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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

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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

eduser@nhw.hume.org.au

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

jane.kealey@nhw.hume.org.au