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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
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
5.5
ho
urs
flyin
g tim
e
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
Challenges
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
Indicative fatality rate / 100 000 persons and fatality
count for motor vehicle crashes per WA police district (Road Safety Commission 2015)
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
WA Country Health Service
Vision
Healthier country communities through
partnerships and innovation
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
ETS has contributed to increased numbers of
medical consultations in WACHS small hospitals
ETS
Regression trend
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
Standard ETS flowchart
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
ETS ED layout – receiver end
• Significant
clinical input
into layout of
ED’s and
camera
• Standardised
formulary
• Standardised
emergency
trolley
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
EMPLOYED
• ETS Clinical Director
• ETS Manager
• ETS nurse manager
• Administrative staff
Workforce• FACEMs
• GP Proceduralists
• Clinical Nurses
• Role for Nurse Practitioners
DOCTORS MOSTLY CONTRACTORS
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
EducationFlexible (Blended) Learning Framework
• Videoconferencing events
o theoretical
o practical
o simulation
• eLearning Program
o ETS HELP
• F2F Education
o ETS staff
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
Practical sessions
• pre-amble – VC etiquette, intros, recording
• record
• monitor issues
• remote control
• attendance and evaluations
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
Simulation sessions
• pre-amble – safety, processes.
• no recording
• monitor issues
• camera and microphone control
• scenario = debrief
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
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.
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
What’s next?
• In-patient support
• Leveraging capacity across entire ED system
• Care coordination
• Ad-hoc specialist access
• Interface with preventive care
Government of Western AustraliaWA Country Health Service
Healthier country communities through partnerships and innovationValues Community | Compassion | Quality | Integrity | Justice
Questions/comments
Experienced ED generalist looking for telehealth work?
Email to: andrew.jamieson@health.wa.gov.au
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