Quality Initiatives: the 22nd ACHS Quality Improvement Awards

Quality Initiatives – Entries in the 22nd Annual ACHS Quality Improvement Awards 2019

Published by: The Australian Council on Healthcare Standards (ACHS) November 2019

© The Australian Council on Healthcare Standards

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Quality Initiatives - Entries in the 22nd Annual ACHS Quality Improvement Awards 2019. The Australian Council on Healthcare Standards.

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INTRODUCTION

The22ndAnnualACHSQualityImprovementAwards2019

TheannualACHSQualityImprovement(QI) Awardswereintroducedin1997to acknowledgeandencourageoutstanding qualityimprovementactivities,programsor strategiesthathavebeenimplementedin healthcareorganisations.

In2019,the22ndAnnualACHSQIAwardswere opentosubmissionsfromalldomesticACHSand internationalACHSImemberorganisations followingtheACHSNSQHS(NationalSafetyand QualityHealthService)StandardsProgram, EQuIP6(EvaluationandQualityImprovement Program),StandardsProgram,EQuIP6Day ProcedureCentres,EQuIP6OralHealthServices, EQuIP6HaemodialysisCentres,EQuIP6Aged CareServices,EQuIP6HealthcareSupport Services,andtheACHSClinicalIndicator Program.

Judgingwasconductedexternallywith separatepanelsofthreejudgesforeachofthe QIAwardscategories:

ClinicalExcellenceandPatientSafety:This categoryrecognisesinnovationand demonstratedqualityimprovementinthe deliveryofsafe,effectivepatientcare.

Non-ClinicalServiceDelivery:Thiscategory acknowledgesademonstratedoutcomeof improvementandinnovationinpatientand/or consumerservicesandorganisation-wide practiceincludingservicesprovidedby communityandalliedhealthorganisations.

HealthcareMeasurement:Thiscategory recognisesorganisationsthathavemeasured anaspectofclinicalmanagementand/or outcomeofcare,takenappropriateactionin responsetothatmeasurement,and demonstratedimprovedpatientcareand organisationalperformanceuponfurther measurement.Healthcaremeasurementcan includedatacollectedfromtheACHSClinical Indicatorprogramorothermethodsof monitoringpatientcareprocessesoroutcomes. Bothquantitativeandqualitativedatacanbe used,howeverthiscategorymustdescribethe initialmeasurement,theanalysisofthat measurement,theaction(s)implemented,and theimprovedmeasurement(s).

GlobalQualityImprovementAward:This categoryisnewtotheACHSQuality ImprovementAwardsin2019.TheGlobal QualityImprovementAwardrecognises organisationsthatareusingAustralian healthcarestandardstostrengthenquality improvementframeworksinternationally.ACHS hasrecognisedtheimplementationof Australianhealthcarestandardsinternationally formanyyears,previouslyawardingHighly CommendedCertificates.

TheGlobalQualityImprovementAwardis selectedfromalloftheSubmissionsreceivedby ACHS.

EachjudgingpanelconsistedofanACHS Councillor,anACHSsurveyoranda representativefromanACHSmember organisation.

Submissionswererequiredtomeetspecific criteriathatwereweightedequally: Judgesassessedalleligiblesubmissionson thefive(5)ACHSprinciplesof:consumer focus,effectiveleadership,continuous improvement,evidenceofoutcomesand bestpractice; 

Judgesassessedadditionalcriteria: improvementinpatientsafetyandcare, measuredoutcomes,applicabilityinother settings,innovationinpatientcareand/or processesandrelevancetotheQIAwards category; 

ThesubmissionMUSTrelatetoaperiodofup tonomorethantwo(2)yearspriortothe yearofentry.

EachwinningsubmissionintheACHSQIAwards receivesaCertificateofAcknowledgement,a QIAwardstrophy,andacashprizeprovidedby ACHS.

ACHSpublishessubmissionsfromall participatingorganisationstoshareand encourageexceptionalqualityimprovement strategiesamongsttheACHSmember organisations.

Theextendedversionofthisdocumentwillbe publishedontheACHSwebsite (www.achs.org.au).

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

NON-CLINICALSERVICEDELIVERY

HEALTHCAREMEASUREMENT

HIGHLYCOMMENDEDSUBMISSIONSBYCATEGORY

The22ndAnnualACHSQualityImprovementAwards2019

CLINICALEXCELLENCEANDPATIENTSAFETY

RoyalWomen’sHospital-Melbourne,VIC QualityandSafety AssessmentandCareoftheJaundicedNewbornatHome CarolynLooney SummaryAbstractpage15

Karitane,NSW

KaritaneToddlerClinic

Internet-ParentChildInteractionTherapy:Improvingaccesstospecialisedparenttraining programsforfamiliesfromruralandremoteareasofNewSouthWales JaneKohlhoff SummaryAbstractpage16

WACountryHealthService,WA SouthwestHospitalsitesandPopulationHealth CareoftheVulnerableChild SharleneAbbott,CarolineVernon,JulieMatters,KatinaJones,AnnLefroy,DonnaGuthridge andMarieO’Donoghue SummaryAbstractpage18

NON-CLINICALSERVICEDELIVERY

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

HEALTHCAREMEASUREMENT

CentralCoastLocalHealthDistrict,NSW

CLINICALEXCELLENCEANDPATIENTSAFETY

WINNER

CalvaryPublicHospitalBruce,inPartnershipwithCapital HealthNetwork

InnovationandRedesignUnit

TrialingaGeriatricRapidAcuteCareServiceintheACT

DrJohnMerchant

AIM

ToestablishaconsumerfocussedResidential AgedCareFacility(RACF)OutreachService basedatCalvaryPublicHospitalBruce(CPHB), toactasaliaisonbetweenacutelyunwell residents,theirrelativesand/orcarers,identified facilitates,LocalMedicalOfficers(LMOs), EmergencyDepartment(ED)staffandACT AmbulanceService(ACTAS),forimprovedcare delivery.

SUMMARYABSTRACT

TheGeriatricRapidAcuteCareEvaluation (GRACE)Serviceisanoutreachservice providingenhancedintegratedcaretoacutely unwellagedcarefacilityresidents.Themodel originatedattheHornsbyKur-ing-gaiHospital andCalvaryPublicHospitalBruce(CPHB)was selectedbytheCapitalHealthNetwork(CHN) throughtendertotrialalikeservicefitforlocal purpose.Thetrialwasjointlygovernedand resourced,overseenbyaProjectBoardwith consumerrepresentation,integratedinto existingsafetyandqualitysystemswithinCPHB, conductedovertheperiodAugust2017to March2019,andservicedfivenorthside residentialagedcarefacilities(RACFs).The locallydevelopedmodelofcare(MoC) includedatelephonesupportserviceforfacility staff,on-sightassessmentandcareprovision, casemanagementwithintheEDandwardstay, andpost-dischargecareifrequired.Aneeds basededucationprogramwasalsoprovidedby GRACEstaff,withcontentbeingidentifiedby localfacilitystaff.Medicalgovernance remainedwiththeattendingLocalMedical Officer(LMO)forcommunitybasedcare,and theAdmittingConsultantforinpatientcare, includingHospitalinTheHome(HiTH) management.Resultsshoweda22%decrease inEDtransfers,a21%reductioninadmissions,a

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

15%reductioninEDShortStayUnit(SSU)ALOS andan8%reductioninALOSforotherward admissionswhencomparedtobaseline.An independentqualitativereviewandadhoc feedbackshowedhighlevelsofconsumer, carerandstaffsatisfactionandexperience. Post-trialtheACTGovernmenthasprovided recurrentfundingtoallowforaphasedService expansionoverthenexttwofinancialyearsto allACTRACFs.

REPORT

APPLICATIONOFACHSPRINCIPLES

1.ConsumerFocus

TheGRACEtrialwasborneoutofagapanalysis ofservicesundertakenbytheCHNwhich identifiedavoidableEDattendancesand hospitaladmissionsofolderpeopleasapriority areainimprovingcareoptionsandexperience forthisoftenoverlookedgroupofhealthcare consumers.

Theaimofthetrialtranslatedintoanumberof highlevelconsumerfocussedtrialobjectives whichincluded:

1.Collaborationwithconsumersandhealth carestakeholderstodevelopaMoCthat provided:

a.Adecisionmakingsupportsystemfor serviceactivation(seeAppendix1), b.streamlinedcommunicationwith,and accesstohospitalbasedservices, c.coordinatedconsumermanagement plandevelopmentinconsultationwithall stakeholders, d.continuingcaresupportandadvocacy overtheacuteillnessphase,and e.aneducationandskilldevelopment programtobeinformedbylocalcare providers(seeAppendix2).

2.ThroughtheMoCpromotesupportofacutely unwellresidentsasclosetotheirplaceof residenceaspossible,and

3.Enhancetheflowandcoordinationofcare foracutelyunwellresidentswhoare transferredtotheacutesystem,andcontinue careasclosetotheirplaceofresidenceas possible.

Theresultantmodelconsistedoffourmain servicearms.Theseinvolvedproviding:

1.Anadvice/support/educationresource toRACFstaff, 2.Acuteassessmentandclinicalsupportto acutelyunwellRACFresidentsattheir placeofresidence, 3.Casemanagementandadvocacyfor RACFresidentswithintheED,withpostdischargesupport,and 4.Casemanagementandadvocacyfor RACFresidentsadmittedtohospital,with post-dischargesupport.

ThehighlevelKeyPerformanceIndicators(KPIs) endorsedbythePBastrialoutcomemeasures wereconsumerfocussedandchosentoassess theextenttowhichtheidentifiedservicegap andcareoptionshadbeenaddressedandthe abilitytosustaintheserviceintothefuture.The KPIsincludedthefollowingqualitativeand quantitativemeasures:

1.Aqualitativereviewofconsumerand staffexperienceandsatisfaction, 2.DecreasedtransferstotheCPHBEDfrom participatingRACFs, 3.Reducedacuteinpatientadmissionsfrom participatingRACFS, 4.DecreasedALOSwhereadmissionwas unavoidable,and 5.Anevaluationofthefinancial sustainabilityoftheServicegoing forward.

Aspartofthecommunicationplan,an informationbrochurewasdevelopedoutlining theGRACEServicetoprovideinformationto consumers,theirfamilyandfriends.The brochurewasdevelopedwithstrongconsumer representation,workingtogetherwiththeCPHB communicationsofficerandServicestaff(see Appendix3).

2.EffectiveLeadership

Governance

Thetrialwasoverseenbyajointgovernance frameworkwhichincludebothCPHBandthe CHN.Thetrialwasconductedaccordingtoa ServiceAgreement(SA)whichoutlinedthekey deliverablesandtimelines.

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

ThePBwasestablishedandcomprisedof representativesfromCHN,CPHB,HealthCare ConsumersACT,aclinicalmanagerfroma participatingRACF,ACTASandLMOsproviding careinthetrialsites.TheCPHBrepresentatives includedstafffromtheED,generalwards, PatientFlowUnit(PFU),HospitalinTheHome (HiTH),GPLiaisonUnit,andgeriatricianservices.

Nursinggovernancewasprovidedviathe existingCPHBstructureforthedivisionof medicalservices.Medicalgovernancefornonadmittedtrialparticipantsremainedwiththe LMO,andwithinpatientteamsforadmittedtrial participants.

Allotheraspectsofthetrial’sclinicaland corporategovernancewereincorporatedinto CPHBbaseoperationalsystems

ThePBprovidedoversightandendorsementof foundationaldocumentsincluding: 1.PBTermsofReference(ToR), 2.Projectinitiation, 3.Projectscope, 4.MoC, 5.Reportingplan, 6.Riskregister,and 7.Communicationsplan.

OverarchingMethodology

ThetrialwasconductedaccordingtoPrince2 projectmethodology.

Ethics

ApprovalbytheCPHBHumanResearchEthics Committee(HREC)wassoughtandprovided priortoServiceimplementation.

Trialsiteselection

TrialRACFsiteswereidentifiedthroughreviewof EDreferralpatternswithintheCPHBcatchment area.Thosefacilitieswiththefivehighestreferral activitywereapproachedtoparticipateinthe trial.Allfivefacilitiesagreedtobefoundational trialsites,withservicescommencing3October 2017.Afurthersitewasadded29October2018 inlinewithstaffrecruitmentandincreased servicedeliverycapacity.

Foracutelyunwellresidentswhowerereferred totheED,and/oradmittedfromRACFsoutside thetrialcohort,theGRACEteamprovidedthe samelevelofservicetoensureconsistencyof caretoallRACFresidentsaccessingacute systemservices.Itwasapriorityofthetrialteam toensureallconsumersenteringtheacutecare systemhadequalaccesstotheGRACEService.

DataSystemandCapture Demographics,Geographics&Activity

TheCPHBPatientAdministrationSystem (ACTPAS),andtheEmergencyDepartment InformationSystem(EDIS),wereusedtocapture patientandserviceactivitydataassociated withparticipatingRACFs.

ThedataassociatedwiththeRACFsitewhich enteredinthelaterstagesofthetrialhasbeen excludedfromthedatacohorttomaintain comparativeconsistencywiththebasedataset. Thein-hospitalserviceactivityprovidedto patientsreferredfromRACFsoutsidethetrial cohorthasalsobeenexcludedfromthedata cohortin-linewiththePBendorsed methodologytoassesstrialoutcomes.

Quality&Safety

TheCPHBRiskmansystemwasusedtotrack qualityandsafetydata.Existingclinical governancemechanismswereusedto manageanyrelatedincidentsandissues, complimentsandcomplaints.Theriskregister wasreviewedbythePBatregularintervals.

Sustainability

ThetrialOccasionsofService(OOS)were mappedaccordingtoActivityBasedFunding (ABF)principlesandmethodology.ExistingCPHB ABFsystemswereusedtoconvertactivityto NationalWeightedActivityUnits(NWAUs).This informationwasusedtodeterminepredicted revenueusingtherelevantefficientprice.Trial costsweretrackedaccordingtoaproject specificCostCentresetupwithinexistingCPHB financialsystems.

ACTPASandEDISdatawasusedtoassess opportunisticsystembenefitsincludingimpact onambulancetransfers,EDcapacityand occupiedbeddays.

Recruitment

Arecruitmentprocessresultedinthe appointmentoftwoseniorregisterednursesas theGRACEServiceteam,combiningabroad skillbasewhichincludedcriticalcare, ambulatorycare,patientflow,hospital administrationandclinicalresearch.TheGRACE teamweresignificantlyinvolvedintheproject frompre-mobilisation,developingthe foundationaldocumentsandimplementingthe communicationsplanwithmultiplefacetoface meetingswithRACFmanagersandstaffand LMOs.

3.ContinuousImprovement

TheoriginalMoCperformedwellagainstthe endorsedperformance,qualityandsafety indicatorsandwasreviewedandadjusted duringperiodsofbothplannedandunplanned reviewbythePB.Thesechangeswerein

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

responsetoactivelearningthroughoutthetrial andincludedalterationstotheactivation pathway,particularlyasitrelatedtotheinability ofRACFstafftocontacttheLMOattimes, changestoafterhoursmedicalsupport,andthe interfacebetweenacuteandcontinuing nursingcare.

Therewereanumberofissuesandkeylearnings whicharoseduringthetrialwhichleadto continuousimprovementtotheService.They weretrackedbythetrialriskregisterand problemsolvedatPBmeetings.Thesearelisted below.

•Thetransferofinformationwasmade challengingbythecomplexanddiffering systemsusedthroughouttheRACFs,LMO settingsandCPHB.Atemplatedocument outliningthecareplanandcareprovided wasdevisedbytheServiceandintegrated intothefacilityinformationsystems.My HealthRecordmayofferasolutiontothis issueinthemediumterm.

•Communicationanddocumentation processeswerereviewedthroughoutthe trialtoensuretimely,accurateand completetransferofinformationbetween allstakeholdersinvolvedinthecareofthe patient,ensuringthecareplanandits progresswasrelayedtoallstakeholders.

•After-hoursmedicalcover,particularly requestsforinputintocaredecisionsbythe patient’sLMO,highlightedtheunrealistic expectationofLMOsalwaysbeing availabletosupportcare.Thisissuewasalso recognisedintheindependentreview formingthebasisofarecommendation.As aresultofthistrialoutcome,fundingfora dedicatedGRACEgeriatricianwas requestedandapprovedintherecurrent businesscase,witha0.5FTEgeriatrician havingbeenappointedtotheGRACE team.Thereisplannedincremental increasesinthisFTEalignedtothephased expansionoftheService.Thisstaffmember isavailabletoprovidesupporttotheService teamalongwithHiTHconsultantsona rosteredbasis.

•Earlyinthetrialtherewasrecognitionofthe highdegreeofintersectioninthedeliveryof GRACEandpalliativecareservices.There wereseveralmeetingsbetweenGRACE andHomeBasedPalliativeCare(HBPC) stafftoaddressthisissue.Improved communicationandreferralpracticeswere establishedbetweenthetwoservices. GRACEtrialstaffwerealsorequiredto attendtheProgramofExperienceinthe PalliativeApproach(PEPA)workshop.This

continuestobeapre-requisiteforallGRACE staff.

•CertainpoliciesexistwithintheRACFsector whichmandatetransferofpatientstothe EDforassessmentinparticular circumstances.Insomeinstancesthe GRACEServiceisabletosubstituteforthat requirement,withongoingsupportand educationaimingtoexpeditereviewof thesepolicies.

•Therewasahighburdenofdataentryon clinicalstaff,withaneedtorecord retrospectivelyonreturntoCPHB.Enabling ITsolutionsaswellasadministrativesupport wasrequestedandapprovedinthe recurrentfundingbusinesscase.

•ConfidenceintheskillsoftheGRACEstaffby allstakeholderswasconsideredparamount tothesuccessofthetrialandongoing acceptanceandsustainmentofthe Service.

•TheabilityofGRACEstafftoassessacutely unwellpatientsinthecommunitysetting andcommunicatetheirfindingstomultiple stakeholders,anddosoconfidently,was consideredakeydriverofthesuccessofthe trial.

4.EvidenceofOutcomes

Demographics

TheagerangeofpatientsaccessingtheService was57-102yearswithamedianageof79.5 years.Morefemalesthanmaleswerereferredto theservice,representing63%versus37%of referralsrespectively(seeTable1).

Table1:GRACEPatientsandActivity1October 2016–31January2019

Activity

OverthetrialperiodtheServicewasreferred377 patientsresultingin2705OOS.Thisrepresented anaverageof24referralspermonth,andan averageof7.2OOSperreferral(seeTable3).

Table3:OccasionsofService

Geographics

Thefivetrialsitesrepresentedacohortof473 residentialagedcarebeds.AllRACFswerein theCPHBcatchment(seeTable2).

Table2:ParticipatingfacilityBedProfilevs ReferralActivity

Theoverallserviceactivationrate,when expressedinOOSdeliveredperRACFbedper annum,was4.3.Whenseparatedintocare deliverysettingsforplaceofresidence,EDand ward,theserviceactivationrateswere3,0.3 and1respectively.

Themajorityofserviceactivityoccurredwithin trialRACFs,with70%(1883)ofOOStakingplace atthepatient’splaceofresidence.Seven percent(180)ofOOSoccurredwithintheED, withtheremaining23%(642)inthewardsetting.

OveralltheaveragelengthofanOOSwas29 minutes.TheaveragelengthofanOOS deliveredatthepatient’sresidence,EDand wardsettingwas31,28and22minutes respectively(seeTable4).

Table4:LocationandDurationofService Delivery

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

Fortheperiodofthetrialtherewasa22% decreaseinEDpresentations,anda21% decreaseinadmissionstoawardforresidents fromparticipatingRACFswhencomparedto thebaselineperiod.

Theaveragelengthofstay(ALOS)foradmissions totheEDShortStayUnit(SSU)forpatients presentingfromparticipatingRACFsdecreased by15%,from9.9hoursto8.4hours,comparedto thebaseline.TheALOSforwardadmissions decreasedbyeightpercent,from5.94daysto 5.45days,comparedtothebaseline(seeTable 5).

Table5:KeyPerformanceIndicatorSummary

Quality,SafetyandIndependentQualitative Review

Data

TherewerefiveincidentscapturedinRiskman relatingtopatientsinvolvedinthetrial.All incidentswereratedSeverityAssessmentCode (SAC)3,thesecondlowestratingavailable. Noneoftheincidentsrelateddirectlytothe Serviceortrialstaff.

Thereweresixin-hospitaldeathsforpatientswho wereparticipantsinthetrial.Allwereexpected, withnonebeingreferredtothecoroner’soffice.

TherewerefourMedicalEmergencyTeam(MET) activationsforpatientswhowereadmittedfrom participatingRACFs,threebeingforgeneral deteriorationandonefollowingafall.TheMET activationrateforpatientsinvolvedinthetrial was2.12per1,000OccupiedBedDays(OBDs) comparedtoarateof4.51per1,000OBDsfor CPHBoverall.

Therewerenoreadmissionstohospitalwithin28 daysforpatientsadmittedfromparticipating RACFs.

ComplaintsandCompliments

Thereweretwocomplaintsreceivedrelatingto theServiceforthetrialperiod.Onewasnotified directlythroughCPHBcomplaintsystems,the otherviaathirdparty.Bothwereinvestigated accordingtoCPHBcustomandpractice,with investigationoutcomesreportedtothePBtothe extentthatprivacyandprocesscompliance permitted.

Multiplecomplimentswerereceivedforthe Serviceduringthetrial,viabothverbaland writtencommunication,fromawiderangeof stakeholders.Generalthemesrelatedto improvedcommunication,standardofcare, andtheabilitytoreceivecareattheplaceof residence.

IndependentReview

AnindependentreviewoftheServicewas commissionedbytheCHNSeptember2018to evaluatetheMoCfromaqualitative perspective.Whilethereportremains commercialinconfidencetherewasageneral findingthatallstakeholdersfeltthatthe objectivesofthetrialhadbeenmetthroughthe MoCimplementationtodateandrelateda highdegreeofsatisfactionandpositive experience.

Sustainability

ModellingshowedtheServicecouldbepartially fundedunderanABFmodel.Thetrialstaffing costs,accordingtothetrialMoC,wereshownto besustainableunderanABFmodel,however

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

corporateoverheadsandsupportstaffingcosts wouldnotbemetbytheprojectedrevenue.

Systembenefitssuchasreducedambulance transfers,decreasedEDreferralsanddecreased ALOSweremodelledtoshowareturnof approximately$712,350tothesystem, accordingtothescopeofthistrial.Inrealitythis benefitisrealisedasreturnedcapacitytothe system,withthecaremovedtothecommunity settingprovidedatlowercost.

DuringFebruary2019theACTGovernment allocated$9.6mtobespentoverfouryearsto sustainandexpandtheServicetobeavailable toallRACFsintheACT.

5.StrivingforBestPractice

ThetrialteamvisitedtheHornsbyKur-ring-gai Hospitaltoobserveandlearnfromthefounding GRACEServiceteam.Theteamwasgenerousin sharingtheirexperiences,learnings,documents andservicereports.Theteamremained availableforcontinuingadviceandcomment throughouttheACTtrial(seereference1).

Thetrialteamalsoresearchedotherexamples ofacutesystembasedoutreachservices providingenhancedcaretoRACFresidents.The StVincent’sHospitalinMelbournewasfoundto operateaResidentialAgedCareIn-Reach(RIR) servicefromthehospital’semergency department(seereference2).Thetrialteam wasabletovisittheserviceteamandbuilta strongrelationshipwiththeRIRservicemanager, whoprovidedcopiesofbasedocumentsand continuingadvicethroughoutthetrial.

Otherserviceswereidentifiedandresearched aspartofthetrialpre-mobilisationincludingthe AgedCareEmergencyModeltrialatGosford Hospital(seereference3).

InvolvementoftheACTAmbulanceService throughmembershipofthePBalongwiththe developmentoftheMoCenabledtransferof learningsfromtheenhancedparamediccare andinterventiontrialspreviouslyconductedby theservice.Thislocalknowledgewasvaluable indescribingthetypesofcareissuesthetrial teamwouldlikelybeinvolvedinatthetrialsites.

Throughoutthetrialtheteamcontinuedto monitormedicalliteratureforintercurrent reportsonlikeservicesandoutcomesoftrials involvingoutreachcaretoRACFresidents(see reference4).

TheCPHBsafetyandqualitysystemswereused tomonitorthetrial.Anyissuesidentifiedwere addedtotheriskregisteranddiscussedatthe PBmeetings.Caremodelsandserviceprovision

werealteredasrequiredtoimprovethepatient andservicestakeholderuserexperience.

INNOVATIONINPRACTICEANDPROCESS

TheGRACEServicerepresentedinnovationin theACTcontextbyofferingapreviously unavailablecareoptionforacutelyunwellRACF residents.WhiletheServicewasmodelledon previouslikeservices,themodelofcare developedwasspecifictothelocalneeds,and includedaninhospitalarmforcontinuedpatient advocacy,compliancewiththeagreedtoand patientpreferredcareplan,andproactive dischargeshoulditbesafetodoso.Thisallowed foranincreasedlevelofconfidenceinthe Servicebytheinhospitalcareprovidersthrough improvedrelationshipswiththeServiceteam, whichallowedforearlierdischarge.

Uniquepartnershipswereformedthroughthe trialacrosstheacuteandcommunitycare systemsthroughthejointgovernancestructure andwidestakeholderinvolvementinthePB. Acuteserviceprovidersbecamemoreawareof thebaselineRACFcaresettingwiththereverse alsobeingtrue.TheLMOsinthetrial,once familiarwiththeServiceandtheskillsetofthe team,werestrongadvocatesfortheuseofthe Serviceandtheimprovedcareofferingtotheir patients.

REFERENCES

1.YazdaniY(2012),GeriatricRapidAcuteCare Evaluation,‘BridgingthegapbetweenAcute andResidentialAgedCare’.

2.LarkinsAetal(2009),ResidentialAgedCare In-ReachClinicalSupportPilotProgram Evaluation.

Wherecrossoverserviceswereidentified,such aswithpalliativecare,processeswere innovatedforandredefinedtoallowforearly caretransfertothemostappropriatecare provider,resultinginimprovedcareand experiencefortheconsumer.

APPLICABILITYTOOTHERSETTINGS

Asaresultofthetrial,theACTGovernmenthas providedrecurrentfundingforaphased expansionoftheServicetoincludeallRACFsin thejurisdictionwithintwoyears.

TheServicemodelwouldbeeasilytransferable tootheracutehospitalsofanysizewishingto commenceaGRACEServicewithsimilarservice streamsandobjectives.

TheServicemodelwouldalsobetransferableto othercaresettings,toincludeenhancednursing careforacutelyunwellresidentswithinahome setting,whichcurrentlyfallsoutsidethescopeof theHiTHservice.

Themodelcouldalsobeappliedtodisease specificoutreachservicesparticularlytargeting chronicdiseasegroups.

TheAustralianCouncilonHealthcareStandards

22ndAnnualACHSQualityImprovementAwards2019

3.WenhamC(2013),AgedCareEmergency ModelEvaluation,GosfordHospital,Central CoastLocalHealthDistrict.

4.ArendtsGetal(2018),Aclinicaltrialofnurse practitionercareinresidentialagedcare facilities.ArchiveofGerontologyand Geriatrics,77(2018)129-132.

AudienceSupportandEducationSummary

ConsumersInformationsessionsatthedesignatedtrialsiteswereprovidedto residents,clients,patientsandtheirlovedones/carers.Thesewerehosted atregularintervalsonagreeddates,andfacilitatedbytheClinical Managers(CMs).Theseeventswereofferedasanopportunitytolearn more,askquestionsandincreaseawarenessoftheGRACEService.

RACFTrialtrainingsessionsforthestaffatparticipatingRACFswereundertaken inDecember2017,May-August2018andDecember2018.Sessions includedinformationonpatientassessmentincludingearlyrecognitionof thedeterioratingpatientandcommunicationtechniquessuchasISBAR (Identify,Situation,Background,Assessment,andRecommendation). Basedonparticipantfeedback,thecontentofthetrainingsessionswas revisedtoexpandonISBARprinciples.

Ongoingeducationandsupportwasprovidedregularly,andneedswere oftenidentifiedbyCareCo-ordinators.Examplesofongoingsessions includedAdvanceCarePlanningandmanagementofurologicalissues anddevices.

Informalandopportunisticteachingwasfrequentlyundertakenbythe GRACEstaffonaone-to-onebasis,forexamplesuprapubiccatheter education.

Asaresultoftheeducationsessionsandup-skilling,severalRACFswere abletobecomeself-sufficientinsomeproceduressuchasuncomplicated indwellingurinarycatheterinsertionandprimarywoundmanagement.

GPsGPvisitswereconductedtoestablishaprofessionalrelationshipwithGPs associatedwiththetrialRACFs.TheCMsintroducedtheserviceand objectivesofthetrial,anddiscussedthereferralpathway,management andgovernanceguidelinesassociatedwithpatientcare.Communication pathwaysandmodalitieswerealsoadaptedtothespecificrequirements oftheGPstofacilitatestreamlinedtransferofinformation.

CPHBstaffAnumberofpresentationstointroducetheGRACEServicewereprovided toCPHBstaff.Thesesessionswereprovidedacrossdisciplinesand operationalmanagers.Theywereprovidedregularlythroughoutthetrial periodandasthetrialprogressed.Thesessionswerealsoamechanism ofobtainingfeedbackontheMoCandprovidingupdatesonoutcomedata tostaff.

CLINICALEXCELLENCEANDPATIENTSAFETY

HIGHLYCOMMENDED

RoyalWomen’sHospitalMelbourne QualityandSafety

AssessmentandCareoftheJaundicedNewbornatHome

CarolynLooney

AIM

1.Toimprovepatientexperiencesbyenabling moremothersandbabiestostaytogether athome,intheimmediatepostnatalperiod byassessingthejaundicednewbornand managingcareathome,whereclinically appropriate,andindoingsoreducethe needforthisgroupofnewborns,topresent totheWomen’sEmergencyCare.

2.Toreleasematernityinpatientresources (bedsandstaff)foralternateacutepatient use.

SUMMARYABSTRACT

TheRoyalWomen’sHospitalintroducedtwo pathwaysofcaretoassessandcareforthe jaundicednewbornathome.

Phase1ofthe2017/18projectinvolvedthe implementationofapathwaywherebyhome visitingmidwivesassessandscreenforjaundice withapointofcaredevice(Transcutaneous bilirubinometer(TcB)).Whereindicatedablood testforSerumBilirubin(SBR)isthenundertaken withthebloodspecimendeliveredbycourier backtothehospitalfortesting.Themidwife followsuptheresultsandcommunicatesthese backtotheparentswithamanagementplan.

Thisenablesmotherandbabytostaywithinthe familyunitinsteadofbeingreferredintothe hospital(Emergency)forassessmentandblood testaswaspreviouspractice.

Phase2involvedthefollow-upand managementofbabiesthatareassessedas

clinicallyjaundiceandrequiremanagement withphototherapy.Apathwaywasdeveloped wherebythehomevisitingmidwifenowconsults directlywiththeneonatalmedicalteamanda managementplanisdevelopedand communicatedbacktotheparents.

Managementoptionsincludes:arepeatblood test(SBR)withfurtherreviewbythehomevisiting midwife;admissiontohospitalforphototherapy oradmissionforphototherapyinthehome.For babieswhorequireactivemanagementi.e. phototherapyandmeetthecriteriafor NeonatalHospitalintheHome(NHITH)a neonataladmissionandreviewisarranged directlywiththeneonatalteamwithoutmother andbabyhavingtopresenttoEmergency. Baby(andmother)aretransferredtothe NeonatalHospitalintheHomeTeamfor ongoingmanagementandcarewith phototherapyundertakeninthehome environment.

Thenewbornscreeningforjaundice,collection oftheSBRinthehome,andfacilitationofa pathwayfordirectassessmentandadmission hasresultedinreducedpresentationsof jaundicedbabiestoWomen’sEmergencyCare. Therewereanestimated420presentations savedfortheprojectperiod(Dec2017-Oct 2018).

Inaddition,themanagementofphototherapy inthehomehasreleasedanestimated329 maternityinpatientbed/cotbeddaysand resourceswhichcanbereallocatedfor alternatepatientuse.(April2018-Oct2018, basedonphototherapyathomepatientdays onNHITH).

HIGHLYCOMMENDED

Karitane

KaritaneToddlerClinic

Internet-ParentChildInteractionTherapy:Improvingaccesstospecialisedparenttraining programsforfamiliesfromruralandremoteareasofNewSouthWales

AIM

Theaimofthisinitiativewastodevelop,pilot-test andpermanentlyimplementAustralia’sfirst community-basedInternet-ParentChild InteractionTherapy(I-PCIT)servicetoenable familiesfromrural,regionalandremoteareasof NewSouthWalestogainaccesstospecialised treatmentandsupportfordisruptivetoddler behaviourdisorders.

SUMMARYABSTRACT

Problem

Childhooddisruptivebehaviourdisorders(DBD), typifiedbyoppositionalityandconduct problems,areaprevalentclassofmentalhealth disordersinyouth(Costelloetal.,2003),and oftenthestartofatrajectorytowardspoor psychiatricoutcomes(Campbell,1995;BriggsGowanetal.,2006).Internationally,the recommendedstandardofcareforDBDsis behaviourally-basedparent-trainingprograms (Comeretal.,2013),ofwhichParent-Child InteractionTherapy(PCIT;Funderburkand Eyberg,2011)hasbeenidentifiedasoneofthe mosteffective.PCITcentresaroundparent-child playsessions,andlivecoachingbyatherapist frombehindaone-waymirrorusingblue-tooth wireless“bug-in-the-ear”microphonedevices.

Karitane,aleadingproviderofearlyparenting servicesinNewSouthWales(NSW),has deliveredPCITtofamiliesinSouth-Western Sydneyforover15years.Positiveclinical outcomeshavebeendemonstrated(Phillipset al.,2008),buttherequirementforfamiliesto physicallyattendtheclinicforweeklycoaching sessionsmeansthatfamiliesfromruralNSW cannotaccesstheprogram,representinga significantservicedeliveryinequity.Inourown qualitativeworkwithparentsofyoungchildren withDBDslivinginruralareas(Kohlhoffetal., 2019)wefoundthatconsumerswerehighly motivatedtoengagein

professionalparentingprograms,butthishad notbeenapossibilityforthemduetotheir geographicallocation.

Solution

Tofindanddeliverasolutiontothisproblem,we undertookthefollowingsteps:

1.Reviewingtheresearchliterature:We reviewedavailabledataandlearnedof preliminaryevidenceoftheeffectiveness andacceptabilityofPCITdeliveredvia video-conferencing(Internet-PCIT;I-PCIT). Intheonlyavailablerandomizedcontrolled trial(Comeretal.,2017),40childrenaged 3–5yearsoldwithDBDsandlivinginalarge USmetropolitancitywererandomly allocatedtoclinic-basedPCITorI-PCIT.Both treatmentsyieldedsignificant improvementsinchildDBDsymptomsbutIPCITwasassociatedwithahigherrateof ‘excellentresponse’.Whilebothconditions showedsimilarparticipantretentionand parent-reportedtreatmentsatisfaction,IPCITwasassociatedwithfewerperceived barrierstotreatment.Thisresearch indicatedthatI-PCITwaseffective,butlittle wasknownaboutapplicationstoreal-world ruralsettingsortheAustraliancontext.

2.Formingateam:Inearly2017,weformeda teamwithrepresentativesfromKaritane, threeNSWHealthLocalHealthDistricts(Mid NorthCoastLHD;WesternNewSouthWales LHD,andSouthWesternSydneyLHD),the DepartmentofFamilyandCommunity ServicesandtheUniversityofNewSouth Wales.Together,theteamdevelopeda conceptforanewI-PCITprogramtobe deliveredbytheKaritaneToddlerClinic, madepreliminaryplans,andformalised rolesofpartneringorganisations.

JaneKohlhoff,SusanMorgan,GrainneO’Loughlin,IreneStrauss

3.NSWHealthInnovationsgrantfunding application:InMay2017,wesubmitteda fundingapplicationtotheNSWHealth–InnovationFund,toestablishandpilot-testa newKaritaneI-PCITservice.InSeptember 2017,fundingwasawarded.

4.EstablishinganAdvisoryGroup:InOctober 2017,weformedanAdvisoryGroupwith representativesfromthepartnering organisations(directors,managers, clinicians,consumers).Thegroupmet quarterlywithemailcommunication betweenmeetings.Thegroup’srolewasto adviseonallaspectsoftheprojectand facilitatecollaborationbetweenproject partners.

5.PilotingI-PCITservice:FromNov-Dec2017 keystepsincluded:(i)formalisingevaluation methodology,(ii)establishinginternal workinggroup,(ii)setting-up procedures/practicalprotocols,(iii) procuringandsetting-uptechnology,(v) recruiting,trainingandsupervisingstaff,(vi) establishingandbuildingreferralbase (advertising/mail-outstoruralhealth professionals/parents,mediaexposure, socialmediaoutreach,sitevisitsto partneringLHDstofosterandstrengthen linkswithlocalclinicians).December2017 toDecember2018wastheI-PCITservice delivery&datacollectionphase.

6.Recommendations:Basedonthesuccess andlearningfromthepilotproject,afinal projectreportwaswrittenandaseriesof recommendationsweremaderegarding integrationofI-PCITintothepermanent servicedeliverymodeloftheKaritane ToddlerClinic.

Outcomes

Amixed-methodsevaluationapproachwas integratedintoourpilotprogramfromthe outset.Outcomes(summarisedbelow)were examinedthroughoutthepilotprojectto identifyissuesandmonitorprogress,andatthe endofthepilotperiodtoevaluateclinical outcomes.

1.Reviewofservicestatistics:Regularreview ofservicestatisticsallowedustotrack projectprogressandidentifyissues.Total numbersofreferralsandtreatment completionswereusedasaindicatorof programoutcomes.

2.Clinicalcasestudies:Twoclinicalcase studieswerepublishedinapeer-reviewed journal(11).Thearticledemonstrated programcontent/processes,thepositive clinicaloutcomesattainedforthesetwo families,andalsohighlightedkey challengesandsolutions.

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

3.Qualitativedata:Qualitativeinterviews wereconductedwith6parentspre-I-PCIT treatmentand7parentspost-I-PCIT treatment.Resultsidentified(i)positive outcomesexperienced,(ii)specific programcomponentsperceivedtobe valuable,and(iii)overallconusmerpositivity aboutInternet-deliveryofI-PCIT.

4.Quantitativedata:Standardisedmeasures wereadministeredpre-andposttreatment. Atanoverallgrouplevel,resultsshowedIPCITtobeassociatedwithreduced disruptivechildbehaviours,increasedchild complianceandincreasedutilisationof positiveparentingskills(ps<.05).

Sustainability

Giventhesuccessofthepilotproject,efforts weremadetoensuresustainability,knowledge transferandscaling.Tothisend,thefollowing stepswereundertaken:

1.InDecember2018,ongoingfunding ($240,000).fromtheNSWMinistryofHealth wasobtainedtocontinueserviceprovision throughout2019.

2.InJanuary2019,aninternalKaritane SteeringCommitteewasformedtodevelop policies/procedurestoensuresustainability, effectivenessandqualityclinicalcare.The I-PCITAdvisorygroupwasalsoinvitedto continueonasapermanentgroup.All memberscommittedtoongoing participation.

3.FromJanuary2019,ongoingI-PCIT educationandsupervisionhasbeen providedforToddlerClinicClinicians.I-PCIT hasbecome“practiceasusual”for cliniciansattheKaritaneToddlerClinic.IPCITservicestatisticsarenowreported regularlyonorganisationdepartmental dashboards.

4.Tofacilitatebroader implementation/scalingacrossAustralia andinternationally,outcomesfromthepilot projectwillbedisseminatedat5 conferences,3peer-reviewedjournals,and viasocialandtraditionalmedia.

HIGHLYCOMMENDED

WACountryHealthService

SouthwestHospitalsitesandPopulationHealth CareoftheVulnerableChild

AIM

Alackofinterdepartmentalandinteragency communicationcanleadtoharmordeathofa child.Theaimofthisqualityimprovementwasto increasethetimelinessandeffectivenessof communicationsbetweenallstakeholders acrossachild’sjourneythroughthehealth system.Thegoalistohavenoadverseevents occurduetothesafetynets,processesand pathwaysthatarenowinplace.Therehasbeen ashiftincultureintheorganisationwiththe outcomebeingthatchildprotectionistruly everyone’sbusiness.

SUMMARYABSTRACT

Thisqualityimprovementwasinitiatedaftera tragicincidentin2017involvingayoungbaby whodied.Thehealthserviceinstigatedareview ofthebaby’sandmother’sjourneythroughthe healthsystemandthetouchpointswith differentservices.Thereviewidentifiedalackof timelyandclearcommunicationand knowledgesharingbetweendepartmentsand partneragencies.Eachteamwasworking withintheirownareaindependentlyhowever didnotshareorhandoveranykeyfactors consistently.Thisidentifiedmanygapsinthe knowledgeofandaboutaclient’sjourney, especiallyavulnerablechild.Withthe introductionofnumerousstrategies,theaimwas topreventanotherchilddyingorbeinghurt, whenlackoftimelycommunicationsand processesletthechildandtheirfamilydown. Asaresultofthisreviewanumberof recommendationsandinitiativeswereidentified andhavebeenimplemented.These recommendationsincludedextensive educationandtrainingforvulnerability, identificationoffamilyriskfactorsandrisk assessmentforallstaff.Reviewof communicationandhand-overprocedures betweenantenatal,midwifery,communitybasedservicesandkeypartners. Implementationofanewelectronicmedical recordriskidentificationandalertprocessand procedures.Improvedsystemstoallowaccess andreviewofclientmedicalrecords,previous

mentalhealthhistoryandstreamlinedreferral processes.

WesternAustralianCountryHealthService (WACHS)Southwestissituatedapproximately 200kilometresfromPerth.Theregionisinthe SouthWestcornerofthestateandcoversan areaofover24,000squarekms.with approximately178,000(ABS2016)population. Thereareover25,000(ABS,2016)childrenaged 0-9years,withover2000birthsintheregion annually.

Theregionhasonemajorregionalresource centre,BunburyRegionalHospitalwherethe majorityofbirthsoccureachyear.Fivesmaller hospitalsitessupportobstetricpatientstobirth, alongwithoneprivatehospital.KingEdward MemorialHospital(KEMH)forWomeninPerthis ourtertiaryreferralcentreforobstetrics. Communitybasedprimaryhealthcareservices aresupportedbysocialworkers,mentalhealth staffandalliedhealthstaff.Communitychild healthnurses(CCHN)offeravoluntaryserviceto allwomenfrombirthto4yearscommencingin thefirstfourteendaysafterbirth.

Whenamidwifeidentifiesanyriskfactorsfora baby/iesormother,aSpecialChildHealth Referralisinitiated,alertingtheCCHNtothese risksandanyactionstaken,forexamplea referraltoasocialworker.Identifiedriskfactors canincludedrugandalcoholmisuse,untreated mentalhealthissues,familydomesticviolence homelessness,andthosefamilieswith involvementwithDepartmentofCommunities: ChildProtectionandFamilySupport(CPFS).

Ourkeypartnersincaringforchildrenand familiesareCPFS,DepartmentofEducation, SouthwestAboriginalMedicalService(SWAMS), GeneralPractitionersandEmergency Department(ED)staff.Ofthetwothousand birthsperyearapproximatelyfifteenpercent areidentifiedasrequiringextracareand supportduetovulnerabilitiesorriskfactors.

Priorto2017,eachWACHSdepartmentand agencyhadlocalprocessesthatoverallworked well,however,inisolationtooneanother.These

SharleneAbbott,CarolineVernon,JulieMatters,KatinaJones,AnnLefroy,DonnaGuthridge,MarieO’Donoghue

processeshadahistoryofbeingadhocin regardtoinformationandcommunication sharingforourfamiliesandchildren.CCHNshad theirownprotocolforoperationalprocessesfor thecareofidentifiedvulnerablepopulations, whichhadbeeninplaceforapproximatelyone year.Atthetimeofthisincident,theprocess includedmonthlyreviewsbyCCHNwithsenior staff,forchildrenwhohadbeenidentifiedas havingvulnerabilitiestoensurethatchildren werebeingfollowedup.Separateprocedures wereinplaceforclinicalreviewofpregnant womenatriskformaternitystaff,andsocial workers.

Asaresultofhighlevelleadershipmeetings includingthosewithkeypartners,a multidisciplinaryapproachwasinitiatedtoclose identifiedgapslookingatallareasoftheclient’s healthjourney.Thisincludedreviewingthe client’sprepregnancyhistory,antenataland postnatalcare,whichincludedaccessto mentalhealthrecordsandotherhospital presentations.Involvementwithkeypartners andhealthservicesresultedinthedevelopment ofMemorandumofUnderstanding(MOU)with agenciestomeetandshareinformation,to ensurethewellbeingofachild.

Asrecommended,therehasbeenanenormous increaseincommunicationvianumerous interdisciplinaryandmultiagencyinteractions thatnowoccur.Thesewereinitiatedfromhigh levelleadershipmeetingsbetween departmentsandpartneragencies.Improved processesandreferralpathwaystosocialwork andtochildhealthserviceshasoccurred.An

increaseinawarenessandtrainingwitha significantnumberofeducationsessionsheldby thePaediatricianwereimplementedandwell attended.Initiationofanowstate-wideChildat Risk(CAR)alertsystemhasplayedasubstantial roleinimprovements.Amajorshiftin organisationalculturehasoccurredenabling changewhichhasbeenledbystrong leadershipandafocusonchildadvocacy.All theseenhancementsareregionwideandnow wellembedded.

Thechangesimplementedinthisquality improvementalignwiththeNationalSafetyand QualityHealthStandards(NSQHS) CommunicatingforSafetyandComprehensive Careandaimedtoimprovecommunication andtheoutcomesforchildrenandfamilies.The changesthatwillbedescribedbelowwill demonstratethatcommunicationand informationsharinghasimproved.

Withincreasingcommunication,theoutcomes forthechildareimprovedbyhavingmultiple departmentsandagenciesallsharingthis responsibility.Theoutcomeforthestaffisthat theseimprovementshaveprovideda frameworkforsafeprocessesforcaringfor vulnerablechildren.Finally,theoutcomeforthe organisationhasbeenanincreaseinawareness ofchildrenatriskandtherobustprocedures haveallowedembeddingthatsafecarefor childreniseveryone’sbusiness.

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

CLINICALEXCELLENCEANDPATIENTSAFETY

TABLEOFSUBMISSIONS

NationalCriticalCareandTraumaResponseCentre

ClinicalGovernanceGroup

EstablishingaNewNationalandInternationalBenchmark-AUniqueApplicationoftheACHSEQuIP6 QualityImprovementFrameworktoAustralia’sNationalandInternationalDeployableHealth EmergencyCapability

DrDianneStephens,JaneThomas

NorthernSydneyLocalHealthDistrict,RoyalNorthShoreHospital

NSLHDClinicalGovernanceUnit/RNSHOrthopaedicWard/RNSHHealthInformationService

H.A.C.KHospitalAcquiredUrinaryTractInfection

Wei(Angie)Pang,JanineCarragher,DenisKoong,RosalieBurns,RosemaryHills,MiriamCattell,Nina Rao,JoTallon

RoyalNorthShoreHospital

NeurosurgeryDepartment,EmergencyDepartment,Children’sWard

PartneringwithSchoolstoRethinkAdolescentConcussion

VickiEvans,DanielleCoates,HelenYoung,LizSwinburn,VinceOxenham

Women’sandChildren’sHospital,SA

ChildandAdolescentMentalHealthServices(CAMHS)

Aserviceapproachtoshareddecisionmakingtoimproveclinicaloutcomesforchildren,young peopleandtheirfamilieswithacuteandhighriskmentalhealthconcerns.

TimCrowley,DrMohammedUsman

RoyalNorthShoreHospital SpeechPathologyDepartment WrittentranslatedtherapyresourcesforpatientswithaphasiafromCulturallyandLinguisticDiverse (CALD)backgrounds

JaclynHooper,KrystalFurey,4thYearUniversityofSydneySpeechPathologystudents:LaurenBassil, JosephineDeng,JapjotKaur,JasmineLo

CLINICALEXCELLENCEANDPATIENTSAFETY

TABLEOFSUBMISSIONS(CONTINUED)

RoyalPrinceAlfredHospital

EmergencyDepartment

CompleteCare:Closingtheloopforourparamedics

Dr.SineadNiBhraonain,TracyMillen,BradleySpinks,PaulaSinclair,NatalieMenzie,SharonCampbell, NobbyAlcala

Karitane

KaritaneToddlerClinic

Internet-ParentChildInteractionTherapy:Improvingaccesstospecialisedparenttrainingprograms forfamiliesfromruralandremoteareasofNewSouthWales

JaneKohlhoff,SusanMorgan,GrainneO’Loughlin,IreneStrauss

MelbourneHealth

NorthWesternMentalhealth

TacklingTobaccoinMentalHealthServices

ShaneSweeney,SuzanneTurner,LorenaChapman,RachelWhiffen,SarahWhite

RoyalPrinceAlfredHospitalandAgencyforClinicalInnovation

NutritionandDieteticsRoyalPrinceAlfredHospital(RPAH);2AgencyforClinicalInnovation(ACI);3. InstituteofAcademicSurgery(RPAH)

AState-wideGastrostomyTrainingProgram

SharonCarey,MelSchier,DavidStorey

WACountryHealthService-SW

PopulationHealthWACHSSW-ChronicConditionCareCoordinationService,Bunbury BunburyChronicConditionCareCoordinationService

KendraMutch,NicoleJeffree,AdamLyndsay,JodiLarke

StAndrew’sHospital,BloodSafeProgram,BloodSafee-learningAustralia,ClinpathLaboratories

CriticalBleedingSimulationProjectGroup

Clinicalsimulationtoembedimprovementsincriticalbleedingmanagement

SharonBlaney,DuncanBamford,AlisonSarles,TrishRoberts,TinaDonaldson,LauraShandra,David Peterson,TrudiVerrall

CLINICALEXCELLENCEANDPATIENTSAFETY

TABLEOFSUBMISSIONS(CONTINUED)

GoldCoastHealth

OccupationalTherapyDepartment

Aninnovativeinterprofessionalmodelenhancingcareforpatientswithcomplexcareneedsinthe hospitalacuteenvironment

JennyNel,MeaganHartley,MareeKrug,PhillipChow,JustineRobinson

RoyalPerthBentleyGroup

SafetyandOrganisationalLearningDirectorate

RPBGSafetyThermometer:asimplefivepointratingtorecogniseareasofexcellenceinclinical safetyandqualityacrosstheRoyalPerthBentleyGroup(RPBG).

RussellTonkin,SamanthaRankin

EastMetroHealthService,RoyalPerthandBentleyGroup

RoyalPerthandBentleyGroup,Service3

RainbowStandardTickAccreditation

JillSpears,BarryHughes,AaronMcArtney,JaneArmstrong

RoyalPerthBentleyGroup

ChoosingWiselySupportTeam

ChoosingWiselyatRoyalPerthBentleyGroup

JessicaCasado,SumitSinha-Roy

MetroNorthHospitalandHealthService–RoyalBrisbaneandWomen’sHospitalandMNHHSOral HealthServices

ClinicalPharmacologyDepartment,RoyalBrisbaneandWomen’sHospitalandHealthImprovement Unit,ClinicalExcellenceQueensland

TheQueenslandOpioidStewardshipProgram–Phase1ofOpioidStewardshipusingtheOpioid PrescribingToolkitincollaborationwithlocalteamsofclinicians.

ChampikaPattullo,BenitaSuckling,PeterDonovan,GarethCollins,JonathanThompson,SallyTaylor, MarkGeorge

SouthWesternSydneyLocalHealthDistrict LiverpoolandMacarthurCancerTherapyCentres

ImprovingradiotherapytreatmentdeliveryforlungcancerpatientsthroughdevelopmentofIntra-

CLINICALEXCELLENCEANDPATIENTSAFETY

TABLEOFSUBMISSIONS(CONTINUED)

WesternSydneyLocalHealthDistrict

NSWHealthEducationCentreAgainstViolence(ECAV)

GraduateCertificateinMedicalandForensicManagementofAdultSexualAssault:Buildingaskilled workforcetorespondtothemedical,forensicandpsychosocialneedsofvictimsofsexualassault DrCarolStevenson,LornaMcNamara,DrEllieFreedman,DrKathyKramer,JoanneCampbell,Mary Poole,MariaWoods,SalmaBadr

QueenslandHealth

TheMentalHealthCo-OrdinationHubandtheCo-Responder

ReducingMentalHealthPresentationstotheEmergencyDepartment:AnInnovativeTri-Agency Collaboration

BenScamarcia,JohnVanBeusekom,EmilyHarding,GillianHayward,TraceyMaGuire,LukeLindsay

WACountryHealthService

SouthwestHospitalsitesandPopulationHealth CareoftheVulnerableChild

SharleneAbbott,CarolineVernon,JulieMatters,KatinaJones,AnnLefroy,DonnaGuthridge,Marie O’Donoghue

WACountryHealthService–SouthWest

RehabilitationTeamBusseltonHospital

BusseltonHealthCampus-“WelcometoRehabilitationVideo”

JennyHoskins,LisaMarshall,HannahThomas,KylieGroves,StephanieDaniels,DanielAnderson

SydneyLocalHealthDistrict-SydneyDentalHospitalandOralHealthServices

CommunityOralHealthClinicsSydneyDentalHospitalsandOralHealthServices

EarlyTreatmentofPatientsNeedingSimpleSurgicalExtractions

DrTruptaDesai

AlburyWodongaHealthDentalService

DentalUnit

IntroductoryWaitlistSession

NicolleDavies,CandaceO’Keefe,SineadMcArdle

SydneyLocalHealthDistrict,ConcordCentreforMentalHealth

OccupationalTherapyMentalHealth

HyperacuteExtendedHoursoccupationalTherapyTeam,ChangingTimesforChangingNeeds JulieBohan

NON-CLINICALSERVICEDELIVERY

WINNER

AIM

Theaimofthisprojectistodesignanddevelop aTotalBodyIrradiation(TBI)Bedthroughthe collaborationbetweenthemedicalphysicsand biomedicalengineeringteamsatRoyalPrince AlfredHospital(RPAH).ThenewTBIbedneedsto addressthedrawbacksofthepreviousdevice andbeabletodeliverimprovedoutcomesin termsofpatientsafetyandcare,operation, timeefficiency,WorkHealthSafety(WHS)and InfectionControlrequirements.

SUMMARYABSTRACT

Background

Patientsreceivingabonemarrowtransplantwill undergoatotalbodyirradiation(TBI)regime, withtheaimofachievingsignificant immunosuppressiontoavoidgraftrejection.The TBItreatmenttechniquevariesfromcentreto centre,dependentonfactorssuchasroom configuration,treatmentdeliveryandpatient positionetc.Asthetreatmentisgenerally deliveredatextendedsourcetosurface distance,thestandardlinearacceleratorcouch cannotbeused.AQIprojectwasproposedat ChrisO’BrienLifehouse(FormerRadiation OncologyDepartmentatRoyalPrinceAlfred Hospital)toimprovethepreviouswooden treatmentbedduetoitsageandcondition whichcouldnotmeetthetreatmentstandard andposedarisktopatients’andoperators’ safety.

Literaturereviewsandmarketresourcinghas shownthatthereisnocommercialproduct availabletopurchase.Externalproduct developmentcompaniesarealsoreluctantto undertakethemanufactureduetothelow quantityrequired,andthecostforexternal custommanufactureishigh.TheMedical

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

PhysicsteamapproachedtheBiomedical Engineering(BME)DepartmentatRPAHto discussthepossibilityofmanufacturingthebed in-houseintheBMEworkshop.

Method

Consultationsandreviewsweremadewith otherRadiotherapycentreslocallyand interstate,consideringeachcentre’sTBIbed. EachoftheexistingTBIbedswasindividually differentandcustommadewiththeirown advantagesanddrawbacks.Themost advancedcurrentoneswhichinspiredour designare: 

LyingTBItrolleyatPeterMacCallum CancerCentre,Melbourne

Advantage:motorisedPerspexscreenfor patientaccessandeasyoperation; Disadvantage:Fixedheightwhich requiresthepatientandoperatorstouse a2-stepfootstool. 

TBIbedatWestmeadHospital

Advantage:Heightisadjustablebyusing ahydraulicpump;

Disadvantage:Thepumpingprocessis noisyandwhileelevatingthebed,the motionisdisturbingforthepatient.

Basedonreviewsandconsultationwiththe multidisciplinarystaff(physics,BME,Radiation Therapists,andClinicians)andpatients,and takingintoconsiderationtheclinical requirements,patientsafetyandexperience, manualhandling,safety,BMEongoing maintenanceandinfectioncontrolaspects,the designcriteriaforthisinnovationdesignwere decidedasfollows:



Heightadjustable:Heightshouldbeeasily variableusingasmooth,silentand reliableelectricalmotor;

Result



Heightrange:Lowestpositionshould allowthepatienttositwithfeetonthe floorwithnostoolrequired;maximum highpositionshouldmeettreatment targetposition;

ThebedhasbeenapprovedbytheTherapeutic GoodsAdministration(TGA)asageneral electricalBedClassIMedicalDevicewithtwo listedintendedpurposes:

1.Toraisethepatienttoanadjustableheight suitablefortreatment.



BeamspoilerPerspex:MoveablePerspex screenswithlockablefeature;secure handlestoensureoperationalsafetyand user-friendliness; 

MechanicalsafetyandIntegrity:Aproper bedandframetoensurethesafe maximumload; 

Multi-directionallockablecastors; Infectioncontrol:Mattressandframe materialsuitableforrepeatedexposure tohospitalgradedisinfectantand cleaningsolutions; 

Cost:In-housemanufacturetoensure thatahighcostcustommanufacturewas notneeded; 

Meetsnationalstandards:Thedesign shouldmeetAustralianmedicaldevices standards.

Thebedwasmanufacturedasperthedesign criteriaintheBMEworkshopledbysenior mechanicaltechnicalofficer,LukeKhoo,in continualconsultationwithamultidisciplinary teamofmedicalphysicists,engineers, radiotherapists,manualhandlingcoordinator andinfectioncontrolconsultant.Amotorised mechanismwascarefullyselectedtoprovidea smoothandsilentmotion;aTGAapproved electricalbedwasusedasthebase.Theother mechanicalstructureswerefabricatedin-house whichincludethetopframeforthebed,lateral guideframe,Perspexbeamspoilers,locking holdersetc.Theprojecttookapproximately15 monthstocompletewithamaterialcosttotalof $10,200.Riskassessmentswerecomprehensively conductedbytheRPAHManualHandlingand InfectionControlManagers,andtheywrote verydetailedreportsontheirassessment.A detailedstudywasundertakentoensure appropriatelabelling,indicatingsafeworking load,pinchpointsandotherhazards.Stickers wereprofessionallymadebyanindustrial companyandattachedtothebed.Atrial periodwasconductedandaUserService ManualandSafeWorkPractiseManualwas writtenpriortoofficialclinicaluse.

Theintentionfromtheoutsetwastoapplyfor TGAcertificationofthetreatmentbed,thefirst ofitskindtobethuscertified.Assuch,wehad builtthebedtomeetAustralianStandards, Work,HealthandSafety,andpatientcomfort requirements.

TheAustralianCouncilonHealthcareStandards

22ndAnnualACHSQualityImprovementAwards2019

2.Tohaverelativelyhomogeneousradiation dosedistributionacrossthebed.

Thebedhasa12monthsPreventative Maintenanceschedule,andaninspection every6monthsforthecastors,electricalsafety andstructuralintegrity.ThisInnovativeTBIbedis oneofthemostadvancedTBItreatmentbeds inclinicaluseworldwide.Itcontinuestobeused intheDepartmentofRadiationOncology DepartmentattheChrisO’BrienLifehouseand hassuccessfullytreatednumerouspatients. Patientshavecommentedonthecomfortand designofthebed.BothRadiationTherapistsand MedicalPhysicistsweredelightedwiththe productasitslighterweightandadjustable heightmadeitsimplertosetupfortreatment, andmovefortransportandstorage.The accessibilityfeaturesbuiltintothedesign significantlyimprovedthetreatmentoperation flowandsavedpreparationtimebyupto75% andtreatmenttimebyupto30%.Additionally, theOH&S-friendlyfeaturesallowforbetterstaff ergonomicsandeasyaccesstothepatientin caseofemergencyordistress.

Conclusion

ThisTBIbedhassetabenchmarkandmany othercentreshaveapproachedustoseekthe possibilityofmakingthesameproduct.The designinvolvedcarefulmechanicaland dosimetrycalculationsofthecombination height,weightandmaterialsrequiredto achieveasafeandaccuratepatienttreatment delivery,withconsiderationforpatientcomfort, safetyandoperationalefficiency.Itisaclever designbasedonthemodificationofa commercialbed,takingadvantageofthe expertiseoftraditionaltreatmentbed manufacturerssuchassafeworkingload, castorsforeaseandsafetyformanoeuvrability, andactuatorextensionperformance.The designreducedproductdevelopmenttimeand simplifiedtheprocessforTGAapproval.Itisa greatexampleofcollaborativeinnovationmadetofitthepurposewhichresolvedaclinical demandandbenefittedpatients.

APPLICATIONOFACHSPRINCIPLES

1.ConsumerFocus



Aninitiativeforimprovingpatientsafetyand thetreatmentexperience

TotalBodyIrradiationtreatmentisaformof radiationtherapyusedasaconditioning regimenforsometypesofLeukaemia, LymphomaorMyeloma.Itisprimarilyusedin conjunctionwithhighdosechemotherapyas partofthepre-conditioningpreparationfor bloodstemcellorbonemarrowtransplant.A courseofTBItreatmentisusuallygiventwicea dayover1-3dayswitheachfractiontaking between45-60minutestocomplete.Itisa dauntingexperienceforthepatientsto maintainstillduringthelengthytreatment, henceprovidingacomfortabletreatment deviceisourprioritytothesepatients.

Arangeofengineeringdesignhasbeenputin totheproducttoprovideextracomfortand safetyforpatients.Auniqueandsilentmotor wasusedtoensuretheliftingprocessissmooth andcalmwhichprovidedthepatientswith greaterconfidenceintreatment.Theadjustable heightenabledpatientstositonthebedatthe lowposition,withoutanystepsorstools,hence reducingtheriskoffalling.Extraspaceonthe bedallowspatientstomoveandchange positionifneededinbetweenradiationdelivery, whichmeansarelieftoalotofpatientsinpoor healthwhoarestrugglingtomaintainthesame positionduringtheentireprocedure.Quick releaseheadandfootPerspexallows immediateaccesstothepatientincaseof emergencyordistress,suchasvomitingor cardiacarrest.



Publicinformationisprovidedtopatients andinductionisgivenbeforetreatment

Thereisdetailedtreatmentinformationwitha pictureofthisTBIbedavailabletopatientsand publicontheLifehousewebsiteandan inductionisprovidedtothepatientsoneweek priortotreatment,whichincludesan explanationofusingtheTBIbedandsafety precautions.



Userfriendlyfromaclinicalperspective

RadiotherapistsandMedicalPhysicistsare responsibleforthepatient’ssetupandradiation deliveryduringtreatment,andprovidequality control,transportingandstoringtheTBIbed.The TBIbedhasdetailedsafetyandmanual handlingfeaturestoensurethetreatmentstaffis workingsafely,withoutinjury,whiletheyfocuson thepatients.Thesefeaturesinclude transportationhandlesoneachsideofthebed, aspeciallydesignedtooltoassistalignmentof thewheels,whichalsomitigatestheneedfor

repetitivebending,obviouslabellingforpinch points,andtheslidingdesignofthePerspex beamspoilerscreenwhichallowsstafftoavoid excessivelifting.TheTBIbedneedstobe transportedandoperatedbytwostaff membersasdocumentedintheSafeWork Procedureandevaluatedbythemanual handingcoordinator.

2.EffectiveLeadership



Teambuilding:amultidisciplinaryteam

TheprojectwasinitiatedbytheMedicalPhysics team,investigatingthepossibilityofbuildingan in-housemanufactured,highstandardmedical devicetoreplacethepreviouswoodenbed whichconstantlyposedanOH&Srisktostaff andpatients.TheBiomedicalEngineeringRPAH mechanicalteamhadbeenknownformany projectswherespecifieddesignandfabrication weremadetoassistresearchprojectsand enhancethesafetyandefficiencyofclinical applications.Amultidisciplinaryteamwas formedwhichincludedmedicalphysicists, biomedicalengineers(electronicsand mechanical),radiationtherapists,amanual handlingcoordinatorandinfectioncontrol manager.Thispermittedeachteammemberto providetheirexpertiseintheirfield,whichwas thekeytothesuccessfuloutcome. 

Consultationandcollaboration

TheDirectorsofBiomedicalEngineeringand MedicalPhysicsofferedgreatsupportforthis projectandprovidedstrategicdirection throughthedesignandmanufactureprocess. Meetingsandregularreviewwereconducted toensurethesuccessoftheprojectandstaff memberscollaboratedwellwithexcellent communication.Theendproductdiffered slightlyfromtheoriginaldesign;howeverthe constantcommunicationwiththe multidisciplinaryteamallowedtheorganic evolutionofthedesignintothefinalproduct. Thiswasintheformofreviewsateachstageof themanufacture,ensuringallteamswere satisfied,orconsultingonanyrequiredchanges, beforemovingontothenextstage.

Riskassessmentandmitigation RiskAssessmenthasbeenconductedasper NSWhealthriskmanagementpolicyby consultationwiththebelowteam:

RegulationandMonitoring

ThisTBIbedisthefirstandonlyTGAapprovedTBI treatmentbedwhichhasbeenmanufactured inahospitalbytheBiomedicalEngineering Department.TGAapprovalallowedthenew devicetobeusedinaregulatedmannerand mitigatetheclinicalrisk.BMEcontinuesprovide consultationandmonitoringoftheTBIbedand provideasustainableserviceplanwithspare partsandtroubleshootingguide.

3.ContinuousImprovement

Therewereseveraldrawbacksandsafetyrisks withthepreviouswoodenbedasbelow:



ClinicalRequirement(MedicalPhysicist):The TBItechniquerequiresaPerspexscreento increasetheentranceradiationdoseand scatter,orspoil,theradiationbeam,aswell asimprovevisibilityandeaseofalignment. Thesidepanelsontheoldwoodenbed weretremendouslylargeandheavysheets ofPerspexwhichhadtobemanually loweredoutwardsanddown,posingan OH&Shazardtothestaff,andhindered accessibilitytothepatientincaseof emergency.Thelengthandwidthofthe bedneededbeincreasedforpatient comfortandpositioning,andeaseof accesstoplacenecessarytreatment accessoriesandradiationdosemonitoring devices.

accesstothepatientandminimisedspace requirementswhenmovingthescreen. 

PreventativeMaintenanceand troubleshooting(BME):Thewoodenbedisin NotSafeforClinicalUse(NFCU)condition withnoestablishedmaintenanceschedule. Thenewdesignshouldensuretheproduct meetsAustralianStandardsandissafefor clinicalusewithaPMschedule, troubleshootingguidesandspareparts. 

InfectionControl:Thewoodenbedhasa foammattressandanimprovementwasto replaceitwithamoreinfectioncontrol compliantslimline,medicalgrademattress. Thiswouldpermitthestafftouseclinical approvedchemicalstowipedownthe mattressbetweenpatientsandensuring therearenofoldsorcornerwhichcould harbourtransmittablediseasesandgerms. Additionally,thewoodenpanellingwasnot compliantwithinfectioncontrol.

Toaddresstheabove,theproductwas developedthroughthebelowprocedureand continuousimprovementhasbeen implementedthougheachstepfromconcept toafinishedproduct:



PatientSafetyandExperience:Thewooden bedwasbuiltwithafixedheight.Patients neededtousea2–stepstooltoenterin. However,manyoftheTBIpatientslacked mobilityandwereinpoorphysical condition,makingitdifficulttoenterthebed withthestool,whichalsoposedasignificant riskoffalls.Thetreatmentnormallytakes4060minutestwiceaday,andrequiresthe patientstolayverystill.Amorecomfortable bedspacewouldsignificantlyenhancethe patient’sexperience.Inaddition,amore professionallookingbedwouldincreasethe patient’semotionalconfidenceforthe treatmentandtheorganisationimage.

Animportantdesignconsiderationofthisbed wastheheightadjustmentcriterion,thatitbe manufacturedtoourspecificationsderived fromconsultationwiththetherapistsand patients.Wearrivedatacomfortableandsafe lowheightwhichallowedeaseofuseand facilitatedpatient’sentryandexittoandfrom theTBIbed.



Manualhandlingsafetyanduserfriendly (RadiationTherapistandMedicalPhysicist): Theoldwoodenbedhadnoproperhandles fortransportandthewoodpanelblocksthe lineofsightwhenmoving.Itisonly accessiblefromthelateralsideswhich madeitdifficultforstafftoplaceand positiontreatmentaccessories.Thestaffalso neededtostandonthestepstooltosetup patients,whichalsoposedafallrisk.Theside Perspexscreenopenedinafolding-out methodwhichrequiredextraforceand space.Thepreferreddesignisaslide downwardsforbetterOH&S,easeof

4.EvidenceofOutcomes

Theinnovationandqualityimprovement outcomeshavebeenevaluatedinthebelow tablewithdetails:

5.StrivingforBestPractice

TheTBIbedhassetabenchmarkandmany othertreatmentcentreshaveapproachedus forthedesignanddevelopmentprocess.We havereceivedpositivepatients’andstaff feedback.

TheTBIbedhaswonsecondprizeintheAustralia BiomedicalEngineeringInnovationAward (ABEIA)2019andwaspresentedattheSMBE conferencewhichisrecognisedinBiomedical Engineeringasagreatexamplefordesignand manufactureclinicalapplications.

Furtherimprovementscouldbemadeby sourcingalternativematerialswhichhavestrong mechanicalpropertiesbutlighterweightand framefixationtechniques.Thiswoulddecrease theframeweightandimprovethemaximum loadingcapacity.Itwillnotonlyallowmoreand heavierpatientstobetreatedbutalsomakeit easiertotransportthebed.

INNOVATIONINPRACTICEANDPROCESS

AsthereisnocommerciallyavailableTBIbed, thisproductisoneofthebestavailableTBI devicesinAustraliawiththebelowinnovative features:

SlidedownandsecurelockPerspexscreen

Silentmotorforasmoothandsteadyliftfrom lowtohighposition

Anin-housedesignedandbuiltproductwith alowcost

ThefirstTGAapprovedAustralianStandard medicaldeviceforthepurposeofTBI treatment

APPLICABILITYTOOTHERSETTINGS

Thisproducthasbeenusedasabenchmarkof theTBItechniqueandpavesthewayto

standardisedandimprovedTBItreatment outcomes.Thedesigncouldbeadoptedby othercentresnation-wideandasaglobal reference.

BiomedicalEngineeringplaysanimportantrole inthehospital.Thesuccessfuloutcomeofthis projectsetsanexampleofhowBMEcanhelp clinicalstaffintheresearchanddevelopmentof projectsandbuildingclinicaldevicesand applicationsinaregulatedenvironment.

REFERENCES

1.VanDyk,J.(1986)Thephysicalaspectsof totalandhalfbodyphotonirradiation.New York,N.Y:AmericanInstituteofPhysicsforthe AmericanAssociationofPhysicistsin Medicine.

2.Block,Alecetal.(2017)Low-dosetotalbody irradiation:anoverlookedcancer immunotherapytechnique.Journalof RadiationOncology.[Online]6(2),109–115.

3.CancerInstituteNSW.(2019)482-Totalbody irradiation(TBI)|eviQ.[Online]Availableat: https://www.eviq.org.au/patients-andcarers/patient-information-sheets/482-totalbody-irradiation-tbi[Accessed5September. 2019].

4.ChrisO'BrienLifehouse.(2019)TotalBody Irradiation|ChrisO'BrienLifehouse.[Online] Available at: http://www.mylifehouse.org.au/departments /radiation-oncology/total-bodyirradiation/#1461298726931-e6f1203b-53d3. [Accessed05September2019].

5.NSWGovernment(2019)RiskManagementEnterprise-WideRiskManagementPolicyand

6.Framework–NSWHealth.[Online]Available at: https://www1.health.nsw.gov.au/pds/Active PDSDocuments/PD2015_043.pdf.[Accessed 5September2019].

Appendix2:SpecificationofthenewTBIbed

NON-CLINICALSERVICEDELIVERY

HIGHLYCOMMENDED

RoyalPerthBentleyGroup EmergencyDepartment

AIM

TheVolunteerConciergeServicewascreated toprovideaninterfacebetweenstaffwithinthe clinicalareaoftheEmergencyDepartment(ED) andthefamily,carerorsupportpersonintheED waitingroom.Thisservicewasimplementedto aidthetimelyprovisionofasupportperson(s)to patientsreceivingcarewithintheRPH EmergencyDepartment,therebyimproving carepartnershipsandpatient/consumer experience.Asecondaryaimwastoreducethe occurrenceofepisodesofviolence/aggression intheEDwaitingroomrelatedtodelayed accesstopatientsorprovisionofinformationon patientstatus.

SUMMARYABSTRACT

Thevolunteerconciergeteamwasintroduced totheEDinJanuary2018.Acoregroupof volunteerswereorientatedtotheED,and workedcloselywiththetriageliaisonnurse.This rolewasintroducedtoimproveourserviceto patientsandrelatives,andsupplementthe nursingcomponentofconsumerfocusinthe waitingroom.Theconsensusofstaffand volunteersisanobservedincreaseinconsumer satisfactioninthewaitingroomaswellashigh rateofstaffsatisfactionwiththevolunteers themselves.Thishasalsobeenreflectedina steadyincreaseinpatientsatisfactionafterthe implementationoftheservice.Theconcierges alsofacilitatetheEDtodeliveroncomponents ofTheAustralianCharterofHealthcareRightsfor patients,specificallytherightstorespect, partnershipandinformation.Nowthatthe volunteersarethoroughlyembeddedinour servicedeliverytheEDhasbeenableto improvethetriagemodelofcareandprovide moreseniornursingleadershipinthisarea, benefitingbothstaffandpatients.

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

VolunteerConciergeProjectintheEmergencyDepartment

SarahLouiseMoyes,JulieKnuckey,HayleyMakuch,SimonElliott,SaraLavis

NON-CLINICALSERVICEDELIVERY

HIGHLYCOMMENDED

RoyalPerthBentleyGroup

CentreforWellbeingandSustainablePractice/PostgraduateMedicalEducation

Well,Well,Well–Agoodstateofbeing

RichardRead,MichaelHertz,NicolaFrew,LucyKilshaw

AIM

Webelievethateverypersonconnectedwith RoyalPerthBentleyGroupdeservesthebest possiblecareandwellbeing.Tothatend,we providecompassionatespiritualcarefor patientsandtheirlovedones,servicesto enhancethewellbeingofouremployees, advocacyforculturalchangetobettersupport thesevaluesandprofessionaleducation anchoredinthevaluesofreflectiveand compassionatepractice-allundergirdedby rigorousresearchandprofessional collaboration.

SUMMARYABSTRACT

InFebruary2019,theRoyalPerthBentleyGroup (RPBG)launchedtheCentreforWellbeingand SustainablePractice(CWSP)atRoyalPerth Hospital(RPH)tomoreaccuratelyreflectthe evolvingperspectiveandpracticeofSpiritual Care.TheCentrebringstogetherspiritualcare practitionersprovidingcompassionatecarefor patients,educationprogramsforreflectiveand compassionatepracticesuchasClinical PastoralEducation(CPE)andprofessional developmentcoursesaswellasassociated researchprojectsandconference presentations.Thesuccessofourapproachis evidencedbyincreasingrequestsfromother hospitalstoteachourprogramstotheirstaff.

OurteamoftrainedSpiritualCarepractitioners provideanexceptionalstandardofspiritually andculturallyappropriatecare,offering patientstheopportunitytoexploreissuesarising amidsttheirhealthchallenges.In2018,ourteam provided25,000one-to-onepatientvisitswith over6,000hoursofspiritualcaredelivered.

Theexpansionofourprogramstoincludestaff hasitsoriginsin2016,inresponsetothesuicide ofajuniordoctor.Widespreadconsultation resultedinthecreationofaDoctors’Wellbeing

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22ndAnnualACHSQualityImprovementAwards2019

Officer(WBO)positionsourcedfromwithinthe thenPastoralCareDepartment.Anadditional benefitofthiswastheopportunitytodrawon theexpertiseofthedepartment’sCPEEducator indevelopinganinnovativepeergroupmodel forjuniordoctors.

Overthepast3years,thenumbersofbothjunior medicalofficers(JMOs)contactingtheWBOfor individualmeetingsandinternsparticipatingin voluntarypeergroupsessionshassteadily increased.Thebenefitsofthesesessionsare evidentintheAustralianMedicalAssociation WA’sHospitalHealthChecksurveyofJMO wellbeing,showingthatRPHisthebest-ranked publichospitalformoraleandculture(Wood,R etal,2018).

ThesuccessoftheDoctors’Wellbeingprogram wasthecatalystfortheexpansionofwellbeing servicesforallstaff.Withthestatedgoalof becomingAustralia’ssafesthospitalgroup,the issueofaddressingstaffcareandwellbeing becamecrucialtoimprovingpatientcareand outcomes.Ahospital-wideeducationprogram hasbeenlaunchedunderthename‘Bonstato’ (‘goodstate’)thegoalofwhichistoplacea trainedWellbeingChampionineachhospital teamtofosteremployeewellbeing,team cohesionandapositiveworkenvironment.

CWSPhasalsoembracedanimportantrolein RPBG’sresponsetoincidentsthatimpactwhole teamswithinourworkforce.Alongside mandatoryclinicaldebriefing,CWSPoffers teamwellbeingsessionswherememberscan reflectonandsharetheimpactoftheir experiences.Thesesessionsarereceivingstrong supportfromstaffaffectedbysuchevents. Ongoingindividualsupportandreferralto additionalservicesarealsoofferedwhere appropriate.

TheBonstatoWellbeingtrainingprogramis anchoredintheprinciplesofCPE,an internationallyrecognisedfoundationfor trainingSpiritualCareProfessionalsintheartof reflectivelistening,spiritualassessment, therapeuticresponseandinterdisciplinary collaboration.TheaimoftheCPEprogramisto promotereflectivepracticeandspiritualcare skillsthroughouthealthcare,educationaland industrialcontexts,especiallybyandforthose whoembraceamoresecularspirituality.Inthe pasttwoyears,numbersofRPBGCPEapplicants haveincreaseddramatically,tonearlytwice thenumberofavailablepositions.

Thesecourseshaveenabledstafftorecognise thatspiritualcareisanessentialcomponentof careforpatientswhoarestrugglingwith meaning,relationshipsandasenseofpurpose. Staffthemselvesarewrestlingwiththesesame issuesastheyexperiencethepersonalimpactof exposuretostressfulandchallengingsituations. Theseeducationprogramsareakey componentofimprovinghospitalculture.

CWSPisdrivingorganisation-widecultural changeonanumberoflevels.WiththeDoctors WellbeingProgramempoweringJMOstofind theirvoiceandlearntoadvocatefor themselvesandtheirpeers,theywereableto raisetheconversationaboutunpaidovertimein theappropriatearenaleadingtoourExecutive Directorgoingonrecordin2017tostatethat unpaidovertimeforJMOsatRPBGwillnolonger betolerated.

Furthermore,thenotionofwellbeingbecoming moreentrenchedandreinforcedbythe Executiveisevidencedthroughincreasingcalls onCWSPforstaffsupport.Intheaftermathofa recentviolentincidentwhereanursewas assaultedbyapatient,CWSPwasapproached toprovidesupporttomultipleteamsaffected bytheincident.

OurExecutiveDirectorrecentlywrotetoall RPBGstaffpromotingBonstatosaying,‘Iwould personallyliketoseeeachwardandareainour

hospitalchampioningwellnessandwould encourageallstafftoconsiderattendingoneof thesecourses.’(RPHNews,Messagefrom ExecutiveDirector,5July2019).Theenthusiastic employeeresponsetoparticipationinBonstato withfullysubscribedcoursesacross2019has resultedinfundingforadditionalCWSPstaff.

CWSPiscurrentlyundertakingtworesearch projects:aJMOWellbeingProjectstudyingthe impactofparticipationinpeergroupsinwhich preliminarydataanalysisdemonstratesthe correlationbetweenincreasedresilienceand participationinpeergroupsandaNursing Wellbeingprojectassessingtheimpactof spiritualcarepracticesonnursewellbeing. Nursingpeergroupsarecurrentlyinsessionwith finaldatacollectionscheduledforlate November.

Interestin‘theRPHmodel’hasexpanded beyondRPBG.Over2019/20,agrantfromthe PostgraduateMedicalCouncilofWA(PMCWA) toCWSPissupportingaseriesoffull-day educationalworkshopsforJMOsandmedical educatorsfromotherhospitalsacrossWA. Sessionsfortheremainderof2019arefully subscribedandrolloutwillcontinueinto2020.

Ourvisiontocareforpatients,staffandhospital culture,supportedbyeducationandresearchis beingincreasinglyembracedbyotherhospitals andhealthservicesacrossWA.Recognition beyondWAisevidencedbyregular presentationsatnationalmedicaleducation meetings.Furthermore,in2019,CWSPwas awardedaBestofCareAwardforOutstanding SpiritualCareTeambySpiritualCareAustralia, thepeakprofessionalbodyforspiritualcarein Australia.

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NON-CLINICALSERVICEDELIVERY

TABLEOFSUBMISSIONS

NorthernSydneyLocalHealthDistrict Workforce&Culture FluPortal:Enablinglargescalevaccinations PavinGovinda,LauraBrain

EpworthHealthcareRichmond FoodServices TransitiontoExcellenceThroughRoomServiceDining NazimBayrak,DeirdreMcKaig,NoeleenXerri

RoyalFlyingDoctorService–Tasmania MentalHealthProgram FromGoodtoGreat–PrimaryMentalHealthProgramRFDSTasmania NicoleGrose,ZoePage,JohnKirwan

SouthernAdelaideLocalHealthNetwork ConsumerEngagementUnit ToListen,Act,MakeBetter,Together…Thejourneyofaco-designedConsumerEngagement Framework,Planandorganisationaloperatingprinciple. MellitaKimber,PeterKing

RoyalPrinceAlfredHospital,inpartnershipwithChrisO’BrienLifehouseMedicalPhysicsTeam BiomedicalEngineeringDepartment CollaborationandDevelopmentofanInnovativeTotalBodyIrradiation(TBI)BedfortheBestPatient

HEALTHCAREMEASUREMENT

WINNER

RoyalNorthShoreHospital IntensiveCareUnit ReducingInappropriateArterialBloodGasTestinginaQuaternary IntensiveCareUnit

DrOliverWalsh,KatelynDavis,DrJonathanGatward

AIM

Toidentifytheindicationsforarterialbloodgas (ABG)analysisinourIntensiveCareUnit(ICU) andreducethenumberofunnecessaryABGs performed,withoutcompromisingpatientcare.

SUMMARYABSTRACT

Introduction:Arterialbloodgas(ABG)analysisis themostfrequentlyorderedpathologytestin theIntensiveCareUnit(ICU),carryingahigh costandcontributingtoiatrogenicanaemia. Orderingislargelydrivenbyculturalfactorsand asignificantproportionoftestsarenotclinically indicated.

Objectives:ToidentifytheindicationsforABG analysisintheICUandreducethenumberof inappropriateABGswithoutcompromising patientcare.

Methods:Themultidisciplinaryprojectteam surveyedtheindicationsforABGanalysisatour 58-bedquaternaryICUduringfortnightlyperiods beforeandafteramultifacetedintervention. Thisconsistedofseveraleducationinitiatives targetingmedicalandnursingstaffandthe introductionofaclinicalguideline.Thenumber ofABGsperformedfromJulytoDecember2017 (pre-intervention)wascomparedwiththe numberperformedduringJulytoDecember 2018(post-intervention).Testsweredefinedas inappropriateifperformedatregulartime intervalsinastablepatient,atchangeofshift, whentakenconcurrentlywithotherbloodtests, inresponsetoadecreaseinventilationor oxygendelivery,orafteratreatmentwas ceasedinastablepatient.Thestudywas enrolledonthelocalQualityImprovement ProjectsRegisterandethicalapprovalwaived bythelocalethicscommittee.

Results:TheproportionofinappropriateABGs decreasedfrom54.8%to28.9%betweenthe twosurveys.ThenumberofABGsdecreased

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

from33,005inthefirstsix-monthperiodto22,408 inthesecond(a31.3%reductionwhenadjusted forICUbed-days,p<0.001).Thiscorrespondsto anaverageof4.6ABGsperbed-dayduring July-December2017comparedto3.1perbeddayinthepost-interventionperiodofJulyDecember2018.AllfourICU‘pods’ demonstratedadecreaseinthetotalnumber ofABGsperformedbyatleast20%.This representsanannualsavingofapproximately $800,000,aswellas100litresbloodand1,800 nurse-hours(approximately1.0FTE).Therewas nosignificantdifferenceinthestandardised mortalityrate(APACHEIII)betweenthetwo periods(0.65vs0.63,p=0.22).Initialanalysisof July2019datashowedanaverageof3.2ABGs perbed-day;indicatingdurabilityofthe changeinpracticebroughtaboutbyour intervention.

Conclusion:Clinicianeducationandthe implementationofaclinicalguidelineresultedin asubstantialdecreaseinboththeproportionof inappropriateABGsandthetotalnumber performed,resultinginsignificantcostsavings.If similarresultscouldbeattainedinmanyother ICUsinAustraliaandNewZealandthiswould leadtodramaticcostsavings.Thisprojectis applicabletoothercriticalcareareassuchas coronarycareunits.

REPORT

APPLICATIONOFACHSPRINCIPLES

1.ConsumerFocus

Arterialbloodgas(ABG)isarapidpoint-of-care testthataccountsforover80%ofalltests orderedintheintensivecareunit(ICU)setting (Ullman2016,Astles2009).Onaverage4-8ABGs areperformedperpatientperday,withthe frequencyoftestinggenerallyproportionalto patientacuity(Ullman2016,Merlani,2001,

Roberts1991,Pilon1997).Theprocessingfeefor eachtestinNorthernSydneyAreaHealthDistrict is$35.34andtheconsumables(syringes,gauze, alcoholwipe)accountforafurther$1.91per ABG,bringingthefinalcostperABGto$37.25. Thetestrequiresapproximately5mLofthe patient’sbloodandatleastfiveminutesofthe bedsidenurse’stimetoperform.

Priortothisprojectour58-bedquaternarylevel ICUperformedapproximately65,000ABGs annually.Thisequatestoover$2.4millionin processingfeesandconsumables,andrequires morethan330litresofourpatients’bloodaswell asover5,500nurse-hours(morethanthreefull timeequivalentstaff).Performingunnecessary ABGshasseveraladverseimpactsonpatients, inadditiontotheobviousfinancialimplications. Mostimportantlythebloodlosshasbeenshown tocontributesignificantlytothedevelopmentof iatrogenicanaemiaandsubsequentneedfor bloodtransfusion,theso-called“anaemiaof chronicinvestigation”(Barie2004).95%ofICU patientsareanaemicbyday3andalmosthalf receiveredcelltransfusionsduringtheirICU admission(Corwin2004,Rodriguez2001).Blood transfusionscostover$400perunit(Australian RedCross,2016)andareindependently associatedwithincreasedlengthofstayand mortalityincriticalcarepatients(Corwin2004, Vincent2002).30%ofalltransfusionsincritical careareattributedtophlebotomy(Hayden 2012,Corwin1995).Otherdetrimentaleffects includeincreasedriskofinfectiondueto frequentlyaccessingarterialcatheters, discomfortandinterruptiontosleepwiththe subsequentincreasedriskofdelirium.Finally,as wellasthetimetakenperformingthistask,there isincreasedriskofsplashinjurytostaffeverytime anarteriallineisaccessed.

2.EffectiveLeadership

ThecoreprojectteamincludedanIntensive CareRegistrar,IntensiveCareConsultant,and the‘QualityCo-ordinator’IntensiveCareNurse. Additionally,thereweretwoclinicalnurse ‘champions’ineachofthefourseparateICU podswhowereinvolvedinthedisseminationof theeducationalcontentandadvocatedforthe surveystobecompleted.Thismultidisciplinary approachenabledustoidentifythevarious impactsthatexcessiveABGsamplinghadon thedeliveryofhigh-qualitypatientcare.The teammetatleastmonthlyintheleadupto implementation.Athoroughreviewofthe literatureconsolidatedourknowledgeabout thetopic.Wethendesignedamultifaceted educationinterventionwhichwasdeliveredin theinterimsix-monthperiod(January-June 2018)betweenthetwosix-monthlystudyperiods (July-December2017and2018).

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Theinterventionconsistedofthreemajor components.Anin-servicewasdevelopedthat focussedonthecost,numberandreasonsthat ABGswereperformed,aswellasacase-based discussionofacceptableandunacceptable indications.Thiswasdeliveredbytheclinical nursechampionsad-hoc,approximatelytwice weeklyineachpodfor12weeks,whenclinical dutiesallowed.Thesesessionswereattendedby 70%ofthe223nursingstaffandmanyofthe juniormedicalofficers.Secondly,ourproject teampresentedtwiceatthelocalICUQuality Forumwhichgaveallmedicalandnursingstaff theopportunitytocontribute.Lastly,aclinical guidelineforABGtestingwasdevelopedin consultationwithallspecialists,fellowsand seniornursesintheICU(seeappendix5,figure 20).Minoraspectsofourinterventionincluded displayinginformationonpostersaroundthe ICU,writinganarticleeachmonthinthelocal ICUnewsletterandpostingonprivatesocial mediagroupstoupdatestaffontheprogressof theproject.

Theinterventionwasdevelopedunder guidancefromtheIntensiveCareBestPractice Group,oftheAgencyforClinicalInnovation.It wasendorsedbytheICUDirectorandICUNurse Manager.Regularfeedbackwassoughtfrom theentireIntensiveCarestaffbody.

3.ContinuousImprovement

WeinvestigatedthelocalindicationsforABGs byconductingasurveyduringafortnightinthe pre-interventionphase(seeappendix2,figure 13).Theseresultswerecomparedtoanidentical timeperiodafterourintervention.Wethen comparedthenumberofABGsperformedover asix-monthintervalineachofthefour“pods” (twogeneralICUs,onecardiothoracicICUand oneneurointensivecare)beforeandafterthe intervention.Resultswereadjustedfor occupancyusingICUbed-days.

Apilotstudywasconductedduringthe fortnightlysurveyperiodsinboththepre-and post-interventionphases.Resultsfromthis suggestedadecreaseofgreaterthan40%in bed-dayadjustednumberofABGsasa consequenceofourintervention;2869vs1397 ABGsperformedwithlessthan8%differencein occupancybetweentheperiods.

Finalresultscomparingthesixmonthspostinterventiontothesixmonthspriortoitrevealed anoverall31.3%bed-dayadjusteddecreasein thenumberofABGsacrossthefourICUpods (seefurtherdetailsin‘evidenceofoutcomes’)

Toassessforcontinuousimprovement,theJuly 2019datawassought.Therewere4,419ABGs wasnotyetavailableatthetimeofwritingthis report.Usinganaverageofthenumberofbed-

daysinJuly2017and2018(1359),afinalfigure of3.25ABGsperbed-daywascalculated.Thisis comparabletothe3.1forJuly-December2018 andsuggestsadurablechangefromthe4.6per bed-dayinthepre-interventionperiodofJulyDecember2017.

Weplantocompareourpost-interventiondata tothesamesix-monthperiodeachyear,to moreaccuratelyassessthedurabilityofthe project.

4.EvidenceofOutcomes

709surveyswerecompletedduringtwo-weeks inthepre-interventionphaseand417inasimilar periodpost-intervention.Afterimplementation oftheclinicalguidelinethereweresignificantly moreABGsperformedinresponsetoaclinical deterioration(8.0%vs17.7%)andsignificantly fewerfor‘culturalreasons’includingroutine monitoringatregulartimeintervals,shift changesorwhenotherbloodtestsweretaken (26.9%vs9.7%).TherewerealsofewerABGs orderedafterchangesinoxygendeliveryor ventilatorsettings(17.2%vs8.6%).Asignificantly greateramountwereperformedtoguide infusions(16.9%vs30.5%)andothertreatments manyofwhicharegovernedbypre-existing policiesthatmandateregularABGssuchas continuousrenalreplacementtherapy(CRRT) (3.4%vs9.1%).Overalltheproportionof inappropriateABGsdecreasedfrom54.8%to 28.9%betweenthetwosurveys(seeappendix3, figures15-18).Theproportionofdoctor-initiated ABGsincreasedfrom10%to22%,withthe remainderbeingnurse-initiated.

Therewere33,005ABGsperformedinsixmonths priortotheinterventionand22,408inthepostinterventionperiod;areductionof32.1%.The twoperiodshadsimilaroccupancy;therewere 1.2%fewerbed-daysinthepost-intervention period.This31.3%reductionwhenadjustedfor ICUbed-days(p<0.001)correspondstoan averageof4.6ABGsperbed-dayduringJulyDecember2017comparedto3.1perbed-day inthepost-interventionperiodofJulyDecember2018(seeappendix1,figures1and 2).Thisrepresentsanannualsavingof approximately$800,000aswellasover100Lof blood(equivalentvolumeto350blood transfusions)and1,800nurse-hours (approximately1.0FTE).Therewasnosignificant differenceinthestandardisedmortalityrate (APACHEIII)betweenthetwoperiods(0.65vs 0.63,p=0.22)

Onaverageoverthesix-monthperiodsthe cardiothoracicICU(6E)hadareductionof 20.9%,theneurointensivecare(6F)34.5%and thegeneralICUs42.9%(6G)and31.0%(6H)(see appendix1,figures4-11).ThoughallfourICUs displayedadecreaseintotalABGsperformed

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byatleast20%,thecardiothoracicunit predictablyhadthesmallestreductiondueto theexistingprotocolsthatgovernpost-cardiac surgicalpatients,whichmandatefrequent ABGsinthefirst48hrspostoperatively.

5.StrivingforBestPractice Healthcarecostsareincreasingatasignificantly fasterratethancanbeaccountedforby inflation,populationgrowthandageing.In25 yearsfrom1989to2014healthexpendituregrew from$50billionto$154billion,representingan increasefrom6.5%ofgrossdomesticproductto 9.7%(AustralianInstituteofHealthandWelfare 2016).

Clinicianshaveaprofessionalresponsibilityto utilisehealthresourcesinajustandethical manner.Uptohalfofthebloodtestsorderedin ICUarethoughttobeunnecessary,including 30-66%ofallABGsperformed(Merlani2001, Melanson2007,Pilon1997).Reductionsofover 40%havebeenachievedwithoutnegatively impactingpatientcare(Melanson2007, Martinez-Balzano2017,Blum2015,Ullman2016, Merlani2001).Therearenovalidatedguidelines forABGsamplingandnolocalpoliciesfrom NSWHealthorTheCollegeofIntensiveCare MedicinetodirectABGtesting.Ordering patternsappeartobeprimarilydrivenby culturalfactors(Wang2002,Merlani2001, Melanson2007).Traditionalpracticehasbeen toorderABGsonventilatedpatientsatregular intervalsfor“routine”monitoring,aswellasafter anychangeinventilatorsettingsandbeforeor afterextubation.Melansonetalfoundthatover 60%ofallABGswereperformedforthese reasons;25%forroutinemonitoring,28%fora changeinventilatorsettings,and8%pre-or post-extubation.Only26%wereinresponsetoa respiratoryevent.Inanotherstudyofcritical carecliniciansina98-bedICU,90%ordered ABGsforroutinesurveillance,80%afterevery changetotheventilator,70%pre-extubation and65%for“convenience”whenanarterial catheterwasavailable(Martinez-Balzano2017). Thepresenceofanarterialcatheterhasbeen showntobethemostpowerfulpredictorofthe numberofABGsorderedwhencontrolledfor illnessseverity(Zimmerman1997,Muakkassa 1990).

Duetothelargeburdenonthehealthcare system,staffandmostimportantlypatients,and thepromisingresultsofotherstudies,wethought itvaluabletoaimtoreducethenumberof unnecessaryABGsinourICUthroughstaff educationandtheintroductionofaclinical guideline.

ThestudywasenrolledonthelocalQuality ImprovementProjectsRegisterandethical approvalwaivedbythelocalethicscommittee.

INNOVATIONINPRACTICEANDPROCESS

Severalstudieshaveinvestigatedthe indicationsforperformingABGsintheICU,and subsequentlyattemptedtoreducethenumber ofinappropriateABGsthrougheducationand implementationofaclinicalguideline(MartinezBalzano2017,Merlani2001,Roberts1991,Pilon 1997).Thisisthelargestandmostrobust Australianstudyinvestigatingthepracticesof ABGsampling,andconsequentlyshowingthat aconciseinterventioncanhavealargeeffect onpracticeinourclinicalsetting.

Theintegrationofamultidisciplinaryteamwas essentialtooursuccess.Asidefromthecore threeteammembers,eightclinicalnurse championsandmanyotherICUdoctorsand nursesthatprovidedfeedbackandsuggestions onanad-hocbasis,theprojectrequiredinput fromthatpathologydepartment(regarding costandnumberofABGs),theICUScientific Officer(forbed-daysandoutcomemeasures) andtheHospitalScientist(forcostof consumables).

Ourlarge-scalemultifacetedapproachas describedaboveusedseveralformsof interactiveeducationalcontentwhichwas deliveredatvarioustimestovariousgroupsof clinicians.OurICUhasalargenumberofclinical staffincludingover220permanentnursesplus agencyandcasualnurses,15StaffSpecialists andapproximately40juniormedicalofficers, mostofwhomrotatethroughtheICUfor between3and12months.Asaconsequence, webelievethatthedevelopmentand implementationofaguidelinewasthemost essentialcomponentofoursuccessandthe almost$800,000annualsavings.VeryfewICUs areknowntofollowaclinicalguidelineforABG sampling.Webelieveadherencetothis guidelinewillbeessentialforasustainedeffect.

REFERENCES

1.AndrewsT,WatermanH,HillierV(1999). Bloodgasanalysis:astudyofbloodlossin intensivecare.JAdvNurs.30(4):851-857.

2.ANZICS(2017).CentreforOutcomeand ResourceEvaluationAnnualReport Melbourne

3.AstlesT(2009).Iatrogenicanaemiainthe criticallyill:Asurveyofthefrequencyof bloodtestinginateachinghospital intensivecareunit.JournalofIntensiveCare Society10;4

4.AustralianInstituteofHealthandWelfare (2016).25yearsofhealthexpenditurein Australia1989–90to2013–14.Healthand

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APPLICABILITYTOOTHERSETTINGS

Thereisasignificantamountofmisapplication ofresourcesinthehealthcaresystemandan increasingefforttocurtailunnecessarytesting, asdemonstratedbythewidespread internationalsupportofthe“ChoosingWisely” campaign(CriticalCareSocietiesCollaborative 2014).Inparticular,30-60%ofallinpatient laboratorytestingislikelywasteful(Zhi2013, Miyakis2006)andaspreviouslystated, approximatelythisproportionofABGsare thoughttobeunnecessary.

The58bedsinourICUrepresent2.4%ofalladult andpaediatricICUbedsinAustraliaandNew Zealand(ANZICS2017).Ifweassumethatour institutionisrepresentativeofthenational averageintermsofoccupancy,numberof ABGsperformedandcostofthetest,a proportional31.3%bed-day-adjusteddecrease acrossalloftheseICUswouldrepresentan annualsavingofapproximately$33million,4400 litresofbloodand40fulltimeequivalentnurses (73,000nurse-hours).Thisisnotwithstandingthe costofassociatedbloodtransfusionsandother downstreameffectsofiatrogenicanaemia.The primaryauthorintendstodisseminatetheresults ofthisprojectlocallyatthe2019Trainee PresentationEveningatRoyalPrinceAlfred Hospital,andgloballyatthe2019World CongressofIntensiveCareandwitheventual publicationinaninternationallyreadcritical carejournal.

Thisprojectisapplicabletoothercriticalcare areassuchasCoronaryCareUnits(Wang2002), theEmergencyDepartment(Zhi2013), OperatingTheatreandNeonatalICUs(Ullman 2016).Furthermore,thetheoreticalframework maybeappliedtoothercommonlyusedtestsin hospital.Manyotherbloodtests, microbiologicaltestsandchestx-rayshavealso beenfoundtobeoftenorderedunnecessarily (Prat2009,Kobewka2015).

welfareexpenditureseriesno.56.Cat.no. HWE66.Canberra:AIHW.

5.AustralianRedCrossBloodService(2016). 2016/17bloodbagcostindicators.URL: https://transfusion.com.au/bsib_july2016_3

6.BariePS(2004).Phlebotomyintheintensive careunit:strategiesforbloodconservation. CritCare8(Suppl2):S34–6.

7.BlumFE,LundET,HallHA,etal(2015). “Reevaluationoftheutilizationofarterial bloodgasanalysisintheIntensiveCareUnit: effectsonpatientsafetyandpatient outcome.”Journalofcriticalcare302: 438.e1-5.

8.CorwinHL,GettingerA,PearlRGetal (2004).TheCRITstudy:anemiaandblood transfusioninthecriticallyill–currentclinical practiceintheUnitedStates.CritCareMed; 32(1):39–52.

9.CorwinHL,ParsonnetKC,GettingerA (1995).RBCtransfusionintheICU:Istherea reason?Chest108:767–771

10.CriticalCareSocietiesCollaborative(2014). Fivethingsphysiciansandpatientsshould question.ChoosingWisely.URL: http://www.choosingwisely.org/wpcontent/uploads/2014/01/SCCM-5thingsList-012014.pdf

11.HaydenSJ,AlbertTJ,WatkinsTR,etal(2012). Anemiaincriticalillness:insightsinto etiology,consequences,and management.AmJRespirCritCareMed. 185(10):1049-1057.

12.KobewkaDM,RonksleyPE,McKayJAetal (2015).Influenceofeducational,auditand feedback,systembased,andincentive andpenaltyinterventionstoreduce laboratorytestutilization:asystematic review.ClinChemLabMed2015;53:157-83.

13.Martinez-BalzanoCD,OliveiraP,O'RourkeM etal(2017).AnEducationalIntervention OptimizestheUseofArterialBloodGas DeterminationsAcrossICUsFromDifferent Specialties:AQuality-ImprovementStudy. Chest;151(3):579-585.

14.MelansonSE,SzymanskiT,RogersSOetal (2007).Utilizationofarterialbloodgas measurementsinalargetertiarycare hospital.AmJClinPathol.127(4):604-609.

15.MerlaniP,GarnerinP,DibyMetal(2001). Qualityimprovementreport:linking guidelinetoregularfeedbacktoincrease appropriaterequestsforclinicaltests:blood gasanalysisinintensivecare.BMJ. 323(7313):620-624.Erratumin:BMJ.2001; 323(7319):993.

16.MiyakisS,KaramanofG,LiontosMetal (2006).Factorscontributingtoinappropriate orderingoftestsinanacademicmedical departmentandtheeffectofan educationalfeedbackstrategy.Postgrad MedJ;82:823-829.

17.MuakkassaFF,RutledgeR,FakhrySMetal (1990.ABGsandarteriallines:The relationshiptounnecessarilydrawnarterial bloodgassamples.JTrauma;30:1087–1093; discussion1093–1095

18.PilonCS,LeathleyM,LondonRetal(1997). Practiceguidelineforarterialbloodgas measurementintheintensivecareunit decreasesnumbersandincreases appropriatenessoftests.CritCareMed; 25:1308–1313

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

19.PratG,LefèvreM,NowakEetal(2009). Impactofclinicalguidelinestoimprove appropriatenessoflaboratorytestsand chestradiographs.IntensiveCareMed;35: 1047–53

20.RobertsD,OstryzniukP,LoewenEetal (1991).Controlofbloodgasmeasurements inintensive-careunits.Lancet; 337(8757):1580-1582.

21.RodriguezRM,CorwinHL,GettingerAetal (2001).Nutritionaldeficienciesandblunted erythropoietinresponseascausesofthe anemiaofcriticalillness.JCritCare;16:36–41

22.UllmanAJ,KeoghS,CoyerFetal(2016). ‘TrueBlood’TheCriticalCareStory:Anaudit ofbloodsamplingpracticeacrossthree adult,paediatricandneonatalintensive caresettings.AustralianCriticalCare29;90–95

23.VincentJL,BaronJF,GattinoniLetal(2002). Anemiaandbloodtransfusionsinthe criticallyill:Anepidemiological, observationalstudy.JAMA;288:1499–1507

24.ZimmermanJE,SeneffMG,SunXetal (1997).Evaluatinglaboratoryusageinthe intensivecareunit:Patientandinstitutional characteristicsthatinfluencefrequencyof bloodsampling.CritCareMed;25:737-748)

25.WangTJ,MortEA,NordbergPetal(2002). Autilizationmanagementinterventionto reduceunnecessarytestinginthecoronary careunit.ArchInternMed;162(16):18851890.

26.ZhiM,DingEL,Theisen-ToupalJetal(2013). Thelandscapeofinappropriatelaboratory testing:a15-yearmeta-analysis.PLoSOne; 8:78962

APPENDIX

Appendix1:NumberofABGsperformedaccordingtomonthandthefourconstituentICU‘pods.’Theseare adjustedforoccupancyandthetotalcostanalysed.

Figure1

Figure1demonstratesstatisticallysignificantdecreasesinthenumberofABGsperbed-dayduringevery monthinthepost-interventionperiod,comparedtopre-intervention.Thisisevidencedbyoneormore specialcausevariationtests(appendix4)onthecontrolchartbeingbreached.Itresultsinthesummary statistics,atright,beinginaccurate.Thishasbeendealtwithinfigure2.

Figure2

Figure2hassplitoutthespecialcausevariationinfigure1demonstratingastatisticallysignificantshiftin performance.TherehasbeenastatisticallysignificantdecreaseintheaveragenumberofABGsperbeddayfrom4.6to3.1,whichcorrespondstoastatisticallysignificantdecreaseintheaveragenumberof ABGspermonthfrom5,500to3,750

Figure3demonstratesthattherehasbeennosignificantchangeintheoccupancy(bed-days)inanyof thefourICU‘pods’acrossthetwostudyperiods,withsix-monthlytotalsaveraging1600-1920bed-days.

ItisthereforeappropriatetomonitortheabsolutenumberofABG(asstaffunderstandthesebetter)rather thanarateperbed-day.Seefigures4-11forafurtheranalysisofthenumberofABGsineachpodof theICU.

Figure4demonstratesmultiplespecialcausevariation(appendix4);astatisticallysignificantdecrease inthenumberofABGinpod6Esinceprojectcommencement,asanalysedinfigure5.Therehasbeen astatisticallysignificantreductioninaverageABGfrom1469to1162permonth.Thisisareliableprocess asitisexhibitingonlycommoncausevariation.

Figure12demonstratesthemonthlyexpenditureonABGsforeachofthefourICUpods,comparingJulyDecemberin2017with2018.Allfourpodsachievedstatisticallysignificantcostsavingsasaresultofthis project;theaveragemonthlycostofABGsperpodhasdecreasedfrom$51,226in2017to$34,779in 2018.

Appendix3:IndicationsforperformingABGsinourICU;ananalysisofthesurveysin2017and2018

Figure14

100 80 60 40 20 0 Number of ABG for Inappropriate Reasons Percent

C93 7366655752382112 Percent0.8 18.917.116.814.713.49.85.43.1 Cum%100.0 18.935.952.767.480.990.796.199.2 400 300 200 100 0

Figure14demonstratesthereasonsforinappropriateABGordering.Fivecategoriesaccountfor80%of allinappropriateorderingandthesecanbebroadlydividedintotwogroups;changeinoxygendelivery (DO2)orventilatorsettings(seefigure16),and‘culturalreasons’(seefigure18).Theseweretheprimary targetsintheinterventionstageoftheproject.

Figure15

50% 40% 30% 20% 10% 0%

DeteriorationGuidecurrenttreatmentAftertreatmentceasedOther 1

1 1

Percentage Change Average

ParetoChart:ReasonsforInappropriateABG(2017) PPost-testPre-testPost-testPre-testPost-testPre-testPost-test re-test

ReasonforABG:ComparingPreandPostIntervention 2017versus2018(JulytoDecember) BeforeandAfterChangesImplemented

UCL LCL

Figure16

Figure16demonstratesstatisticallysignificantchangesinallsubcategoriesof‘guidingcurrenttreatment,’ asevidencedbybreachesofthespecialcausevariationtests(appendix4):anincreasefrom17%to30% intheorderingofABGsafterachangeininfusion,adecreasefrom17%to9%forchangestooxygen delivery(DO2)orventilatorsettings,andanincreasefrom5%to11%forotherreasons/notselected.

Figure17

PPost-testPre-testPost-testPre-test

Figure18demonstratesastatisticallysignificantreductionasevidencedbybreachesofthespecial causevariationtests(appendix4):adecreasefrom26.9%to9.7%intheorderingofABGsforcultural reasons(iewhentakenforconvenienceatthesametimeasotherbloodtests,atthestartorchangeof shift,orbecauseanABGhadnotbeendoneforseveralhours).Thereisnostatisticallysignificant differenceinanyothersubcategories

Appendix5:Clinicalpathway,takenfromtheclinicalguidelineforABGsamplingthatwasdevelopedaspartof ourintervention

Figure20

HEALTHCAREMEASUREMENT

HIGHLYCOMMENDED

HunterNewEnglandLocalHealthDistrict ClinicalGovernance

Empoweringpatients,family,andcarersforimprovedrecognition andresponsetoclinicaldeterioration

DanielMcCarthy,MaryBond

AIM

Toincreasepatientawarenessof,andaccess to,apatientandfamilyactivatedescalation program,andtherebyimprovetherecognition andresponsetoclinicaldeterioration.

SUMMARYABSTRACT

BACKGROUND:Failuretorecognise,respond to,andescalatecareofdeterioratingpatients isamajorcontributortoadversepatientevents, includingcardiopulmonaryarrestsand unintendedpatientharm2.Patientandfamily activatedescalationprogramsthatarewell implemented,widelyaccessible,and embeddedintostandardpracticehavethe potentialtoimprovetheearlyrecognitionof clinicaldeteriorationandtherebyimprove patientoutcomesthroughearlierintervention2.

Patientandfamilyactivatedescalation programsprovideamechanismforpatients, familymembers,andcarerstodirectlyescalate concernswhentheynoticeworryingchangesin clinicalcondition.InNewSouthWales,the establishedpatientandfamilyactivated escalationsystemforpublichospitalsisthe ClinicalExcellenceCommission'sREACH Program.TheREACHprogramadoptsagraded escalationapproachwhereby,(1)patientsare encouragedtofirstraiseconcernswiththeir treatingclinicians,(2)iftheystillhaveconcerns patientscanrequestaClinicalReviewfroma MedicalOfficer,and(3)ifpatientshave continuedconcernstheycanplacea“REACH Call”andaskforhelpfromaseniorClinical Managerwhomustrespondwithin30minutes.

HunterNewEnglandLocalHealthDistricthad partiallyimplementedtheprogrambeforeJuly 2017howeverbaselineevaluationsindicated theprogrammerequiredimprovement,and implementationneededtobeextendedtoall facilities.Adistrict-wideevidence-based

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improvementandimplementationplanwas subsequentlydevelopedandimplemented.

METHODS:Basedontheprinciplesofclinical redesignmethodologyandchange management,interventionstoimproveand spreadimplementationoftheprogramwere providedinfourPlan,Do,Study,Act(PDSA) cycles.Theinterventionswereappliedacross39 diverseinpatientfacilitiesincludingthoseina majormetropolitancentre,severalinlarge regionalcentres,andmanyinsmallerruraland remotecommunities.Keyinterventionswere electronicauditdevelopment,staffstorytelling, ShortMessageService(SMS)notificationsto patientsonadmission,communityforums, webpagedevelopment,PolicyCompliance Procedureenhancement,andan implementationpackageformanagers.Aprepostevaluationdesignwasconducted involvingsurveysofpatients,staff,and managersviathesecureSelectSurveyTM platform,auditingusinganonlineQualityAudit ReportingSystem,andtheuseofGoogle Analyticsdatatoevaluatewebpage performance.Samplesizewas179patientsand staffatbaselineand545patientsandstaffpostimplementation.

RESULTS:PatientaccesstotheREACHProgram increasedby44percent,patientawareness increasedby10percent,andastatistically significantimprovementinoverallcompliance withREACHbest-practicecareelementswas achievedincreasingby24percentfrom52 percentatbaselineto76percentpostimplementation.Statisticallysignificant improvementswerealsoachievedfor, improvedpatientunderstandingofREACH,the provisionofREACHinformationflyerstopatients, andthedisplayofREACHpostersinpatient rooms.AmongpatientsactivatingaREACHcall, 13percent(n=5)hadabnormalvitalsignsatthe

timeoftheircall,and54percent(n=21)ofall callsrequiredachangetothepatient’s managementplantoaddressclinicalconcerns despitethepresenceofabnormalvitalsign observations.

CONCLUSION:Theimprovementand implementationapproachusedbyHunterNew EnglandLocalHealthDistrictincreasedpatient awarenessof,andaccessto,REACHbest practicecare.REACHwassuccessfulin identifyingclinicaldeteriorationinjustoverone intenpatientsactivatingaREACHcall,and enabledanearlyresponsetoclinicalconcerns injustoverhalfofallpatientsactivatinga REACHcall.

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HIGHLYCOMMENDED

CentralCoastLocalHealthDistrict Neurosciences

ImpactofadigitallyenabledstrokeserviceonKPIsandbestpracticemetrics BillO’Brien,JamesEvans,KhaledAlanti,LaurenWheeler

AIM

Juniordoctors,whoareexpectedtoprovide acutefrontlinecareforstrokepatients,have limitedinitialexpertiseastheyrotateeverythree months.Modernstrokecarehasbecomemore complexasbettertreatmentsbecome available,thustheneedforadecisionsupport platformthatguidesthemthroughtheprocess ofacutecarewithintheirworkflow.Thegoalof thisprojectwastoimprovethecareofstroke patientsbypromptingjuniordoctorstodoa targetedassessmentwhilsthavingaccesstoinbuiltbestpracticemanagementordersets. Secondaryaimsweretoensureconcisebut thoroughdocumentation,tohaveautomatic datacaptureasaby-product(negatingthe secondaryworkofdataentry),andtoenable seniordoctorstohaveagoodoverviewofthe processesofcare.

SUMMARYABSTRACT

In2018approximately4000juniormedical officersworkedintheNSWPublicHealthsystem, almost1000ofwhomhadnotbeenmedical officerstheyearbefore.Juniordoctors,with varyingdegreesofexperienceand competency,administerthebulkofacutecare, particularlyinthefirst24hours,undertheregular supervisionofseniorconsultantphysicians.The NeurosciencesDepartmentatGosfordHospital introducedaDecisionSupportPlatform(DSP) thatstandardisestheadmission,wardround anddischargeprocessestoensureconsistent deliveryofbestpracticesbyproviding promptedguidancetojuniormedicalofficers. Translatingbestpracticeintoroutineclinical careisdifficult.TheDSPprovidestherelevant promptstothejuniormedicalofficerasneeded withinworkflowbydigitisingtheGosford departmentalstrokecareguideandpathway. Thisalsofacilitatestheassessmenttobe documentedrapidlybytheuserandprovides explicitinstructionstonursingandalliedhealth forpostadmissioncare.Thisapproach continueswithaguidedcomprehensive structuretothewardround.Usingtheclinical datacollectedfromtheadmission,wardrounds anddischargeplanning,astandardised

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dischargesummarycoveringalloftheessential itemsisautomaticallycreatedtoallowconcise, explicitandthoroughhandoverofcaretothe communitycareteam.

Akeyfeatureisimproveddocumentation.Poor clinicaldocumentationisawell-recognised probleminhospitalsthroughoutAustralia.It leadstosubstandardcare,reductioninfunding forincompletelycapturingcarecomplexityand resultsinincorrectandincompleteclinicaldata forquality,safetyandresearch.PriortotheDSP juniormedicalofficersdocumentedeach interactioninfreetextasanewpieceofwork creatingahugeworkloadascurrentElectronic MedicalRecordssystemsdonotfacilitatethis process.

TheDSPalsoassistsjuniormedicalofficerswith thecoordinationoftheirtasksbyprovidingalist thatincludespatientlocation,names,primary diagnosesandissues,asawellasoutstanding tasksthatrequireactioning.

Asanoverarchingstrokeservice,achieving consistentbestpracticeischallenging.Key performanceindicatorsofacutestrokeunit carehaveimprovedslowlyorhavenot improvedatalloveraneight-yearperiod nationally.Theconventionalmethodof benchmarkinganddatacollectionistime consumingandtedious.In2007TheNational StrokeFoundationimplementedabiennial clinicalauditofacutestrokecare.Thisrequires astaffmemberatGosfordHospitaltospend3040hourstrawlingthroughtheclinicalrecordofa randomlyselectedgroupof40patients(asa representativesnapshotofthe1200orso patientsmanagedintheprevious2years), identifyingdatapointsnecessaryforthereport. Oftenthedataismissing.

TheDSPgivesaccesstoreal-timeclinicaldata, allowingvisualisationofthemainkey performanceindicatorsoftheserviceforeach patient.Thedashboardlistsallacutestroke patientsintheunitandataglanceprovides,for example,lengthofstay,thedegreeofclinical deficitsat24and72hours,andwhetherthe patientisonappropriatemedication.This

elementenablesseniorclinicianstofix deficienciesincareinreal-time.TheDSPalso allowsforalltheclinicalinformationtobe exportedinaCSVformattoallowformore detailedanalysisandreporting.

Sixmonthsfollowingtheintroductionofthe platformweperformedaretrospectiveanalysis ofElectronicMedicalRecordsofpatients admittedtoGosfordhospitalwithacutestroke betweenJune2018andSeptember2018.Over 4months,136patientspresentedwithacute ischaemicstrokeand11patientshada haemorrhagicstroke.Weexaminedaccessto thestrokeunitaswellasdischargeonappropriate secondarypreventativemedications,including antihypertensivesandantithrombotictherapy. Patientswhosedirectionofcarewaspalliative andpatientswithdocumented contraindicationtosecondaryprophylactics wereexcluded.Wecomparedtheresultsto previousyearsasmeasuredthroughtheStroke

Foundationaudit.Strokeunitaccesswashigher followingitsintroductionin2018comparedto 2017(97%versus76%,respectively).Similar findingswerenotedforpatientswithatrial fibrillationwhoreceivedoralanticoagulantson discharge(90%versus50%)andpatients dischargedonantihypertensives(95%versus 80%).

AnindependentassessmentfromtheCentral CoastLocalHealthDistrictbusinessunit demonstratedimprovementinNWAUs(national weightactivityunits;unitsofhealthcareactivity whereasingleunitisanationaladjustedprice ofcare).Thiswasachievedthroughbetter documentationasepisodesofcareand complexitywerebeingrecognisedbyclinical codersduetothemorecomprehensive documentationthatresultedfromtheuseofthe DSP.Lengthofstayalsodecreasedsubstantially. Thiswasestimatedtocreateefficiencygainsof $900000overa9-monthperiod.

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22ndAnnualACHSQualityImprovementAwards2019

HEALTHCAREMEASUREMENT

TABLEOFSUBMISSIONS

KingEdwardMemorialHospitalWomenandNewbornHealthService

KingEdwardMemorialHospital-DepartmentofPharmacy;Collaborator:WANorthMetropolitan HealthServices-BusinessIntelligence&Performance

RoyalNorthShoreHospital

HunterNewEnglandLocalHealthDistrict

StJohnofGodMurdochHospital

CentralCoastLocalHealthDistrict

GLOBALQUALITYIMPROVEMENT

WINNER

NationalCriticalCareandTraumaResponseCentre ClinicalGovernanceGroup

EstablishingaNewNationalandInternationalBenchmark-AUniqueApplicationofthe ACHSEQuIP6QualityImprovementFrameworktoAustralia’sNationalandInternational DeployableHealthEmergencyCapability

DrDianneStephens,JaneThomas

AIM

TheAimoftheProjectwastoestablishaquality improvementframeworkfortheNationalCritical CareandTraumaResponseCentre(NCCTRC) deployablecapabilitytoensuredeliveryofthe higheststandardofcaretothevulnerable populationsweserveduringdisasterresponse.

SUMMARYABSTRACT

TheNCCTRCistheAustralianGovernments healthemergencyresponsecapabilitytasked withensuringtheworkforceandequipment requiredforanationalandinternational medicalresponsearepreparedequippedand readytodeploywheneverrequired.The NCCTRCisthecustodianoftheAustralian MedicalAssistanceTeam(AUSMAT)capability. TheAUSMATcapabilityachievedWorldHealth Organisation(WHO)verificationasaType1and Type2EmergencyMedicalTeam(EMT) capabilityin2016.TheWHOverificationoccurs againstasetofminimumstandardsapplied globally.

In2017,underthedirectionoftheMedical Director,aformalclinicalgovernancesystem includingaClinicalGovernanceFramework andCommitteewasestablished.The committeedecidedthatformalnational accreditationofthedeployablecapability wouldenhancethequalityofcareprovided andguideongoingimprovementofpatient outcomesinthedisastersetting.

TheNCCTRCExecutiveagreedtoexplorea qualityframeworkthatwouldelevatethe organisation’squalityimprovementprocess beyondtheWHOminimumstandardsandaim toapplyAustralianCouncilofHealthCare

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Standards(ACHS)toouruniquefieldcapability setting.InAugust2017anACHSscopingvisitwas undertakenbyseniorACHSsurveyorsto determinetheframeworkthatwouldapplyto thisuniquecapability.TheEQuIP6Framework waschosenasitprovidedtheflexibilityto accommodatethecomplexityofadeployable healthfacility,thefixedandvirtualworkforcewe manageandtheapplicationofdisaster response/humanitarianprinciplestoourwork.

TheNCCTRCjoinedtheEQuIP6programinMay 2018.

Theprocessofself-assessmentidentifiedgapsin oursurveillanceandauditprogramsthat requiredinnovativeadaptationofexisting hospitalbasedtoolstothefieldhospital/ disasterresponsesetting.Newtoolswere developedforauditingmedicalrecords, medicationsafety,handhygiene,pressureinjury andfallsriskinthefieldhospitalsetting.Anew incidentreportingformwasdevelopedto incorporatesafetyandsecurityriskreportingin additiontoclinicalincidentreporting.The principlesappliedtoallthetoolsdeveloped includedsimplicity,outcomeimprovement focused,easytoincorporateintodailyactivities inthefieldwherestaffandtimeresourcesare limited.Theself-assessmentprocessidentifieda deficitindocumentationofprocessesand policiesandledtoanongoingprogramof improvementinformaldocumentationofwhat wedo.Theself-assessmentidentifiedthe AUSMATclinicalguidelinesrequiredaformal reviewprocessandtobemoreaccessibleto thefixedandvirtualworkforceandaclinical guidelinesprojectisinprogresstoachievethis outcome.

TheNCCTRCunderwentorganisationwide surveyinJune2019andachievedasuccessful outcome.Allapplicablecriteriaachieved MarkedAchievementwithseveralcriteria achievingExtensiveAchievementandone criterionachievingOutstandingAchievement.

Theapplicationofanationalaccreditation frameworktoadeployableEMTcapabilityis uniquenotonlywithinAustraliabutonthe internationalstage.Humanitarianorganisations deliveringhealthcareinthefieldformanyyears donothaveaqualityimprovementframework inplace.TheNCCTRChasdemonstrateditis possibletoapplyaqualityimprovement frameworktoadeployablefieldcapabilityand provideastandardofcarethatmeetsnational healthfacilityaccreditationcriteria.TheEQuIP6 frameworkappliesamoredetailedclinicaland corporatequalityframeworktotheEMT capabilitythantheWHOverificationstandards. ThetoolsandprocessesthattheNCCTRChas putinplacewillbesharedwiththeglobalEMT communityandsetanewstandardforclinical qualityinthefield.

REPORT APPLICATIONOFACHSPRINCIPLES

1.ConsumerFocus

TheNCCTRCdeploysAUSMATtorespondto vulnerablepopulationsrequiringhealthsupport followingadisaster.Theprojecttoseta benchmarkforaqualityimprovement frameworktoapplytoourresponsecapability bringsthefocusofdisasterresponsebacktothe vulnerablepopulationsweserve.Itisour philosophythateveninthechaosofdisasterthe populationdeservesthebestqualityclinical carethatitispossibletoprovide.

Toolsdevelopedinclude: Newpatientobservationcharttoincludean earlywarningsystemfordeterioratingpatients adaptedtothefieldhospitalsetting

Pressureinjuryandfallsriskassessmentand managementtoolsadaptedforthefield hospitalsetting

Patient,familyandlocalstaffsatisfactionaudit tooladaptedtovulnerablepopulationin disastersetting.

2.EffectiveLeadership

TheNCCTRCsponsoredandcontributedtothe developmentoftheWHOEMTminimum standardsfirstpublishedin2013.Thesestandards setanewbenchmarkforglobalEMTresponse. TheapplicationoftheEQUiP6frameworktothe fieldsettinggoesbeyondtheEMTminimum standardstorecognisethatgoodqualitycareis

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

asimportantinthedisastersettingasitisinour dailyworkinthehealthcaresystem.National accreditationisanewfocusfortheglobalEMT communityandtheNCCTRCisawellrespected internationalmemberofthiscommunity–our leadwillprovideanewbenchmarkforother teamstoaspireto.

3.ContinuousImprovement

TheEQUiP6frameworkisanongoingcycleand theworkcontinuesthroughourclinical governancegrouptocompletecurrent projects,implementrecommendationsfrom Surveyorsandfindnewwaystoinnovateto bringthequalityimprovementsfromthehealth systemsettingintothedisasterresponsesetting.

ToolsandAuditcycleshavebeenadaptedto thefieldhospital/deployed/disastersettingfor:

Handhygienecompliance

Patientidentificationprocesses

ClinicalHandoverprocesses

Medicalrecorddocumentation

Medicationsafety

Incidentreporting

Currentprojectsongoing:

Clinicalguidelinesreviewandimproved accessibilitytothefixedandvirtual workforcethroughanonlineplatform

Developingsystemforongoing credentialingofvirtualworkforce

4.EvidenceofOutcomes

Thesuccessfulaccreditationsurvey demonstratesitispossibletoapplyquality improvementtoolsandprocessesusingthe EQuIP6frameworktotheAUSMATdeployable/ disastersetting.

TheWHOEMTinitiative,theInternational FederationofRedCrossandRedCrescent Societiesandseveralotherglobalpartnershave followedtheprogressofthisprojectand expressedinterestinapplyingourlearningsto otherteamsandsettings.

5.StrivingforBestPractice

TheNCCTRChasanimportantplaceintheWHO globalEMTmovement.Wewereoneofthefirst teamstoundergoWHOverificationandhave providedmentorstoteamsthroughoutthe worldtohelpthemachieveverification.Our leadisrespectedwithintheglobalcommunity andwehavearesponsibilitytocontinuallystrive toimprovetowhatwedoandprovidean examplefortheglobalcommunity.Weare stronglycommittedtoprovidingthebestquality ofcarepossibletothevulnerablepopulations weserveinthedisastersettingandbysetting ourselvesthegoalofACHSaccreditationand embracingtheEQUiP6QualityImprovement Programwehavesetanewbenchmarkforthe

globalEMTcommunity.TheNCCTRChasmoved beyondWHOminimumstandardstoembrace bestpracticepossibleforthedeployable/ disastersetting.

INNOVATIONINPRACTICEANDPROCESS

Anationalaccreditationprocesshasnot previouslybeenappliedtoadeployable/ disasterresponsehealthcapability.The NCCTRChasadaptedtoolsusedwithinthe healthsystemtothedisastersettingtoelevate thequalityofclinicalcareprovidedtothe vulnerablepopulationsweserve.Asuiteof clinicaltoolsaimedatimprovingcarehasbeen developedandadoptedintothefieldhospital

REFERENCES

TheAustralianCouncilonHealthcareStandards 22ndAnnualACHSQualityImprovementAwards2019

setting.Thisinnovativeapproachtodisaster responsemedicineraisesthebenchmarkfor otherglobalteamsandprovidesthefirstACHS qualityassurednationalresponsecapabilityfor disasterswithinAustralia.

APPLICABILITYTOOTHERSETTINGS

Thisaccreditationprocessandtheadaptation ofaqualityimprovementframeworktothefield hospitalanddeployablehealthcapabilitywill setanewbenchmarkforclinicalquality standardsfornationalandinternational EmergencyMedicalTeamandhealthdisaster responsecapabilities.

2.WHOFMTClassificationMinimum