optimising the model of care for patient management at the tweed cancer care and haematology unit...
TRANSCRIPT
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Brendan Esposito CNSCancer Care and Haematology Unit
The Tweed Hospital
October 2015
Handover Utilising MOSAIQ EMR
Optimising the Model of Care for Patient Management at The Tweed Cancer Care and Haematology Unit
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Where’d he say he’s from?
The Tweed Cancer Care and Haematology Unit (CC&HU) is an ambulatory day treatment unit within The Tweed Hospital (TTH).
An initial implementation of a handover process was attempted by nursing staff in November 2011.
Coinciding at this time was the implementation of the dedicated oncology specific, electronic patient record system (EMR), MOSAIQ.
Sequenced process of patient handover utilising MOSAIQ EMR was begun on 7th May 2012
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Handover – What’s the big deal
The commonly understood model of shift to shift
nursing handover does not apply to most ambulatory
day treatment units. Most ‘tailor made’ handover
process and checklists are not readily applicable .
None-the-less, ‘handover’ of patient clinical
information remains quintessential to safe clinical
practice.
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Handover - What’s it got to do with EMR?
With the recent increased use of computer systems, electronic
medical record keeping and electronic devices that enable
communication, there has been a corresponding increase in
interest concerning how these innovations are impacting on
the transfer of clinical information and patient handover.
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MOSAIQ – What is it?
Electronic Medical Record System
Dedicated Multi-Departmental Oncology Management System
Interfaces with external systems
All patients accessible to all disciplines
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What does it do? EMR-patient notes
Assessments tools
Documents, letters, reports
Chemo orders
Generates blood test and investigation orders
Laboratory and investigative results
Appointment scheduling
Daily basis-patient ‘queuing’ and staff allocation
Medicare code capture and billing
Statistical analysis – crystal reports
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What’s it look like?
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CINSW Project Grant
The aims of the project where seen to be relevant to the
CINSW Strategic Plan 2011-2015
The project was funded through a successful application
for a CI NSW Cancer Services Development grant
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Aim of the Project
To demonstrate the effectiveness of morning
handover utilising MOSAIQ EMR within Cancer
Care and Haematology Unit at The Tweed
Hospital and its impact on patient care delivery
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Methods Used
A comparison of morning handover using MOSAIQ to local and national standards
Benchmarking local handover practices
Comparison of Essentials of Care observations and Staff Satisfaction Surveys
Examination of Incidence Reports
Interrogative EMR Patient Chart Audit
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Comparisons to Standards National standards (NSQHS standard 6)
Australian Commission on Safety and Quality in Health Care
Australian Resource Centre for Healthcare Innovations
Clinical Excellence Commission
NSW Safe Clinical Handover Program
NSW Health Policy directive PD2009_60 Clinical Handover - Standard Key Principles
Northern NSW Local Health District Procedure, Nursing/Midwifery Shift Clinical Handover – Point of Care/Bedside NC-NNSW-PRO-6361-12
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Results of this Comparison
Handover utilising MOSAIQ EMR meets local and
national standards with limited exceptions:
No documentation of ‘handover’ present
Patient involvement in the process could be
greater or more explicit
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Benchmarking
Six similar ambulatory units in the Northern NSW Local Health district and geographical proximal to TTH were canvassed.
The Nursing Unit Managers of these units were provided a copy of the SAFE CLINICAL HANDOVER-KEY PRINCIPLES FOR SAFE AND EFFECTIVE HANDOVER and a modified questionnaire taken from the same document
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Results of Benchmarking
5/6 response rate
‘Handover’ practices vary widely locally
All units experienced similar circumstances and intrinsic problems
Standard handover formats devised for ‘shift to shift’ settings did not suit
Very few units (1/5) document ‘handover’
4/5 units employ EMR
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EOC and Staff Surveys
CC&HU began engagement with the EOC program in October 2010. This cyclic process begins with data collection. Data is collected in various ways, one of which is observational studies of ward processes and activities
This qualitative data consisted of observations of the environment and staff interactions and also included the application and interpretation of a Questionnaire about Clinical Handover (QCH) in August 2012 and Nursing Workplace Satisfaction Questionnaire (Fairbrother, Jones and Rivas, 2010) in 2010
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EOC and Staff Surveys (Hang in there… He gets interesting in about 3 more slides)
Aspects of the previously applied QCH (2012) were compared with results from an expanded QCH in 2014
Results from the 2014 NWSQ were compared to the previous results from the same questionnaire applied in 2010
A compared sick leave 12 months prior and then after implementation of handover
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Results of Surveys and Observations
EOC observations and staff satisfaction surveys indicate that handover using MOSAIQ is valued by staff and has resulted in greater staff satisfaction and a perception of safer and better co-ordinated patient care.
A reduction in staff sick leave has also been observed in the period after the implementation of handover utilising MOSAIQ.
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An examination of Incidence Reports
A total of 61 incident reports (Incident Information Management System) were examined
Incidents between 16 Aug 2010 and 24 Jan 2014 were examined
Four incidents were noted to concern the communication of clinical information
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Results of this Examination
Two incidents prior to implementation resulted in patients being treated with low neutrophil counts (despite a checking procedure being in place) because this clinical information had not been communicated
Handover inserts another ‘group’ check into existing procedures. No further incidents of this nature have been noted
A third report revealed partially completed chemotherapy orders were discovered during handover for a patient booked for Tx. The potential for chemotherapy to be inadvertently administered was detected
A similar report described incorrect dosages of chemotherapy being discovered during the handover procedure.
These incidents lend support to the handover having improving patient safety
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Chart Audit 50 EMR audited: 25 before implementation and 25 after
Is there evidence a review of blood results by nursing staff occurred on the day of treatment?
Has the patient been previously delayed chemotherapy treatment? Was this because of information discovered during handover?
Is there evidence the patient received chemotherapy education?
Is there evidence these orders/plans were acted upon? • Are there specific medical orders associated with the treatment in place prior
to the scheduled appointment?• Is there evidence of a nursing plan associated with the treatment in place prior
to scheduled appointment?• Is there evidence these orders/plans were acted upon?
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Results of Chart Audit (Nearly there guys…)
An increase was seen in the nursing assessment of patient blood results and the number of patients receiving chemotherapy education, prior to the patient receiving chemotherapy
The handover process has resulted in an increase number of medical instructions being actioned nursing staff
A similar increase is shown in the number of nursing plans being actioned nursing staff
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Conclusions
There now exists a dedicated, formalised, embedded and sequenced process of patient handover utilising MOSAIQ EMR to review patients, which is considered essential and valuable to the nursing practice within the CC&HU. This has positively impacted on the safety and care of patients and lead to improvements in staff satisfaction and feelings of collegiality. This process meets National and local standards and is readily applicable to the local circumstances within the unit described and may possibly prove applicable in other ambulatory settings utilising EMR systems.
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Recommendations1. NSQHS standard 6.2 Establishing and maintaining structured and
documented processes for clinical handover
2. NSQHS standard 6.5.1 Mechanisms to involve patients and, where relevant carers in the clinical handover are in use.
3. This report to be made available to other ambulatory care units
4. Develop quantitative measures/KPIs– Wastage of chemotherapy– Patients OOS– Time in motion– Number of documented ‘handovers’
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Acknowledgements
The hard working CC&HU Nursing Team
Lily Fenech - EOC Coordinator Northern NSW LHD
Stephen Manley – Cancer Systems Innovations Manager, CINSW
Greg Fairchild – Post Doctoral Research Fellow, NaMO
Sue Brooks - NUM, CC&HU TTH