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Introduction: In Aotearoa New Zealand (NZ) there is a knowledge gap regarding the place and contribution of rural hospitals in the health system. New Zealanders residing in rural areas have poorer health outcomes than those living in urban areas, and this is accentuated for Māori, the Indigenous people of the country. There is no current description of rural hospital services, no national policies and little published research regarding their role or value. Around 15% of New Zealanders rely on rural hospitals for health care. The purpose of this exploratory study was to understand national rural hospital leadership perspectives on the place of rural hospitals in the NZ health system. Methods: A qualitative exploratory study was undertaken. The leadership of each rural hospital and national rural stakeholder organisations were invited to participate in virtual semi-structured interviews. The interviews explored participants' views of the rural hospital context, the strengths and challenges they faced and how good rural hospital care might look. Thematic analysis was undertaken using a framework-guided rapid analysis method. Results: Twenty-seven semi-structured interviews were conducted by videoconference. Two broad themes were identified, as follows. Theme 1, 'Our place and our people', reflected the local, on-theground situation. Across a broad variety of rural hospitals, geographical distance from specialist health services and community connectedness were the common key influencers of a rural hospital's response. Local services were provided by small, adaptable teams across broad scopes and blurred primary-- secondary care boundaries, with acute and inpatient care a key component. Rural hospitals acted as a conduit between community-based care and city-based secondary or tertiary hospital care. Theme 2, 'Our positioning in the wider health system', related to the external wider environment that rural hospitals worked within. Rural hospitals operating at the margins of the health system faced multiple challenges in trying to align with the urban-centric regulatory systems and processes they were dependent on. They described their position as being 'at the end of the dripline'. In contrast to their local connectedness, in the wider health system participants felt rural hospitals were undervalued and invisible. While the study found strengths and challenges common to all NZ rural hospitals, there were also variations between them. Conclusion: This study furthers understanding of the place of rural hospitals in the NZ healthcare system as seen through a national rural hospital lens. Rural hospitals are well placed to provide an integrative role in locality service provision, with many already long established in performing this role. However, contextspecific national policy for rural hospitals is urgently needed to ensure their sustainability. Further research should be undertaken to understand the role of NZ rural hospitals in addressing healthcare inequities for those living in rural areas, particularly for Māori. [ABSTRACT FROM AUTHOR]

Introduction: Access to ultrasound imaging services is limited in rural areas and point-of-care ultrasound (POCUS) has the potential to address this gap. We aimed to examine how POCUS is utilised by doctors in contemporary Australian rural general practice. Methods: A portable ultrasound machine and access to a training course were provided to four general practices in rural South Australia, and the type and frequency of POCUS scans were recorded, along with user information, between July 2020 and June 2021. Participating general practitioners (GPs) completed a survey at the commencement of the study regarding their previous experience and confidence in using POCUS for specific assessments and procedures. Results: Of the 472 scans recorded, most (95%) were for clinical indications, 3% for teaching activities and 2% for self-learning. Overall, 69% were obstetric scans, followed by abdominal (12%), gynaecological procedures (10%), other procedural (7%) and thoracic exams (1.5%). Users reported higher confidence for lower complexity POCUS. Conclusion: Although POCUS has diverse potential applications in rural practice, GPs reported limited confidence for certain scans and used POCUS predominantly for obstetric indications. Further studies should examine the barriers to POCUS utilisation, with particular attention to training requirements, reimbursement for use and access to machines. [ABSTRACT FROM AUTHOR]

Introduction: The use of implantable cardioverter defibrillators (ICDs) is increasing in both New Zealand and Australia. Also, both countries are experiencing an ageing of their rural populations. Much of the ICD literature focuses on the experience of those living in urban environments, with little known about the experiences of those living in rural contexts. This study aimed to answer the following questions: ‘Does living rurally impact the ICD recipient experience and that of their partners?’ and ‘Can understanding their experiences inform best practice care for those living rurally with an ICD?’ Methods: This qualitative study employed purposive sampling and semi-structured interviews to produce rich narrative data. A general inductive approach was then used to analyse data, producing a series of coded themes through an iterative strategy, to generate an understanding of the rural lived experience after ICD implantation. Interpretations and conclusions were tested with participants at a debriefing meeting at the conclusion of the study. Results: In total 14 ICD recipients and nine partners/carers /whānau (family) were interviewed. One recipient was Māori (indigenous New Zealander) and one female, and overall age range was 57–89 years. The length of time from ICD insertion varied from less than 1 year to 12 years. The final analysis highlighted the substantial role played by partners/carers of recipients. How this recipient–partner/carer dyad managed the post-ICD insertion experience was a major theme in this study. The perennial challenges of advance care planning and ICD deactivation conversation, unmet need for peer support and gaps in the provision of health-related information were all highlighted as challenges to these rural participants. The rural locale, however, posed limited challenges. Loss of a driving licence following receipt of shock therapy was irksome due to the unavailability of public transport but the impediment posed by the device on the practicalities of rural living, such as the need to use power tools and move electric fences, was, for some, more of an issue. Conclusion: This is one of the few studies that has considered the influence of rural location on the post-ICD insertion experience of patients and their partners/carers. ICD insertion did not appear to substantially negatively impact on the lives or experiences of rural recipients and their partners/carers. While this study did not set out to explore the role of informal carers who live rurally, the study findings suggest that female partners of rural ICD recipients undertake a significant role in terms of shouldering varying responsibilities including medication management, emotional support and transportation. As the age of ICD recipients increases, so does the age of their partners, therefore, they are also likely to be living with one or more long term conditions. Health professionals need to be aware of this additional burden as research suggests rural informal caregivers are less likely to report associated issues. [ABSTRACT FROM AUTHOR]

Introduction: In 2008, the Medical Council of New Zealand recognised rural hospital medicine as a vocational scope of practice. The aim was to provide training and professional development standards for medical practitioners working in New Zealand’s rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health in New Zealand’s far north is an established integrated health service that includes a rural hospital and serves a largely Māori community. The aim of this study was to explore how the new scope had affected health practitioners and the health service at Hokianga Health. Methods: A case study design was used, employing qualitative methods. Documentary analysis was undertaken tracking change and development at Hokianga Health. Twenty-six documents (10 from within and 16 from outside Hokianga Health) were included in the analysis. Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health. The interviews explored participants’ views of the rural hospital medicine scope. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately. Results: Four themes capturing the main issues were identified: (1) ‘What I do’: articulating the scope of medical practice at Hokianga, (2) ‘What we do’: the role of the hospital at Hokianga, (3) ‘On the fringes’, and (4) Survival. With changing regulatory policy an established part of Hokianga Health practice, the hospital aspect was outside the scope of general practice. This mismatch created a vulnerability for individual doctors and threatened the hospital service. The new scope filled the gap, rural hospital medicine together with general practice now covering the whole practice scope at Hokianga Health. With the introduction of the rural hospital medicine scope and the accompanying national definition of a rural hospital came a sense of belonging and increased connectedness, Hokianga Health and its practitioners realigning with the new scope, its policies, processes and language. The new scope brought for the first time a specific focus on the inpatient and emergency care aspects of practice at Hokianga and with this validation of the hospital aspect of the medical practitioners work. The critical importance of a fit-forpurpose scope and rural-specific postgraduate training programs in minimising inequity of care and opportunity for rural communities was emphasised. The importance of benchmarking with its associated costs was also highlighted. The main challenges identified related to the real (as well as potential) increased regulatory requirements of two separate scopes of practice for practitioners and a small rural health service working across primary and secondary care. Conclusion: In better equipping medical practitioners for rural hospital work and strengthening hospital systems and standards, the rural hospital medicine scope has met its intentions at Hokianga Health. The rural hospital medicine pathway is a necessary partial solution to rural medical practitioners maintaining a broad skill set. Continued flexibility is required in training programs in order to meet a range of different practitioner and rural health service needs. [ABSTRACT FROM AUTHOR]

Introduction: Point-of-care ultrasound (POCUS) has the potential (FAST) and aortic aneurysm (AAA) - in the rural context. to improve access to diagnostic imaging for rural communities. Methods: This study is a subgroup analysis of a larger study into This article evaluates the sensitivity and specificity, impact on POCUS in rural New Zealand. Twenty-eight physicians in six New patient care, quality and safety of two common POCUS Zealand rural hospitals, with limited access to formal diagnostic examinations - focused assessment with sonography in trauma imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care. Results: For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a 'significant' or 'major' impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients. Conclusions: In the rural context, POCUS AAA is a reliable 'rule out' test for ruptured abdominal aortic aneurysm and FAST scan has a role as a 'rule in' test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature. [ABSTRACT FROM AUTHOR]

Introduction: Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital. Methods: This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost-benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted. Results: Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to 'make it work'. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost--benefit analysis showed a clear cost saving to the health system as a whole. Conclusions: This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-fromlaboratory context. [ABSTRACT FROM AUTHOR]