Operationalising and embedding telehealth

Transcription

1 Operationalising and embedding telehealth The experience of the WA Emergency Telehealth Service Dr Andrew Jamieson Clinical Lead, SIHI Western Australia Country Health Service Acknowledgements to Melissa Vernon, Justin Yeung and Yvonne Zardins #pinksocks

2 The (WACHS) would like to respectfully acknowledge the Elders past and present of this country in which we live, share and operate. WACHS also acknowledges the ongoing contribution of Traditional Owners as caretakers of their communities and Country.

3 Western Australian Country Health Service (WACHS) Working in partnership to improve: The culture of safety and quality in rural healthcare. Emergency and acute clinical services including infrastructure. The health of country people with a focus on: o o o o maternal, child and adolescent health chronic conditions public health and disease control social and environmental issues impacting health. Aboriginal health and Aboriginal employment in health. Mental health, alcohol and other drug issues. Ageing in the country. Service access: o o o o o telehealth inter-hospital transport more services closer to home (e.g. cancer, renal) end-of-life care links with metro services.

4 How WACHS operates Delivers acute and primary health services to regional Western Australia: o 400,000 emergency visits/year o 180+ employed doctors, contracting doctors. Operates within a Regional Network Model and provides an integrated service delivery system: o 70 hospitals of varying size o 36 nursing posts o Population Health o Aged Care.

5 How WACHS operates Strong budget driven regional clinical and corporate governance structures. Community engagement regionally service providers, consumers and carers, local government and other stakeholders. Supported by metro based Head Office. Executive governance CEO and Executive. Department of Health is system manager. Board ultimately responsible for organisational governance.

6 5.5 hours flying time

7 Challenges

8 Leading cause of death by remoteness in Australia, compared with major cities (AIHW 2014) Rate ratio (compared with major cities) 1.0 No difference x times higher than major cities Major Cities Inner regional Outer regional Remote Very remote 1 Coronary heart disease 2 Cerebrovascular diseases 3 Dementia and Alzheimer Coronary heart disease Cerebrovascular diseases Dementia and Alzheimer 4 Lung Cancer Lung Cancer Coronary heart disease Cerebrovascular diseases Lung Cancer Dementia and Alzheimer Coronary heart disease Lung cancer Cerebrovascular diseases Diabetes 5 COPD COPD COPD COPD 6 Colorectal cancer Diabetes Cancer, unknown, ill defined 7 Diabetes Colorectal cancer Diabetes Dementia and Alzheimer Cancer, unknown, ill defined Land transport accidents 8 Cancer, unknown, Cancer, unknown, Colorectal cancer ill defined ill-defined 9 Heart failure Heart failure Heart failure Suicide 10 Prostate cancer Prostate cancer Prostate cancer Heart Failure Coronary heart disease Diabetes Lung Cancer Land transport accidents Cerebrovascular diseases Suicide COPD Cancer, unknown, ill-defined Other ill-defined causes Perinatal congenital conditions

9 Indicative fatality rate / persons and fatality count for motor vehicle crashes per WA police district (Road Safety Commission 2015)

10 Fatalities and critical injuries from motor vehicle crashes in WA (Road Safety Commission 2015) Fatalities (including delayed fatalities) higher in rural but critical injuries lower lower survival rate from critical injuries Fatality rate WA vs Australia

11 Policy drivers Health Priorities 1. Prevention and community care services 2. Health and hospital services 3. Chronic disease 4. Aboriginal health Enablers 1. Workforce 2. Accountability 3. Financial Management 4. Partnerships 5. Infrastructure 6. ICT 7. Research and Innovation

12 Vision Healthier country communities through partnerships and innovation

13 Clinical Services Framework WACHS Emergency Care Level One Level Two Level Three Level Four Level Five Level Six First aid, assessment and resuscitation Emergency ambulance services with access to rapid transport Care provided by a registered nurse with or without assistance from a GP Basic resuscitation equipment and drugs Access to ETS As for Level One plus: 24/7 services by registered nurse / nurse practitioner with support by medical practitioner Resuscitation and stabilisation capability Transport and / or coordinate transport to access emergency services care As for Level Two plus: Local GPs rostered to provide 24/7 cover with service by registered nurse As for Level Three plus: Emergency operating theatre facilities On-call generalist specialists Access to senior registered nurse Access to designated allied health services Some allied health undergraduate education Access to emergency specialist As for Level Four plus: Medically staffed 24/7 Medical and surgical subspecialists available on-call Accepts transfers from other hospitals in region Access to ICU and CCU facilities Access to specialised allied health services As for Level Five plus: Emergency medicine consultant on duty 24 hours per day* State-wide referral role Backup from full range of medical and surgical specialists and diagnostic services ICU and CCU facilities *Not currently operating in WA

14 Emergency Care Capability Framework WACHS Category: Emergency Service Nurse Led Emergency Care: Level A and B Emergency Care Emergency Service Emergency Department: Level A and B Comparative WA Health CSF Level of Emergency Service Minimum Service Provided and availability: Level One Level Two Level Three Levels Three to Five Minimum service provided onsite and includes: first aid #basic resuscitation and stabilisation coordination of an *emergency transfer Level A: service may be available outside and during facility s scheduled hours of operation Level B: service is available during the facility s scheduled hours of operation only Minimum service includes that provided by nurse led emergency care plus: treatment for minor injuries; and service is available seven days a week, twenty four hours a day (24/7) Minimum service includes that provided by emergency care plus: #advanced resuscitation and stabilisation and treatment for all presentations Minimum service includes that provided by emergency service plus: advanced treatment for all presentations with; onsite laboratory and imaging services, which may include CT; patient transfers are accepted from other facilities In addition Level A services: have access to anaesthetic capability, emergency theatres and high dependence unit facilities Minimum Service: Provided by: A registered nurse (RN) will provide the service: with/without support of a medical practitioner with access to clinical and/or management support as per site s: adult and maternity observation and response escalation and medical emergency response process30 As for nurse led emergency care plus the RN: is onsite 24/7 and has; access to a medical practitioner who may attend on-site or is available virtually in real time through the sites tele-health capability As for emergency care plus: the medical practitioner will attend onsite as required As for emergency care plus: Level A services have: medical practitioners onsite 24/7; with access to: medical/surgical specialists and proceduralists Level B services have: medical practitioners who are onsite within working hours / weekend days and

15 The Emergency Telehealth Service (ETS) An initiative of the Southern Inland Health Initiative o Improving emergency care for country residents. Royalties based non-health funding o Budget based, not activity based. Supported by centralised Head Office team o Project employment structure based on funding availability.

16 ETS = a state-wide, specialist led emergency medicine service Mixed FACEM and ED credentialed generalist workforce. Dedicated service, not part of any other roster. Nurse Coordinator always on duty. High definition enabled video conference face to face consultations. Current activity 1,400 1,500 consults per month. Monday-Sunday hrs daily. Currently rolling out phased 24 hour service introduction now 4 days/week.

17 ETS history and activity 2011/12 ETS concept aimed at rural emergency medical workforce issues. Commenced Aug pilot sites. Early observations: education dedicated team governance clinical standards accessibility/availability. April hospital and nursing post sites across 7 regions.

18 Service development principles Consultant-led to support delivery of quality, effective emergency medicine. Advocacy for the patient and local clinicians to facilitate the best possible outcome for country patients. Governance and operational management to be firmly established within WACHS, compliance with established WACHS clinical governance pathways and relevant policies to ensure consistency/quality of service in a country context. Collaborative regional development of the ETS model taking into account local geography, service provision context and workforce models. Regional decision making and local protocols will guide intraregional transfers with appropriate guidance and negotiation from the ETS physician.

19 ETS service model A bureau service, provided by a central office outside of regional structures. A virtual ED ; clinicians on duty, waiting for calls. Medical roster Nursing roster Administrative support

20 ETS has contributed to increased numbers of medical consultations in WACHS small hospitals ETS Regression trend

21 Clinical governance Statewide credentialing Clinical quality and risk: o driven from patient s end, with both ends input o collaborative investigation and conclusion. ETS governance structures Record keeping and oversight Policy adjustment to telehealth provision: o agenda item within normal governance structures where possible o enabler, not an end in itself.

22 Standard ETS flowchart

23 ETS ED layout receiver end Significant clinical input into layout of ED s and camera Standardised formulary Standardised emergency trolley

24 Workforce FACEMs GP Proceduralists Clinical Nurses Role for Nurse Practitioners DOCTORS MOSTLY CONTRACTORS EMPLOYED ETS Clinical Director ETS Manager ETS nurse manager Administrative staff

25 Education Flexible (Blended) Learning Framework Videoconferencing events o theoretical o practical o simulation elearning Program o ETS HELP F2F Education o ETS staff

26 Practical sessions pre-amble VC etiquette, intros, recording record monitor issues remote control attendance and evaluations

27 Simulation sessions pre-amble safety, processes. no recording monitor issues camera and microphone control scenario = debrief

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29 Working environment ETS emotional distance Engagement techniques Live ED on the floor dedicated camera work, less physical variety 30-50% telehealth only mixed workload decreased locus of control; third party reliance Engagement and training of nursing colleagues ED clinicians are take charge and usually do siloed and solitary, often in a dark room Standard debriefing and team meetings team based, supportive

30 Critical success factors Identified need with mostly rapid uptake by WACHS staff. Exceptional product FACEMs and ED Generalists. Well defined service delivery model that aligned easily with existing systems. Executive support and leadership. Client focus patients AND local ED nurses and doctors. ~75% of all consultations are definitive; patients go home.

31 What s next? In-patient support Leveraging capacity across entire ED system Care coordination Ad-hoc specialist access Interface with preventive care

32 Questions/comments Experienced ED generalist looking for telehealth work? to: