NMAHP eHealth Leads Meeting5th & 6th March 2007

Telehealth & Decision-making

Eunice E Muir

A New Channel and A New Clinical Service?

1870’s 2007

NHS 24

Since 2002 NHS 24 has provided nurse-led telephone triage to the population of Scotland (full roll out Nov 2004)

NHS 24 is a patient-centred service working in partnership with local health systems

Point of contact for access to clinical services in the OOH’s NHS 24 uses clinical decision-support software and

electronic data capture during clinical assessment Over 200 algorithms which direct questions and provides

supporting evidence-based information and outcome options

The software records data in ‘real time’ including algorithms used and outcomes generated

All calls are recorded and linked to the patient record Electronic records processed for clinical appropriateness

Decision-making

Evidence-based health care suggests that decision-making should involve an integration of:

Research evidence Practitioner experience Resources available Patient values

Decision Support

Algorithms can support safe, efficient and effective consultation when their use is underpinned by robust critical thinking and decision making

Requires competence in the identification of key clinical indicators during the initial

assessment call control call structure open questioning emotional intelligence e.g. an understanding of the patient

expectation

We have learned that a modular approach aligns learning interventions accordingly, allowing information to be assimilated over a more appropriate period of time.

Consultation skills

Technical skills Clinical

Skills

Verbal HandshakeInitial AssessmentAlgo Negotiation

Algo. useHISLOCClinical ProcessTelephony

SafeAppropriateTherapeuticValue

Explanation

Side by Side

Levelling sessions Roleplay

Live practice

Coaching

Learning should be contextualised through practice and drawing on the experience within the organisation – a multidimensional learning experience

Perinatal Telehealth Project

Birthrate plus

Workforce planning and resource tool

Categorises patient groups on a needs basis Category ‘X’ being inappropriate admissions to

Labour Suites Data suggests figures of 30% and above in

Scottish Maternity Units

Literature Review

Search strategy The review was focused on identifying key articles within

the published literature and on work that has already been carried out within NHS 24 and equivalent organisations internationally.

Databases searched• MEDLINE• BioMed Central• Blackwell Synergy• CMA Infobase• PubMed• ScienceDirect• Cochrane Library• BMJ Clinical Evidence + Grey Literature

Key Findings

The International Council of Nurses Monograph provides a state of the art overview of the issues, barriers, perspectives and factors (technical, administrative, cultural, human and success factors that pertain to nursing in Telehealth Milholland 2000

Emphasis of midwifery training has been on face-to-face Guidance on making assessments and providing appropriate

support and advice by telephone available in contemporary midwifery literature Sookhoo and Biott 2002

Experiential learning emphasised Risk averse decision-making due to fears of litigation

Webb 2004 Various processes and factors identified that affect midwives’

decision-making about early labour Cheyne et al 2006 Telehealth nursing evidence from America and Canada American Nursing Assoc; American Telemedicine Assoc.

The OPAL study(Options for Assessment in early Labour)Spiby et al Nov. 2006

Maps early labour services in England and explores innovations

Explores the service users and providers perceptions of Part 1 (the telephone component) of the All Wales Pathway for Normal Labour

Obtains healthcare providers’ views about using NHS Direct for early labour advice

NHSScotlandPerinatal Telehealth telephone questionnaire

Heads of Midwifery and Lead Midwives were asked a series of questions to establish current practice in NHSScotland

Some of the questions: What telehealth care is provided by midwives in

your area? What documetation is used? How do you evaluate the advice and decisions

made? Do midwives have preparation/CPD prior to

providing telehealth care?

Next Steps

Front-line development of Triage documentation for Antenatal Pre Labour (priority) Post Natal

(Midwifery and Obstetric working groups)

Piloting and testing in urban and rural settings Agree evaluation methodology Develop CPD education and training programme for

midwives Consider implications for undergraduate and post

graduate education curriculum

Next Steps

Patient experience survey Clinical review of NHS 24 maternity algorithms Identification of gaps in either algorithms or

knowledge base

Quick Wins Establish controlled access to quality assured

web sites via NHS24.com Consider referral pathway from midwives to

OOH provider

Waving not drowning !

I am not alone! Close partnerships and shared

vision Ministerial Action Group KCND project Midwifery Leadership

programme NMAHP eHealth Strategy eHealth Lead midwives Practice Development Midwives

NMAHP eHealth Leads Meeting5th & 6th March 2007

Telehealth & Decision-making

Eunice E Muir