Critical Care Telehealth Experience Mildura team Dr Alison Walker - - PowerPoint PPT Presentation

Mildura Base Hospital Critical Care Telehealth Experience

Mildura team

Dr Alison Walker Clinical lead Andrea Bock Project Lead

Mildura Base Hospital (MBH)

• 165 bed teaching hospital
• ICU - level 2:
• Recently expanded to 8 beds incorporating ICU, HDU and CCU catering

for an adult and paediatric population of approximately 61,000

• Closest tertiary centre:
• Adelaide, 400km away
• Melbourne Tertiary centres >500kms away
• Staffed and equipped for up to 4 Ventilated (ICU) patients, HDU, CCU and

Paediatric patients (Average 61 per year)

• Diverse cultures and the second highest Aboriginal population in Victoria

Why Telehealth?

• Isolation
• Collaboration
• End of life decision making
• Governance

Clinician Engagement

• Launch with Alfred
• Social
• Resistance from consultants
• Started
• “Plugging away”
• Acceptance through good outcomes and relationship building

ICU Telehealth - What we wanted to achieve

• Keep appropriate patients at MBH
• Support our Physicians and Anaesthetists; collaborative approach to

care

• Decrease number of avoidable retrievals
• Support our staff afterhours
• Deliver training and education options to Nursing and Medical staff

with strong ties to the Alfred, RMH

• Multidisciplinary care planning

Avoided=16 avoidable = 10 Oligate = 47

ICU Tertiary Transfers

Aug 2017-Jan 2018

5 10 15 20 25 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Avoided Avoidable Non avoidable

Avoidable = 10 Non-avoidable = 47

Telehealth Consultations

In 6 months …

• Myxoedema crisis
• Asthmatic- difficult to ventilate
• New Cardiomyopathy & ongoing Urgent care facilitation
• Septic oncology patients
• Out of hospital cardiac arrests
• Complex ventilation
• Necrotizing Fasciitis
• Empyema
• T1 &T2RF
• COPD/Pneumonia Electrolyte disturbance

formal Telehealth consultations attended:

with the Alfred (Dr. Tim Leong) between the hours of 8am-5pm weekends, nil overnight !!

100 85% 90% 10%

Telehealth Outcomes

At completion of six months:

Outcome Measures Target Performance

Decrease In transfers 25% decrease

22%

Increase in number of patients treated in ICU locally rather than transferred 25% increase

16 patients

Number of acute dialysis treatments Aim for 10 patients in first year Chronic

patients in ICU – 4 total

Transfers from SCN-decrease 10 % decrease Reduction in cost of transfer 25% reduction $285,000 Net Promoter score 80% NET of 9-10

90% NET of 9-10

Total length of stay Decrease Patient Stories 90% positive

100% positive

Increased satisfaction through structured learning & development 90% satisfied

100% positive

Comparing August 2016-Feb 2017 to Aug 2017-Feb 2018: ANZROD plots confirm no increase in SMR despite increased patient complexity. The ANZROD EWMA chart shows an increased acuity of patients with a decreased mortality

Professional Development

• Embedded 2/52 Telehealth education
• Case presentations and collaborative learning style with Medical and

Nursing involvement (ED and ICU Staff)

• Hyponatraemia
• Cardiac arrest case study
• Splenectomy case study
• Cardiogenic shock
• Management of acute asthma

Benefits of Telehealth for Consumers

In 6 months: 16 round trips to a tertiary centre averted for patients and their families Avoided 20,400KM!!!!! Cultural implications (ATSI fear of flying & removal from family & country) 3 Tertiary centre beds facilitated through Telehealth (fast track)

How valuable is telehealth support to you in caring for HDU/ICU patients?

1 2 3 4 5 1 2 3 4 5 1= Not at all 2= Very little 3= Neutral 4= Some extent 5= Great extent

How likely are you to recommend use of telehealth in the future?

2 4 6 8 1 2 3 4 5 Rating 1= Not at all 2= Very little 3= Neutral 4= Some extent 5= Great extent

ICU Telehealth - The Future

• Collaboration with the Alfred, RMH and RCH
• Deliver training and education
• Scale to other rural and regional hospitals
• EOI process
• 3 health services
• Increase capacity, build collaborative relationships
• Develop a sustainable robust telehealth service

Participating sites

Participating sites:

• Bairnsdale Regional Health Service
• Wimmera Health Care Group
• Central Gippsland Health Service

Alfred Health

Objectives

Decrease avoidable patient transfers Improve consumer experience Improve critical care staff satisfaction Deliver education relevant to regional critical care clinicians Assist with the clinical governance activities of the regional critical care services Primary Secondary

Progress

In 3 months MBH & AH have worked with the sites to support implementation of Telehealth

• IT procurement of Technology infrastructure
• Resource sharing (MBH TelehealthToolkit)
• assistance with Stakeholder engagement
• Identification of clinical champions
• pre-implementation data collection
• consumer engagement
• site visits

Future

• Objectives (Primary and Secondary) met
• Peer to peer support
• Increased capability and sustainability
• Shared Learnings
• Improved customer experience
• Improved staff satisfaction

MBH Critical Care Telehealth

54 round trips to a tertiary centre averted for patients and their families Avoided 64,800KM!!!!! Cultural implications (ATSI fear of flying & removal from family & country) 6 Tertiary centre beds facilitated through Telehealth (fast track) $509, 814 in ARV retrieval costs saved !!!

Case studies

Patient: 43 yo male admitted to ICU – IPPV, decreased GCS, and lethargy. Recently dx Hypothyroidism. Support: Telehealth to Alfred for second opinion 3/7 ICU stay for ventilatory support Advice & collaboration provided regarding: – Diagnosis (Myxodema crisis) – Pathology/radiology requirements – Antibiotics

Case Study 1:

Our very first Telehealth patient... The week prior to Intensivists’ official commencement date July 2017

Result:

Dr Tim Leong at the Alfred collaborated with MBH staff sometimes 2/3 times/day to assist in keeping Marlon at MBH with support Marlon walked out of our ICU, he was so very appreciative

Our very first Telehealth patient... The week prior to Intensivists’ official commencement date July 2017

Case Study 1:

43 yo male admitted to ICU – IPPV, decreased GCS, and

• lethargy. Recently dx

Hypothyroidism.

Case Study two

Patient: 60yo ICU admit with Exac Asthma High flows Patient remained at MBH (previously flown out) Support: Daily TH/ support re patient management Learnings: Medical & Nursing (exposure to expertise in the clinical setting)

IPPV Asthma Unstable Kept locally

Case Study 2:

Patient: Aboriginal patient admitted with Severe Sepsis/MOF IPPV/High dose Inotropes. Vascath inserted & dialysis required Support: Day 1- MBH Consultant wanted to transfer patient out considering severity of illness/supports

Intersection of Telehealth and cultural considerations

Case Study 3

14 days were spent in our ICU surrounded by family/friends After successful extubation our treating Consultant discussed transfer to Melbourne for fistula formation & long- term dialysis After collaborative meetings with the patient, family and treating teams again elected to stay at home Extended family visited every day at times >10 visitors per day

Case Study

Patient:

22yo admitted to ICU with Influenza A, Aspiration pneumonia/Septic shock PHX: Intellectual disability/Lives in residential facility requiring 24hr nursing care/wheelchair bound/non-verbal

Support:

IPPV, inotropic support O/A….medical staff documented ?T/f on admission D7: Failed extubation re-intubated D18: Failed extubation re-intubated D22: Tracheostomy inserted & nasojejunal tube Multiple complexities 56 day ICU admission

Case Study 4

Learnings

• Transfer vs “what family want” too hard basket
• Financial implications (56 day hospital stay)
• Emotional implications
• PD for staff
• Support surrounding EOLC “two heads are better than one”
• Increase capacity, build collaborative relationships
• Develop a sustainable robust Telehealth service

Outcomes

• Keep appropriate patients at MBH
• Support our Physicians and Anaesthetists; collaborative approach to

care

• Decrease number of avoidable retrievals...today Nil !!!
• Support our staff afterhours
• Deliver training and education options to Nursing and Medical staff

with strong ties to the Alfred

• Multidisciplinary care planning with TH and Allied health involved in

EOL care

• Scaling our Project to other sites.

Scaling Video

Critical-care-telehealth-scaling-project