Mildura Base Hospital Critical Care Telehealth Experience
Mildura team Dr Alison Walker Andrea Bock Clinical lead 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
ICU Tertiary Transfers Aug 2017-Jan 2018 25 20 Avoided 15 Avoided=16 Avoidable 10 avoidable = Avoidable = 10 10 Non Non-avoidable = 5 Oligate = 47 avoidable 47 0 Aug-17 Sep-17 Nov-17 Dec-17 Jan-18 Oct-17
Telehealth Consultations In 6 months … 100 formal Telehealth consultations attended: 85% with the Alfred (Dr. Tim Leong) 90% between the hours of 8am-5pm 10% weekends, nil overnight !! • 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
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 25% increase rather than transferred 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 & 90% satisfied development 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? 5 1= Not at all 4 2= Very little 3= Neutral 3 4= Some extent 5= Great extent 2 1 0 1 2 3 4 5
How likely are you to recommend use of telehealth in the future? 8 1= Not at all 6 2= Very little 3= Neutral 4 4= Some extent Rating 5= Great extent 2 0 1 2 3 4 5
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 Primary Decrease avoidable patient transfers Improve consumer experience Improve critical care staff satisfaction Secondary Deliver education relevant to regional critical care clinicians Assist with the clinical governance activities of the regional critical care services
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
Case Study 1: Patient: 43 yo male admitted to ICU – IPPV, Our very first Telehealth decreased GCS, and lethargy. Recently dx patient... Hypothyroidism. The week prior to Intensivists’ official Support: commencement date July 2017 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: Result : Our very first Telehealth Dr Tim Leong at the Alfred collaborated patient... with MBH staff sometimes 2/3 times/day to assist in keeping Marlon at MBH with support The week prior to Intensivists’ official commencement date July 2017 Marlon walked out of our ICU, he was so very appreciative 43 yo male admitted to ICU – IPPV, decreased GCS, and lethargy. Recently dx Hypothyroidism.
Case Study 2: Case Study two Patient: IPPV Asthma 60yo ICU admit with Exac Asthma Unstable High flows Kept locally Patient remained at MBH (previously flown out) Support: Daily TH/ support re patient management Learnings: Medical & Nursing (exposure to expertise in the clinical setting)
Case Study 3 Patient : Intersection of Telehealth Aboriginal patient admitted with and cultural Severe Sepsis/MOF considerations IPPV/High dose Inotropes. Vascath inserted & dialysis required Support: Day 1- MBH Consultant wanted to transfer patient out considering severity of illness/supports
Case Study 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 4 Patient : 22yo admitted to ICU with Influenza A, Aspiration pneumonia/Septic shock Multiple complexities PHX: Intellectual disability/Lives in residential 56 day ICU admission 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
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
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