Of 24 clinicians who expressed their interest in participating in the study, fifteen took part in interviews; 10 medical practitioners, two registered nurses, two occupational therapists, and one paramedic. Eleven participants primarily practiced in a regional or rural area, whilst four participants had their primary location in a metropolitan area; three of whom had a current role in air retrieval of older trauma patients from rural sites. Twelve of 15 clinicians had over ten years of experience since acquiring their professional qualifications (Table 2).
Three key themes were identified: 1) enablers of trauma care for older people in rural areas; 2) barriers to trauma care of older people in rural areas and; 3) changes to improve trauma care of older people recommended by rural clinicians. In addition to these three themes, and to facilitate guidance for trauma care improvement, results were reported at patient-, clinician- and system-level (Table 3).
Enablers of trauma care for older people in rural areas
Clinicians described patients from rural areas as tough and robust, “the classic bushy” (Table 4a). Patients were frequently observed to still be working into older age and therefore sustained significant injuries related to farm work, involving machinery, cars, and cattle; “he got trod on by a big beast” [DR8]. Often, patients sought medical care late, such as one patient who “[came] in three days after being squashed by a trailer” [DR2]. Because of perceived stoicism, injuries may be missed or underplayed. Clinicians perceived patients as being attached to their land and community; “people here really would rather get their care close to home. The people who areliving up here, choose to live up here. They don’t like cities.” [DR2]. Participants described clinicians as often being the sole practitioner, and thus needed to be generalists with a broad skill set, and the ability to make clinical decisions and provide care with very few diagnostic tools and equipment “they can do a lot with nothing” [DR5].
Table 4
a – Enablers - Summary of rural clinicians’ experience and example quotes
Key themes
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Factor-level
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Subthemes
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Example quotes
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Enablers
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Patient
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The resilience of people in rural areas
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my standard patient is an Italian farmer in his mid-80s who is still working. The patients under triage their own trauma. They come in three days after being squashed by a trailer. DR3
he had some fractures in his hands that he didn’t tell anybody about …because he was such a toughie. RN1
he was very determined that he was going to get back to the farm. RN1
even if there aren’t those services set up or available, you’d be able to draw on community support to find someone to help out…those kinds of community connections just exist a bit more in that remote environment. OT2
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Staff
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The experience and training of rural clinicians
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These guys have been out there for decades… they’ve seen it all. They can do a lot with nothing. DR6
I have a couple of orthopaedic surgeons, and two general surgeons [who] are amongst the most physician-like surgeons. They’ve got to be here because you just don’t have back up. You’ve got to be a generalist doctor. DR2
what the geriatric term was really helpful for, was… learning how to find out about (patients) function … what they’re trying to achieve. Now I’d be comfortable [to] have that discussion about goals of care.” [DR3].
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Relationship between clinicians and the rural community
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Clinicians out there would know a lot of the community. That previous knowledge of the patient and their clinical history I think really helps. Whereas you won’t necessarily get that in an urban setting. “They look different” or “They wouldn’t usually present for this”. DR5
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System
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Delivering better care through a multidisciplinary approach
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the orthopaedic team was relatively well supported by ortho geris, medical teams. I think that made them less anxious about admitting comorbid people. DR2
a lot of those trauma patients don’t need to be in a big tertiary hospital, but they need good multidisciplinary, good holistic care. DR5
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A robust system for major trauma
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In every small hospital, we have early notification trauma guidelines where, if someone presents with the usual anatomical, physiological, mechanisms… we would be very quickly looking to move them to the nearest place that can look after them. DR4
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Table 4
b – Barriers - Summary of rural clinicians’ experience and example quotes
Key themes
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Factor-level
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Subthemes
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Example quotes
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Barriers
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Patient
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A life-changing event
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He had lots of comorbidities, he was a bit of a ticking time bomb. DR1
the smallest of things can happen and it significantly changes their life pathway. RN2
For a lot of people in this age bracket, it’s life changing. They don’t get to go back home or when they do, they find it so difficult that they can’t cope. RN1
If something like this happens, this is life changing and it’s incredibly complex. They often spend significant time in hospital. This is often probably their last 1000 days really. RN1
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Being alone
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In rural areas, people often live quite remote on a farm. They get to a certain age and they have an accident. Then they completely lose their independence from one day to the other because they don’t have the support they need and it’s very difficult to live on a farm by yourself. DR6
That causes a lot of social dislocation for the patient. They can be quite isolated because their partner may be elderly, can’t visit them – especially with COVID, it’s been really difficult – their families can’t visit them, especially when they’re palliative. [DR4]
Old people who sustained terrible intracranial injuries who get put on a flight… six hours away from their loved ones, only to be then said, “Oh no, this is palliative… The outcome is still the same but they’d be surrounded by loved ones when they died, not at (city hospital) with no one there.” [DR6]
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Not speaking up
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They’re just a different generation… they are a more vulnerable generation because they don’t advocate like they should. And the country folk particularly.” [RN1]
You’ll get someone who’s been sick for a month, “Oh I just didn’t want to bother you” [RN2].
“Remember that question you asked me eight times and I told you to ask the doctors? They’re here” “I won’t bother them. They look busy” OT1
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Staff
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Rural clinicians feel unsupported
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I don’t think there is specific lack of resources for old people. There’s a specific lack of resources for everything. DR6
More community support would be better … it’s all a bit thin on the ground. DR3
[we] are always understaffed…always struggling to get a full trauma team together. So often it’s a GP and the nurse and that’s it”[DR4].
[it is] uncomfortable looking after a patient who’s got some blood in their head… what do you do if they do go off (deteriorate)? You’re miles away from help” [DR7].
Very often in this situation, after hours, I’ll be there by myself with a resident. … you’re pretty much on your own. I can think of a situation where one of our guys who has recently left desperately wanted a hand…. But there was literally no other surgeon… for 300 to 400 kilometres. DR2
We have sometimes a spinal service – it’s one consultant, so obviously he can’t work all the time. RN1
We tried to sponsor [rural clinicians] to go for courses. But it was extremely difficult because they’re so understaffed, they can’t take the time off. DR5
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Older trauma is hard and not sexy
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The fracture is the littlest part, but everything else is super difficult around it. DR5
[Younger trauma patients] are a great trajectory –they just need a little bit of allied health and then off you go. Versus the older person, “it’s just a couple of ribs,, but they’re going to here for four weeks because allied health can’t get them out of the hospital”. OT1
It’s paradoxical, but when the mechanism of injury is less… rural patients have less access to care, because it’s either not recognised or they don’t have access to the early imaging that they would normally and decision making. [DR3]
If you’ve got a 15 year-old who’s got multi system trauma, people get excited about that. But if you say you’ve got an 87 year-old who’s on home oxygen and blah, blah blah, it’s a different dynamic. DR7
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System
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The tyranny of distance
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People come here by road up to a couple of hours away. West of here there is essentially no hospital for 800 kilometres. DR3
I saw people where we were the first hospital they’d landed in and it was about 14 hours after their trauma. DR9
We talk about these people having to be in theatre within 24 hours. These folk are lucky if they get to a hospital with a surgeon within 24 hours. DR2
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The systemic lack of resources in rural practice
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There’s often delay in getting the patient back into their community because of the lack of allied health, lack of rehab, lack of brain injury [services]. OT2
They’ll end up being discharged to one of the outlying hospitals and they just sit in a hospital bed and eventually end up in a nursing home. Whereas many of those patients in the city with better care would be getting back home and living independently. DR4
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A fragmented health system
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“this gentleman with chest injuries lay flat on his back for maybe two to three days before … (the specialist centre) got back to us about what they wanted for his spinal care. I just think that’s unacceptable care” [RN1].
I only own it when it is on my own soil, and if it’s not on my soil, then it’s not my [problem]. DR1
Patients … heli-retrievaled in from out of our district, are not actually eligible for rehab within our hospital. So they need to be transferred back to their local hospital or to a tertiary hospital within their own catchment to be able to complete their rehab. DR10
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Table 4c – Changes - Summary of rural clinicians’ experience and example quotes
Key themes
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Factor-level
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Subthemes
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Example quotes
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Changes
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Patient
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Supporting patients in their hospital journey
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the indigenous folk in the Northern Territory always were allowed an escort, which I thought was fantastic – certainly for the elderly patients… you need that support. To have somebody flown in with you and supported while you’re in hospital. RN1
I can’t imagine anything worse than, the last thing you remember you’re in a car accident and then you wake up in this place where, you’re sore and you don’t know what’s going on. The best thing for delirium is something that means something to you, the awareness of something familiar..,. [having] a next of kin readily available, a surrogate decision maker for that person that’s accessible. DR9
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Enabling discussions on advanced care planning
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In our community, we don’t have good discussions about ceiling of care of elderly patients. A lot of people in nursing homes are scared to do that because they think they’ll get no care. I think there’s a lot of confusion around the language of that and it’s often left to junior doctors… to have those conversations. DR10
A good discussion early about how this might change their life... to have a clear understanding of the pathway that might occur in hospital and also involving families. RN1
Having a discussion… once you get to the first smaller hospital in conjunction with the treating specialists at the receiving hospitals. That way, informed decisions about trajectories can be made and patient’s wishes or the patient’s proxies can be assessed. DR9
It takes a long time. It’s time consuming in a time poor environment. But they get to stay at home and they die at home or in their own town. A lot of the rural doctors don’t want to make those decisions because they live there and they’ll see them at the shops or the pub. Having other people come in and help make those decisions is really important. DR4
Maybe we’ve got to put in place some trigger, when somebody is a trauma and they are over a certain age, there’s a prompt to ask, Do they have an ARP (acute resuscitation plan)? [DR4].
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Staff
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Making multidisciplinary and coordinated care, the standard of care
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In old people, it’s not so much the injury because the bone gets treated the same way in a 90 year-old as it gets in a 40 year-old… So the ideal situation would be to have this system where we have a shared treatment or a surgeon geriatrician [DR5].
You need a generalist… for a small hospital, a good, general physician is invaluable. In a smaller hospital, you have to get on a bit more. Bigger hospitals can sometimes be a lot harder to have relationship building. If you’re a smaller centre, if you’ve got a way of having a joint care model that has a general physician and your surgeon working together, then that’s a good model for those patients.DR2
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A coordinator for in-patient and post-acute care
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They gone from seeing us twice a day, making sure everything is working to now being by themselves, not really sure about the medications they’re meant to take, when they’re meant to come back in. DR7
Someone who actually telephones them and checks they’re okay would go a long way to making sure that we avoid complications and that they’re either not overdosing themselves on analgesia we’ve given them, or underdosing themselves. DR9
A trauma nurse navigator post-discharge, would be very valuable in the older person. This is that link between the hospital and the person’s home because once they’re discharged and go back to the GP, they might miss the outpatient clinic because they didn’t have it coordinated for them. DR10
A nurse practitioner fills that gap between discharge and GP, especially with regards to analgesia, doing chest x-rays, wound care and lots of other psychological support [DR6].
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Enabling the training of rural clinicians in older trauma care
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A stronger emphasis on the types of cases we actually see frequently, regularly rather than the higher acuity cases. It’s this paradox. We train for something we might do once a year, but the elderly faller gets maybe a couple of hours of training [PM1].
To have your radar up; awareness and greater focus and management of the smaller things, that if not done properly, lead to somebody who might have been leading an independent life, to be nursing home-bound or wheelchair-bound, for injuries that in a younger person wouldn’t necessarily lead to that outcome [DR5].
Education has to be in the rural hospital because they’re so understaffed, they can’t take the time off... that’s the only thing that’s sustainable. And you need to tailor it to their needs. It doesn’t make sense to do rural trauma education and talk about REBOA. DR5
We should be going a week every couple of years, through one of the big trauma centres and just doing trauma [education]. The skills are really heavily concentrated down there. DR2
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System
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Improving integration within the health system
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It’s better to get them into the right place at the right time, but then you don’t want to overwhelm the system. How do you put the line for when you’re going to pull the trigger? DR1
To use each facility to the capacity they can for as long as they can, but recognising early on, if they do need a tertiary level care, bringing them down to the place they need. [DR6].
Accessibility to a universal medical record, would be handy. All you need on it is comorbidities or recent medications and next of kin. That’s just good care, not only patient centric care but telling next of kin that their loved one has been involved in a car accident. DR10
The problem is we are funded at individual sites and so there is no financial benefit for thinking bigger and broader. So how do you get the administrative side of things to understand the clinical benefit is if we all talk together. DR1
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Care protocols and standardized referral pathways
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Whether or not we should have different criteria for older people. Do you do it on age? Do you do it on frailty? Other factors? DR1
However it’s incorporated, it needs to be in a way that is rapidly assessable, by paramedics or pre-hospital clinicians. You’ve got this information overload and you’ve got to add another layer of information. DR7
A documented pathway of care that emphasises the risk related with geriatric trauma, deciding who goes home, who stays and who goes to [the city]… some guidance on who to image. DR2
Flowcharts and straightforward evidence-based contemporary, ‘this is what you do in this case’ without it being a bible. DR9
For the multi trauma patient, it’s an ad hoc, phone call to phone call. There’s no point a rural generalist with 20 years’ experience, trying to get advice from one of our junior doctor. DR1
A system whereby there can be early access to a senior clinician at subspecialty level… for particular injury patterns or severity or important decision making, that would go straight to a fellow or consultant level [DR4].
A trauma lead that you can just ring as a single point of contact for trauma. When you’re not sure what speciality teams need to be involved or you don’t want to do that hour and a half ring around to all the teams who need to do something but none of them want to admit the patient… that could be helpful... DR2
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Supporting and expanding the use of telehealth
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When it’s set up properly, you can set the cameras… [to see] the monitor, where the vital signs were and the other side, I could look at the patient. It’s like a chameleon [DR9].
With telehealth, how much of an overreach do you have to support versus guide versus tell. It’s often more of a senior clinician that just needs a bit of a handhold and advice as opposed to direct supervision. DR10
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Knowledge of patients from previous clinical and non-clinical encounters was also viewed as a strength; “You know them, you’ve met before, you’ve had a chat and I think that rapport that already exists is protective” [DR10]. Participants viewed the trauma system as well-rehearsed and oriented towards the management of major trauma cases, with early prehospital notification, protocols with clear identification criteria for critical patients, and fast retrieval to metropolitan trauma centres, “our system has evolved so that we are much better at the both the pointy end of the resuscitation, access to theatre and the ICU side” [DR1].
Barriers to trauma care of older people in rural areas
Clinicians reported that older rural patients may often live alone and remotely, and lose their independence after sustaining an injury; “If you’re a 75 year-old who fractured your dominant distal radius and you have no family up there, I don’t know what you’d do.” [OT2] (Table 4b). When transferred to another hospital, patients were also isolated, away from their community, thus unable to draw on their usual support. Patients may also die after sustaining trauma, away from their community.
Clinicians viewed older patients, and patients from the country as having different expectations from the health system from patients living in urban areas, “the people up here don’t complain. They will get most horrendous care and they will never complain”. [DR2]
Participants emphasised a widespread lack of staffing both in rural hospitals and community services, which was not specific to older trauma care. They identified a lack of staff to manage complex and urgent cases. Participants regarded the lack of specialised clinicians as a cause for patients not having timely access to diagnosis or definitive treatment, or being managed in a way not consistent with clinical guidelines “when you’re in a rural environment, you don’t have everything there. So your care pathways are different” [DR5]. When there is a specialist, they are often the only person on-call and “the job is enormously wearing for them (consultants).” [DR2].
Lastly, with the majority of working hours taken by clinical duties, clinicians did not have the time to participate in professional development, research, or quality improvement activities Participants purported this may also contribute to the difficulty in retaining health professionals in the country “because we’re not training people here, it means we don’t retain people” [DR2].
Participants reported that mechanisms of injuries were often not as dramatic as in younger patients, which may contribute to under-triage of older trauma patients “they’ve been on the ground … because the way ambulance triages elderly falls” [PM1]. Moreover, trauma in older patients could be perceived as comparatively dull “something a bit more exciting about the younger person with the motorbike accident and the gunshot wounds” [DR8].
A major barrier raised by participants was that distances from the injury site could be very large “distance is the biggest issue we have because … that always delays transfer. And that always delays timely treatment” [DR5], as well as a lack of hospital beds impeding patient flow, and rehabilitation facilities and community services in rural areas.
Participants reported that the different health services worked in isolation, a lack of streamlined referral pathways, which could contribute to delays of care when awaiting an opinion from specialised centres. Due to lack of integration in the health system, there was no incentive in providing care to a patient out-of-catchment “they have to be in the hospital for the hospital to take responsibility for that discharge plan” [OT1]. As a result, patients spent an excessive amount of time in acute beds awaiting transfers, solely to be able to access rehabilitation facilities, outpatient and community services.
Changes to improve trauma care of older people
When possible, participants thought that an escort for older patients during retrieval would be beneficial, as is already the standard for children and Indigenous Australian patients, “if you weren’t able to get a lot of history from the patient, having family (present) can really help” [DR8] (Table 4c).
Participants identified advanced care planning as a major area for improvement. The likely trajectory of the patient in light of their injury and current health state should be clearly explained to them, and should ideally involve senior clinicians and be given sufficient time. Additional recommendations put forward by participants included a documented advanced care plan as part of the retrieval checklist.
Participants advocated for a holistic approach, with early review by a general physician or a geriatrician “a lot of those trauma patients don’t need to be in a big tertiary hospital, but they need good multidisciplinary, holistic care” [DR6]. Management should be based on an integrated or shared model of care between physicians and surgeons.
Participants advocated for a dedicated position for care coordination in and out of hospital “a care coordinator who fights for the patient so that we have one bus that brings them in, they have their whole day of appointments and then go home again” [RN1], as well as to provide a link back to the patient’s relatives and primary care physician.
Participants overwhelmingly advocated for more education on older trauma care. Effective education programs require engagement of participants “if people don’t understand why they’re doing something… it gives no benefit” [DR1], should be tailored to rural practice, and ideally be taught in rural centres. However, participants identified the lack of staff cover to take professional leave as a major barrier to accessing education, and proposed this may be remediated through covering rosters within individual professional organizations.
Participants thought that streamlining patient care would be facilitated by integrating the various health services into a trauma system “a robust system in which we have clearly identified a feeder system… where …there are actual people responsible for the support throughout that network” [DR1].This would require an accurate understanding of the level of care that can be provided at various locations and the designation of different levels of trauma services with capabilities to manage various aspects of geriatric trauma, e.g. integrated physician/surgeon care model, regional anaesthesia and observation in ICU. This would require governance with “a state-wide trauma coordinator… who is the first port of call as a senior clinician to assist with decision making” [DR3], and linking medical records.
Participants also recommended a system that would assist in the early identification “a better trigger at triage that says this person is a risk”, that is simple and easily applied in triage. Yet triggers should not be oversensitive “and rushing everybody to the higher priority. You don’t want to be the boy that cries wolf with everybody” [PM1].
Protocols for common injury patterns (e.g. chest trauma, anticoagulation, head injury) that were easy to follow were thought to be particularly useful in rural settings. Streamlined referral pathways were also highly valued by participants.
Participants identified telehealth as a useful tool. Telehealth was sometimes used in resuscitation bays for the management of trauma patients, and could be expanded to other inpatient settings. For instance, for remote assessment of patients by specialized services in metropolitan centres “having some sort of administrative agreements, saying that we (can) make decisions based on the information that we see over an electronic platform” [DR10].