. Many patients require and receiveradi'ological investigation for suspecfed fractures and mosÌ are observed

in casualty for a variable period after lheir examination and inveslig-ation is completed. A proporfion of those severely injured are shocked

and require intravenous fherapy. Those with fracfures need to have theirfracfures spl inied and immobi I ized. Most crash victims who presenf tohospital have sustained bruises, abrasions or lacerations, which requiredressings or suturo. Many are observed in casualty before being dis-charged from the departmenf and either admitfed for in-palient care orreferred for out-patient fol low-up.

ln lhe fol lowing discussion of f he qua I íty of the care províded

for a sample of 328 crash vicflms presenting to the casualty deparlment

of the Alfred Hospital, the elements of the care provided wil I be examined

in the fol lowing categories:-1. Hisfory taking and lhe performance of the physical

exam i nat i on .

2. The casualty treatment performed.(a) lntensive resuscitation.(b) lntravenous fherapy.(c) Fracture management.

(d) Wound care.

3. The overal I assessment of casualty care.

4. Rel iabi I ily of the assessments.

5. Paf ients? attiTudes fo the care they received.

179

(1) THE HTSTORY AND PHYSTCAL ENAMTTIATION

(d The MedieaL Histona

ln mosf cases involving trauma, lhe hisfory of tho presenfing

cornplainl is clear cut and there is thus little need for detailed enquiry

into the patienf ?s previous medical and social history during casualty

frealment. Neverlheless, ft ¡s of some importance to know not only thatpatients have been involved in a road crash, but also fheir type ofinvolvement. Slnce patferns and mc¡chanisms of crash injury are well

documented, the types of injury lhaf differenl pafients are likely tohave sustained may be inferred Îf the crash lype is known. Hence know-

ledge of tho type of involvement can be of considerable assistance in

diagnosis.

It was observed that most crash victims were labelled with the

diagnosis M.C,A. (Motor Car Accidenf) vicfim on admission to lhe depart-

ment. This al l-embracing diagnostic misnomer was used to cover al I types

of victim wifh all degrees of injury ranging f rom minor to very severe.

It was commonly used as an admîssion dîagnosis, particularly by members

of the nursing staff, and the admifting nurse was often observed toreport tM.C.A. in cubiclerto the sister-in-charge after writing M.C.A.

in the casualty admission regisler'. Additional details on the patientts

type of injuries may or may nof be noted and reported at this lime. The

use of this term occasionally masked the pnesence and detection ofpatlents with severe injuries who were awaiting medical attentlon. 0n

one occasion a 68 year old man, who had sustained head injuries, a

fraclure of his left upper arm and fractured ribs with a flall lhoracic

segment, waîted 12 minufes to be soen by a doctor as a rosult of These

factors. 0n a second occasion, a 42 year old pedeslrian who had sustained

a fracfure of his righl femoral shaft lay in a cubicle for 85 minutes

before he was assessed. His provisional diagnosis was I isted in the

casualty register as M.C.A.

The knowledge that a patient was involved in a crash usually

180

leads the examining medical officer to ask two direct quostions, which

frequently complete lhe medical history obtained.(ì) rWere you knocked out ?t or eDo you remember what happened

i n the crash ?r

These questions are deslgned to determine whether the

patient lost consciousness in the crash and the patientrs

response is of some importance, since it determines

whether he is observed in casualty for a minimum of four

hou rs .

(ii) ?frlhere does it hurt ?f designed lo determine the major

sites of lnjury for subsequent examinafion.

Although mosl doctors accepted involvemenf in a crash as

evidence of probable injury, they often failed lo elicil the important

informafion about the type of involvement which can be of considerable

assistance in diagnosis. Moreover, lhe poor communications which existed

between ambulance officers and casualfy staff members, and befween

casually staff members (see Chapler 7) was frequently observed to limifthe amount of informafion avallable to fhe doctor at the fime of his

inillal examination. Thls situation was further compounded by the fact

that ambulance officers rarely compleled the Ambulance Report Forms for

each palient.

The hislory-taking process was observed lor 255 patients. 0n

five occasîons (21Ð nedical officers obtained a complete and detai led

medical history from the patients, all of whom had minor or moderate

injuries. On nineteen occasions fi,4%), an incomplete hisfory was ob-

tained when more detailed informafion could and should have been gathered

from eilher fhe palîent or other sources. Seven of these patienls had

suffered severe or greater injuries and represented lgfi of the severely

injured patienfs for whom lhe history laken was observed. These

observations are summarized in Table B/7.

18'l

fable Bl7

COMPLETENESS OF THE I'4EDICAL HISTORY

231 90.6

19 7.4

255 100.037 100.074 1 00.0144 1 00.0Tota I

7 18.96 8.16 4.2I ncomp I etehi story obta i ned

30 81.165 87. B136 94.4Brief hi sforyof presenti ngcomplaint

Tota I

n

5 2.O

n ftn f"

3 4.1

n 7"

2 1.4Detai led medicalhistory el lcited

Severe orGreater

ModerateNil & MlnorComp I eteness ofH i sfory 0bla i ned

DEGREE OF INJURY

ft) The PhusieaL Eæamíiwtion

The completeness of the physical examinalion which is undertaken

for any casualty patient should be dependent on the nature and severity of

the prosenting injuries and their cause. Many crash victims pF€:senf wifh

minor abrasions and lacerations and require no more than examination of

the lnjured part. Those patients who have sustained moderale or greater

injuries as a resulf of road crashes have normel ly undergone considerable

energy exchanges in the process of obtaining lheir lnjuries and lhus a

more comprehensive examlnation is indicatod because of the greater I ike-

lìhood of multîple injury.

The initial physical examihation forms an ímportant part of the

management of the lrauma patienf in casualty, since the priorifies in

treatmenl and the special investigations required are determined by what

is found in thls examlnation. Thus, a detai led examination should be

performed by one member of the medical staff.

The removal of a patientts clothing is an essenfial prel iminary

182

to the performance of a satisfactory physlcal examination. Ë¡ghfy-Two

per cent of the patienls observed were completely undressed before fhey

were examined by the doctor, 14/o were examined through clothing or were

parfly undressed with adequale exposure of the affecfed part. 0nly alof patienfs were examined fhrough clothing in a manner which made

adequate examination d¡ff¡cull. Vlith respect to fhis criterion, the

casualty examina'lion was rated as good.

Patients are usual ly undressed by members of fhe nursing staff,frequently by lrainee nurses. lt was observed that, whi lsf nurses are

careful in removing clothes, inexperience and a reluctance to cut clolhingoccasional ly resulf în considerable discomfort for lhe patienf. Moreover,

the manipulation involved may enhance fhe risk of exacerbaling injuries.One palient wíth a suspected cervical spinal injury was rolled over and

sat up while his jumper, shîrt and underclofhing were removed over his

head rather than cut off. Patients with I imb fractures wer@ occasional ly

subjected to pain from movemenf af tho fracture sife while clolhing was

removed intacl. The decision fo cut clothíng cannot be faken lightly in

view of the resulting cost and inconvenience to the patient, and repres-

enÌs another reason why a frained member of lhe nursing staff should be

present al the fime of the inítial nursing examination and procodures.

ln assessing lhe qual ily of the examinations performed for fhe

study patients, attention was paid fo lhe compleleness and appropriateness

of lhe examinalion in the prevai I ing circumsfances. Thus when a medical

officer examined a patienl thoroughly, paying particular attention to the

injured body regions and establishing a base line for the patienles

overall clinical condition, he rated a favourable score for that examin-

ation. lt was considered lhat all crash victims with moderate or greafer

degrees of injury warranted a physical examinafion whích included examin-

alion of fhe head and neck; testing of pupillary reactions; chest examin-

afion with ausculTation and checking for possible rib fracturss; abdominal

palpaf ion; assessment of the bony pelvîs and limbs; and cardiovascular

185

assessment which included measurêment of the pulse and blood Pressure.

The compleleness of the physical examination was assessed for

227 (69Ð of lhe 328 patlents studied. One hundred and one patients vlere

not rafed because lheir physical examination was nof observed. Ëifleen

rc.6%) of the pat ients had comp I ete phys i ca I exam i nal ions perf ormed. A

further 179 Jl.81) receíved examÌnations in which fhe presentíng lnjurieswere assessed along with a superficial general examinatic¡n. Thirty-three(14.6%) received incomplefe examinations when a detailod examination was

indicated by lhe clinical condilion of the paf ient. The dislribuf ion of

the assessmen-ls of the physical examination by the degreo of patlent

injury is shown in Table B/8.

Tab I e B/B

ADEQUACY 0F Tl-lE PHYSICAL EXAlvllNATloNS PERFoRMED

BY DEGREE OF PATIENT INJURY

0nly 9.7% o+ patients wilh moderate or greater injurios received

complefe assessmenfs in accordance wiTh the defined criteria, and 23.6fi

of lhe group received incomplefe examinations. This Îs of some concern

since failure to perform a detailed assessment soon after admission may

227 100.093 100.0134 1 00.0Tota I

33 14.522 23.6t1 8.2I ncomp I eteexaminafion

n r,

15 6,6

179 78.962 66.7

n %

6 4.5

117 87.3

Comp lele physica I

exami naf ionpe rformed

Exami nation ofinjured area wifhadditional super-ficial examinatlon

n fr

9 9.7

Tota IAdequacy ofExam i nal ion

DEGREE OF INJURY

184

have implicalions for both the palientrs clínical condilion and the time

he spends in receiving casualty care. When severely lnjured palients are

admitted lo the deparlment a rapid assessment of lhe major injuries is

one of the f irst and rnosf imporfant trealment tasks. Furthermore, if is

imporïant that one member of the medical staff should complete a detailed

examinaTion fo detect any previously undiagnosed injuries after lhe

palientrs condition has been stabi lized. lt was observed thaf thisdeïai led assessment was usual ly not performed for severely ínjured

paÌ i ents.

It may be argued that pafienÌs receive complete examinations

after they are admitted as in-patients ancl fhat fo porform lhese assess-

ments in casualty would only prolong Ìhe patientfs slay in that depart-

ment. ln every case lhere was time and opportunity for a detailed

assessment lo be completod durlng the patientrs stay in the casualfy

dopartment. Moreover, the advantages in lerms of improved patient flow

through diagnostic and treatment services fo be gained as a result of

lhi s exami nation are considerable.

lnjured palients invariably receive radiological examination

before they leave the casualty department. Ëarly detai led cl ínical exam-

ination defines lhe body aroas which need X-ray and obviales 1-he need for

the patient to return for furfher X-ray investigafions after admissîon.

Even wilhin thr: department, assessment of the patient before requesting

X-ray invesligation avoids lhe delays and inefficiencles which result from

lhe patient having to return for further radiography. lt was observed on

several occasions that patienÌs were sent back to X-r-ay for f urther f ilms

because lhey had been inadequately assessed before the initial request

for X-ray was made . This situation is illustrated by the followlng case:

cASE 1 1 237 A 56 year old male pedestrian was admitted to

casualty after being struck by a car. He had suffered head injuries with

facial and scalp lacerations, a dislocafion of his righf shoulder and a

185

compouncJ fracture of his left tibia and f íbula. He was seen by a doctor

within lwo mînules of admission and received a superficial examination of

his fracturedl"g, shoulder and head injuríes. His abdomen and pelvis

were not examined and his pulse¡ and blood pressure were noT measured. He

was laken to the X-ray department for skull, shoulder and limb X-rays

25 minules after arrival. He spenl 15 minutes in the X-ray depertment

and then relurned lo the casualty cubicle where he was examined by the

admitting surgical registrar. This doctor examined the patlenlrs pelvis

and suspected a fracture on cl inical grounds. The palient was returned

to fhe X-ray dcpartment for further films of his pelvis and left femur.

He was admillod lo in-patient care 40 minutes later, 82 nínutes afferarriving in the department. The delay caused by the need for repeat

X-ray service afler lhe incomplete initial examination was aPProximafely

2O ni nutes.

ln summary, several areas of deficiency in the performance of

the history an<1 physical examination for crash vlcfims were revealed ln

the sludy. These def icie;ncies occurred relatively commonly in the

mänagement of severely injured patients and were observed to have

impl icatÌons for the subsequenl management of these cases.

(2) THE TRF:ATMENT PERFORMED

The procedures used in managing crash victíms in casualty vary

according to the lype and severi'ly of the injuries involved. Nevertheless

certain procedures vvere pcrfcrmed cornmonly and these were chosen fordetai led examínation as indicators of the qual ity of casualfy trealment.

As well as beíng lhe common treatment methods used, they represenf pro-

cedures for which 'the qualily of performance was likely to af fect

outcomes.

(Ð lntensiue Resu.seitation

lntensive resuscitation including endotracheal intubation,

artificial respiratîon and external cardiac massage was required for

two palients in thc series.

186

CASE 11266 A 51 year old male was admitted after a colllsíonin which he, as a pedesfrîan, vras struck by a car. He sus'tained multiplesevene lnjuries including bi laferal fraclured lower legs, a fracturedskull and abdominal injttrles. His blood pressure was not recordable on

admission, he was in a-systole and had l'ixed dilated pupi ls. lnfenslveattempts at resuscitaffon incl uding endofrachea I i ntubalion w!th venti l-ation, external cardiac massage, defibri I lalion, and intravenous therapywere inslituted fmmediately. lt was not possible fo resuscitatE: hîm.

çASE_Z|_133- An B year old boy was admitted following an

accident în which he had fallen from, and been run over by, a trailer.0n admission he was conscious, shockod, wlth a syslolic blood pressure

of 60 mm. Hg. and a pulse rate of 120. He was resuscitated promptly, an

infravenous catheter was inserfed, and, affer a superficial examination,a presumptîve diagnosis of a rupfured abdomlnal viscus was made. The

child uras laken for X-ray and suffered a carCiac arrest in that depart-npnt. Affempts at resuscltatlon by the medical offîcers in atlendancefailed. -Ihe consulfant surgeon on call v/as summoned al fhe time of thechildrs admission. lie arrived 30 minutes later, by which f ime the childwas dead. A presumptive clinical diagnosîs of ruptured aorta we-'s reached

buf a post mortem was not performed and the diagnosîs was thus not con-

f i rrned.

A procedure has been developed ín the hospifal whereby an

anaeslhetic registrar and the medical regisfrar on duty are summoned tothe casualfy department in extreme medical emergencies. The procedure îswel I lried and tested since medical emcrgencies presenf relatively oftcn.More senior consultant staff are not on call for such emergencies, and

this accounts for fhe delay before the honorary consulfant arrived inthe second case quoted. ln bofh casr:s resuscitative rneasures were imp le¡n-

enfed immediatcly and fhe care of fhe patienfs, who were in eætnenris, was

judged to be satisfacfory. Hospital anaesthetic and medical staff mem-

bers nesponded promptly to the emergency calls and were in thc casualty

187

department assisTing with care within four minules in both cases.

General observation of these, and olher, emergency patients

suggestecj thal when ernergency patients p resented and were recoqnized as

such, they received prompt care.

(b) fntnauenous T?terapu

An establ ished maxim in trauma managemenl slates fhat fsevere

trauma is lhe earl iesl sign of hypovolaemic shockf. (Newhouser, 1955. )

The replacement of circulating f luicl volume is the accepted treatment of

this condition and inlravenous therapy is the procedure of choice for

achieving 1'his goal. Several speakers at lhe symposium of the Royal

Auslralasian College of Surgeons in 1969 reiterated the prîmarr¡ import-

ance of lhe early commencemcnt of intraverrous therapy for maintaining

circulalory physiology in frauma palients. The L¡enef its of the procedure

have been demonstrated in war zones (Howard, \956; Hardaway, 1968), where

the effoctiveness of early intravenous therapy in resuscitation has been

proven. As a resull, many doclors now advocate lhat drips should be used

to resuscifate severely injured pafienfs at the scene of the crash, or

in the ambulance. (Royal Australasian Col lege of Surgeons, 1970. )

lntravenous therapy was instltuted in casualty for fourteen of

lhe palienls admilte;d during Fhase Two of the study. Forty-seven

palienls had sustained severe injuries and il was apparent thal medical

officers were conservativE: in their use of this procedure for injured

victims.

One of the reasons for this conservatism was staled to be lhe

danger of over-hydration of patients wilh head lnjuries. Head injuries

often accompany olher severe injuries in road crashes and thus thiscaution may be justi f iab le. Neverthe less lhe ri sks of over-hydration i n

the acute phase of the management of severe shock are sa i d lo have been

exaggerafed (Simpson, 1g7O) and potential mismanagement of pafients

1BB

(which over-hydration ropresenl's) îs an uns¿¡tisf actory reason for wif h-

holding a useful fherapeufic measure. The study observalions suggested

lhat a more likely reason for this conservatism was that resident medlcal

officers were simply nof aftuned to the llkelihood of severely injuredpatients Ceveloping hypovolaemic shock. lt was noted, in conlrast, thatthe cardiogenic shock v¡as a well recognized problem and pationts who had

suffered myocardial infarc'fions roufinely received intravenous trans-fusions in casualty.

ln most cases, medical officers did noi commence infravenous

tlrerapy until the patienÌs had developed overt clinical signs and symptoms

of shock. The following lvro sludy cases illustrate observed pracf ice.

CASE 1 1456 An 18 year old man was admitfed lo hospital

following a collision between his motor cycle and a car, in which he

suffered head injuries. Thesr: included e massive soft fissue avulsion

involving the left cheek, I ips and nose. His other injuries included

minor abrasions of tho lhorax, arms and legs. His blood pressure on

admission was 140/180 with a pulse rate of 120, Continual and coplous

blceding was observed from arteries in fhe <lepths of the facial wound.

He was seen within two minutr:s of arrival by the in-patienf surgical

registrar and a consultanf surgeon, who inspected the wound and sfated

that he required plastic surgery. The wound was subsequenfly re-dressed

by lhe nursing staff, but was rû-examined on 4 subsequenÌ occasions by

different membeirs of lhe mcdical and nursing staff. Fifty-níne minufes

after admission l're was laken for X-ray and, whílst being X-rayed, he

became clinicalty shocked. His blood pressure dropped to 90/50 mm. H9.

and his pulse ral'e was 1?-0 beafs/minute. Affer fhe attention of the

medical off icer was drawn 1-o his condÎtion a drip was inserted - 94

minutes after the patient had been admÎlted.

CASE 1 1 421 A 42 year old male pedesfrian sustained head

injuries with multiple minor facial lacerations and a fracture of the

189

shaft of the right femur when he was struck by a car. His femoral

fracture was not immobi I ized during eifher ambulance or casualty care.

0n admission his blood pressure was 100/70 with a pulse rate of 100. He

was clinically shocked. The patient was admilted at 2335 hours on a

Thursday night, when lhe sîngle medical offlcer in the casually deparf-

menl was busy suluring a second palientrs wounds and fhe admítting

officer was nof present in the deparfment. The patienf was Ìaken forX-ray and was seen by the doctor on his return, by which time his blood

pressure had fallen to 95/70. A drip was inserted 15 minutes lafer,97 ninutes after the palient had been a<Jmitted to the department.

ln bolh cases the patients presented with sevene injurieswhich suggestecl thaT they would require transfusion during their medical

care. Neverlheless the doctors involved did nol recognize the need fortransfuslon and long delays were involved before the infusions were

commenced. Delays in commencing intravenous fherapy were observed to be

the rule, rafher than the exception, for those of 'f'he study patîenls who

received lransfusions. The dis-lribution of the observed delays belween

the time of casualty admission and fhe commencement of întravenous therapy

for lhe 14 patienls who receiveC transfusions is shown in the following

Tab I e.

Tab I e B/9

DELAY BETWEEN AM4ISSION AND TIME OF INSTITUTIONOF INTRAVENOUS THERAPY

Tota I

14

100.0

1

7.1

1 00.092.9

3

21 .5

92.9

1

7.1

71 .4

3

21 .4

64.3

2

14.3

42.9

4

28,6

28,6

No. ofPat i ents

Percentage

Cumu I aÌive f'

1 80+120-17960-1 1 930-5920-2910-190-9

Elapsed Time in Minules

Range:

Mean T ime:

4 - 195 mlnutes

54.3 n inutes S. D. 39.9 ni nules

190

These long delays and lhe practice of nol- instituting treatment

until the patÌents were clinically shocked are contrary to the currenflyrecommí-JnderJ slanCards for trauma managemenl, wh ich requ ire the ea:rly

commencement cf intr¿rvenous therapy. (Sando , 1970.)

Although the commencement of transfusîons al the scene of the

crash has bcen advocated by some doctors (ambulances carry lhe necessary

equipmenl fo permil doclors fo perform the procedures), none of the study

patients had received such lreatmenl at the scene. The observers consid-

erecl thaf lransfusion would not havo been necessary at the scene of any

of fhe study crashcs. Morcovcr, conditions for setfing up fransfusíons

at the roadside are far from îdeal. Hence, in the observerst opinion, ¡tis norrnally preferable, in the oxisting system, fhat patlents be taken foa def initive care facility for i-his procedure. ln me-tropolilan areas the

delays in resuscitating patients as a resull of lhis lransport should be

smal l, givcn efficiency in fhe casuelty departmenf. ln practíce they are

long because of dclays incurred v¡ithin fhaf deparlment.

phera I

was

Three palients had had infusions commenced in country or peri-hospitals before they arrived at the study hospital. One of these

cAsE 1 1444. A 60 year old male was fransferred from a country

hospital r¡fler initial resuscifalion in that hospital. A pedestrien, he

had been struck by a car and suffered a fractured sku I I , compound fracfure

of the le"ift femur and minor abrasTons. He had been resuscitaled by a

country geneìraI practitioner who had commenced an íntravenous infusion,

immobilized the femoral fracture wiTh a Thomas splinf, and confirmed his

clinical diagnoses radiologically. The general practitioner rang the

admifting officer of the study hospital to advise him that he was trans-ferring thc p;:fi'.rnt. The admítting off icer did not warn the casualty

slaff of his impending arrival and they wclre thus unprepared when the

pationt arrived at 2155 hours. His blood pressure on arrival was 95/60

191

and he was admitted to the acute emergency cubicle where he was seen by

a doclor within fwo minutes. This tjoclor did not measure fhe patientfsblood pressure in his initial clinical examination, buf he did nofice

that lhe drip'was into Ìhe tissues. ll was then removed and not replaced,

in spite of the fact fhaf lhe palient was still clinically shocked. The

Thomas splint þ/as removed from the fraclured leg and not replaced. A

head injury chart was commenced after 35 minutes and he was admltted toin-patient care, 55 minutes affer arrìving in the casualty department.

This case involved a serîes of deficiencfes in the management

of a severely injured palient. Similar siluations, wherein the combin-

ation of a superf icial clinical examinaf ion, unsatîsfactory trealment

and long time delays resulted in the patient receiving poor qualify care

in the casualty deparlment, wero observed on several occasions during

the study.

Allhough 14 of lhe 47 patienls received Transfusions, the pro-

cedure was indicated for several olher patienfs in vïew of their cllnÎcalcondîtion, bul it was no1- performed. For example,

CASE 1 1237. Tho 56 year old male pedestrian, whose case was

described in lhe prevlous section, sus'ta ined a compound f racf ure of his

left lower limb with a suspected f ractured pelvis. He was clinicallyshocked. The resident medical officer made lhree at1-empts to insert a

drlp into forearm veins before abandoning the procedure. The patlent was

in casualty for B0 minutes before he was admltted to in-patient care and

r¿/as clinically shocked lhroughout this period.

The qualiÌy of the performance of lntravenous therapy for the

14 persons who received the procodure was assessed by lhe observer. The

înfusion was inserted properly with good techníque in 6 cases. ln a

further 6 cases the infusion was sel up with satisfactory technique aftera considerable delay. ln the remaining two cases, long delays and

192

non-recognîtlon of the need for the procedure were coupled wlth poor

technique in ils perfofinance.

ln summary, fhe performance of infravenous fherapy in the

emergency care syslem diverged considerably from the practices expecfed

on the t¡asis of the normativo standards. Considerable delays lninstituting the procedure were common. l{oreover, if was used conservaf-

ively wilh mosf patients not receiving inf usíons untl I they were

cllnically shocked. This praclice is at variance with currentlyrecommended standards.

(e) The Itlanaqernent of Línb Eractures

Thirty-seven patients admitted during lhe second phase of the

sludy had sustained a total of 52 limb fraclures. Thirty-one of these

patienls had had their fractures immobí I ized by ambulance officers bofore

they arrived in the casualty department. Air splinfs were used for 21 offhese patients. As wos menfíoned in an earl îer chapter, ambulance offíc-ors used air splints to immobilize long bone fractures whenevor possîble

and, allhough Thomas splints were available for immobilizlng femoral

shaft fractures, they were rarely used.

It was common Þractice for these ambulance spl ints to be

rcmoved in lhe casually department and replaced by a padded wooden splintor, as oflen happened, not replaced at all. The alr splint was retained

in use Ìhroughout casually care in four cases. Eleven patients had lhe

air splint removed and replaced by a padded wooden splint. Six patients,

whose fractures had been splinted by the ambulance officers, had the

spl ints removed in casualfy and not replaced. Two pafienfs, whose

femoral fractures had been immobi I ìzed wifh modifTed Thomas spl ínts by

country doctors, had the splints removed and not replaced in lhe casualty

department.

Aîr spl ints are a salisfactory and effective method of

193

ímmobilizíng fractures (Gartrell, 1965) and there ís no good reason why

they should be removed and not reapplied in casual-iy departments, partic-ularly since changeover splints were avaílable fo replace The amblulance

spl int. Moreover, thc wooden spl ints which were commonly used fo replace

the air splinfs usually failed lo immobilize the f raclure. (Fig. 8.2,)Sand bags, which were used to support fractures on two occasions, were

equally inef fective. (Fig. B.l. ) lmmobilizat íon of f ractures ls a long

standing and accepfed principle in fhe treatmenl of trauma. Since most

patients spenl a considerable fime waílîng for admission and treatment in

casualty departmenls lhere can be no good reason why this comparatively

simple procedure was not used roulinely in the casualty departments of

teach i ng hosp i ta I s.

Failure fo spl int fracÌures was observed t<¡ resull in consider-

able discomforl for palíents. Pafients suffered pain from movemenls at-lhe fracture site, particularly when members of lhe nursing and medical

staff were observedtomanÌpulate unsplinted limbs in the course of per-

forming other procedures. Moreover, thcre is a risk of exacerbating softtissue in.jury when f ractures are ncf immobilized. The following case f rom

lhe series illustrates a clinical situatíon in which several of these

factors were involved.

CASE 1 1485 A 62 year old oedestrian sustained concussion,

minor abrasions of his lefl'arm and a comminuted fracture of his righttibia and fibula when he was struck by a car. His leg was splinted by

the ambulance officers at fhe scene and he was gîven trichlorelhylenefor pain during ambulance transporl'. 'Ihe splint v¿as removed after he

arrived ín casually. He was seen by a doclor wilhin 10 minutes of

arriving in the deparlment and was subsequently taken for X-nay. 0n

relurning from X-ray 15 minutes lafer, a member of the nursing slafflifted his fraclured leg by lhe foot bccause it was profruding from the

blankets al lhe foot of fhe barouche. Since there were no empty bods

in the hospilal on The nighl, it was decided lo manage the patient from

' sluL[dS uapooil ^q

paspldðr orant s1ui[dS rlV Z'B '0t¡

------:r.#l*a

¡

I

t\

194

casualty. After 140 mínutes in the department his blood pressure fel I

from 120/85 to 65 mm. Hg. systolic and he became clínically shocked.

The attending medical officer was alerted and he performed an electro-cardiograph" which was normal. l-le ordered that 500 mls. of stable plasma

protein solutîon be adminisïered intravenously over 2 hours. The infusion

was commenced and was completed in three-quarters of an hour, by which

time his blood pressure had risen to 100 mm. Hg. sysfolîc. Five and a

half hours after admission he was faken lo Ìheatre where fhe fracture

was reduced and a plaster casf applied. The patient returned to fhe

casually department after two hours in lheatre and vras discharged loout-patient care l0 hours laÌer.

A combination of factors were thus involved in assesslng the

manrs casualty care as poor. Firsl, an adequate splint was removed from

the fractured lower I imb and not replaced. Subsequent negl igent manip-

ulalion of that I imb caused fhe patient considerable pain. The patient

underwenf a period of prolonged hypotension (his blood pressure was

below 90 mm. Hg. systolic for a period of 2 hours) and, although an íntra-venous lnfuslon was set up, the drip was not monitored as dlrected by the

doctor. Furthermore, the patienf, who would have been admiTted to

hospilal under normal circumstances, was treated as an out-patient in

spite of the sudden unexplained period of hypotension and his overall,severe i nj ur i es.

Assessments of the freatment used in the management of limb

fractures for the sfudy patients were as fol lows:

Table B/10

?_2 59.5

37 100.0

Sp I i nt not app I i ed when i nd i cated.Þliú-,1neffect i ve when app I i ed

Tota I

n %

15 40. 5Effecti ve sp I i nt app I iedto immobi I ize fraclure

No. of Patients

THE MANAGEMENT OF LIMB FRACTURES IN CASUALTY

195

The management of limb fractures in fhe casualty departments

vanied considerably from that expected on the basis of the normative

standards for the manâgement of such patients.

ø) þlound Marwgement in CasuaLtg

The commonest ínjuries sustained by victims of road crashes

are bruises, abrasions and lacerations, and most of the study patients

had received such injuries to one or more body areas. These injurieswere usually treated in casually by members of lhe medical and nurslng

staf f , or by rned ica I students.

Abras ions

t4inor abrasions were cleaned and dressed by nursing staffmer,nbers. Mercurochrome paint was commonly used as an antibacterlalagent. One patienf in the series had sustained severe abrasions.

cAsE 1 2033 A 20 year old man received extensive

abrasions of his thorax, abdomen and back when he was ejected from the

car he was driving and dragged along a bifumen road. Extensive bitumen

tattooing had occurred. He was seen in casually by a rosident medical

officer who consulled lhe admitting surgicaf registrar and was advised

that lhe abrasions should be scrubbed in casualty, The patient was given

10 mg. Morphia and an attempf was made to clean the bitumen from the

abrasions wilh Savlon and-lowels. Predicfably, the procedure was halted

by the patíentts puin and proteslations. He had suslained minor lacer-

alions to his head and left elbow which were sutured before he was

discharged from casualty, 11 hours after admission. The bifumen had not

been scrubbed from the wounds when he was discharged.

The fallure to clean these abrasions was contrary to the stand-

ards for the management of such wounds which should have been thoroughly

scrubbed and cleaned, after the patient was adequately anaosthetized.

The patient dicl nol return for further follow-up and thus the extent of

196

any resultant lattoolng could not be determined.

\l/ith this nofable exception, the overall managemenf of minor

abrasions in the department was considered lo be satisfactory.

Lace rat i ons

Lacerations and cpen wounds had offen been dressed by

ambulance officers befora the patienls reached the casualty department.

They were usually cleanod and re-dressed by members of fhe nursing

staff dur ing the verious weitîng periods in casualfy care. Subsequenfly,

they were usually inspected by several medical and nursíng staff members

and students before definitive 'trealment was undertaken.

l4ulfiple wound lnspectlr:n was common. ln the case of fhemolor cyclisl tn¡ho had suf fered massive soft tissue lnjuríes (Case 11456,

see p. 1BB), lhe facial wounds r¡rere inspected on f ive separate occasions

by different slaff members, before the patient was admitfed for in-patienfcarc. Oflen Cressings were nof replaced afler such inspections wilh theresult fhat open wcunds were left exposed beneath hospl-lal bedding.(Fig. 8.4. ) This presumably enhanccd the rîsks of wound contamination and

cross infection.

l-acerations were the second most common type of injurysuslained by palients in lhe study. Facial and head lacerationsaccountc;d for approximately three-quarfers of all lacerations recorded.

The lrealment of f acia I lacerations is based on f timeproven concepts of surgical managemenfr and includes tfhorough cleansÌng,

debridement, moficulous haemostasis, exploration of the depth of the

wound, repair layer by layer with oblileration of the dead space by means

of deep sutures ¿:nd fhe use of appropriate, fine suture material toapproximate the skinr. (Howol l, 1967. ) Similar management principleswere described by lhe members of the Royal Australasian College of

-<--

ì¡ry

\

r..è.s .lÜrr

,

nt'Ðt-----

Fìg" 8.4 þlounds were left exposed benreath hospital bedding.

197

Surgeons in emphasizlng the fact lhat lhe rhighest standards of wound

repair and care should always be applied to facial wounds to achieve themaximum cosmetic and f unctlonal resulf r. (Royal Australasian Col lege ofSurgeons, 1910.')

Since facial lacerations were common and aval lable hospitalbeds fow, mosf lacerations were sutured in casualfy and managed on on

out-patient basîs. Patients wilh major soft tissue injuries, and thosepalients with c¡ther injuries which warrantecl in-patienf care, were usual lyadmitted lo hospital. Nevertheless, many patienfs who required admlssion

for ín-palient surgical care had their soft fissue injuries sutured incasually before they were admitled to the wards.

Casually theatres were avai lable for these procedures but were

rarely used. Most lacerations were sutured in the acute receivlng ordressing cubicles. Since faci I ities for the performance of these proced-

ures were less than ideal in lhe cubicles as compared to fhe theatres,their use represents an unsatlsfactory compromise which resulled in less

tlran idea I standards of asepsis and treatment.

The limlled availability of medical staff for minor procedures

meant that many of these lacerations were sulured by medical students.Students who had never previously inserted sufures were observed toperform the prlmary closure of facial lacerations and were nêitherinslructed nor dlrectly supervlsed by medical staff members at the time

the procedure was performed. ln general, lhe technical competence dis-played in the sulure of lacerafions was commensurate wîth the experience

of the surgeöns and was thus rarely compafible with fhe normative stand-

ards as descrÌbed by the Col lege of Surgeons.

The equipmenl used for minor surgical procedures was good.

lnstrumonts, drugs and dressings were conveniently packed ln s-leri lecontaíners. Surgeons usual ly masked for procedures; gowns were worn

198

occasional ly and g loves rarely.

Wounds þ/ere usually prepared for surgeny by swabblng them with

skin antiseptic. Hair was usually, but nol always, clipped or shaved frqn

the edges of scalp laceralions. lf was observed that halrs had been in-cluded ln many of lhe scalp wounds vrhich were inspected after the sutur-

ing was completed.

Anaesthesia was usually induced try local infiltralion fhrough

the wound edges. Regional nerve blocks were not usecJ in any of the ob-

served cases. A common defecl in surglcal fechnique was that inspeclion

and suture of the wound was commenced before the anaesfhetÌc had had time

lo lake effect.

Thorough inspection and cleansing of the depfhs of lacerations

was nol well performed, and frequently the involvement of deeper struct-ures was nof assessed. This Is i I lustrated by the fol lowing case.

CASE 11224 A 59 year old male was admitfed following a crash

in which his head struck and shaftered fhe windscreen of his car. He was

concussed and had suslained a deep laccraticn of the bridge of lhe nose

involving the medial canthus and left lower eyelid. The nasal bones were

fractured. The casualty resident consulted the senior surgical regisfrarwho inspected the wound superficially but did not probe ifs depths. The

resident was lold to suluro the wound and lhîs was done using skin sufures

only. Subsequently, when the palient was obs€rved as an out-patient,considerable cosmetic deformity of the nose was noled along with evidence

of naso-lacrimal duct damage.

This wound required careful inspectíon for glass fragments,

assessmenl for the involvemenl of deeper strucfures, and meficulous

suture, none of which were performed.

199

A nolable deficiency in the management of wounds was thefailure ol'the surgeons to close wounds in layers. The inexperience ofthose performing'fhe procedures was reflecled in a reluctance to probe

wcunds and define analomica I structures for definifive repair. As a

nesull subculaneous sutures r¡rere not used to cbliterate dead space and

haematoma formation was often observed beneath scalp and facial wounds

as a resull. The following cases involved several of these fypical freat-menl deficiencies.

CASE 11106 A 55 year old male was admitted after sufferinga 41r laceraf ion of thr? right ternpora I region in a crash. The wound in-volved the skin, subcutaneous tissues, lemporal fascia and muscle, ond

fhe rîght superficial lemporal arfery which was bleeding profusely. The

palienl l.las seen briefly, l3 minutes affer admission, by a docfor who

ordered that fhe wound should be re-dressed. No aftempt was made lo clipoff the artery. A second doctor examirred lhe patient 45 ninutes later and

ordered a skull X-ray. At thîs stage the palient had lost a lof of blcod

and his blood prossure had fallen lo 100 mm. Hg. The observer thus

suggesfed Ìh¿:t lhe wound should be repairecl and the arlery clipped. This

was performed, 93 minutes affer the patient was admitted. Suosequently

hair around lhe margins of the scalp wound was trimmed (but not shaved)

and an al1'ernpf vras made to anaesfhetizc The wound by inf iltration of local

anaesthetîc lhrough its marg i ns. The superficial temporal arfery was fiedoff and lhe resident then commenced to close lhe skin without resforîngthe deeper anatomical struclures. After further advice from fhe observer,

the muscle and fascial layers were îdenlified and reconstituted. The

patient became hypotensive during the procedure, which took the residentapproximatelV 4* hours -lo completo. No specific lreatmenf was undertaken

for the hypotension, but he uras observed for 5 hours in the department

before being discharged, 11 hours after casualty admission.

The rcpair of this laceration should have been a relativelystraighfforr,iard surgical procedure. Nevertheless, the inexperíence of

200

lhe casually staff and their complete lack of supervision and directionmeanl that the procedure t+as unnecessarí ly time consuming, poorly per-

formed and resulled in considerable discomfort for fhe patient.

The adequacy of the performance of wound repair for the study

patients was assessed as fol lows.

Table 8/l 1

PERFOFü\4ANCE OF WOUND REPA IR

No. of Patients

Tota I

56 72.7

12 15.6Poor wound closure wlth poorsuture lechnique

Fair wound repalr

n fr

9 11 ,7Sufure performed wifh adequatelocal anaeslhesla, correcfmaterials and good technique

77 100.0

The ulf imate ar'biter of the quality of minor surgical proced-

ures is the cosmetic result. lt is diff iculf to predict what this willbe at lhe fime the procedure is performed. A review of case histories of

these palienls was atlempted in order to delermine the relevant treatment

outcomes. lt was found that details of wound healing were rarely recorded

by lhe out-patlent surgeons and it was lhus impossible to assess the

resu I ts.

Several organizetional factors were observed lo be important

for the management of minor wounds in casualty. During the day when

casualty work loads were heavy, one member of the resldenf medical slaffwas rostered to perform fhe minor procedures required in lreating these

injuries. This staffing arrangement usual ly handled the work load salls-faclori ly. At night, however, a single medical officer was rostered forduty in the deparlment after 2300 hours on most nights of the week and

201

was responsible for al I assessmenf and lreatment procedures performed.

He thus managed both major and rninor emergencies presenting to thedepa rtment.

This sílualion had several impl ications for casualty care. Once

a doclor had commonced a surgical procedure, his availability for assess-

ing other patients was I imitcd and, occasional ly, severely injurodpatients were not seen promptly on admission as a result. Conversely,

the arrîval of new pafíenls was observed to delay lhe performance of minor

procedures, and therefore prolonged lhe casualty waiting and lreatment

times. Whl lst admitting officens and in-patient staff were theoretical lyavailable to support casualty slaff at these times, it was observed thaflhey werc rarely summoned. Residents on duty preferred to work on untilthe work-load had decreased and lhe back-log of palients was cleared.Although long casualty queues developed at all hours of the day because ofdemands orr sfaf f and facililîes, it was only at nighTs that non-availabil-ily of staff was a potenf facfor in producing these queues. The absence

of a formal mechanism urhereby additional slaff were called to casualty tohelp out at fhese times was considered to be one of lhe most important

causes of dolays in casually care. The development of such situationsrepresents a derel iction of responsibi I iTy by admitting officers and more

senior supervisory staff .

l4edical sfudents were rostered for casualty duty and often per-

formed sutures and minor procedures, lhcreby helping lo rel ieve thepressures on the residenf slaff. ln doing so they performed a useful

servíce and gained valuable experience. l.levertheless, it was slgnif icantthal they were unsupervised (as were fhe fîrst year casualty residents)and lhus lacked practical instruction in correct surgical techniques.

Hence lhe technical compelence displayed in lhe performance of procedures

was usual ly poor. Practical experience is the most valuable form oflearning, but it should be backed with aclequate super-vision and instruct-ion. Moreover, the fact lhat junior staff rarely had fhe opportunity to

202

rev¡ew their palients when'they relurned for subsequent treatment,diminished the value of the learning experience. They lacked even theopportunity to learn by their mistakes.

Casualty residents and students cannot be expecled to provldegood qual ity care withoul aCequafe supervision and instruction from

trained slaff members. Furlhermore, since most of the minor surgery lsperformed by these persons, there is I i+tle chance of high quality care

beirrg provided for patients wlthin lhe deparfmenfs. As a result, theerrors in primary repair of sutures which were singled out for partic-ular cornment by members of the Royal Australasian Col lege of Surgeons(1970) were the errors fhat were observed mosf commonly in the managemenf

of the study patients, viz.(i ) Fai lure to remove dlrt and foreign bodíes from

abrasive type of wounds and lacerations.(¡¡) Failure to suture the muscle layers and irregular

skin lacerations back fo their correct positions.(iii) Suluring wounds under lension with large sutures.

( iv) Fa i I ut-e to exp lore ad.equafe ly the depths of f ho

wound and recognize derepe--r structures.

(3) AN OVERALL ASSESSILENT OE THE SUALTTT OF CASUALTY CNNE

It is apparenf from fhe preceding descriptions of parlicularaspects of lhe care provîded for crash victims in casualty, fhat large

discrepancies exisf between lhe normative standards and the care acfual lyperformed. ln an attempl to quantify these differences, and thereby

assess the overall quatlty of the care, lhe correlalîon between fhe care

provided for each patienl and that expected on the basis of the standards

was rated on a fhree point scale.

Those patients whose care was compafible with fhat described by

the normative slandards were assessed as havíng received good caro.Divergence from the normative standard was assessed in fwo categories.

203

Those cases for which the care provided diverged from the normatlve stand-

arC bul was, nevertheless, compatible wilh the usual care provided in the

deparlment were rafed as having received falr care. A poor rafing was

assigned where a wide divergence from the normative standards was

accompanied by performance inferior to that expecled on the basis of the

care usual ly performed in the department. (Obsorvation carrled out

during Phase One of the study had provided a baseline for assessing

ompirical standards for casualty care in the Alfred Hospifal.)

Assessments were recorded Íor 311 of lhe 328 study palients

and are analysed, by degree of injury, in Table B/12. Six patientsabsconded before care was completed and wore thus not included ln the

populalion. ln a further 11 cases, one or more areas of care were not

observed and these patienls were lhus also excludod. These 17 patientswere evenly cjisfrîbuted between the two groups; B had suffered minor or

no injury, 6 were moderalely injured and f had severe or greater injuries.

Tablo 8/12

DtsTRrBUT|ON 0F THE QUALITY 0F CARE PROVIDED FoR PATIENTSBY DEGREE OF PATIENT INJURY

38 12.2268 86.25 1.6

nft1 75 100.0

1 56 1 00.0

nqlù

6.3

1 9.8

11

27

n

151

101

fr

92.0

78.7

n þ

3 1.7

2 1.5

Nil - Minor

Moderate - FaÌa I

Tota I

Qual ity of Casualty Care

Fa ir PoorDegree of lnjury

Tota I

X 13.133 ñE-.lt*Ur I .

The distributlon demonstrates fhat patients with severe degrees

of injury received poor care more frequenfly and that the observed differ-ences achieve statistical significance at the one per cenf level.

311 100.0

2

204

The dlstrlbution of qual lty assessments emphasizes the differ-ences befween the normative and empirîcal standards of care. Only 1.6fiof palienls received care which was rated as good and thus comparable

wilh lhe normative standards, Two comments are pertlnent ln view of fhisfinding. First, fhe poor correlafion suggests that the normative stand-ards are unrealistlc. Secondly, ît emphasizes the large discrepancy fhatexists belr¡reen professiona I slandards and the professiona I pracf lce ofemergency medical care in casualty departmenfs. lt could be argued thatlhe care provided in teaching hospitals should correlate closely withnormative sTandards, since those institulions are responsible for trainingjunior staff and are manned and nominally supervised by fhe leaders ofthe professlon who set the slandards. The existence of fhis divergenceemphasizes lhe lack of administrative and supervisory confrol which is a

fundamental cause of the deflciencios in casualty care.

Comparing the quality of care observed în this phase of thestudy with the observations recorded by the lwo observers in Phase One, itcan be seen lhat fhe proportions of patîenfs receiving unsatisfactory carediffer betweon the two groups, but that these6ifferences are nof statist-lcal ly signifícanl.

Table B/i5

QUALITY 0F CASUALTY CARE FoR THE Th'O STUDY PHASES

42757 13.3370 86.7Tota I

n

116

311

n

l938

þ

16.4

12,2

n

97

273

lL\

83.6

87. B

Phaso One

Phase Two

Unsatisfactory(Poor )

Sat i sfactory(Good & Fair)

No. of PafientsQual îty of Care

Tota I

x2= 1.26 D. F. 1 N.S.

205

On the basis of fhese observalions approximatelV 13fi of the

crash victims observed during bolh phases of -lhe sludy received unsatis-factory care ín casualty. lt w¡s shown in the earlier sectlon that approx-

imately 6fi of patienls received unsalisfaclory ambulance care al fhe

scene. Ir,lhile the care provided in casualty is not directly comparable

with thal provided al the sccne, both ôre elements of an imporlant and

continuous medical care process. The fact fhat a larger propcrtíon ofpatients receive unsatisfactory care in casualty is of concern and

supports the contention thal planners of emergency services should

consider care within casualty when planning changes in fhe emergency care

system.

(4) RELTABILTTY OF THE ASSESSMENTS

The assessments of quality made by the two observers during the

firsl phase of the study represented a combined judgement of the care they

had witnessed. ln the seccnd phasc observations were made by a singleobserver. More detailed cri'ierie were used for specifying the standards

and procodures for assessment of the care in an attempt to reduce lhe

varialion whîch must inevifably occur due torwifhin-observerr inconsisf-encies. No specific measures were taken in the study to control such

influences, beyond the general awareness by the observers of the problems

i nvo I ved. Neverthe I ess, the fact that 1 6% of paf i enls were j udged as

having rece îr,,ed unsatisf actory care dur ing the Phase One sf udy as compared

with 12% in lhe second phase suggests that there was consistency between

lhe observations in thc two sfudy phases.

One may argue thaf c¡bservers are likely to be more critical in

assessing the car-e of severely injured patients, who usually require more

treatment procedures moro urgently lhan lhose with minor injuries, and

that this inf luence could affect lhe assessmerrts made. ln vieur of this,three faclors should be consiclered with respect to the present study.

First, the observers were aware of these influences af lhe time of the

sTudy and thus tried to control for fhem. Secondly, more severely

206

injured patients neecl hlgh quality care for their optimum managemenf and

any divergence from such standards is undesirable and thus noteworthy.

Thirdly, similar inf luences would have prevailed and, were they signif ic-ant, should have been revealeC during the observafions of ambulance care.

Observer bias is o factor which is difficult to control in

direct observafion studies and here again, beyond the general awareness

of the problems by the observers, no specific measures were taken tocontrol this aspect of qual ity assessrnent.

The i nf I uence of lhe cl¡server on the process under study i s a

thírd important facfor in direct observation studies. lt was felf, in

both pl-rases of the sludy, lhaf the inf luence of the observer on the

system was small. Thís factor was dîscussed and tested in Chapter 6. lfis worth noting that the observerrs presence is mosl likely to resulf inthe performance of be'lter caro in a relatively shorter time. ln vievr ofseveral of the findings in this study if ls to be hoped that the care

provicjed under these circumslances did not represent the optimal capacity

to perform which would be expected on the basis of this premise.

(5) PAMENTSI ATIITADES TO TT]E CARE THEY RECETVED

A postal queslionnaire was used -lo determine patientst opinions

of their ambulance and casualty trealment in the second phase of the

study. One hunclred and e ighty-three $5.5%) of the pat ients responded

to the questionnaire.

The characterlslics of lhe respondenls and non-respondenfs in

thq qust ionna ire samp le w,.:re compared ln Chapter 6, where f he two groups

were compared for age, sex, degree of injury, and time spent in the

casually deparlment. ln Table B/14, the assessmenfs of lhe qual ity ofcare Drovided for the two populalions, as raTed by the observor al the

time of casualty treatmenl, are compared.

207

Tab I e B/14

QUALITY OF CASUALTY CARE FOR QUESTIONNAIRERESPONDENTS AND NON-RESPONDENTS

Qual lty ofCasua I Ca re

lf the categories in the Table are collapsed to ensure thatexpected numbers in the respective cells are greater than five, a chisquare fest on fhe proportions in the good plus fair, poor and notobserved/not lndicated calogories, shows that the differences between thefwo populallons do not achleve statislical signif icance (XZ = 3.10;D.F. = 2i N.S.). Therefore by this criterlon, as for those describedpreviously, the respondents may be considered representafive of theobserved study population.

Pafíenls were invited lo assess fhe care they received by

responding Ìo specific questions (Appendix 4). The quesfions and

distribution of responsês to each of them are described below.

Atnbulanee Caye

One hundred and f i fty respondenls hacl been treated by the ambu l -ance servíce and fheir assessments of the care provided were expressed inresponse to fhe questlon: Did you think the treaünent you nece.iued fromthe anbulanee men üas good" fair, o? poo? ? Responses are shown i n

Table B/15,

328 100.0145 1 00.0l83 100.0Tofa I

Tota I

n

5

268

3B

11

6

%

1.5

8t .7

11.6

3.4

l.B

Non-Responsen

I

116

17

6

5

dþ

0.7

80.0

11 .7

4.1

3,4

Responsen %

2.283.1

11 .5

l. t

0.5

4

152

21

5

1

Good

Fa irPoor

Not Observed

Not lndicated

Response to Questionnaire

208

Table B/15

OPINION OF AMBULANCE CARE

150 I 00.0ïofa I

n

118

23

4

5

lo

78.7

15.3

2.7

3.3

Good

FairPoor

I'lo 0pinion

No. of Respondents0pinion

The majority of those who received ambulance lreatment were

favourably disposed towards the care they received. Two of the patientswho thought their ambulance care was poor had received minor injuríes,one moderate injury, and the fourfh was very severely injured. Those

with minor and rnoderate injurles were equally crif ical of fhe medicaland nursing care in casualty, although fhe patient with moderate injurîesmade parlîcular comment on the fact thal he thought the ín-pailentnursi ng care he receivc.d was excel lent.

The severely injured patient was transferrecj from the Alfredto Prince Henryrs HospitaI after being treafed in casualty, because ofshortage of beds Ìn the Alfred. He ra'led the medical and nursing carehe received as good but offered the fcllowing comment: rTravelling fromone hospital to another by ambulance when one is dying is nof good enough.There are too many incompetenf people in attendance.t

Since he was accompanied by a resìden-l- medical off icer, inadditlon to the ambulance crew, during the transfer, hls assessment ofpoor ambulance care was probably more relaled to the decision lo transferhim befween hospitals than to lhe ambulance care as such. Neverlheless,bettcr communlcation between the ambulance service and the hospitalsbefore his admission lo the first hospifal would have avoided the need

for the subsequent transfer.

209

Cav'e in. CasuaLtt¿

Patients were invlted to express opinions on the care providedby fhe doctors, lhe nursing staff and fhe time they spent in receivingtrealment.

(a) Medical Care

Patlents assessed the care they received from doctors by

responding to fhe followÌng question: Díd you think the cæe gou reeeitsed,

from the doetor uas jood, fair or poor ? (Tabl e 8/16,)

Table B/16

OPINION OF MEDICAL CARE IN CASUALTY

183 1 00.0Tota I

n

123

40

14

6

fr

67 .2

21 .9

7.7

3.2

Good

Fa irPoor

iio 0pinion

0pinion No. of Re dents

Whereas 79% of patienfs lhought the ambulance care was good,671Á held similar opinions of the meclica I care in casualfy. perhaps ofmore interest is lhe fact lhat BÍ thought their medical care tvas poor,as comPared wi+h 3f" who made this assessment of their ambulance care.

(b) Nursinq Care

l¡Jhen asked Díd you think the eate you neeeiued ftorn the rutnsírqstaff uas good, faín on poon ? the following responses wore obtained.

210

Table B/17

0PINlotl 0F NURSING CARE IN CASUALTY

183 1 00.0Tota I

Good

FairPoor

l{o 0p in ion

0pinion SNo. ofn

128

28

17

l0

69.9

15.3

9.3

5.5

The difference,s between the distribufions of the responses

relating to nursing and medical care are not sfatistically signif icant.However, proportionately more patienl-s expressed dissatisfaclion vlithmeclica I and nurs i ng care than w ith amlru lance care.

(c) Casualty Trealment Times

Patienlst response'rs to the question Did you think the time

you spent ín easl/a,Lty uas shorter tlmn gou eæpeeted, about u\nt you

eapeeted" or Longer tlnn you erpeeted ? are shown in Table B/18.

Table B/18

OPINION OF CASUALTY TREATMENT TIMES

183 1 00.0ïota I

n

37

76

62

B

dlo

20.2

41 .5

33.9

4.4

Shorter than expected

Abouf what expected

l-onger than expectod

I'lo 0p in ion

No. of Respondents0pinlon

A lhird of the patienls experíenced longer delays than they

had expected and this suggests a degree of dissalisfaction wilh fhe

211

ïreatment times. Mosf pafîenfs are aware that casualty departmenls are

busy and fhat waiTing times may thus be long. Their expectafions as fowhat represents a reasonable waifing timc are, no doubt, tempered by

their perceptlon of their own illness and its severity. Thus it was notsurprising thaf comparison of fhe patienl'st responses with the actualtimes spent in receiving care did nol shour any significant correlalion.

Elghteen patients added sponTaneous comments to lheir questionn-aires in which they stated that wailing limes were too long. Waifinglimes to see the docfor ernd wailing for X-ray were singled out forparticular comment.

)ueraLl. Opinion of Etnez,qeney Tneatrnent

The majority of patients wcre satisfied wilh the treatment lheyreceived, as was shown by'fhe response to The question: Did you thinkthe otsanaLl treabnent you y,eceiued fon yow injwðes uas good" fai,n orpoon ?

Tablo B/19

CPINION OF OVERALL TREATMËNT

183 1 00.0Tota I

n

129

35

17

2

dtl0

70.5

19.1

9.3

1.1

Good

Fa irPoor

No 0pinion

No. of Respondents0p in ion

One hundred patienls added comments relating to their trealmentto their repl ies. Forty of these were favourable and sîxty unfavourable.Eighteen of the unfavourable group related to time delays, 34 to treat-ment deficiencies and I to other areas of the care performed. Fivepatients commented on lhe anxiety caused to parents or relatives due to

212

poor communications between casualty staff and waiting relallves.

(6 ) suwLry_

The quality of care provided for lhe pallents observed in the

second phase of the study has been reviewed in this section by examining

elements of the process of lhe care provided. A considerable discrepancy

has been demonstrated between the normative standards of care as propounded

by senior members of the profession and the acfual standards of care

practised in the casualty department, with less lhen 2fr of patientsreceiving lreatment compatible with fhese standards. Moreover, approx'-

imately 13ft of patients were assessed as receiving unsatisfactory care

in comparison wilh lhe empirical standards for the managemen't of road

crash victims in fhe Alfred Hospital.

Patienfsfatlitudes lo care, as determined by responses to a

postal questîonnaire, indicated that, whi lst most patienls consldered

tlreir f reatmenl saiisfactory, a large proportion ß4%) felt thatcasualty waiting times were longer lhan they expected. Three per cent

of patients felt that the ambulance care lhey received was Poor, and

10% held similer opïnion.s of casualty care. Ratings of the quality ofcare by two observers in the first phase of the study found similarproportions of unsafisfactory care, wilh 6$ of patients being assessed

as having receìved unsatîsfactory ambulance care and 16É unsatisfactorycasua lty treatment.

(3) An Analvsis of Patterns of Casualtv Service for Road Crash Viclims

Data relating to patient flow patferns through the casualty

deparlmenl have been described in this study and may be usecJ for such

administralive purposes as planning mociif ications of exisling systems

or set-l i ng rea I i sl I c operat i ng standards.

lf modificalions are intended, îf is useful (and of some

213

imporlarnce to management) to be able to preclict tho likely effects ofany projec-led charnges. Onc method of making such predictions involves

the use of simul¿:lion models. Simulalion modelling provides a means

whereby management can lest the effects of changes in an operating

system without changing the existing system. Thus, for example, theeffects on casualty waifing times of changing staff ratîos or treatmentpriorilies can be assessed by si,mulating the exisling system and examin-

ing lhe effects of various altv-rnative operatîng methods on lhe outpuls

of the mode I .

Simulalion models ¿ìre used for the descriptíon of system

operations in those situations where malhernatical analysis is likely tobe e ither too complex or foc costly to be benef icial. Such situationsusually involve many interactîng variables which are dif f icult to describe

în terms of mathematical functions, but which can be successful ly

simulated by fho use of a model which represents the essential featuresof the system. The lechniques have been used for management problems

ranging from the planning of servicing and repair requiremenfs formachinery breakdowns in factories to the determînafion of unloading

schedules for ships in dockyards. ln lhe emergency care field, simulationmethods have been used to solve ambulance location problems (Savas,1969)

and fo analyse service and detection systenrs on freeways. (Kel ler, 1971.)

(ù THþ} TECHNTSAE OF SflVULATED SAIIPLTNG

l4onte Carlo, or simulated sampling, ís an operations research

technique which permifs the introduction ínfo a system of data whîch have

the properlies of a given distribution. A model is developed which

describes the essential features of the system and thîs model is fhen

driven by input data from the observed system. The reactions of the

syslem components and its outpufs fo infroducod changes can be assessed

try analysing thc distribulion of the output variables produced by

running the simulation. The value of a simulation is determined by itsabi I ily lo predicf the bcrhaviour of lhe system under study.

214

Four slages are necessary in simulating a given system and

are i I lustraled below by reference to casually deparlment operations.( i ) The frequency distribufions of patient arrivals

and e lapsed t imes r:ur i irg the var ious f reatment

phases are measurod and converfed into cumulativeprobabi I ity distributions.

(¡i) A simulation model describing the elcments of the

system lo be studied is derived.( i¡ i) Randc.rm sampling f rom the cumulative distributions

determines lhe specif íc arriva l, waitíng and

treatment times for use in simulating the casualtylrealment system.

By using random numbers fo enfer fhe cumulaf-

ive distributíons, specif ic fime values which

are associated with each rando'm number are

gathered in proporÌion to lhe probabi I ify oftheir occurrence as doscribed by the originalf requency d I stri bulion.

(iv) The actual operation of the casually treafment iss imu lated.

Simulation involves selection of a patientarrival from the observed arrival distribution.Adclitional sampling from fhe mcdícal of f icers¿:rvice time distribution, fhe probabillfy ofthe patient requiring X-ray, the time spenl inX-ray distribulion, and fhe observation and

treatmenl time díslributlon drives lhe model and

allows examination of the outputs, of waitinglime fo see The medical offlcer, and total tlmc

spent within the system.

ln fhe fcl lowing seclions, lhe observed patterns of casuallyoperation will be discussed, using a simulalion model to fest the

215

possible effecls of certain changes in fhe operation of the department on

the outputs of the system. lt should be stated al the outset lhat thedata used were col lected before lhe author had had the advantage of f'he

advice of an operations reseapcher to assist in the study design. Hence

the data available limited bcth the scope of fhe simulalion and the typeand applicabillty of the model used. The aím of the followlng analysisis thus fo demonsfrate the applicability of the technique to the

casually problems under sludy.

(b) APPLTCATTON OF A STMULATTON MODEL TO THE OBSERVED

CASUALIY DATA

The arrival patterns of crash viclims al fhe casualty department

of the Alfr.ed Hospital were dlscussed in Chapter 6 of this lhesis and fhe

dislributions of these arrivals for each hour of the day of week were

shown in Table 6/19 (see Appendix l).

Table B/20 shows the dislribufion of fhe total times spent inthe department for fhis group of patients

Tab I e B/20

FREQUENCY DISTR|BUTtON 0F THE Tl¡4E SPENT tN CASUALTYFOR THE TOTAL CRASH POPULATION

n

223

319

241

133

176

B4

35

B6

B5

dlo

17 .2

24.6

1 8.6

10.5

13.6

Cr. 5

J1

6.6

1382 100.0Tola I

0- 59

60-1 1 9

120-1 ,19

180-239

240-299

300-359

360-419

420+

Not Known

Pat i enlsT ime Spent

i n Casua lty(M i nutes )

216

A sub-sample of these patients were selected for use in the

simulation study. Two groups of crash víctims who arrived in fhe depart-

ment at different times of tho week were selecteci in order fo simulate

different palterns of casualTy operation. Arrivals during the periods

12OO hours lo 2400 hours on Sunday to Thursday were selected as represent-

ing a group of pafients who arrive ai times when a smaller ProporTion of

emergcncy palients are seen in the deparfment. 0n Friday and Safurday

nighfs a larger proportion of road crash victims are seen in a patient

population which contains proportionalely nrore emergency patients fhan

fhe Sunday lo' ThurscJay poriod. A second period was lhus chosen io

include the periods 1800 hours Saturday until 0200 hours on Sunday

morning. The numbers of patients seen in the respective periods along

with lhe tolal arrivals during those periods for the total samPle period

are shown in the fol lowing Table.

Table B/21

TOTAL AND OBSERVED TRAFFIC CRASH VICTIMS BY DAY AND SHIFT

3476 p.m 2 a.n,Tofa I

bt

57

182

165

5 p.m - 2 a.m.

- 2 a.m.6 p.m

Fn i day

Saturday

11?48112 noon - midnightTofa I

1B

15

23

25

31

110

94

B5

82

110

12 noon - nridnight

12 noon - midnight

12 noon - midniqht12 noon - midnight12 noon - midnight

Sunday

Monday

Tuesday

Wt:dnesday

Thursday

0bservedArrivals

Tola I

ArrivalsshiftDay

1lB

The inter-arrival lime distributions are dlfferent for road

crash palienls arriving during the lwo specified sampl ing periods as

can be seen in the distribution shown in Table 8/22 for a random sample

of 200 cf lhe tofal crash patients who arrived during the periods.

Arrivals occur more frequenlly ín the Friday-Saturday period, with a

IS FIRST M.O. BUSY I'IITH A

CRASH PATIENT?

GENERATE TRAFFIC CRASH

PATIENT ARRIVALS

IS SECOND M.O. BUSY l.lITH

A CRASH PATIENT?

PATIETIT TXITSCASUALTY

PATIINT WAITSFOR DISCHARGEFROM CASUALTY

PATIENT ISX-RAYED

DOES PATIENT REQUIRE

X-RAY ?

SECOND M,O.TREATS PATIENT

FIRST M.O.TREATS PATIENT

NOYES

YES

YESNO

NO

Fig. 8.5 Simulation Model Flow Diagram

217

med¡an inter-arrival time of 26 minufes as compared with 82 minules forthe weekday perÍod. The larger percentage of zero inter-arríval times

for fhe Friday-Saturday population inclicafes a higher frequency ofmultiple patient arrivals during fhoso timcs (usually due to the simul-taneous arrival of palients from the same road crash).

Iable B/22

DISTRIBUTIOI'{ OF

ALL TRAFF I

I\TËR-ARR I VAL T IiVES FOR

CRA PAT I ENTS

Tola I

As has been described elsewhere in this thesis, once a patlentarrives in casually he is processed through a series of treatment

services, each of which has a queue associafed with it. The pattern ofpatient f low is represented by lhe f low chart in Fig. 8.5.

1 00.0 100.0

fr

23.5

6.0

6.0

1 tl.5

6.06.07.03.5

12.5

8.5ÔEL.)

3,0

1.5

1.0

0.0

2.5

dlD

17,5

5.0

3.0

4.04.04.5

6.0

1.5

12.0

9.0

8.0

8.0

3.0

2.5

1.5

10.5

\J

1- 5

6-10

11-20

21-30

31-40

41-50

51 -60

61-120

121-180

181-240

?_41-300

301 -360

361-420

421-480

481 +

Friday - SaturdaySund¡:y - Thursdav

Arrîva ls During Time Periods( t¡y pe rcenfage )

I nter-arr î va I

, Time(l"li nutos )

218

Service límes for l'he medical officer and fhe X-ray department

vlere recorded for each observed crash patienf and lhe dlsfribulion oflhese serviccl times for the two time periods are shown in Table B/23.

fable B/23

DISTRIBUTION OF SERVICE TIMES FOR OBSERVEDTRAFFIC CRASiI PAT IENTS

99.9100.0100.0Tota I

f'

1.7

25.4

13.6

22.0

22.0

6.81.7

6.8

ft

8.6

27.6

19.0

11.2

r3.B

3.4

0.0

10.3

,Ã

6.8

35.1

?_0.3

20.3

12.2

2.7

1.3

1.3

r,

'tl.r16. 1

22.2

13.9

9.7

0.0

4.2

2.8

0-910-19

20-?9

30-39

40-49

50-59

60-69

70+

X-RayM.0.X-Rayt4.0.

Time inlnlinutes

Sunday - Thursday Fnîday - Saturday

1 00.0

lf can be seen that the service times in both categories are

longer during the weekend evening pericds, a fact which may be due folhe larger proportion of severely injured pafîents present in casualtya1- these times.

The distribulion of lotal limes spent in casualty indicatesthat the averagc road crash patient spends several hour-c in the system

bcfore dischar ge. Neverfheless, lhe service f íme distributions indlcatethal 311, and 45'1" of the patÌents spenl more than 30 minutes with thomedîcal officer and 621' oÍ the patients spenf less than J0 minutes and

40 mlnutes ln X-ray durlrrg the weekCay and weekend periods respectively.Hence patients must spend long limes r^raitlng for the various services lnthe deparfmenl. Some of this waiting time ls spent walting for a busy

219

serv¡ce - for example, fhe medical officer or the X-ray deparfment'

Another portion of it represenls a part of fhe treatmenl process and

includes time spenf waillng for the results of diagnostic procedures and

llme spenl under observation.

Aims of bhe SírruLatíon,

The reducfion of walling and treatment times in casualty is a

general ly accepted adminisfralive goal. ln the next sectíon two posslble

alfernatives for reducing the total fime a patient spends in casualty

are considered by using a simulation model.

First, fhe effecl- of givlng priority to crash patients over

all ofher pafienls is examined. The hypothesís is thaf signiflcantreductions in total casually service time will result f rom glvÎng

casualty patienls priority in the gueue waÎfing fo see the medical

of f i cer.

Secondly, the effecf of a reduction in lhe amount of time fhe

medical officer spends with each patienf is examined, uslng a medical

officer service time distribution derived from observatlons made in

another Vicforian l-lospital. One would predict that reducing medical

officer service times would increase the oatienf flow and thus save

casua lty treatment time.

The Simúation MadeL

The casualty treatment system can be represented by a Monte

Carlo simulation model Four queueing situalions are evidenf in the

syslem flow diagram (Fig. 8.5). Patients may be subject fo delays

while waif îng for clerical processing on admission to casualfy, waiting

for lhe initial consultafion with a medical off icer, waiting in X-ray,

and waiting for discharge, either after lhe initial medical off icerconsullation or after X-ray. WaitÌng fimes during this latter phase

may include several modical consultations, observation, and treatment

220

procedures (e.9. suture of lacerations). These four queueing services

within casualty can be described mathematical ly by their respective

service lime distributions. The delays at each service are a funcfionof the service timos. Altering the service tlmes has an exfra lmpact

on lhe Total time in fhe system, since it also affects the waifîng tlmes

f or subsequen-l serv icos.

The palient arrlvals used for the simulation are generated

from fhe distribution of infor-arrival times determined for lhe road

crash population prosentlng to the Alfred Hospital casualfy department

during the study periods and shown in Table B/22.

The lnitlal assessment and documentation by lhe admittingnurse was assumed to have a constant service time of 2 minutes and thistime is lhus added to lhe arrival time of each patient in fhe simulationin recognifion of lhe service.

During most of the time periods chosen for lhis study the

casualty department was staffed by two residenf medical officers who

were responsible for fhe reception, assessment and treatmenl of acute

casualty admissions.

Once lhe palienf is admitTed fo the deparfment he is seen by

one of these two medical officers. The flrst medical officer corresponds

to the tfirst onr resident in the hospifal and he is the doctor glven

preference if bolh are idle when a netlt admission occurs.

It is assumed that road crash victims have prlorily over

other casualty patients. Therefore these pallenls have only to waif fora medical officer when bofh doctors are examining road crash patienfs.The observed service times of lhe medical officers for the two differenttime periods are presented in Table B/23,

RN(J)RN(r) r(r) Rx(G)IA RN(A) A(l) r(I) B(I) = c(I)

T(r)+2M.O. RN(D)No.

D(I) E(I) =c(r)+D(r)

c(r) s(l) =E(t)€(r)

J(l) L(r) =H(l)+J(I)orE (r) +J(r)

S (I)L(t)

= w(r) =

-r(r) c(r) -B(r)

o

o

o

36

52

52

318

32L

357

357

573

to99

l1t5113r

1131

t r31

LI17

]-77

1493

r50l1501

t667

t793

1839

47

49

L27

L29

L52

t44335

358

4ú4L6

581

1107

LL32

1148

1150

LL73

L224

1187

1550

1509

L524

t724

1820

1886

048

2?5

744

7L7

757

728

580

224

944

543

065

254

885

oo8

150

954

478

475

506

368

963

2L3

356

533

o 713

o 347

I O90

| 924

1 365

I 337

1 740

o 673

I 001

r t55

o 226

o 701

L 292

o 777

o 063

L 354

o 633

o 068

L 244

o 399

L 937

0 166

o 215

1 007

596

LLs2

1193

1165

t269

120.2

r09

931

628

735

869

907

829

627

627

700

960

144

275

706

64r739

153

796

753

658

839

198

242

429

15

3r5

105

135

225

255

225

r05

105

135

345

15

45

135

105

165

15

r95

165

105

225

t5

45

45

r07

389

232

264

317

399

560

508

509

551

94L

LL61

LL71

L32g

I270

1338

1284

t397

L7L5

r639

r749

rt 54

1880

r931

t07

389

232

224

125

347

242

r87

¡52

194

368

68

62

L97

139

207

r07

220,tt

138

244

87

a7

92

o

I2

3

4

5

6

7

8

9

IO

llL2

t3

t4

l5I6

t7

lgl920

2l

23

24

c29

199

t2L

521

449

o2l931

28L

551

oll909

979

452

4'32

22L

116

608

158

956

314

137

872

816

624

o

o

o

36

I6

o

266

3

36

o

216

526

t6t6

0

o

46

o

3r6

Io

166

126

46

798

859

925

996

416

303

244

715

815

878

078

oo4

2L2

26r

223

432

824

ú4864

o58

300

881

4r8

853

45

45

80

80

25

15

L5

35

45

55

6

6

l515

I525

45

6

55

6

15

55

25

45

02304446 47

38 49

54 r27

56 L29

320 320

323 323

359 359

361 361

575 575

1101 lrol1117 1117

1133 1133

r135 1135

1137 1148

1r79 1179

r18r l18l1495 1495

1503 1503

1505 1509

L669 L669

L?95 1795

1841 1841

I 92

74

45

25

15

65

25

25

45

45

6

15

15

45

25

45

15

25

45

15

15

25

80

15

15

6

o

t1l

I173

73

o

2

I2

o

o

o

o

o

o

o

IIo

o

o

o

4

o

o

o

t

1

I1

I2

1

I2

I2

2

II

403

1s34

rt39

1835

Fig, 8.6 Calculations f or 24 runs of the Simulation ttlodel using

rhe Friday/sarurdãv-ri*ã Disrri-buitàñi ãn¿ givtng prioritv ro road crash parients"--J (see keY next-Page) '

l=

RN=

A(l) =

T(l) =

B(l) =

C(l) =

Patient arr¡val number.

Random number.

I nter-arrival time .for patient

Time of arrîva I of patient I .

Time cf completion of nursingassessmenf.

Time seen by medical officer.

F(l) = The decisîon as to whether I is to beX-rayed.(0 = X-ray; 1 = Nol X-rayed.)

G(l) = The lime spent in X-ray for thosepatients who require lhe servlce.

H(l ) = Cumulative time spent in the deparfmentto the tîme of completion of the X-ray.

J ( l) = Observatîon and treatrnent time forpatienf l.

L(l ) = The cumulative clock time at discharge.

S(l) = The system time (total casualty treatmentt irne ) for pat ient I .

W(-I) = The waiting lime to see a medicaloff i cer.

M.0. = The number of the medical officer whosees the patienf.04.0. 1 always sees the patient if hei s free. )

D(l) = Time spent with the medical offÎcer.

E( l) = Cumulalive time spent in casualty,unti I the completion of the medicalofficer consultation.

KEY TO FIG. 8.6.

7_21

After beíng seen by a medical officer, palienfs are sent toX-ray, discharged, or they wait for some additional service. For thepurposes of the simulation patients either go fo X-ray or they are dis-charged from casualty. Seventy per cent of the sunday to Thursdaypopulalion received X-rays as compared with onlv 50l of lhe Friday-saturday patienfs. Those patients who are discharged from casualtywithout X-rays waif for variable periods before fhey are discharged.The service time of this discharge operation (the observation and treaf-menf time) varies considerably since mosf patients are not dischargedimmediately. For example, many pafienls with head injuries are observedfor at least four hours and fhose who require in-pafienf admissíon waitfor the completion of admission documentation procedures before theyleave the casualty department.

Two separafe simulations of 100 arrivals at the casualfydepartmenl were run using fhe inter-arrival and service time distrlb-utions shown in Tables 6/22 end B/23, a conslanf nurse assessment timeof fwo minules and the dislribution of times to discharge after service.One run represented the Sunday-Thursday time period and lhe other simul-ated the Friday-Saturday situatíon. Twenty-four runs of the Friday-Saturday simulation are shown in trlg.8.6. The resulting simulatedwaÎting times to see the medlcal officer during both time periods arecompared in Table B/24 (see p,22D,

During bolh time periods the wailing f îmes are subslanlf allyreduced by giving priorify fo road crash patients, but even with theprlority policy, 6f, of lhe Friday-saturday crash patlenls wall longerthan 50 minutes for their first medical consultation.

222

fable 8/24

DISTRIBUTION OF I{AI-TING TIME TO FIRST SEE THE MEDICAL OFFICER

The observed and simulated system fimos are shown in

Table B/25.

Table B/25

DISTRIBUTION OF CRASH PATIENT SYSTEM TIME

215215Vedian Tlme

(M i nufes )

dfo

88.0

2.04,0

1.0

1.0

4.0

olo

13.6

12.6

2t.0I8.910.8

8.1

1.8

7.2

fr

92.0

1.0

5.0

2.0

al0

23,4

19.6

18.7

13.1

7.5

5,6

2.89.3

0-45-9

l0-19

20-29

30-39

40-49

50-59

60+

Simulafed0bservedSimulated0bserved

Waiting Tlmei n Mi nutes

Friday - SafurdayPopulation

Sunday - ThursdayPopu lat ion

fr

11.0

28.0

23,0

16.0

6.06.0

3.0

7,0

fr

1 5.0

32,0

18.0

6.0

1 3.0

10.0

3.0

4.0

fr

15.0

51 .0

19.0

5.0

4.04.0

2.0

dlo

22,0

31 .0

1 4.0

10.0

8.0

9.0

5.0

t.0

0- 59

60-1 1 9

120-179

180-239

240-299

300-359

360-419

420+

S imu lated(N = 100)

0bserved(N = ll8)

Sunday -'ïhursdayPopuletion

0bse rved(hl = 1 12)

S imu lated(N = 100)

System Timein Minules

Frlday - SaturdayPopulafion

223

The distrlbutions show that a reduclion in the total lime spenf

in casualty occurs in -l-he simulated system due to the priorlfy glven tocrash patients over othor pafients. However, fhe reduction is smal I and

if represents a relatively small percenfage of the overall sysfem time.

A third simulation was carried out for the Frlday-Saturday

evening perlod to estimate the effect on the lotal fime spent incasualty, of a reductic;n in Ìhe time spent wifh the medical off icer. A

distribution of medical officer consultation tlmes was avai lable from

tho study carried ouf in olher Victorian Hospltals (Brand,1971). For

the purposes of the simulation, the medical c.rff icer consultation fimes

chosen were those of rHospifal 6r, which was the hospital with the

shorlesÌ average consulfation times of any of'the hospitals reported

in that sludy. Table 8/26 shows the distribufion of medlcal officerservice tlmes observed in thaf hospital whîch were used for the

s imu lation. Table 8/26

MEDICAL OFFICER SERVICE TIME DISTRIBUTION IN THE CASUALTYDEPARTMEI{T OF 'HOSPITAL 6T

.21

2A

.47

.03

0-56-12

l3-15

1 6-50

DislributionT íme I nterva I

(M i nutes )

A simulation of 100 arrivals was run using this consultalion

fime dlstribution wifh the obsorved Friday-Saturday distributions forarrival, X-ray, and observalion and treatment TÎmes as before. The

slmulated system time dislributlon obtained is shown ín Table B/27

and compared with the system time distribution obtained using the

observed medical oÍl icer service times f rom the Alf red Hospital.

224

fable 8/27

S IMULATED SYSTEM T IME D ISTR IBUT IONS ON FR IDAY-SATURDAY EVEN INGS

fr

o

21

14

I10

1l

7

2

6

6

1

0

4

r,

1

10

19

9

15

B

10

6

6

6

3

2

5

0- 29

30" 59

60- 89

90-119

120-149

150-179

1 B0-209

210-239

240^299

300-559

360-4 1 9

420-479

480+

UsingHospifal 6 M.0.Servíce Times

(N = 100)

UsingA lf red M.0.

Service Times(N = 100)

System Timei n Mi nutes

Percentage Di stri bulion of Patients

VÍith the faster service times of rHospltal 6r, thirty per

cenf of crash patients are discharged within one hour whereas only eleven

per cenl are discharged within that time interval wlth the observed

service times. The median time spent by patients wlthin the system ls

reduced by approximately 30 minutes by using the medical off icer llmes

from fHosþital 6r. Approximately 15 minutes of this reduced time is due

fo the faster service of the rHosþltal 6rme<lical officers. Thus the

reduced service llme has a doubling effect on the total systan time

reducfion for a patient, saving both time with the medical off icor and

time waiting to see him. However, even with this doubling effect,about 5% oÍ patients remain in casualfy for more than síx hours with

elther medical off icer servlce lime distribulion.

225

DiscussionThis simple simulatlon model is used to demonstrate fhe

methodology and potential appl icabi I ity of the technique to casualty

care problems. Because the data col lected related to lhe observed road

crash victims only, the f îndings of the simulatlon cannot be extrapolated

to lhe total casualty case mix. Moreover, the data aval lable from

casualty records does not permit the validity of the model used to be

tested. The only elapsed time which could be calculated for patients,

other than those observed in fhe study, was the total lime spent În the

casually deparfment. Hence the validity of the model cannot be defin-itely fested. Nevertheless, the results reflect reallfy and suggesl thatmore detailed time sludies could be expected to offer pracf ical solutions

to problems in casualty department administration.

þ) CONCLUSTONS

The analysls of lhe time study data permifs the followingconclusions about casually services to be drawn.

( i ) Road crash patients experience considerable delays incasualty.

(i i ) Road crash patients arrive more frequently on Friday and

Saturday nights fhan during the week nights.(i i i ) Medical officers spend more fime treating the average

weekend evening road crash patient than they do in treatingthose that arrive on weekday evenings.

(iv) Road crash palients spend more lime in casualty on weekend

evenings than during the weokday evenings.

ln addition, the use of a simulation model to tesf the effectof changes in sysïem operalions on The casualty medical officer waitlng

times and syslem time has shown lhat(v) Reducing the medical officer servíce time seems fo reduce

the lotal system time for a patient more than slmply

giving priority to road crash patients over otherpatients in the casualty deparlmenf.

226

(vi) Reducing lhe medical off icer service time in lhe AlfredHospífal casually departmenf lo that of rHospital 6t

saves, on the avcrage, 30 minutes in the casualty depart-ment per pafient; 15 ninulos in reduced time with the

medîcal off icer and 15 minutes in the time spent wailingfo see that doctor.

Operations research has been widely used in indusfry for solv-ing queueing problems which are very similar lo those experienced in

hospifal out-patienf and casualty departments. Problerns of delays in fheseparate 'freatment services caused by pressures on space, equipment and

manpower can be solved by applying fhese analyfical methods. The partic-ular value of mathematical modelling of complox svstems lies ín the ease

with which lhe variables used in formulating the model can be manipulaled

and the effects of lhese manipulations on the various system outputs

observed.

The results of the simuIation performed in this study predictthe effecls of two changes in the method of processing road crash

palien-ls lhrough freatment services in fhe hospital casualty department.

The collection of dala from a more comprehensive patienl group would

permit the study and manipulallon of f low characferistics for allpalienfs passing through the emergency deparfment. Such factors as

increasing the number of trealmenl personnel, or altering patterns ofservice, may be examined and lheir effects on waiting times and patientflow predicted. Results of analyses such as these could be used by

hospilal administrators lo improve manpower a llocations and admlnísten

the processing of patienÌs lhrough the treatment system more efficiently.

Larger simulalions involving many variables can be rapidly and

simply processed by computor. The computer pcrmifs the performance oflarge numbers of simulation runs wlth large numbcrs of differenfvariables, since fhe memory capabi I ities of the machine al low lhe

227

storage and progress¡ve bui ld up of the outpuf variables. Using such

facilities, ê slmulation model can become very realistic, ref lectinglhe contingencies which apply in the roal situation. A particularfeature of the operation is the ability to program for the costs ofeach alternative examined and deduce, as an oulput, the cosl-effective-ness of fhe measures.

An lmportant limltation on the use of operations research

techniques at present is lhe lack of suitable dala descrlbing system

operalions. Most hospital recording systems do nol permit the recal I

of informafion useful for such purposes. Slmi larly, the present rocord-ing systems used by other emergency se¡rvicos do nof record useful data

for such analyses. Special studies must lhus be underfaken to obtainfhe necessary data or, alternatlvely, special dala systems or modlfic-ations of existing recordirrg systems need to be introduced. ln eithercase forward planning is required to ensure the applicabllity and uso-

f u I ness of the clata wh i ch i s co I lected.

Operalïons research has much to offer the health care syslem,

particularly in view of the cost-effectiveness calculafions which can

be included in the studies. t4odifications of data systems to perml+

the routine collection of usable informalion would allow the techniques

to be used mcre widely. Applicaf ion of the methodology should aidadministrative decision making and organizational efficiency.

228

Chapter 9

CONCLUS IONS AND RECOMMENDAT IONS

This study of road crashes and crash pafients was undertakento invesfigate the operation of the emergency care system in an area ofMelbourne. The care provîded at fhe scene and during ambulance frans-port has been related to that provided wilhin the hospital casualtydepartnent and fwo imporlant variables, time delays and the qualify ofpatient care, used fo evaluafe the performance of the emergency

serv i ces .

The major tîme delays during êmergerìcy care occurred withinhospital casualty departments. Ambu lance response times were shortand delays during the phases of ambulance service were generally small.ln casualty departments, however, long delays in al I the treatmenlphases were the rule and applied lo patients irrespective of theirdegree of injury.

Simí larly, the assessments of fhe quality of Ìhe care pro-vided for patients within the system showed fhat significanlly more

patients received unsafisfactory care during casualty than duringambulance frealment. Moreover, the care provîdod wíthin casualfydepartments divergod widely from the normative standards as defined by

seníor members of fhe medical profession. Such large discrepancieswere nof apparont between the ambu I ance care and the def i ned standardsfor fhaf process.

These findings substanfiate the assertion that planners ofemergency services should consider care within the casualty deparfment

when planning modif icatîons to existing services. ln the system studied,particular emphasis should be placed on împroving the effíciency and

qual ity of care provided in hospital casualty departments.

229

A systems approach was used in the study to analyse theemergency care of road crash victims in terms of fhe communications,transport, documentation and treatment subsystems which conrprlse theemergency care system. The major conclusions and recornmendafions ''r

arising from the sfudy will be discussed as they relate to each ofthese four major subsystems.

COMMUNICATIONS

(l ) Communicaflons between Emergency Services (see pp .105-112)Poor communications belween fhe ambulance servlce and

casualty departmenfs affocf patient care in the system and result inthe loss of important ínformation relating to the patienlrs careduring the early post-crash phase. These communicafions broakdowns

are unlikely to be resolved by the installation of împroved tele-communicatlon I inks between the services. They are the result offai lures in inter-professional communicafion betwoen the providers ofemergency care and are thus likely fo require more than fechnicalinnovations for lheir correcflon.

Reeonmendatíons(a) Ambulance and casualty staff members should be encouraged

to liaíse more closely, in order to facllitate mutual

understanding and respect for their tasks within theemergency care system. Case review segsions may be ofvalue in achleving this objective.

(b) Ambulance officers should be regarded as para-medicalprofessionals.

(c) A medical practitioner should be appointed to the sfaffof the ambulance communicatlons centre.ln the flrst insfanco this doctor should administer the

230

bed bureau for the cify. He should also be aval lable toprovido medlcal advico for ambulanco officers at thescene of emergencies and be responslble for advislngcasualty slaf f of imminenf patient arrivals. ulf imately,he should conlrol admissions to emergency beds in al I

fhe major city hospitals ancl be responsible for ensuringthe even distrit¡ution of patients between hospltals.Finally, lf telemetry of patlent data becomes feasible,this doctor shoulC rmonitor the equtpment, advlseambulance officers on treafment, and transmif rolevantdafa to tho receiving casualty staff.

Q) Communications wlthin Hospital (see pp,113-115)A lack of communicatíon was observed between members of the

casualty staff, patients, and their relatives. several patients com-plained of the lack of information provlded during emergency care.Hospital slaff occasional ly attempted to keep patients and relatlvesinformed cf their progress. Nevertheless, the lack of a formal mechanismfor aftending to this important are.¡a of care meant that it was oftenoverlooked.

Rqcormnendøtíon

One member of the trained nursing staff in the departmentshould be appcinted to I ialse between doctors, patientsand their relatives.

(3) Communications Eoui pmenf (see pp.49; 102)

Ambulanco communicalions equipment is adequate for exístingoperations but considerable benefits could be expected from theinstal lation of more sophisticated equipment to assisf data recordlngand processing and faci I itate overal I fleet control. computerlzedsysfems are used for this purpose in several overseas counfries.Existing government departments, notably tho Postmasler-General ts and

231

Army Departments, have communícations experience whlch is relevant fothe emergency care siluation. This expe;rtise should be made avaílableto fhe civi I ian emergency services.

Reeomnenåation

The use of more sophisticated communicatíons systems

should be investigated by the emergency scrvices.

TFANSPORT

(l ) Ambulance Vehiclcs ( see Pp.48; l68-171)Existing ambulance vehicles in Melbourne are wel I designed and

equipped for routine ambulance work. one vehicle is equipped as an

emergency care ambulance and is manned by medical and frained ambulance

staff. This servícers role has yet to be complefely defined and itsusefulness af lhe scene of road crashes ís likely to be limíted.Nevertheless, fhe avai labi I lfy of such services for al I emergencíes isa deslrable development in ambulance care. These ambulances should be

hosp ita I based.

Reeormpndations

(a) Subjecl to the findings of the demonstration project,additional emergency ambulances should be based atselecfed major cily hospitals to service the metropol itanarea. Existing demands are unl íkely to warrant lhedeployment of more than three such ambulances.

(b) Given existing ambulance response limes and traff icconditions in Melbourne, there are no indications forthe use of hel icopters as alternative ambulance

vehicles in the Melbourne metropolitan area.

2t2

(2) Ambu lance Loc ron

The deployment of the ambulance fleef wifhin fhe metropol ltanarea is a complex problem. lt is complicated ln the Melbourne area by

the fact that fhe major public hospitals, parlicularly fhose servíng thearea studied, are al I located close lo fhe cify centre. Ambulance

service limes are affected by the relative locafions of the ambulance,the emergency and the hosplÌal. Operations research analysts could. helplo resol're the problems of ambulance locatlon in the metropolitan area.

Reeotmtenåation

Operations research techniques should be used lo analyzeproblems of ambulance deployment in the metropol ifan area.

(3) Ambulance Transport (see pp.120-123)

lf was nof possible fo demonslrafe any significant change inthe condition of paflenfs as a result of their road Transporf. Two

factors which relaled lo paTient safety and comfort during Transportwere the lack of resfraint mechanisms for seated ambulance patients and

fhe lack of changeover stretchers in casualty departmenfs.

Reeor¡tnenÅa.tione

(a) The Jordan I ifting frame should be used for I iftingseverely injured pafients throughouf theír ambulance

and casualfy care.

(b) Ambulance pafients should not be permitted to sif on

the strelchers in the rear cabin of ambulances withoutadequate crash reslraint.

(4) Protecf ion of the Crash Scene (see pp. l lB-l l9)Present arrangemenls for protecting those lnvolved in

emêrgency care af the crash scene are inadequate.

253

Reeontmendatíons

(a) Emergency services should be required to carry and use

warning devices (e.9. f wifches hatsr, safety triangles)to alert oncoming motorists. The towing services should

be requíred to set out these devices, since they are

usual ly the firsf on fhe scene and perform a secondary

role in the early posl-crash phase.

(b) Al I emergency service personnel should be required towear high visibility safety clothing.

DOCUMENTATI0N (see pp,148-154)

ln present operations data are recorded by each of fhe emerg-

ency services to moet their individual neods, and important operatinginformation is difficult to recal l. As a result, comparisons of per-formance within fhe various areas of the system cannoÌ be made. Forexample, the V.C.A.S. hes for some years recorded fhe times of occurrenceof several of the more imporlant events during fhe ambulance call. The

d¡ff¡culty in collating these separate data items has meant that, unfílrecently, no review of ambulance response fimes has been made by theservice. Furthermore, I i+tle information ls avai lable on the types ofambulance cal I attended and the proportlon of the workload thaf each

represents. Equal ly therc is I ittle data by which performancê and work-loads in hospifal casualty departments may be assessed. such basicinformation is essential for assessing existing servlces and rationallyp I ann i ng future needs.

Existing recording systems have deficiencies over and above

those relating lo the recal I of usoful data. Observafions made duringthis study suggest fhat the recording instruments used are unsafis-factory. Ambulance report forms were raroly used, and fhe casualtymedical record offen contalned incomplete or irrelevant dala. lt ls

234

essential that data shoulcl be simple to collect, useful to those

collecling it, and collected in a manner which is compatible with

modern data processing techniques. Presenl recording systems lack

most of lhese fc;afures.

A co-ordinated documentation subsysfem ls required to col lectdata relallng to the services, fhe crashes and the care received by

the patients. Two types of dala need fo be collected on a routine basis:

(i) lnventory Dala

This information relates to the strucfural aspecfs of

care and needs fo be updated regularly lo permif regular

assessmenf of fhe state of the services.

(ii) Response Dafa

This includes information on response times, utl I izationrates and other performance measures which permlf the

assessment of the efficlency and qual ity of the services

prov i ded.

Documentatlon sysfems for emergency medical services have been

Invesllgated and designed in the United Stales (Bordner, ,l968; Stanford

Research lnstitute, 1969) as a means of recording data which are

demonsfrably useful lo the services. Difficulfies have been experienced

in introducing lhese systems. (Norlhrop, 1911; Stanford Research

lnstitule, 1970,) The intrcduction of new data systems is a difficullunderl'aking in a singl<; service, to say nothing of an integrated

system to involve several services. Therefore it is importanT thatthey should replace or complement exisfíng instruments ralher than add

to the already large volume of paper work that confronts those vrorking

in the services.

235

Reeorrunendatíons

(a) A co-orclinated documenfafion subsystem should be

considererJ for use by the emergency services involvedin caring for road crash victims.

(b) Existing recording instruments, notably the ambulance

report form on a casualty and fhe hospital casualtymedlcal record, should be complefed in appropriatedetai I for each patient,

TREATMENT

(l) Firsf Aid at the Cras h Scene (see p,129)Although the ambulance service was the major provider of first

aid af the scene of the sfudy crashes, members of the general publicoffen performed effectivo first aid during fhe early post-crash phase.Mass education campaigns have been suggested as methods of raising thegeneral level of f irsf aid skill in fhe ccrnmunity, wilh the aím ofimproving the emergency care of victims. lt should be noted that, intruly I ífe-saving sifuafions, the ski r rs of the anaesthefist orresuscllatíonist are likely to be required; skills whích are beyond

fhe training of many medical practltioners to say nothing of fírstaiders. l+ is noteworthy that docfors rarely altended the studycrashes. They can contribute to the welfare of those ínvolved and

should thus be encouraged fo atfend and treaf patients at the sceno.The life-saving potenf ial of f irsl aid is diff icult to determine, bufits very existence is sufficient fo encourage rational allempts toachieve ¡t. voluntary first aid schemes should be encouraged, and, ifwider first aid training ís fo be adopted, it should be directed ln thefirst insfance fo selected occupational groups such as faxi and towtruck drivers.

2t6

(2) Ambulance Care

T.he performance of ambulance care for crash victlms was

observed to be satisfactory given the level of fraining and skÍll offhe ambulance officers. Training and equipmenf standards are commensur-

able with those described for similar services overseas. As with allprofessionals, it ís desirable thaf ambulance officers should be as

skÎ lled as possible and ambulance authorlties in Victoria are apparentlytakíng positíve steps fo improve the standards of care within theservice. Def iciencies in care occurrecJ infrequently and on no occasionwas fhe palientrs condition adversely affected by the care (or lack ofit) providecl.

(3) Casua lty Care

Major deficiencies were detected in the performance of carewilhin hospital casualty deparfments. Tlme delays during casualtywere excûssivo, departments were manned by junior staff who lacked

supervision, and poor qual ify care was frequently observed.

Reeornnendations

(a) Senior medical off icers should be appointed to supr,:rvise

casualty operafions lhroughouf the day.

These docfors should take over the supervisory functionsof the existing casualty surgeons (see pp. 138; 160).

(b) Casualty medical sfaff should be rostered so fhat daí lyworking shifts can be reduced to a length which iscompatible with personal ancJ departmenfal eflíciency(see p.160).

(c) Admiffing officers should be present in the casuallydepartment lhroughout their rosfered duty periods(see p.201).

237

(d) A formal mechanlsm is needed to summon back-up doctors

fo casualty when workloads become excessive, parllcularlyduring the late night hours (see p,201),

(e) An exporienced doctor should be presenT in the casualtydeparfment at al I tlmes to consult wilh junior sfaffmembers,

(f) Existíng arrangements for patíenf lriage are total lyinadequate (see pp.134; 179).( ¡ ) A senior nursing sister should assess al I pafients

on admission and report directly to a trlage medica I

off i cer.(i¡) Palionts should be seen by medical officers accord-

ing to priorities determined by their severity ofinjury rafher than their posif ion in the palionfqueue.

(g) An obscrvafion ward, manned by traíned nursing staff,should be avai lable lo provide faci I it¡es for the observ-atlon of pafienls awalting transfer or discharge from

emergency care (see p ,146),

(h) Junior sfaff need instrucfion and supervision in theperformance of:(l ) Resuscítation, notably intravenous therapy.

( i i ) The management of fracfures.(¡ii) Minor surgical procedures (see pp,185-202).

239

SUMMARY

Many of the defíciencies ln the emergency care system,particularly those occurring in casualfy deparfmenls, wi I I requireremedial changes in patterns of organization. ln thls regard,considerable benefit could be expecled from further defai led study ofthe system, using operations research technlques. The casualfydepartment, as lhe weakest I ink in the syslem, warrants partícularattenf i on.

Reeornnendation

A sysfems analysis of the casualty department shouldbe undertaken wifh the objective of developing a

model for eff icient casualty operations.

No

Appendix 1

TABLES

V.C.A.S. EMERGËNCY CALLS DURING THE TOTAL SAIVIPLE

PER I OD

V.C.A.S. EMERGENCY CALLS DURING TIMES ON DUTY

PROPORTION OF SAMPLE CRASHES TO THE ESTIMATEDCRASHES OCCURRING IN THE STUDY AREA DURINGTHE STUDY PERIODS

AGË & SEX DISTRIBUTION OF CRASH VICTIMS

ARRIVALS OF THE OBSERVED CRASH VICTIMS AT THE ALFREDHOSPITAL CASUALTY DEPARTMENT BY EACH HOUR OF T}IEDAY OF THE hIEEK

AGE & SEX DISTRIBUTION OF THE STUDY PATIENTS(PHASE TI'JO)

PATTERNS OF CRASH INJURY

ARRIVALS OF ROAD CRASH VICTIMS AT THE CASUALTYDEPART}4ENT OF THE ALFRED HOSPITAL BY HOUR OF DAYOF WEEK DURING THE TOTAL SAMPLE PERIOD

NUKIBER OF PATIENTS OBSERVED DURING DUTY PERIODS,|YvITH THE TOTAL NUMBER OF ROAD CRASH VICTIMSADMITTED DURING THOSE PËRIODS

OBSERVED PATIENTS, AS A PROPORTION OF THE TOTALROAD CRASH VICTIMS ADi4ITTED TO THE CASUALTYDEPARÏI4ENT DURING THE TOTAL STUDY PERIOD

AGE AND SEX DISTRIBUTION OF ROAD CRASH VICTIMSADMITTED TO THE ALFRED HOSPITAL DURING THE TOTALSAMPLE PER IOD

239

Paqe

240

241

242

243

244

245

246

247

248

249

6/1

6/2

6/4

6/7

6/ 11

6/ 12

6/ 15

6/ 19

6/20

6/21

6/22 250

T ime

TOTAL

Est.CRASHES

0000- 0359

0400- 0159

0800- 1159

1200- 1559

1 600- 1959

2000- 2359

299

779.6

13 5.2

22 8.8

60 24.0

70 28.0

76 30.4

58 23.2

Mon

320

L60. 0

21 10.5

1B 9.0

54 27.0

70 35.0

87 43.5

70 3s.0

Tues.

109

754. s

16 8.0

19 9,5

56 28.0

66 33.0

80 40.0

72 36.0

Wed

355

L77 ,5

28 L4,0

26 13.0

66 33.0

89 44.5

62 3L.0

84 42,0

Thur.

439

2L9. 5

46 23.0

15 7.5

64 32.0

74 s?.0

121 60.5

119 59.5

Fri.

433

259.8

B0 48.0

l0 6,0

47 28.2

66 39.6

1 10 66.0

120 72.0

Sat.

346

17s .0

l1?

l5

27

70

6B

54

56.0

7.5

73,5

35.0

34.0

2? .0

Sun .

2501

1263.9

316 764.7

125 67.3

374 78õ.7

505 252.L

604 305.4

577 294,7

Tota I

f abLe 6/ 1

V.C.A. S. EMERGENCY CALLS DURlNG THE TOTAL SAMPLE PERIOD

By Time of DaY and DaY of Week

Estinated Cvashes in ftaLì'es

N)Þo

TOTAL

Est.CRASEES

0c00- 0359

0400- 0759

0800- 1159

I 20C- 1559

1600- 1959

2000- 2359

Time

l0l

40.4

19 7.6

22 8.8

29 L7.6

31 72.4

Itilon

106

53. 0

17 8.5

22 7L.0

34 17.0

33 L6.5

Tues.

106

53. 0

21 L0,5

23 L1.5

33 16.5

29 L4.5

Wed.

116

58.0

?7

31

23

29

73. 5

78. 5

77.5

74. 5

Thu r.

174

87 ,0

28 L4,0

31 15.5

57 28.5

58 29.0

Fri.

l88

112.8

9 5,4

26 75.6

34 20,4

72 43,2

47 28.2

Sat.

12

6.0

t2 6.0

Sun.

805

170. 2

21 77,4

I fB 69.7

169 85.7

248 128.3

227 77î,.7

ïota I

'leble 6/2

V.C.A.S. EMERGENCY CALLS DURING TtI"lES ON DUTY

By Time of DaY and DaY of Week

Estínated Ctashes ín ItaLiesNÞ

242

.2624.¿¿.172330ÏOTAL

.61

,24

.21

.26

22

,67,55

.26

34

.12

35

.14

06

.11

.31

30

.16

t5

.14

.19

.17

.18

.14

24

,27

35

.0f:

,39

.23

.52

.08

0000- 0559

0400- 0759

0800- 1159

lzaa- 1559

1 600- 1959

2000- 235s

\verageSun.Sat.Fri.Thur.Tues. WedMon.Tlme

.24

f able 6/ 4

PROPORTION OF SAMPLE CRASHES TO THE ESTIMATED CRASHES

OCCURRING IN THË STUDY AREA DURING THE STUDY PERIODS

(by 4 hourly periods for each day of the week)

TOTAL

0-9r0-19

20-29

30-39

40-49

50-59

60-69

1O+

N. K.

AGE

128 32

t1

51

21

2A

B

4

3

d

5

3

10

133

MF

Dri vers

CAR/TRUCK OCCUPANTS

29 40

1

t2

B

z

3

I

1

1

(t

16

7

I

aL

1

MF

FrcntSeatPass.

12 21

5

1

4

5

7

4

1

2

2

1

MF

Rea rSeatPass

41

1

1

MF

0ther

12 1 2

5

5

I

I

1

f",1 F

MOTOR

CYCL I STS

f"l F

PEDAL

cYcL I STS

tl 15

32

12-123-t

3122

MF

PEDES-ÏR I ANS

2

,l

1

[.1 F

OTHERS

200 1 10

10

50

71

25

27

9

4

5

19

12

21

3t

14

6

l52

1

MF

TOTAL

Table 6/7

AGE & SEX DISTRIBUTION OF CRASH VICTIMS

f\)è\¡

244

3283811041 6B292319TOTAL

26

21

4

11

7

13

10

15

19

17

26

20

19

26

18

26

27

23

6

9

5

1

1

I

3

+̂

1

1

4

2

Sat

\4

12

2

3

3

5

12

2

10

2

5

9

3

15

2

11

Fri.

2

1

3

4

3

tl

6

6

3

9

4

4

3

2

1tz)

4

1

2

1

4

4

3

1

4

4

4

3

3

1

2

1

2

2

3

2

2

3

2

5

ÂT

1

2

1

3

1

5

3

2

3

2

1

3

.,L

2

1

I

2

2

3

2

0000

01 00

0200

0300

0400

0500

0600

0700

0800

0900

1 000

I 100

1200

1 300

1 400

1 500

I 600

I 700

1 800

1 900

2000

21AO

2200

2300

0059

0159

0259

0359

0459

0559

0659

0759

0859

0959

1 059

1159

1?59

1359

1459

1559

1659

1759

1859

1959

2.059

2159

2259

2359

ïota ISun.Thur.Wed.Tues.Mon.Hour of Day

Table 6/11

ARRIVALS OF THE OBSERVED CRASH VICTIMS

AT THE ALFRED HOSPITAL CASUALTY DEPART}4ENT

BY EACH HOUR OF THE DAY OF THE WEEK

TOTAL

0-910-19

20-29

30-39

40-49

50-59

60-69

70+

I'1. K.

AGE

83 36

13538 12

10 6

Á, çi

B433213-

MF

Dr i vers

CAR OCCUPANTS

19 46

1 6

17

11

5

3

2

2

9

1

3

1

MF

FrontSeatPass.

12 13

2

7

3

1

6

I

)

2

I

MF

RearSealPass.

52

3

I

2

1

MF

Cther

21 3

122B11

t"t F

t40ToRCYCL I STS

132

1

9 I

I

I

1

1

MF

PEDALCYCL I STS

44 27

I7

7

2

2

o(J

4

5

1

3

6

2

2

3

2

2

7

t"1 F

PEDES-TR I ANS

t1

t

1

l''l F

OTHERS

198 130

16

53

65

14

9

16

llI6

12

37

?7

13

15

B

9

9

MF

TOTAL

Íable 6/ 12

AGE & SEX DISTRIBUTION OF THE STUDY PATIENTS (PHASE TWO)

N)5\t

TOTAL

Head

Face

Eye

l,ieck

Thorax

Abdomen

Pelvis

Upper Lirnb

Lower L imb

BODY AREA

35 286 t5c

6

2

10

A

5

^

Fa in(No visible

injury)

TYPE OF INJURY

65

27

2

2

19

6

3

5C

112

Bru i se orAbras ion

47

65

1

12

25

Lacerat i on

20

12

1

4

3

Spra i n

105

14

'll

1

16

3

6

22

30

Fracture orDislocation

r t8

1 10x

.)L

c

I

I nterna I -Soft Tissue

(lvlajor )

712

242

105

2

18

47

21

9

93

177

Tota I

xl 10 Patients suffered concussion

Table 6/ 15

PATTERNS OF CRASH INJURY

1\)ÞOt

247

Tota I

133AL 146145 109233114 1382242

3

3

tl6

5

1

6

6

È

5

9

12

t2

12

8

B

4

2

ö

I

r 0659

- 0759

- 0859

- 0959

- 1059

- 1159

- 1259

- 1359

- 1459

- 1559

- 1659

- 1759

- 1859

- 195<)

- 2059

- 2159

- 2259

- 2359

K.

100

900

800

00

600'

I 000

1r00

1200

1 500

I 400

1 500

I 600

I 700

0059

8159

o259

0359

0459

0559

0000

01 00

0200

0500

0400

0500

10

14

12

5

4

4

4

2

B

4

6

7

5

B

6

6

17

t1

19

13

2A

12

1B

17

1

6

4

I3

4

2

1

4

B

l07

7

3

o

5

5

6

9

I12

19

5

11

1c)

15

4

3

5

1

2

2

3

10

o

5

3

1

3

ö

3

5

12

5

5

I6

B

17

2

5

3

4

7

:

6

I13

6

5

5

7

10

7

I4

12

5

12

5

6

4

33

IB

22

13

17

4

5

5

6

2

6

6

7

B

7

6

17

13

10

l010

9

7

1

40

32

22

4

4

3

6

4

4

1l

4

2

7

11

12

12

15

1C)

12

18

15

23

1'l

25

2

11r

B3

72

37

32

15

IB

27

4B

5B

36

35

34

50

55

45

6?.

72

B1

75

97

69

71

93

6

Sun.Sat.Fri.Thur.WedTues.Mon.Hour of Day

Table 6/19

ARRIVALS OF ROAD CRASH VICTIMS AT THE CASUALTY DEPARTMENT

OF THE ALFRED HOSPITAL BY FIOUR OF DAY OF WEEK

DURING THE TOTAL SAMPLE PERIOD

TOTAL

Time

0000- 0259

0300- 0559

0600- 0859

0900- 1159

1200- 1459

1 500- 1759

1 800- 2A59

2100- 2359

Nct Known

19 25

l1

33

5 5

33

770

?

It'lo¡

11

+ 38

zz 22

55 56

to 70 77

55 11 77

23 27 29 35

Tues. Wed.

41 42

44

11

)ô

1L

11 71

oo

10 7C

Thur.

68 81

22

11

10 11

l0 10

18 22

l1 L7

16 L8

Fri.

1 10 129

26 29

57

20 20

14 79

17 20

28 33

7

Sat

JB 55

15 26

56

34

77

25

6 6

7

Sun.

328 394

47 67

44

31 45

44 45

63 73

63 78

76 86

2

Tota I

lable 6/20

NUMBER OF PATIENTS OBSERVED DURII'IG DUTY PERIODS

ïIIH, TIIE ræAL NUMBER oF Rono CRASH vIæLuS AD'\'IIIIED

ÐT]RTNG THOSE PERTADS TX T?ALTCS

(By 3 hourly periods for each day of the week)

NÞ@

249

.1636.2924.20.16.14TOTAL

.18

04

.24

32

.36

.24

.33

,21

.63

.14

.29

.05

.26

28

29

.37

3B

.47

06

.07

.59

.56

qtr

.21

.34

22

08

.21f

f

06

55

23

.29

07

.18

.17

.23

.41

.35

.14

26

l"tu.31

.17

,14

.26

.15

.20

T ime

0000- 0259

0300- 0559

- 0859

0900- 1159

120Q- 1459

I 5001759

I 800- 2059

2100- 2359

Tola ISun.Fri. Sat.Thu r.Wedi4on . Tues.

.24

Table 6/21

OBSERVED pATtENTS, AS A PROPORTtON OF THE

TOTAL ROAD CRASH VICTIMS ADMITTED TO THE

CASUALTY DEPARTMENT DUIìING THE TOTÂL STUDY PERIOD

(By 3 hourly periods for each day of the week)

NUMBER OF PATIENTS

TOTAL

0-9

10 - l9

2A-29

30-39

4C-49

50-59

6A-69

7O+

N.R.

AGE

A

0bservedMF

2739

16

56

65

13

10

17

1t

-I

3

14

7 1

I

1

1

2

1

1

6

3

2

31

10

13

28

37

10

5

13

12

3

1

10

B

Not 0bserved¡,1 F

Amitted DuringDu Per i ods

29

126

214

72

48

46

32

l9

34

40

34

22

?0

20

18

13

101

993

NKMF

Admilted DuringTirnes of f duty

4B

194

292

90

59

64

44

28

38

26

146

137

54

48

29

28

3?

22

NKl"l F

620 369 3 857 522 3

3

Tota I

Crash Admissions

198 1?6

SËX;

AGE:

/\ vs. B: X2 = 0.939; D.F. = 1; N.S.

A vs. B: X2 = 6.177; D.F. = 7i N.S.

Table 6/22

AGE AND SEX DISTRIBUTION OF ROAD CRASI] VICTII"IS ADI4ITTED

TO THE ALFRED HOSPITAL DURING THE TOTAL SAMPLE PERIOD

A vs. C:

A vs. C:

2X-

2X'

= 0.18f; D,F. = 1; N.S.

= 12.042; D.F. = 7; N.S.

NL'To

251

Appendlx 2

T AND ITIES COMMIS t0N

vtcToRtA, 1971

REVISËD LIST OF STANDARD EOUIPMENT TO BE CARRIED IN AT4BULANCES

-GENERAL_EQU I PMENT

I al I metal multi-position floor sïretcher1 2rrfoam mattress, P.V.C. covered for above3 steel canvas col lapsible slretchers

Note - Vehicles e.g. Ford F 100 which can accommodate 2 all metalstreTchers should be equipped with these and 2 steel canvascol lapsible ones

4 pa i rs of b I ankets4 palrs sheets 54tt x 99tt4 moulded rubber pi I lows1 walerproof sheef1 Nel I Robertson rêscue stretcher1 stainle;ss sleel kidney dish 12"I sfainloss steel basin Brllstainless sleel female urinal1 stainless steel bedpanAssorled splinfsI set Air splinfsTorch - lanlern typeRope - 2 x 40? lashlngs 'lått circumference mani lla rope1 body harness (a loop of llr? manilla rope properly sPliced -

c i rcumf c rence of loop 1 4 r Br? )

Karab i neerGloves - electricianrs rubbert hacksaw and b I ades1 wrecking bar - maximum length 3?

I general purpose saw - rlEclipse No. 66r' in addition to hacksawand b lacjes

2 gal lons water in plastic conlainr¡r1 metal cutling hatchet

.RESUSC I-TAT ION EO

I porfable oxygen apparatus1 rlR.M.troxygen resuscilation assembly - positlve pressure1 rrR.M. " adu I t oxygen rêsusc itat îon mask1 nR.M.n chiId il ?? Ît

6 polythene oxygen masks and tube joiners2 nasal catheters5 Phillips airways1 suction I ine and fîttings1 gallon suction jar1 rubber bung and vent lubes12 ft, pressure tubing

252

Appendix 2 (cont. )

FIRST AID EOUIPNIENT

I metal carrying case (approx. 15t' x 9tr x 6r¡)1 pair stainless steel straighl scissors 5rt1 rr tr rr dressing forceps 5ttI tr tî It sp I inter forceps 5rr

1 er r? 1r dress i ng shears Btr

2 pairs slainless steel straight artcry forceps1 Hayward-Butt Tri lene lnhaler1 6c.c. ampulo Tri lene1 doz. triangular bandages4 crepe roller bandages 2ff4rlil 1r3n1 roll lrradhesive plaster1il3ilifrr1 sterile burns dressing - small lBrr x lBrtI il rr il _lange36tf x36tr1 card safety pins (medium slze)3 x 4 oz. packets cotton woo I

1 eye irrigation unit - po lythene4 sma I I ster i le rrM i nestr dress Ì ngs4 med ium r? re rr

4 I arge lr tr rr

Antiseptic hand cream (Hlbifane)1 packe'f ster i le eye padsTongue spalula - wood2 mouth-to-mouth units (Johnson and Johnson)3 hand lowe I s1 rubber constrictive bandage (Ësmarchis Zttt x 4l1 Modified Thomas Spl int (Hal I ingham type)1 emergency midwifery kit comprised of:

2 unb i lical tiessc i ssorslarge slze sterile padsmall rt rl It

t' asp irafor (ora I )

approx. )

ar.No.

Aopendix 3

MONASH UNIVERSITY

DEPARTMENT OF SOCIAL & PREVENTIVE MEDICINE

EMËRGENCY CARE SYSTEM STUDY CODES

Variable

SEATED POS IT ION Vehicle Occupants

0thePedestr î anPedal CycleMofor Cycl ePillion

253

CardCol.No.

VEDric.FL.FR.RC.RL"R

r 1

2345671

1

I4

s.P.eoS.P.s. P.S.P.r

2

3

4

5

UN IT NO.

CASE NO.

cARt) NO.

VEH ICLE TYPE

AGE

Vehlcle in Crash

Sfudy Caso

Data Card

CarlS.V.l./Uti lltyTruck/BusMotor CyclePedal CyclePedestr i anOtherTram3 WheelsNot Known

1 yr.=01, 1-2 yrs,=02,Not known = 99

0-910 - 1920-2930-3940-495Q '5960-6970+Not known

1-9 2

0-999

6

7

0-99 819

3,4,5

6

7

I234567I9

I234567a

9

CodeDescriplion

AGE GROUP

10

254

I SEX

HE IGHT INI NCHES

10 llJEIGHT INLBS.

11 SEAT BELT

12 SEAT BELÏ TYPE

13 HOSP ITAL

14 ORIGIN OF

ACC I DENT

PAÏ I ENI-

15 MODE OF TRANS,POFJ TO CAS-UALTY

16 ACCIDENT TYPË

Ma loFema I eNot known

Patienfes assessmenf(N.K. = 99)

Pallenfts assessment(N.K. = 999)

WornNot WornNot FittedNot Known

L.ap

3 PointSashFu I I HarnessNlot known

H

Acc i denlOfher Hosp ita I

Other (Specify)

Ambu I anceTax iPrivate vehicleOther (Spec i fy)

Car/CarCarlTruckCa r/TramSingle vehlcleMu lti veh lcl ePedestr i anPecJal CycleMofor CycleOther/Not known

I23

11

14,15,16

17

1B

12,130-99

0-999

9

red

FI

AtfP.HB.H

19

20

21

1

234

I

2349

1

23

1

23

1

234

I234567I9

Card0ol.No.

CodeDescriptlonVariableVa r.No.

22

255

17 LOCAT ION OFACC I DENT

IB ALCOHOL

l9 T IME OF

ADMISSION( Grouped

see 1 l9)

20 DAY OF WEEK

21 MONTH

ELAPSED TIME FROMARRIVAL AT HOS.P ITAL UNT IL PAT-IENT FIRST SEENBY NURSF IN MIN.UTES

GROUPED TIMES

ELAPSËD T IME FROMARRIVAL AT HOS.P ITAL UNT IL PAT-IENT FIRST SEENBY M,O. IN MIN-IITtrC

0 - 1.99 mi les radius

Card

23

24

0a-24 25 26

27

28

0-99 29,30

t{oCo

2 - 3.994 - 5,996 - 7.99B - 9.99

l0 -11.9912+PeninsulaNot known

YesNlo

Nof known

Hour of Day

IrtlcndayTuesdayWednesdayThursdayFridaySaturdaySunday

MayJ uneJulyAugusfSeptemberOctoberNovemberDecember

illtItt?

lr

t9

ltn

ilnt?

t1

1

234567I9

I23

1

234567

I23Â

567B

22

23

24

l -8,

0-999

3l

32,33,

CodeDescrlptionVariableVar.Nlo.

f known = j

34

25 GROUPED T I-MES

26 ELAPSED TIME FROI4

TIME SEEN BY M.O.UNIT IL PAT IENTTAKEI\I TO X.RAYDEPT. IN MINUTES

27 GROUPED TIMES

TIME SPENT BYPATIENT IN X-RAYDEPT. IN MINUTES

2B

29 GROUPED T IMES

ELAPSED T IME FROM

Ï IME OF LËAV INGX-RAY UNTIL PAT-IENT DISCHARGEDFROI¡ CASUALTY INM INTJTES

30 0-999 44,45,46

Descr i pf ion iI

CodeVariableVar.No.

0-4m5-9

l0 -1920 -2930 -3940 -4950 -5960+Not known )

Not appl lcable )

0 - 9 mins.l0 -19 'l20 -29 '1

30 -39 il

40 -49 r?

50 *59 11

60 -69 fr

70+ lt

Not known )fùct app I icab le )

i ns.lrtl.Itillt .-

ilr

0-99çr 36

256

Ca rdCol.No,

35

39

1

2345

67B

9

400-999

1

234567B

9

1

234567B

9

,37,3B

,41 ,42

0 -9 mins.l0 -19 "2A -29 \1

30 -fg il

40 -49 t1

50 -59 rr

60 -69 H

70+ I'

Not knownI'irct app I icab le

43

257

0-99932

31 GROUPËD TIMES

TOTAL TIME SPENTIN CASUALTY INM I NUTES

33 GROUPED T IMES

34 NUMBER OF PAT.IENTS IN CAS-UALTY ON

ARR I VAL

35 GROUPED NUÍ'4BERS

NUMBER OF PAT.I ENTS At',lAIÏINGX-IìAY AT T IMEOF PAT I ENTSARR I VAL

0 - 29 mins.30-59 rÍ

60-89 e,

9A -119 îr

120-.149 il

150-179 ?r

1 80-209 il

210+ eî

Nof known )

Not appl icable )

0-5960 -t19

124 .179180 -239240 -299300 -359360 -419420+Not knownNot appl icable )

0-45-9

10 -1415 :1920 -2425 -2930 -3435+llct known )Not appl icable )

1

23+567I9

1

234567II

ml ns.ilIt

It

ft

tr

?l

47

48,49,

51

0-99 52,53

54

50

1

234567B

9

Code CardCol.No.

DescriptionVariableI'lo

Var.

36 0-9 55

258

37

3B

39

NUMBER OF PAT-IEM'S NOT SEENBY M.O. ATTI¡4E OF PAT-IENTS ARRIVAL

GROUP NUMBER OFPAT I ENTS UNSËEN

No. 0F 14.0 . t sI'/ORK ING IN CAS.AT TIME OF AD-M ISS ION OFPAT I ENT

No. 0F SISTERSPRESENT IN CAS.AT TIME OFADMISSION CFPAT IENT

No. 0F NURSESPRTSENT IN CAS.AT TIME OFADMISSION OFPAT I ENT

42 D I SCHARGE

10 -1112 -1314+Not known )

Not appl icable )

Not known

Not known

l,lct known

A/CL. M.0.No Ref.G/C;O.P.D.Adm i ttedOther l-losp.AbscondedNot knownNot appl icable

0-12-34-56-7B-9

0-99 56,57

58

1-B 599

'l-B 609

l-B 6t9

1

234567B

9

40

41

1

234567

9

Code i Cardþo I .l',*¡

Descr i pt ionVariableVar.No.

62

259

43 DEATH

44 EXAMINATION

At sceneln transifI n Cas.Nof applicableln Hosp, wiThin 24 hrs.ln Hosp. 'r 2 - 7 daysln Hosp . rr B -30 daysln Hosp . r' 30 days+Not known

L ITY CRITERIA USED IN THE STUDY

Complefe Physical ExamExarn llmíted lo appropriate areasI ncomp I ete examÍ natîonExam nof observedExam nol I nd Í catod

1

234567B

9

I2345

63

64

65

67

6B

69

70

71

72

73

74

75

76

66

1

45

46

47

4B

AIRWAY CONTROL

ARTIFICIALRESP I iìAT ION

OXYGEN ADMINIS.TRAT ION

EXTERNALCARD I AC I4ASSAGE

I-IAEMOSTAT IS

EANDAO I NG

SP I IiA[. IMMOB I L-IZATION

SUTURE ANAES.THES I A

I.V. THERAPY

SUTURE

X-RAY

OTHER PROCEDURE(SPECIFY)

Prompt diagnosls of need forproceclure; appropri ate actionimp I emented w i -lh good fech-n i que.

Procedure perforrnerJ wilh fairtechn i que.

Procedure not performed wheni nd i caled.

Performed but not observed.

Procedure not indicated forpat i ents .

)

)

)

))

)

))

)

)

)

)

)

))ì

)

))

)

)

)

))

)

)

)

)

)

)

)

49

50

51

2

3

4

552 I- IMB SPL INT

53

54

55

56

57

CardCol.No.

CodeDescrlptionVari ab I eVar.No.

17

as good

as sa+-

as poor

not

rd

7B-BO

B1 -85

2 86

90-1 03

260

No

5B

CARD IDENTIFIC-ATION

PATIENT IDENT-IFICATION

CARD 2

AMBULANCEREPORÏ FORß4

59 AMBULANCEOFFICER - STAFFCOMI\4U|'ì ICAT I 0¡.J

60 QUAL rïY 0FAMBULANCE CARÉ

Form completed and lodged withcasualty staff.Form not comp I eted

Not observed

Not indicated

Ambulance officers imparl cl inicalhistory to doctor or sister-in-charge.

Brief history given lo any staffmember at the time of admission.

No altempt made to provîde back-ground cl inical infornnation.Not observed

Not lndicated

Good

Sat I sfactoryPoor

Ambu I ance care not observed

Ambulance care not indicated

7_

3

4

87

B8

89

2

3

4

5

2

3

4

61-74

AMBULANCEPROCEDURES I F

OBSERVED

QUAL ITY OF

CASUALTY CAREOveral I casualty care ratedOveral I casualfy care ratedÌ sfactoryOveral I casually cere ratedEva I uation of casua I ty careperfdrmed

"

Evaluation of casualty carei nd i cated .

2

3

4

5

CodeDescriptionVariableVar.No.

75

not

104

Code

I

DescriplionVariableVar.No.

(1)

261

Cardl.No.

105

106

107

l0B

109

110

76 INJURY TYPE

77 BODY AREA(2)

Pa in

Bruise or Abrasion

Lacerat ion

Spra i n

tracture or Di slocationlnternal or major soff tissuei nj ury.Mulf ipl e sevcre injuries.Concuss ionQ)Head

Face

Eye

Neck

Thorax

Abdomen

PelvisUpper Limb

[-ower Limb

Ful I history obtained, includingprev ious i I I nesses and soci a I

history, wlth special emphasîson presenling hlstory.Bnlef hîstory of presenting com-plaint.Incomp Iete hí stor y obta ined.History takingtr not observr:d.

History laking no-l- indlcated.

2

3

4

5

6

7

I

1

?

3

4

5

6

7

B

9

7B

79

BO

B1

82

(1)

(2)

(1)

(2)

IN.JURY 'TYPE

BODY AREA

INJURY TYPE

BODY AREA

CO¡4PLETENESSOF HI STORY

2

3

4

5

113

262

83

Variable

D I SROB I NG FOR

EXAMINATION

EXAMINAT ION OFVARIOUS BODYAREA

(a) Head

(b) Neck

(c) Chest

(d) Abdomen

(e) Pelvis

(f) Extremíties

CARD I O-VASEXAMINATION

NEUROLOG I CALEXAM

Patient completely undressed forexam i nat ion.Patient undressed, but examlnedthrough bed clothes or gown.

Patlent not undressed for exam-ination when indicated.Not observed

Not indicated

Comp lete Exam performed ( I ncl udesi nspection, pa I pation movements,percuss ion, auscu I fation whereindicated).Superf icla I ox¡:mlnalion performed.

Examination of body area not per-formed when i ncJ i cafed .

Examination nol observed.

Examinaf ion not lndlcafed.

Comp lefe C.V.S. assessment lnclud-ing colour, pulse, B.P. ausculfa-f lon.Superf icia I C.V.S. assessment(must include pulse & B.P. for allpat ients w ith Deig . I nJ . greaterthan 2).C.V.S. not examined when indicatedC.V.S. exam not observed.Ëxam not 1 nd i cated.

Complete Neurological exam per-formed. lncludlng cnanial nerves,reflexes, motor power¡ tone, sen-sation.I ncomp I ete neuro I og I ca I cxam.

Neurological exam: not performedwhon indlcatedNot observed

Not indicated

?

3

4

5

115

116

117

118

120

121

122

1t9

B4

85

B6

87

BB

B9

9o

2

3

4

5

2

3

4

5

2

3

4

5

CardCol.No.

Descrlption eCodVar.No.

91

123

263

Va r.Nc.

Variable de

92 CHOICË OF ADDIIONAL DIAGNOSTPROCEDURES

93 OVERALL/\DEQUACY 0FTREATMENT PRO".

CEDURES PER.FORþIED

94 WOUND CARE

95 CHOICË OFTREATMENI' PRO_CEDURES

96 ANALGES I A

T-lAppropriate cj i agnostic a i dslQchosen (e.9. X-l-ìay, E.C.G.)

I

lDíi:gnostic aid rrof used whenii nrJ ica'tedI

lNlot obsorved

irunt ind icatedi

pood therapy fc;r presenting sigþnd sympfoms.I

lFa ir therapy!^¡Poor therapy

iNol observec

Not i nd ical-edi

bood wound care: . Wol¡nd c leaned

ì

þVouncls nof c I c¡aned and dressedþhen indîcated.

lÌrlot observed

flot i nd icalerjI

lApp.onrîate treatment used "t"

ns

n.

t

1?4

126

127

1?-8

2

3

4

2

3

+

5

2

l4

5

nappropriate -l-reatmenf used, (e.9.u'tterf ly closure when suture in-i cated ) .

irE

ioI

freatment nof observed

'lot ind icated

Appropriate analgesia (e.9. mor-:hine) uEed when indîcated (orratient told reason analgesiô canrot be used in tris case e.g. headinjuries).inalgesia used - dosage inadequ)r poor explanation of its effectsleacls to inade¡quale response .

Ana I ges ia was used when i nd icated.\ot observed

\of indicaÌed

2

3

4

2

3

A

5

CardCcl.No.

Description

129

264

97

Variable

TECHNICAL COM-PETENCE DISPLAYIN PERFORMANCE OF

PROCEDURE

OtsSERVAT IOî'J

DURING CAS-UALTY CARE

CONSULTAT IONul ITH s EN toRMED IC/iL STAFF

COMMUNICATIONSW ITH PAT I ENT

Good

Sat i sfactoryPoor

Not observed

No+ indicated

Patien-f observed appropriate ly.(e.9. Head injury charl main-ta i ned, change i n state noti f iedpromptly).Patîent nof observed when in-d i cated .

Not observed

Nof i ndi cated

Consu ltanf opi nion obtained.Admitting officen or inpalientreg i sfrar consu I ted .

Consultant opinion nol obtainedwhen i ndi cafed

Not observed

Not i nd ica'f'ed

Patient informed, and kep'l in-fcnmed, of his conditîon, freat-ment and reasons for delays incasually treafment by Doctor ancJ

Nursi ng staff.Paflent told of his conditlon bunot kept informed througlrout hiscare.No alfempt made by members ofcasualty sfaff to inform patientof his condifion.Not observed

Nof indlcated

2

3

4

5

130

131

132

9B

99

100

2

3

4

2

3

4

5

2

3

4

5

CardCo I .No.

Descrfption['0"

Var.No.

134

r01

102

103

104

105

106

107

108

109

110

COMMUN I CAT IONW I TH RELAT I VES

QUALITY 0FMEDICAL RECORD

PATIENTISUNDERSTAND-ING OF ARRANGE

MENTS FOR

FOLLOW-UP CARE

AFTER tJ I

DEGREE OF

I NJ LIRY

Head

Neck

ïho rax

Abdomen

Upper Limb

Lower L i mb

Tota I

Relatives kepf informed ofpatienfs condition by M.0. and/or nurslng slaff.Re I at i ves to I d of pat i ent fs con-dition but nof on an on-goingbas I s.

No communication between casualtystaff and waiting relafives.Nof observed

Nof lndlcated

Al I posîtive findings and signif-icant Ìreatment events included i

rned i ca I record .

It4ajor f indlngs included, No sig-niflcant detai ls omitfed.lncomplete record wiTh omission osignificanl findings and tevents.Record nol observed

No record indicatecl

Underslands what further tis required and how to obtain it.Uncertain abouÌ fol low-up arrangements af time of discharge.

Nol- observed

Nof indicated

According to scale described inchapter 5.

2

265

CardCol.No.

135

136

142

144

145

146

147

148

149

150

3

4

5

2

3

4

5

2

3

4

t-6

I

lCodeII

I

Descri ptionVarlableVa r.No.

Var.No.

111 MËDICAL OFFICER Number of me.J i ca I of f icer treat in 0-99IDENTIFICATION pat i ent.NUMBER

112 l840-9

266

CardCol.No.

182,183

185 ,6,7

190

197

309

114 PULSE RAÏE

115 BLOODPRESSURE

116 CLINICALCONDITION

117

NUMBER OF

OBSERVAT I ONS

ELAPSED T IMEFROM ADMI SS IONÏO RECORDING OF

OBSERVAT ION

HOUR OF DAYGROUPED

QUESTTONNAtRERESPONSË

113

Brackefs of cl inical observationsf or each pat ient as be I ow ( 1 'l 3-116)

Measured for 30 seconds.

Systol ic in mm. Hg.Diastol ic in mm. Hg.

Minor injury with nc functionaldeficif.Minor injury with mínor func-tional deficît.ft&rd - severe degree of injury witmoderale f unctional dc:f icit.Scvere degree of injury wifh majofuncfional def icit.l,¿lor i bund

Dead

9

9

9999

1BB,l89

36

9194

,.)L

5

00000300060009001 2001 5001 8002100

Yes

No

02590559085911591 459175920592359

2

3

4

5

6

1

234567B

2

Descrlption CodeVaríable

118 310

119

120

121

123

122

124

125

OP IN ION OF

AMBULANCE CARE

2ooctoRfs cARE

3ruuns r NG cARE

4ovrnRtl rREAT-

MENT

5cRsuRLty lvA rr-

ING TIME

DELAY TORESUME NORMAL

AOTIVITY

RÊCOVERYTIME TONORMAL HEALTH

Pocr

No 0plnionNot indicated

Shorter than expec-led.

About what expecfsd.

l-ongelthan expecfcd.

No opinion

Less than a cJay

A few days

About a week

About a forlnightAbout a month

About three monlhs

l"{ore than lhree months

No opinion

Loss than a day

A few days

About a week

About a fortnightAboul a rnonth

Abouf three months

i¡lcre than fhree months

Slí ll no'l recovered

No opinion

Good

Fa ir)

)

))

)

)

)

)

267

Cardl.No.

311

312

313

315

314

315

316

2

3

4

5

2

3

4

2

3

4

5

6

7

B

2

3

4

5

6

7

B

9

CodeDescriptionVariableNo

Var.

268

Appendix 4

MONASH UN IVERS ITY

DEPARTMENT OF SOCIAL & PREVENTIVE MEDICINE

We are interested to know whal you think of the medical care andtreatment you received after you had been involved in a Traffic Accident,and would be grateful if you could answer the following questions.

Each question I ists a set of numbered alternative answers.

Please circle the number (e.g.{!j I opposite the answer whîchbest descri bes your fee I i ng.

Do nof circle moro than one answer per question.

Please answer al I the questions.

lf you received care from an Ambulance Service:-Did you think the treafment you received from thoambu I ancè men was

Good IFair 2Poor 3

2

)

When you were treated in fhe t{ospifal OasualtyDepartment immediately affer the accident:-Did you fhink'lhe care you received from theDoctor was

Did you think lhe care you rÐceived from thenursing staff was

Good 1

Fair 2Poor 3

Good 1

Falr 2Poor 3

4

Some people fhink that the time taken fo receivefreafment in hospîtal casualty deparfments isexcess i ve: -Did you think thc time spent in casualty was Shorter fhan

you expected 1

About whatyou expected 2

Longer thanyou expected 3

5 Do you fhink fhe r:verall treatrnenl you receivedfor your injuries was

Good 1

Falr 2Poor 3

269

6 Do you have any commenfs to make about your treafnent.lf so, please indlcate them here

7 How long after the accidenf was itbefore you resumed your normalacfivities

Less than a day

A feur days

Abou'l- a weok

About a fortnlghtAbouï a month

About three monfhs

More than threemonths

2

3

4

5

6

7

B How long after the accídenf was l.l'before you felt you were back tonormal healfh

Less than a day

A few days

About a week

About a fortnighlAbout a month

About three months

More than threemonths

2

3

4

5

6

7

Thank you for your help in answerlng this questionnaire. Wehope that your responses will help us lo understand our emergencynedical services better with a view to minimizing the road toll.

Please place this queslionnaire in the reply-paid envelopeenclosed and mai I ¡t.

270

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W.

ofof

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HADDON,

276

t,/. (1968) rrThe Changing Approach to the Ëpidemiology, Preventionand Ame I iorat ion of Trauma.lr Amer ican Journa I of Pub I ic

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-9M.D t::::9 4-

<":'

Appendix 5

TREATMENT DELAYS BY TIME OF WEEK

During the second ~hase of the study, proportionately more of

the patients presenting to the casualty department on Friday and

Saturday nights than of those presenting at other times of the week

were included in the sample. This excess of Friday/Saturday patients

resulted partly from the fact that every Friday and Saturday was worked

as a requirement of the sampling frame and partly from the pattern of

arrivals of crash victims at the department during times off duty.

In the following tables the delays experienced by patients at

different times in the week are analyzed in an attempt to determine the

effects of this stratification in the sample on the waiting times in

the separate care phases . The periods 0800 - 1159 hours and 1200 -

1759 hou rs on weekdays (Monday - Friday) and 1800 - 2359 hours from

Sunday -· Thursday are compared with the evening periods from 1800 -

0159 hours on Friday and Saturday nights. Staffing patterns and work-

loads in the casualty depa1~tmentwere broadly similar within each of

these time groups. Thus each group :;;ay be compared v,1ith the othc:~:; ~,1 determi ni ng the effects cf the stratification on the overall time

d12 lays fc,· the w,2ek 0

·2a1. Waiting Time to See A Medical Officer

Tables Al to A5 show the distributions of the delays experienced by

patients waiting to see a medical officer during each of the time periods.

The mean waiting time in each of the periods is similar and, although there

is wide variation in the times obser~ed within each period, the differences

between time periods are not significant. (Table A5). The distribution of

waiting times for the week shown in table 7/13, which combines the delays

observed in the first and second phases of the study, is similar to the

total distribution show~ in Table A5 and appropriately reflects the waiting

times experienced by patients.

Al

Tables Al-A5

WAITING TIME TO SEE THE MEDICAL OFFICER

0800 hours - 1159 hours Monday - Friday

Elapsed Time in Minutes

0-4 5-9 10-19 20-29 30-39 .40-49 50-59 60+ Total

No. of Patients

Percentage

Cumulative%

. 4 3 6 4

17.4 13.0 26. 1 17.4

17.4 30.4 56.5 73.S

Range: l - 78 minutes

Mean: 22 . 9 minutes

l 3 -- 2 23

4.3 13.0 I -- 8.7 99.9 I I I I

1a. 2 I ~11. 2 I . I 9i. 2 9S.9

I I ! .J,_

S.D. 20.C minutes

I

288. A2 1200 hours - 1759 hours Monday - Friday

No. of Patients

Percentage

Cumulative%

Elapsed Time in Minutes 0-4 5-9 10-19 20-29

10 · 11 13 8

16.7 18. 3 21. 7 13.3

16.7 35.0 56.7 70.0

Range: 1 - 235 minutes

Mean: 25.l minutes

30-39 40-49 50-59

8 3 3

13.3 5.0 5.0

83.3 88.3 93.3

S.D. 27.0 minutes

60+

4

6.7

100

. A3 1800 hours - 2359 hours Sunday - Thursday

No. of Patients

Percentage

Cumulative%

Elapsed Time in Minutes 0-4 5-9 10-19 20-29 30-39 40-49 50-59

14 16 10 7

21.9 ~5 15.6 10.9

21.9 46.9 62.5 73.4

Range: l - 95 minutes .

Mean: 22.8 minutes

4 4 2

. 6. 3 6.3 3. l - · .

79.7 86.0 89 . l

S.D . 24.9 minutes

60+

7

10.9

100

Total

60

100

Total

64

100

A4 1800 hours - 0159 hours Friday/Satu rday and Saturday/Sunday

No. of Patients

Percentage

Cumulative%

Elap~eJ Time in Minutes 0-4 5-9 10- 19 ~0-29 ! 30-39 140 --49 50-59 60+ Tota l

I

, -~ I 27 1 i

14 13 2C1 • , (\ 4 7 108 · - · 1

l\,J

I .

13.0 12.0125.0 12.s l 11..o l 9. 3 3.7 6.5 100.0 I I

13.0 25.0 : 50.0 I I

GR.s ! PO.S i 89.8 93.51100.01 . I . I I

Range: 1 - 129 minutes

Mean: 25.9 minutes S.O. 22.6 mir.u tes

l

Table A5

Waiting Time To See The Medical Officer

TIME OF WEEK Elaosed Time in Minutes

0-4 5-9 l 0-19 20-29 n % n % n % . n "L ,o

Weekday Mornings 4 17.4 3 13. 0 6 26. l 4 17 .4

Weekday, Afternoons 10 16.7 11 18.3 13 21. 7 8 13.3

Sun. - Thurs. Nights 14 21.9 16 25.0 10 15.6 7 10.9

: .

Fr i. - Sat. Nights 14 13.0 13 12 .0 27 25.0 20 18.5

Other 12 21. l 7 12. 3 14 24.6 13 22.8

I

Tot al 54 17.3 50 ~ 6.0 70 22.4 52 16. 7

2 X = 17.825 D.F. = 20 N.S.

30-39 n % n

l 4.3 5

8 13. 3 10

4 6.3 13

13 12.0 21

5 8.8 6

31 9.9 55

TOTAL 40+

% n

21. 7 23

16. 7 60

20 .3 64

19.4 108

l 0. 5 57

17.6 312

%

99. 9

100

100

99.9

100

99 .9

N (X) I..O

/ .

X-Ray Service Time 290.

The X-Ray service time distributions for each of the four sub-

samples of patients are .shown in Tables A6 to AlO. Although the

numbers of patients in the various groups are small, particularly in

the morning group, the distributions of service times in each group

are similar, with mean times ranging from 26 minutes for the patients

observed on week nights to 37 minutes for those seen in the Friday -

Saturday evening periods. Although the distributions do not differ

significantly from time period to time period, proportionately more

patients received service in less than twenty minutes on weekday

afternoons and at night than during the mornings. The small number of

patients in the morning group, which resulted from the sampling frame

used, may have meant that the contribution of this group was under­

represented in the distribution of overall times for the week. Never­

theless, more observations would be required to confirm any such effect

because of the large variation in the observations within each of the

separate time groups. Tables A6-Al0

X-RAY SERVICE TIMES

0800 hours - 1159 hours Monday - Friday A6

Elapsed Time in Minutes

0-9 10-19 20 -29 30-39 l ~0-49 i 50-59160-69 I 70+ TOTAL No. of I , Patients -- l 8 :5 2 -- l 18 I

Percentage -- 5.6 44.4 27.3 i1 . 0 5.6 -- 5.6 100 I '

Cumulative% -- 5.6 50.0 77.8 88.8 , 94.4 1 94.4 1,00 I I j

Range: 16 - 107 minutes

Mean : 35 .7 minutes S.0. 20.3 minu tes

A7

No . of Patients

Percentage

Cumulative%

AB

No. of Patients

Percentage

Cumulative%

1200 hours - 1759 hours Monday - Friday

Elapsed Time in Minutes 0-9 10-19 20-29 30- 39

4 10 - 12 9

8.3 20 .8 25 18. 7

8 .3 29 .1 54. 1 72.8

Range: 7 - 157 minutes

Mean: 33.1 minutes

40--49 50-59 60-69

7 3 --

14. 6 6.3 --87.4 93.7 93.7

S.D. 23.7 minutes

70+

3

6.3

100

1800 hours - 2359 hours Sunday - Thursday

Elapsed Time in Minutes

0-9 10-19 20-29 30-39

1 16 11 7

2.4 39.0 26.8 17. 1

2.4 41.4 68.2 j 85.3 I

Range: 6 - 68 minutes

Mean: 25.7 minutes

40-49 50-59 60-69

5. 1

12.2 -- z·.4

97.5 99.9 99.9

S.D. 12.5 minutes

70+

--

--99.9

. 291.

Total

4a

100

· rota 1

41

99.9

I

A9 1800 hour!: - 0159 hours Fri day /Saturday and Saturday /Sur:d a:' ·----·-·- ---------- =--=,~-------------·· --·-·· ··---· -!

!

' t '---------- ---i :1,~. o -t.:

. p;:: "'.': ~ t.i ; i..,

Percr ,·;:~=c.

Ctn:1;; ~r c. t ·: t, , ..

- · ··;":"·_-,- Tirne in Minutes, - ··· l --- --·-· -· i - , • · • ' , ~ ... .. • t · . ,_ ... r • ·- ~ - •· :: - 1~· '. '): .~:' L.:c_-' _ _ , _, lc,Q-49 jso-59 ?o-~~; 1_ I , _, - ! IQ, • '

f~ C' < .::~:

' ·.::-~ft:

. l

., ,-i ;:;; ;

I t

1 " 11 I

; - " I : , ,: i 20 8 ,,. c.. l . . ., . . . :

,,_. ';• !:.l ,:: I ;1 .. ,•1· Q,~ Q i..U. ~ , •"' ! · 'v.,""' ,,.,v. U

I ,... i 1 ! C. I , I l

3.8 '. ... (' . 9" 6 ' ::i-· ,.. ' u. i :.,.._. ::i !

- _ _j _ __ : - _· --'-- --- -

: ··.· 1 f. - nr-: :" J"'..· ·.::

., \ ~,.;, .:c .. , S.D. 24 .S rninu ~e~

l.,.

7 I-"

1 l;r-,

I~~ , ., i 1 11 i 11""' \ . \..- ...

5:-

}.

_ !

,,,

TIME OF WEEK

Weekday Morr~1gs

Weekday Afternoons

Sun. - Thurs. Nights

Fri. - Sat. Nights

Other

TABLE AlO

X-Ray Service Times

0-19

n % l 5.6

Elapsed Time in Minutes ______ ,. _ _ : 20-29 I 30-39 t 40-49 ! C' )+ I

n %·tn-~% l1_,_, ___ -··;;- -i'"-~?o

8 44.4 ! 5 27.8 2 1:.1

l

14 29. 2 I 12 2il. 9 ! 9 14. 6 ·2 .5 I 4

17 41 . 5 In .:: :, . . 2 •

1·5 "8 ., I I ·, 1 .::'. • ,J , ~ ' 13 • a.

6 17 .s / ·. ,, ~ ~ . :; \.

Total ___ _,___s3_ 2~~J~--~~'!_L_

2 'i- 465 D ,.. X = ~~- .r.

TOT,AL

1

:O• ,

",;' ~,<'l!

Observation and Treatment Time 293.

The observation and treatment time represented a large portion of

the total casualty treatment time for most patients who entered the system.

Variations in these delays by time of week are shown in Tables All to Al5 . . Weekday evenings and the Friday and Saturday night periods were those with

the shortest average delays. The perennial shortage of inpatient beds

(which was only resolved when daily discharges of patients were completed)

may have been a cause of the longer delays observed on weekday mornings

since patients waiting for inpatient beds were normally kept in the

casualty department.

Proportionately fewer of the sample patients were seen during the

mornings.on weekdays than on Friday and Saturday nights. Hence it would

appe~r th2t the effect of the sampling variations may have been to under­

estimate the overall observation and treatment delays for the week. The

·-' c- : ~2r ·, t:: .. "ir! t imes within each period is, however, extremely large, and it

~ ~:en from Ta ble Al5 that the differences in the distributions fe r

~mes of t h~ WF0k are not statistically significant.

·. ; f0 fc: f~11 --tU2

• ·:D -!Jf /\_ 7 f-11[ r~-r TIMES

-, . fie.,-' . ! l !,, .~ ~-':t:-: ;,. 1 --y :- r 1da.y

. ~ ,:.;·;;·r l ,..,,,_..O [ , , .. _ .. ·, -:>u-

I .. a, I

1

'-!··;~ - ..- • .. .. ~- ·- r·

____ J_ ~.-·.:'---! 359 1360+ ! 3 •i

,: .• Gr --1 13.6

i;6 . 4I 100 r

I !

I

1Sl.1 minute:

I

2,~7 I

r ., I

A12

No. of Patients

Percentage

Cumulative%

A13

1200 hours - 1759 hours Monday - Friday

Elapsed Time in Minutes 0- 30- 60- 120- 180- 240- 300-29 _ 59 119 179 239 299 359 360+

11 10 9 9 8 8 4 3

17. 7 16 .1 14.5 14. 5 12.9 12.9 6.4 4.9

17. 7 33.8 48.3 62.8 75.7 88.6 95.0 99.9

Range: 9 - 724 minutes

Mean: 158.1 minutes S.D. 144.9 minutes

1800 hours - 2359 hours Sunday - Thursday

Elaosed Time in Minutes

294.

Total

62

99.9

Total 0- 30- I 60- 120- f 180- 240- 1· 300- 1 . I 29 59 119 179 I 239 2,99 , ?5Y __ ,. ~§9~-~-~~-

No. of I t ~ Patients · 25 7 12 91 41 ~-1 --··~ 2 !

Percentage

Cumulative:%

I , - - --

39. 7 111. 1 I 19 . o I 1.1 .. 31 6 -:' !

39, 7 l 50. 8 I 69. 8 I 84. 1 ! ~·G. ~ I

R~nge : 7 - 870 minutE~

r. ~, t, : 102.9 minute~

0159

-:in ' ,.; \ } -

r:a

I"";, LI

.• 1 20 . 2

:1 ! ,, . . 4

i 26 !

2Ll ' !

66.t: 1 I

_ _,_ __ l

:1 , , ; 4 - 780 Tr. F;i_c ·.

--~ ": 11 6.0 mi nu-css

I ,.. ~ 1 t ':" ')

63

?3. 9

0

,:'\ -.,

I '

TI ME OF WEEK

:!, .... -:..:.~rs

S~n. - Thurs . Nig~ts

. • Sa~.

e

TABLE Al5

~~~ ervation and Treatment Times

Elapsed Time in Minutes 0-29 30-59 1 60-l19 1 120-119--1·· 1so~23 40+ TOTAL

n iO n "00 n n n n n 'O

,i 18.2 I 1 4. 5 I 5 22. 7 I 3 13. 6 I 5 22. 7 I 4 18. 2 I 22 99. 9

'P l7. 7 110 16 . l I 9 14. 5 I 9 14. 5 I 8 12. 9 I 15 24. 2 I 62 . 99. 9

5 7 ., 11 . 1112 19.0 9 14.3 4 6.3 6 9.5 63 99.9

:: ,: . 2 I 26 25. o I 11 lo. 6 I 12 11 . 5 I 12 11 . 5 I 104 loo

.. , ~1 . -: I 1 o '17. 5 I 4 7 .o I 3 5. 3 I 7 12 .. 3 I 5 7 1 oo

.-, "'!I.I~ 1 :: • 6 I 62 20 . l I 36 11 . 7 I 32 lo. 4 I 44 14. 3 I 308 loo :---~-- --L ----L----"'

X .. NS. N '-0 <.n

~

296 .

Total Casualty Treatment Time

Tables Al6 - A20 present the distributions of the total times spent

in the casualty department. The average delays were longer on weekday

mornings than during the other time periods studied. and the differences

between the distributions for the different times of the week are

statistically significant (Table A20). The major differences are in the

small proportion of patients who spent less than two hours in the depart­

ment on mornings and afternoons during weekdays as compared with other

times, and the relatively large proportion of patients who spent longer

than 5 hours in the department after presenting at these times. The

effect of the stratification in the sample may have been to under-represent

the overall experience for the week, since relatively fewer of the morning

and afternoon patients were observed. The large variations within time

periods noted previously are also present in the total treatment time

distributions.

'

. l ;· -. ~ "

. .-, r.~,r

ii ' '""l" ;...., l',i, I.,, ~ .• ' • ;.

L_ ___ __ ,_ , ·-

Tables Al 6-A20

TOTAL CASUALTY TREATMENT TIMES

0800 hours - 1159 ho urs Mor.c2.y - Fr iday

• • ,._,w,_ _ _ _ . -·

.~-1._c~c: .~¢-~.J~·._~~· '"· __ ~i_'~- _r~·;:. ,_·-:f ·· ? . ~ ri 1jw: 1 ~ LU- \ -: o:_.. - : / li.0 1

~ ; ~-uo- 360-~ 1 ~ ~ j JS I ~-" . l ( :·.g f' . ·,;/; ~i 1 S

i 6 I

I

- i-··· - 1 · ·--· ·-i -i! I . l . , . ";. ') Ip:- ~ ' ;. I .-..• ·t •• ,r· .• . •

' :· ! . f

.~ ' " 3 " I 1 i:: ll 1· ~ r.: (";~ t,.. ·,.~ I .J • • \ ; ..) , ' n. , r-;. I 1 (, .~ I -· L: I.

' ·-. t

I ., - - f .• r -. i • ' b l. I I.J./ . -.. , •'-• -' - r &... 11o·- ' . ' /3~. ·,

·-" . --- · ---''-------'- ~ . - ·' --- ------

~2n~e:

~9

Mean: 248.8 minutes .. ,_ ... LI ,. 166. 2 111;

!

_J ---i

·1 ?6 I

A17

No. of Patients

Percentage

~umulative %

Al8

~o. of :>ati ents

'ercentage

:umulative %

1200 hours - 1759 hours Monday - Friday 297.

Elapsed Time in Minutes 0- 60- 120- 180- 240- 300- 360-59 119 179 239 299 359 419 420+ Total

7 14 10 5 5 14 4 3 62

11. 3 22.6 16. l 8. l 8. l 22.6 6.5 4.7 100

11.3 33.9 50.0 58. l 66.2 88.8 95.3 100

Range: 34 - 760 minutes

Mean; 216.l minutes S.D. 146.3 minutes

1800 hours - 2359 hours Sunday - Thursday

Elapsed Time in Minutes 0- 60- 120- 180- 240- 1 300- 360-59 119 179 239 299 359 419 420+ Total

8 7 7 I 6 -- . 2 66 I 16 30 l .

24.2 30.3 ,2.1 10.6 10.6 i 9., -- 3.o 99.9 I I . .

24.2 54.5 66.6 77.2 87.e !96 .9 196 .s 19si .9 1 I I I , r ______ __ ,_ i I • I ---l

R&nge: 23 - ~21 r1 ,

Me~.r.: ~ s: (-i mrnu ( ·1 ., J, _, . I • t .. I t(_:

A19 1800 hours - J~! t1 rd , ... .... , ·'

1--~·7·-, - ----

1--- .. ·-; l' . I ,- .

No . of Patient~

Perrentr./4b

umukti \.~

' ... .. . ~ -

11,, .... l'h ..

7

;._;tf: ~ ~ ll ... __, . ' . :.....::: :.-

TIME OF WEEK

0 - 119 n 0

0

Weekday Mornings 7 26.9

Weekday Afternoons 21 33.9 .

Sun. - Thurs. Nights 36 54.5

Fri . - Sat. Nights 52 48 . l

Other 31 54.4

fetal 147 46.1

x2 = 21.102

Tabl e i.\L~

Total Casualty i re < :· .. .: :·: :··,'.r:e:,

.........,.._ ·-

Elapsed Time in Midu tes 120 - 179 180 - 239 240 - 29Y- I .

n % n % ' . n %_......, . ~

4 15 . 4 4 15.4 3 11. 5

10 16. l 5 · 8. l 5 8.1 2

8 12. 1 7 10.6 7 10.6

. 18 16. 7 7 6.5 15 13.9 1

10 17.5 7 12.3 4 7.0

50 15. 7 30 9.4 34 10.7 5 "

D. F. = 16 *

·----;:_ ~ :- - -~ ' "' ' ·"t ' 1 --.r ...... ~?, ---- r· , cc ,_, _ __ ,,, _ ,....:. ::.....-- , ·-

.1 % I: . ~o

8 3C , c I l),: :, ·,

l

8

0

5

8

33 .9

, ') , I.:. , I

t -: •

8.8

18 . 2

r .. 1..,-:-

62

66

r L'1r~

5/

319

·1ou

99 .9

,, ' d ,)

'JOO

100

-----~ f-.) lO co