phil tideman - iccnet - extending access to better heart care; how iccnet are offering...
TRANSCRIPT
-
Regional Systems for Extending Access to Better Heart Care
Dr Philip Tideman Clinical Director of Cardiology and the Integrated Cardiovascular Clinical Network,
Country Health SA Local Hospital Networkand
Deputy Head of Cardiology, Southern Adelaide Local Health Network
South Australian Safety Symposium, Stamford Plaza Adelaide 17 May 2016
-
My Office Rural SA
-
Geographic Variation in Coronary Heart Disease in
Australia 1986-96 more deaths than expected from acute
myocardial infarction resulted in mortality rates from CHD up to 30% higher in men and 21% higher in women living outside of capital city statistical divisions.
The gap widened between 1986 and 1996 and is greater amoung younger age groups
Sexton and Sexton, MJA 2000; 172: 370-4
-
SA Country Health Workforce - Largest Integrated Health Service in SA
Population 420,000 (28% SA)
Acute Care 66 hospitals
Total workforce 7,100 Nurses ~3,600 Salaried Drs - 46 GPs 424 GP registrars 41 Allied Health - 620
-
Aims & Objectives Eliminate disparities in CVD outcomes between
metropolitan and non metropolitan populations
Support the primary care doctor/nurse in diagnosis andevidence-based acute management of cardiacconditions
Enhance the clinical effectiveness of the primary careteam through the provision appropriate CME, clinicalresources and clinical systems
Accommodate differing levels of experience andconfidence of primary care teams in dealing with acuteand chronic cardiac problems in all types of non-metropolitan health care settings.
-
Clinical Network Operations: Critical Componenets
Workforce Medical Nursing Allied Health Administrative and Technical support
Systems of Care Clinical Tools and Clinical Systems
Education, Training and Skills Maintenance Access to Essential Equipment and ICT
Services Research, Development and Evaluation
-
Clinical Resources in All Rural Hospitals for ACS Management
1. Integrated, Evidence-based Clinical Pathways
Immediate Steps Initial Diagnosis and
Risk stratification Initial Treatment Further Diagnostic
Testing and Risk Stratification
Triage Chest pain / ACS SOB / CHF AF (in development)
-
Clinical Resources in Rural Hospitals for ACS Management
2. CHSA Digital ECG Management System
Generation, distribution, reporting, storage, retrieval and analysis of ECGs in a digital format
Assists: Recall of old ECGs Serial comparison of current
ECGs Distribution of high quality
ECGs to multiple providers Integration of ECG into EMR
-
An Example
ECG FACSIMILE DIGITAL ECG into INBOX
-
Clinical Resources in Rural Hospitals for ACS Management
3. Universal Access to Single-Bolus, Fibrin Specific Thrombolytic
Tenectaplase (Metalyse)
24/7 availability in every hospital, RFDS Pt Augusta, other sites
Tenectaplase
-
Clinical Resources in Rural Hospitals for Acute Management
4. Extended POCT Pathology Troponin T Pro BNP D-Dimer Hb, WCC Na, K Creatinine Glucose HbA1c
Lactate ABG (pO2, pCO2, pH) LFT Lipids Coagulation - INR
Cobas Epoc
Hemocue
Accu-chek Inform II iStat
-
Clinical Resources in Rural Hospitals for Acute Management
5. Cardiology Consultant Advice 24/7 service aim 10 min Response Time
Sheet3
Month
% 5 mins
Month
Number of Calls
Chart1
6
6
6
7
7
8
6
6
7
6
7
7
7
6
6
6
6
6
7
7
7
Average (mins)
Month
Average (mins)
Sheet1
Month/YRNumberAverage (mins)% 10 mins%5minsMonth/YRAverage (mins)
Jan114665Jan6
Feb101660Feb6
Mar121661Mar6
Apr141755Apr7
May133756May7
Jun132845Jun8
Jul164659Jul6
Aug109658Aug6
Sep154755Sep7
Oct173659Oct6
Nov148748Nov7
Dec161750Dec7
Jan129758Jan7
Feb118662Feb6
Mar157658Mar6
Apr151665Apr6
May197657May6
Jun141660Jun6
Jul187755Jul7
Aug179756Aug7
Sep171753Sep7
Sheet1
Average (mins)
Month
Average (mins)
Sheet2
Sheet3
-
Clinical Resources in Rural Hospitals for Acute Management
6. Seamless Transfer to Tertiary Cardiac Care for High Risk Patients Common clinical pathways Shared formulary and
medication protocols IV GTN IV Tirofiban
Integrated care between: Rural hospitals Rural doctors, nurses, allied health Tertiary specialists and cardiology
services Ambulance service Aeromedical Evacuation and
Medical Retrieval services
RFDS Base, Pt Augusta
-
Regional In-Hospital ACS Deaths
02468
101214161820
91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07Financial Year
% In
-Ho
sp
ital A
CS
Death
s
Southern Metro (Moving Average) South East (Actual) South East (Moving Average)
iCARnet Commenced April 2001
Regional network fully operational
Chart1
91/9219.191/92
92/9314.292/93
8.48730303691315.4333333333
7.134771959811.612.9333333333
5.53189478656.810.4666666667
4.57527454112.310.2333333333
4.20627280728.79.2666666667
4.410152561911.410.8
4.41944514778.59.5333333333
4.51421096798.99.6
4.22745816484.37.2333333333
4.09632639526.56.5666666667
3.973296511396.6
4.12401286364.46.6333333333
4.45555342644.86.0666666667
5.02572467384.94.7
Southern Metro (Moving Average)
South East (Actual)
South East (Moving Average)
Financial Year
% In-Hospital ACS Deaths
Sheet1
% ACS Separaitions Resulting in Death91/9292/9393/9494/9595/9696/9797/9898/9999/0000/0101/0202/0303/0404/0505/0606/07
Southern Metro (Moving Average)8.48730303697.13477195985.53189478654.5752745414.20627280724.41015256194.41944514774.51421096794.22745816484.09632639523.97329651134.12401286364.45555342645.0257246738
South East (Actual)19.114.21311.66.812.38.711.48.58.94.36.594.44.84.9
South East (Moving Average)15.433333333312.933333333310.466666666710.23333333339.266666666710.89.53333333339.67.23333333336.56666666676.66.63333333336.06666666674.7
Sheet1
Southern Metro (Moving Average)
South East (Actual)
South East (Moving Average)
Financial Year
% In-Hospital ACS Deaths
Sheet2
91/9292/9393/9494/9595/9696/9797/9898/9999/0000/0101/0202/0303/0404/0505/0606/07
19.114.21311.66.812.38.711.48.58.94.36.594.44.84.9
15.433333333312.933333333310.466666666710.23333333339.266666666710.89.53333333339.67.23333333336.56666666676.66.63333333336.06666666674.7
2.65476510782.54907390592.45198332421.28481155850.7635201130.7995369031.84049107781.74154039952.18852224791.89316509422.02913957321.4868559919
Sheet2
Actual
Forecast
Data Point
Value
Moving Average
Sheet3
Sheet4
-
Provider Clinical Network: Critical Factors for Success
Multi-disciplinary Co-ordinated and Integrated care vertical and
horizontal Clinician leadership Executive and Consumer buy-in Evidence based care Continuous Practice Improvement safety and
quality Incremental change Comprehensive care within an appropriate service
delineation framework Across the continuum of care Harnessing appropriate use of new technology
-
Provider Clinical Network
3 important and unique characteristics in clinical change:
Engagement of care providers Adaptability Sustainability
-
Extending Care to Large and Remote Workplaces: Case Study
Oz Minerals Prominent Hill Mine site 750 km NW of Adelaide Approximately 800 employees on site FIFO 2 remote Area Nurses plus paramedics
manning a small health centre Traditional Emergency Care provider
RFDS nearest Base Pt Augusta Minimum response time 90-120 minutes
-
Extending Care to Large and Remote Workplaces: Case Study
Oz Minerals Prominent Hill Mine site Introduced essential equipment fo acute
cardiac management Portable ECG Monitor Defib 12 lead ECG capability POCT Pathology Troponin T Contact with Cardiology Consultant within 10
minutes, 24/7 with ability to coordinated with RFDS Doctor, MedSTAR retrieval service
Tenectaplase and other emergency medicn
-
Extending Care to Large and Remote Workplaces: Case Study
Oz Minerals Prominent Hill Mine site Advantages
Potentially shorten time to Thrombolysis Each hour delay in reperfusion increases mortality risk by
1% Early triage, appropriate triage by involving
Consultant Cardiologists and Retrievalists in addition to RFDS
Can now deal with a wider spectrum of potential acute cardiac presentations (STEMI, NonSTEMI, USAP, pericarditis, low risk CP, AF, PSVT)
-
Extending Systems of Care: The Future
Telehealth Integrated and universally accessible
Clinical databases New Models of care and systems
organisation Workforce and CME Closing the Gap for ATSI People
-
Telemedicine To Date iCARnet rural hotline Digital ECG network Integrated POCT Pathology network Cardiac EMR Implementation (limited inpatient EMR)
Successful office based EMR (VIP software) Limited inpatient EMR success
Pacemaker/AICD home based follow-up system Outpatient Video-consultation
Urgent new patients, patient review/ follow-up
Education, Training, Accreditation and Technical support Australian Point-of-Care Practitioners Network www.appn.org.au Rural Cardiology www.iccnetsa.org.au
http://www.appn.org.auhttp://www.iccnetsa.org.au
-
Digital TeleHealth Network (DTN) Video-Conferencing
Low risk (Troponin negative) chest pain assessment
No doctor on-site ED resuscitation assistance Complex inpatients not for
transfer (palliative care) Routine follow-up and urgent new
consultations Remote support for GP based
Exercise ECG testing Routine EP device followup POCT training, accreditation,
technical support Other Continuing Medical
Education, training & accreditation
-
Virtual Emergency Service Support
Intensive care video-conferencing support to rural hospitals
Qld SA (limited)
Rural Virtual Emergency Service WA SA planned SAVESS
-
Aggregating Digital Clinical Data Sources
Digital ECG All POC
Pathology All BGLs CATCH
Cardiac Rehab Home
Telemonitoring Decision
Support Tools
-
Other Examples of Integrated Clinical Data Systems
Web-based for universal access iCVIS
Fuji clinical reporting systems Synapse Epiphany
Alcidion Miya health informatics platform Integrated clinical decision support
-
Integrated Cardiac Clinical Streams
Re-organising tertiary management ACS and Ischaemic heart disease Arrhythmia / EP Heart Failure and *Structural heart disease
New Clinical pathways AF CHF Valvular heart disease (TAVI +/- mitral)
-
CATCH An enabler of Cardiac Rehab
Literature review of alternative CR models Mapped available country resources Central referral and booking system for country
patients for cardiac F2F Rehab referral where service available
locally (17 programs in country, 4 in GP) Telephone CR service - 7 structured sessions
over 7 weeks with Cardiac rehab nurse CATCH website for online CR
-
Conclusion
Introduction of central referral service & telephone CR program Increased participation Increased completion rates Improved readmission rate & length of stay Positive clinical outcomes
-
Vascular Respiratory and Metabolic Clinical Network Cluster
-
Clinical Change without Clinical Networking and Integrated Care
-
www.iccnetsa.org.au
Twitter:@heartphilt
http://www.iccnetsa.org.au
Regional Systems for Extending Access to Better Heart CareMy Office Rural SAGeographic Variation in Coronary Heart Disease in Australia 1986-96SA Country Health Workforce - Largest Integrated Health Service in SAAims & ObjectivesClinical Network Operations: Critical ComponenetsClinical Resources in All Rural Hospitals for ACS ManagementClinical Resources in Rural Hospitals for ACS ManagementAn ExampleClinical Resources in Rural Hospitals for ACS ManagementClinical Resources in Rural Hospitals for Acute ManagementClinical Resources in Rural Hospitals for Acute ManagementClinical Resources in Rural Hospitals for Acute ManagementRegional In-Hospital ACS DeathsSlide Number 15Provider Clinical Network: Critical Factors for SuccessProvider Clinical NetworkExtending Care to Large and Remote Workplaces: Case StudyExtending Care to Large and Remote Workplaces: Case StudyExtending Care to Large and Remote Workplaces: Case StudyExtending Systems of Care: The FutureTelemedicine To DateDigital TeleHealth Network (DTN) Video-ConferencingVirtual Emergency Service SupportAggregating Digital Clinical Data SourcesOther Examples of Integrated Clinical Data SystemsIntegrated Cardiac Clinical StreamsCATCH An enabler of Cardiac RehabConclusionVascular Respiratory and Metabolic Clinical Network ClusterClinical Change without Clinical Networking and Integrated CareSlide Number 32