operationalising and embedding telehealth · healthier country communities through partnerships and...

Government of Western AustraliaWA Country Health Service

Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice

Operationalising and embedding telehealth

The experience of the WA Emergency Telehealth Service

Dr Andrew Jamieson

Clinical Lead, SIHI

Western Australia Country Health ServiceAcknowledgements to Melissa Vernon, Justin Yeung and Yvonne Zardins

#pinksocks



The WA Country Health Service (WACHS) would like to

respectfully acknowledge the Elders past and present of this

country in which we live, share and operate.

WACHS also acknowledges the ongoing contribution of

Traditional Owners as caretakers of their communities and

Country.



Western Australian Country Health Service (WACHS)

Working in partnership to improve:

• The culture of safety and quality

in rural healthcare.

• Emergency and acute clinical

services including infrastructure.

• The health of country people

with a focus on:

o maternal, child and

adolescent health

o chronic conditions

o public health and disease

control

o social and environmental

issues impacting health.

• Aboriginal health and

Aboriginal employment in

health.

• Mental health, alcohol and

other drug issues.

• Ageing in the country.

• Service access:

o telehealth

o inter-hospital transport

o more services closer to

home (e.g. cancer, renal)

o end-of-life care

o links with metro services.



How WACHS operates

• Delivers acute and primary health services to regional Western Australia: o 400,000 emergency visits/year

o 180+ employed doctors, 1000+ contracting doctors.

• Operates within a Regional Network Model and provides an integrated service delivery system:

o 70 hospitals of varying size

o 36 nursing posts

o Population Health

o Aged Care.



How WACHS operates

• Strong budget driven regional clinical and corporate governance structures.

• Community engagement regionally – service providers, consumers and carers, local government and other stakeholders.

• Supported by metro based “Head Office”.

• Executive governance – CEO and Executive.

• Department of Health is system manager.

• Board ultimately responsible for organisational governance.



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Challenges



Leading cause of death by remoteness in

Australia, compared with major cities (AIHW 2014)

Rate ratio (compared with major cities) 1.0

No difference1.5 2.0 3.0 4.0 5.5

x times higher than major cities

Major Cities Inner regional Outer regional Remote Very remote

1 Coronary heart

disease

Coronary heart

disease

Coronary heart

disease

Coronary heart

disease

Coronary heart

disease

2 Cerebrovascular

diseases

Cerebrovascular

diseases

Cerebrovascular

diseasesLung cancer Diabetes

3 Dementia and

Alzheimer

Dementia and

AlzheimerLung Cancer

Cerebrovascular

diseasesLung Cancer

4 Lung Cancer Lung CancerDementia and

AlzheimerDiabetes

Land transport

accidents

5 COPD COPD COPD COPDCerebrovascular

diseases

6 Colorectal cancer DiabetesCancer, unknown,

ill defined

Dementia and

AlzheimerSuicide

7 Diabetes Colorectal cancer DiabetesCancer, unknown,

ill definedCOPD

8 Cancer, unknown,

ill defined

Cancer, unknown,

ill-definedColorectal cancer

Land transport

accidents

Cancer, unknown,

ill-defined

9 Heart failure Heart failure Heart failure SuicideOther ill-defined

causes

10Prostate cancer Prostate cancer Prostate cancer Heart Failure

Perinatal

congenital

conditions



Indicative fatality rate / 100 000 persons and fatality

count for motor vehicle crashes per WA police district (Road Safety Commission 2015)



Fatalities and critical injuries from motor vehicle

crashes in WA (Road Safety Commission 2015)

Fatalities (including delayed

fatalities) higher in rural but critical

injuries lower 2012-14

- lower survival rate from critical

injuries

Fatality rate

WA vs Australia



Policy driversHealth Priorities

1. Prevention and community care

services

2. Health and hospital services

3. Chronic disease

4. Aboriginal health

Enablers

1. Workforce

2. Accountability

3. Financial Management

4. Partnerships

5. Infrastructure

6. ICT

7. Research and Innovation



WA Country Health Service

Vision

Healthier country communities through

partnerships and innovation



Clinical Services Framework – WACHS

Emergency Care

Level One Level Two Level Three Level Four Level Five Level Six

First aid,

assessment and

resuscitation

Emergency

ambulance

services with

access to rapid

transport

Care provided by

a registered nurse

with or without

assistance from a

GP

Basic

resuscitation

equipment and

drugs

Access to ETS

As for Level One plus:

24/7 services by

registered nurse /

nurse practitioner

with support by

medical

practitioner

Resuscitation and

stabilisation

capability

Transport and / or

coordinate

transport to

access

emergency

services care

As for Level Two plus:

Local GPs

rostered to

provide 24/7

cover with service

by registered

nurse

As for Level Three plus:

Emergency

operating theatre

facilities

On-call generalist

specialists

Access to senior

registered nurse

Access to

designated allied

health services

Some allied

health

undergraduate

education

Access to

emergency

specialist

As for Level Four plus:

Medically staffed

24/7

Medical and

surgical sub-

specialists

available on-call

Accepts transfers

from other

hospitals in region

Access to ICU

and CCU facilities

Access to

specialised allied

health services

As for Level Five plus:

Emergency

medicine

consultant on duty

24 hours per day*

State-wide

referral role

Backup from full

range of medical

and surgical

specialists and

diagnostic

services

ICU and CCU

facilities

*Not currently operating

in WA



Emergency Care Capability FrameworkWACHS Category: Emergency Service

Nurse Led Emergency Care: Level A and B

Emergency Care

Emergency Service

Emergency Department: Level A and B

Comparative WA Health CSF Level of Emergency Service

Level One Level Two Level Three Levels Three to Five

Minimum Service Provided and availability:

Minimum service provided onsite and includes: first aid #basic resuscitation and

stabilisation coordination of an

*emergency transfer

Level A: service may be

available outside and during

facility’s scheduled hours of

operation

Level B: service is available during the facility’s scheduled hours of operation only

Minimum service includes that provided by nurse led emergency care plus: treatment for minor injuries;

and service is available seven

days a week, twenty four hours a day (24/7)

Minimum service includes that provided by emergency care plus: #advanced resuscitation

and stabilisation and treatment for all

presentations

Minimum service includes that provided by emergency service plus: advanced treatment for all

presentations with;

onsite laboratory and

imaging services, which

may include CT;

patient transfers are

accepted from other

facilities

In addition Level A services: have access to anaesthetic

capability, emergency

theatres and high

dependence unit facilities

Minimum Service: Provided by:

A registered nurse (RN) will provide the service: with/without support of a

¥medical practitioner with access to clinical

and/or management support as per site’s: adult and maternity observation and response escalation and medical emergency response process30

As for nurse led emergency care plus the RN: is onsite 24/7 and has; access to a medical

practitioner who may attend on-site or is available virtually in ‘real time’ through the sites tele-health capability

As for emergency care plus: the medical practitioner will

attend onsite as required

As for emergency care plus: Level A services have: medical practitioners onsite

24/7; with access to:

medical/surgical specialists and proceduralists

Level B services have: medical practitioners who

are onsite within working

hours / weekend days and



The Emergency Telehealth Service (ETS)

• An initiative of the Southern Inland Health Initiativeo Improving emergency care for country residents.

• Royalties based non-health fundingo Budget based, not activity based.

• Supported by centralised “Head Office” teamo Project employment structure based on funding

availability.



ETS = a state-wide, specialist led emergency

medicine service• Mixed FACEM and ED

credentialed generalist workforce.

• Dedicated service, not part of any other roster.

• Nurse Coordinator always on duty.

• High definition enabled video conference face to face consultations.

• Current activity 1,400 – 1,500 consults per month.

• Monday-Sunday 0800-2300hrs daily.

• Currently rolling out phased 24 hour service introduction – now 4 days/week.



ETS history and activity

• 2011/12 ETS concept aimed at rural emergency medical workforce issues.

• Commenced Aug 2012 - 8 pilot sites.

• Early observations:

• education – dedicated team

• governance

• clinical standards

• accessibility/availability.

• April 2017 - 76 hospital and nursing post sites across 7 regions.



Service development principles

• Consultant-led to support delivery of quality, effective emergency medicine.

• Advocacy for the patient and local clinicians to facilitate the best possible outcome for country patients.

• Governance and operational management to be firmly established within WACHS, compliance with established WACHS clinical governance pathways and relevant policies to ensure consistency/quality of service in a country context.

• Collaborative regional development of the ETS model taking into account local geography, service provision context and workforce models.

• Regional decision making and local protocols will guide intra-regional transfers with appropriate guidance and negotiation from the ETS physician.



ETS service model

• A bureau service, provided by a central office outside of regional structures.

• A “virtual ED”; clinicians on duty, waiting for calls.

• Medical roster

• Nursing roster

• Administrative support



ETS has contributed to increased numbers of

medical consultations in WACHS small hospitals

ETS

Regression trend



Clinical governance

• Statewide credentialing

• Clinical quality and risk:o driven from patient’s end, with both ends’ input

o collaborative investigation and conclusion.

• ETS governance structures

• Record keeping and oversight

• Policy adjustment to telehealth provision:o agenda item within normal governance structures

where possible

o enabler, not an end in itself.



Standard ETS flowchart



ETS ED layout – receiver end

• Significant

clinical input

into layout of

ED’s and

camera

• Standardised

formulary

• Standardised

emergency

trolley



EMPLOYED

• ETS Clinical Director

• ETS Manager

• ETS nurse manager

• Administrative staff

Workforce• FACEMs

• GP Proceduralists

• Clinical Nurses

• Role for Nurse Practitioners

DOCTORS MOSTLY CONTRACTORS



EducationFlexible (Blended) Learning Framework

• Videoconferencing events

o theoretical

o practical

o simulation

• eLearning Program

o ETS HELP

• F2F Education

o ETS staff



Practical sessions

• pre-amble – VC etiquette, intros, recording

• record

• monitor issues

• remote control

• attendance and evaluations



Simulation sessions

• pre-amble – safety, processes.

• no recording

• monitor issues

• camera and microphone control

• scenario = debrief



Working environment

ETS

• emotional distance

• dedicated camera work, less physical variety

• decreased locus of control; third party reliance

• siloed and solitary, often in a dark room

“Live” ED

• on the floor

• mixed workload

• ED clinicians are “take charge” and usually do

• team based, supportive

Engagement

techniques

30-50%

telehealth only

Engagement

and training of

nursing

colleagues

Standard

debriefing and

team meetings



Critical success factors

• Identified need with mostly rapid uptake by WACHS staff.

• Exceptional product – FACEMs and ED Generalists.

• Well defined service delivery model that aligned easily with existing systems.

• Executive support and leadership.

• Client focus – patients AND local ED nurses and doctors.

• ~75% of all consultations are definitive; patients go home.



What’s next?

• In-patient support

• Leveraging capacity across entire ED system

• Care coordination

• Ad-hoc specialist access

• Interface with preventive care



Questions/comments

Experienced ED generalist looking for telehealth work?

Email to: [email protected]

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