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Establishing an after-hours Emergency Department Telehealth service in the
Hume region of Victoria
Jane Kealey
Telehealth Project Officer
Northeast Health Wangaratta
Northeast Health
Wangaratta
• Hume region • The project
- Aims, methods, governance - The process, protocols and clinical governance - Challenges and achievements
• Early results • Interim evaluation • Hume HS’s VC enabled future
Outline:
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Northeast Health
Wangaratta
• North East Victoria 42,923 sq km – pop > 300,000 • Victoria 237,629 sq km – pop 5,603,100 • Queensland 1,730,648 sq km – pop 4,560,059
• agriculture, viticulture, tourism, health, manufacturing • Wangaratta – Jazz capital of Australia
• 1 of 5 DH regions in rural Victoria (3 metro)
• older; lower SES; poorer health status & outcomes than Vic averages
• not much exposure to telehealth
• 19 public health services – 2 regional , 1 sub-regional (NHW), SRHS
Hume Region Geography & Demography
Northeast Health
Wangaratta
• November 2012 GP shortage in Yarrawonga • Solution for supporting low number GPs in workforce provide 24hr medical service to local urgent care centre (UCC)
Vic Dept of Health, NHW & YH came up with...
> Telehealth > Triage categories 4 & 5 > 11pm to 7am ......1st patient April 2013
• May 2013 NHW $1M funding to apply model ED telehealth to the Hume region
Background Story – 2 years old:
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Northeast Health
Wangaratta
Hume Region ED Telehealth
• Hume Setting:
* Barriers accessing AH urgent medical services – not only distance -
transport; costs medical care; postpone care am
* Low numbers present to UCC – flexible use VC hardware important for
sustainability in SRHS – project is enabling strategy for Broader Service
delivery
* Important to support existing referral patterns - NHW / GVH/ AWH
- plus local variations (eg. Alpine/
Corryong/ Seymour/ Kilmore)
* Virtual strangers to telehealth
Northeast Health
Wangaratta
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Aims of Project: * Establishing connectivity across the health services of the Hume Region to enable
high quality and secure videoconferencing
* Provide after hours medical care and support to nursing staff at UCCs in small rural
health services when a local GP is not available
* Establish a sustainable service model to enable the continued provision of medical
services via videoconferencing to UCCs
* Identify and explore the delivery of other potential telehealth services via available
infrastructure across the Hume Region and to Metro health services
* Establish a suite of practical resources that will support implementation and adoption
of telehealth services into UCCs
Northeast Health
Wangaratta
Rules of Informatics: * Editorial MJA 198 (4) 4 March 2013 – Enrico Colera
“ Why e-Health is so hard”
* Basic ‘Rules of Informatics’
1. Stake holder engagement
2. Culture change
3. Slow and considered implementation
4. User training
5. User friendly systems that fit into clinical workflow
* Start with a clinical problem that needs solving
* “complex intervention in a complex system”
* “success at individual sites is no guarantee of success elsewhere”
* greater investment in user training
Northeast Health
Wangaratta
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Governance: * Project Control Group members includes:
Department of Health
HRHA
NHW Executive/ Board
* Steering Committee Membership includes:
GV & Hume Medicare Locals
Ambulance Victoria
University of Melbourne
Senior Clinicians
Northeast Health
Wangaratta
•
VC environment prior to project: * Hume Region not suited to UCC Teleheatlh
* Polycom units in boardrooms and education centres
* Most SRHS existing 4Mbp copper connections and ageing wireless
networks
* Upgrade connections – bandwidth & wireless networks for reliable
good quality VC
* Procurement VC units – considered wireless Practitioner Carts for
widespread use in SRHS
* Roll out Central Hume initial stages; GV and Upper Hume later stage
Northeast Health
Wangaratta
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Expressed needs:
* Management of triage category 4 and 5 overnight
* Management of all categories over a weekend
* Support for management of triage 3 or complicated presentations
* Specialist input - especially orthopaedics and mental health
* Support for existing call arrangements across multiple sites or from
home using mobile devices
* Support using VC from ARV/ PIPER etc..
Northeast Health
Wangaratta
Clinical Governance: * Based on clinical protocols & methods from the pilot service to Yarrawonga * MOUs important when starting new & unfamiliar service – clinicians req’d to practice inside scope of agreed protocol, includes scope of practice within own organisation * Patient safety paramount
* Ensure high quality medical care – audit and case review
* Closely replicate physical presentation of a patient to the ED – clerical, nursing and medical input
Northeast Health
Wangaratta
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Patient presents to UCC
2100 - 0700 hrs
Triaged by RN
Triage category 1,2,3
Local GP consulted
Triage category 4 & 5
Can patient be treated local RN?
yes : UCC RN treat locally
no: TELEHEALTH
ISBAR - Telehealth Referral
UCC RN scan & email to ED
UCC RN phone ED reception + triage RN
(03) 57225261 (triage nurse - registers patient ED workload and gives estimated
waiting time)
ED MO phone UCC RN
- ISBAR handover
- Confirm Videolink
ALL CONSULTATIONS via VIDEOLINK
VIDEO LINK
ED MO video call UCC
ED MO : Telehealth Consultation Record - MR 8-02B
UCC RN : UCC form
ED receptionist: SCAN & EMAIL Telehealth Consultation Record to UCC (immediately after telehealth consultation)
If IT issues - consider
telephone link
Health Information Services
Northeast Health
Wangaratta
• Episodes currently not reported to the DH
– don’t fit into VEMD or VINAH
• Vital system used NHW ED
– TH patients entered into workload for integration into ED workflow
– Allocated to ‘TH’ cubicle
– TH patients ‘removed’ from reportable data
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Issues on the Journey: * Regional Telehealth Strategy not yet established
* Range of difference support needs/ wants
* Range of different current IT capabilities – data collection
* Range of preparedness of organisations
* Range of preparedness of GPs
* Labour-intensive-relationship management – ‘down skill’ threat
* Building sustainability through broader use of equipment
*
Northeast Health
Wangaratta
Challenges: * Existing infrastructure not suited to clinical video consultation
Hardware
Bandwidth
* Scoping hardware solutions took time – heavily influenced timing
* Christmas shutdown on hardware delivery/ installation / connection
upgrades
* Health services senior leadership leave periods
* Additional recurrent costs to health services – av site additional $12K
infrastructure
* Not a priority for some health services
Northeast Health
Wangaratta
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Challenges: * so many sites, so little time – acquitting funds 30th June 2014
* managing diaries and commitments
* availability of staff at sites
* commitment of staff at sites – managing change
* 8747 km travelled by car in Hume region alone Sept‘13 – Jun’14 to
make 52 site visits (in Victoria)
Northeast Health
Wangaratta
* Engagement by 16 health services in the Hume region
* Establishing 16 VC enabled UCC / SRHS
* Development robust ED telehealth protocol – integrates
into ED workflow
* Development of education and training materials –
video in progress; handbook; MO training package (almost
released UoM medical student training module)
Northeast Health
Wangaratta
Key achievments:
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*
* Fully embed ED telehealth in the region – sites at different
levels of maturity
- site champions
- recently VC enabled > established and independent in
managing service and education
- establishing Hume Nurses Telehealth Network
- relationships
- promotion to community - choice
* Rapid development of additional services to maximise
investment and drive sustainability
* Funding models
Northeast Health
Wangaratta
Sustainability into the future:
Referrals – Cumulative Total
Northeast Health
Wangaratta
1 2 3 7 8 9 10 0
20
40
60
80
100
120
Apr 13 M J J A S O N D Jan 14 F M A M Jun 14 J A S O
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Presentations x Triage Category
Triage Category (Cat) Number of referrals
Cat 2 2*
Cat 3 21
Cat 4 68
Cat 5 13
Unknown 6
*Cat 1&2 unsuitable for service: SRHS staff advised to initiate immediate transfer of patient (no VC)
Northeast Health
Wangaratta
Waiting times: presentation to referral to consultation
(mins) Presentation to
Referral
Presentation
to
Consultation
Referral to
Consultation
Consultation
Time
Mean 43.5 (43) 76 (71) 34 (28) 16.1 (16.5)
Median 32 (29) 55 (55) 25 (26) 10 (10)
Range 5 – 184 10 – 240 1 – 127 1 – 52
NB: • No change in range 30th June to 30th Sept • total sample size reduced by incomplete data sets • future comparison of triage categories
Northeast Health
Wangaratta
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Waiting Times x Triage Category
Northeast Health
Wangaratta
Mean
(range)
Presentation
to Referral
Presentation
to Consultation
Referral to
Consultation
Consultation
Time
Cat 3 80 (30-184) 130 (55-240) 30.5 (26-35) 13.5 (10-20)
Cat 4 29 (5-90) 59 (10-180) 29 (1-127) 18.5 (1-50)
Cat 5 50 (45-55) 65.5 (46-85) 20 (1-40) 7.5 (3-15)
NB: • Larger sample size is required to calculate significance of difference b/w triage categories • reliability of data for Cat 3 & Cat 5 reduced by incomplete data sets.
Age groupings (yrs)
Northeast Health
Wangaratta
0
5
10
15
20
25
0-5 6-15 16-25 26-40 41-55 56-70 71-85 85+
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Diagnostic Groupings
Northeast Health
Wangaratta
0
2
4
6
8
10
12
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Discharge destination
Northeast Health
Wangaratta
Home 51%
Transfer other health service
29%
incomplete 6 %
Self discharged against advice
3%
Failed to wait 3%
TH review before discharge
5%
TH referral (same problem)
3%
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Day of Referral
Northeast Health
Wangaratta
Monday
Tuesday
Wednesday
Thursday
Friday Saturday
Sunday
73% yes
27% no
Medication
orders
Early feedback: ‘Satisfaction’ greater than the numbers indicate –
supportive to RNs and GPs
Regional approach to community education required to
raise awareness of service
Seen as the starting point for broader application
technology
Northeast Health
Wangaratta
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Evaluation University of Melbourne / Health and Biomedical Informatics Centre
Northeast Health
Wangaratta
Perspectives 5 groups interim analysis
1. Patients and carers
2. Nursing staff at the referral sites
3. Medical officers at the consulting ED
4. Clerical officers
5. General practitioners servicing the referral sites
Add nursing staff at consulting ED final analysis
Evaluation University of Melbourne / Health and Biomedical Informatics Centre
Northeast Health
Wangaratta
Longitudinal, mixed methods
• Focus Groups
• Interviews
• Questionnaires – hard & electronic
• ED data
• Medical Record Review
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Evaluation Framework: University of Melbourne / Health and Biomedical Informatics Centre
Dr Ambica Dattakumar (IBES) Accessibility: People can obtain healthcare at the right place, at the
right time irrespective of incomes, physical location and cultural backgrounds.
Continuity of care: Ability to provide uninterrupted coordinated care
or service across programs, practitioners, organisations and levels over time.
Responsiveness: Healthcare service is patient oriented and the client is
treated with dignity, respect and confidentiality and encouraged to participate in choices related to their care.
Northeast Health
Wangaratta
Evaluation Framework University of Melbourne / Health and Biomedical Informatics Centre
Early Results:
1. Telehealth has improved accessibility where implemented
2. Feasible method of delivering a responsive, patient oriented service given positive attributes early feedback
Yarrawonga GP After 1 year of service – “life changing”, “reduced the impact
of overnight calls” on their personal lives and their capacity to consult the following day.
Northeast Health
Wangaratta
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VC enabled futures
Northeast Health
Wangaratta
Adult Retrieval Victoria / PIPER • Clinicians On Line to connect directly to health services in Hume • VC beneficial in emergency retrieval of patients needing transfer to
metropolitan health service • Encourage use of technology low acuity ED telehealth service
High Risk Foot Telehealth • Hume has 1 HRF podiatrist • Set up HRF clinics within Hume using telehealth • Links to Melbourne Health & Northern Health HRF clinics • Build capacity in Hume podiatrist workforce & upskill other clinicians • 2 pilot cases resounding success for patients and clinicians
VC enabled futures
Northeast Health
Wangaratta
Outpatient / Sub-acute Services • Pre-admission clinic, fracture clinic, rehabilitation • Numbers
Mental Health * VST – Florey Institute (NHW, GVH, AWH)
* Residential In Reach ED telehealth • Almost ready for a pilot at Illoura (NHW facility) • Process same as ED telehealth – different needs
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Conclusion
Northeast Health
Wangaratta
• Observed and lived the ‘Rules of Informatics’
1. Stake holder engagement
2. Culture change
3. Slow and considered implementation
4. User training
5. User friendly systems that fit into clinical workflow
• Flexibility – no ‘one size fits all’ model
• Significant clinical acceptance + high level leadership support
• Remote end RNs critical to ED telehealth success - refer
• Hume needs pilot cases.......cultural change
• Advantage of Qld, WA experience
• Relationships, trust & ‘touching patients’ (Ewan McPhee)
Acknowledgements
Northeast Health
Wangaratta
• John Elcock – Director of Medical Services • Jonelle Hill-Uebergang – DDON • Ian Wilson – Director ED • Margaret Bennett – CEO • Robert Mackenzie – ED RN • Jane Antonello – ED clerical administrator • All staff NHW ED • Meryn Pease - DON • Rowan O’Hagan – UoM, Education Coordinator • Ambica Dattakumar – UoM, Investigator • Helen Haines – UoM, Primary Investigator; NHW Research Coordinator