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