Western NSW Local Health District (WNSWLHD) enhanced its Critical Care Advisory Service (CCAS) by conducting an audit, delivering staff education, streamlining clinical pathways and improving the patient experience.
To increase the number of clinicians in WNSWLHD who phone the dedicated CCAS line appropriately, by 50 per cent by 2016-17.
- Provides best practice care in a timely manner, with minimal clinical variation.
- Ensures timely and appropriate escalation of clinical deterioration.
- Reduces the risk of patient harm and the need for out-of-district transfers.
- Improves the patient experience and delivers care close to their home.
- Supports the development of clinicians, while increasing satisfaction and retention.
- Enhances partnerships with key stakeholders across the local health district.
- Achieves objectives on a broad scale using existing resources available.
WNSWLHD has hospitals in more than 40 regional and rural locations in NSW, spread across 31 per cent of the region. As such, access to specialist medical services can be a challenge. In 2008, the CCAS was established to deliver a coordinated outreach service and specialist management guidance for clinicians caring for critically ill patients. It was delivered by the Patient Flow Transport Unit (PFTU) using telehealth technology, and is considered a successful model for ensuring patients receive the right care, in the right place, at the right time.
The CCAS has made a number of gradual improvements to the program since its inception, to maintain service quality and growth while supporting a transient clinical workforce of more than 7000 people. However, service demand and productivity has increased significantly in recent years, despite resourcing remaining stable. An increase in critical care patients has the potential to increase morbidity and mortality, emergency transport costs and healthcare resources. As such, it was determined that new ways of working were required, to better manage the increase in CCAS events with existing resources.
- A multi-level audit and governance review of the CCAS was implemented in 2015, to improve consistency of service delivery and strengthen partnership engagement, as well as identify ways to improve care. This included the development of governance processes relating to quality and safety, as well as a feedback system where the nurse coordinator calls the referring team within 24 hours of the event, with a clinical update and discussion about what worked well and what could be improved. A nurse manager then conducts a secondary review of the event and provides a written report detailing the event and outlining quality improvement suggestions to be discussed at each facility’s quality and safety meetings.
- In 2015, a CCAS Toolkit was released with an A to Z listing of resources, including newsletters, referral patterns and information about partner services and CCAS business processes.
- A CCAS training movie was developed in 2016, to increase staff education on the service, including how and when to access it. The movie was placed on the intranet and incorporated into inductions for new staff. Health service managers were also responsible for ensuring it was viewed by existing staff.
- Monthly PFTU morbidity and mortality meetings were conducted using video conference technology in December 2015. All local health district and state partners were invited to examine patient journeys and discuss systems and processes affecting patient outcomes and experience. An evaluation tool was developed to receive feedback from attendees.
- Weekly best practice forums were established and trialled for five months in 2017, to strengthen the support role of PFTU for rural and remote clinicians.
- 12 clinical pathways were developed for the PFTU, to standardise business processes, reduce unwarranted clinical variation, define escalation processes and maximise efficiency. A script was developed, with five mandated questions for the beginning of each phone referral, with CCAS referral criteria developed to identify critically ill patients and streamline care coordination practices. Internal audit tools were developed to measure compliance and effectiveness.
- A clinician survey was undertaken from January 2015 to December 2016, to measure staff experience with the level of support provided by CCAS team when caring for critically ill patients, including whether their clinical needs were met, the value of feedback system and ideas for improvement.
- Patient and service rounding was undertaken in 2016, to evaluate what was working well and what could be improved.
- Partnerships were established with clinical nurse coordinators and clinical nurse educators across the local health district, to champion appropriate access and use of PFTU and CCAS. In 2014-15, CCAS nurse managers visited facilities and provided in-service education. As CCAS activity increased, this was no longer sustainable and video conference education was offered, including a tour of the PFTU. This education was incorporated into orientations for new registered nurses in the PFTU and CCAS.
Sustained – The project has been implemented and is sustained in standard business.
2014 - 2017
- WNSWLHD Patient Flow Transport Unit
- The WNSWLHD Living Well Together strategy aims to provide ‘one health service across many places’.1 CCAS and PFTU play a critical role in delivering this goal, by providing staff in rural and remote facilities with access to experienced clinical decision-making support and experienced clinical leadership in critical care emergencies.
- The total number of clinicians calling the CCAS line with a critical ill referral increased from 274 in 2013-14 to 509 in 2016-17. This is an 82 per cent growth in three years, which exceeded the aim of the project.
- The number of clinicians calling the CCAS line instead of the non-emergency patient flow line (a queue conference system) reached 60 per cent by March 2017, improving access to specialist management advice.
- The number of Transport Level Category A (emergency or life-threatening) inter-facility transfers remained at 2.3 per cent of all patient transfers between 2012 and 2016, despite significant growth in CCAS activity. This shows that the project has reduced unnecessary transfers and optimised modes of transport through early best practice treatment.
- Results from service, staff and patient rounding between 2015 and 2016 showed that CCAS service and patient rounding were 100 per cent positive, and clinician rounding was 99 per cent positive.
- Weekly best practice forums were suspended following the trial period, due to poor attendance by local health district clinicians. Despite this, feedback from attendees show it provided a valuable professional development and networking opportunity. It will be trialled again once the PFTU is better resourced to promote the forums and improve engagement with clinicians.
- Feedback on the training movie was positive, with comments as follows:
- ‘It is an excellent service’
- ‘We need to include this in the LHD orientation for new staff’
- ‘Great training movie, it gives you a wide knowledge of the process that occurs with CCAS. Well done’
- ‘Great for small outback towns’
- ‘Very well done, easy to understand and our little remote towns welcome this service very much’
- ‘Excellent, glad we got to see behind the scenes’
- ‘Well explained and professional production. Nice work’.
- WNSWLHD has engaged audit and advisory firm KPMG to develop a business case and implementation plan for the expansion of the PFTU over the next five years. This will include transition to proactive remote support virtual model operating out of PFTU. Future innovations will continue the development and expansion of the CCAS, using the latest technologies and models of care, such as electronic medication management and remote patient monitoring.
- 2017 NSW Premiers Award - Improving Service Levels in Hospitals Winner
- 2017 WNSWLHD Innovation Awards – Bob Leece Transforming Health Award Finalist
- Standardising best practice requires consistent communication, feedback, support, resources and a relentless focus on patient safety and quality service.
- Identifying challenges and enablers early on was vital to the success of the project.
- Align the goals and processes of nurse coordinators and CCAS consultants early in the project, to ensure a safe and quality service.
- It is important to build a reliable service that is perceived as open and transparent, but adds a supportive layer to local health district staff.
- It is important to build and maintain reliable data systems to evaluate the effectiveness of the project and influence change management strategies.
- Build capacity in the local health district, by sharing knowledge and data between critical care services.
- Build the program into existing local health district systems, and formalise pathways, roles and responsibilities into endorsed procedures.
- Provide constructive feedback during the project and always welcome feedback from stakeholders, with updates on any subsequent action taken.
- Provide recognition to staff and be sincere and supportive, while dispelling myths and continually promoting the objective of the project.
Western NSW Local Health District. Strategic Plan 2016-2020. Dubbo NSW: WNSWLHD; 2016.
Nurse Manager, Critical Care Advisory Service
Patient Flow Transport Unit
Western NSW Local Health District
Phone: 02 6809 8811 or 0427 398 238