From outback to operating room: aeromedical retrieval and management of open-fracture trauma patients in Western Australia

Early Abstract:

Introduction: Patients with open fracture injuries represent a high-risk cohort that require timely management to reduce complications such as infection, non-union and chronic pain. Early antibiotics and definitive surgical care are key interventions that improve outcomes. In Western Australia (WA), vast distances and limited access to healthcare services outside the metropolitan area can result in delays to treatment and necessitate aeromedical retrieval. This study compares the management of open fracture patients presenting directly to the state major trauma centre, Royal Perth Hospital (RPH), versus rural/remote patients retrieved via the Royal Flying Doctor Service Western Operations (RFDSWO).
Methods: A retrospective audit was conducted on open fracture patients presenting to RPH in 2023. Patients were divided into primary presentations (direct to RPH, n=60) and secondary presentations (RFDSWO retrieval, n=30). Data collected included demographics, injury characteristics, antibiotic dosing, and timings such as time of injury, first healthcare contact, retrieval, arrival at RPH and first operation.
Results: Secondary presentations were retrieved from a median distance of 1246 km. The median time to retrieval was 14 hours, with 73% retrieved within 24 hours of injury. This prolonged retrieval time was reflected in the median time from injury to arrival in RPH ED which was 1.5 hours for the primary presentation group versus 19.5 hours for the secondary presentation group. Median time to surgery was also longer in the secondary presentation group (19.5 hours versus 36.3 hours) as well as median time from injury to antibiotic administration (2.7 hours versus 11.1 hours). Cefazolin as a first-line antibiotic was appropriately given in 92% of cases, however patients rarely received the recommended broader spectrum antibiotics for severe or contaminated wounds.
Discussion: The observed delay in provision of appropriate antibiotics and definitive surgical management stems from geographic and resource challenges experienced in WA's rural and remote areas. This is further complicated by prolonged time to initial healthcare contact as well as extended retrieval times. Current guidelines do not consider the isolated and low resource environments that are present in much of Western Australia. New RFDSWO clinical guidelines have been developed for the management of open fractures, including emphasis on the importance of early and appropriate antibiotics as well as a protocol for the use of RFDS medical chests stocked with oral antibiotics to bridge delays to intravenous antibiotics. 
Conclusion: Given the massive size and sparse population of WA, rural and remote patients with open fractures face delays to crucial interventions when compared to similar patients presenting to a metropolitan trauma hospital. Enhancing early antibiotic administration protocols and education within the aeromedical retrieval service and rural/remote sites could improve the timeliness and consistency of care for patients requiring long-distance retrieval to tertiary care. 
Keywords: access to health care, air ambulances, antibiotic prophylaxis, Australia, bone and joint infections, emergency medical services, open fractures, patient transfer, rural health services, trauma.