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Telerenal Services in Northland
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Telerenal Services in Northland

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Dr Walaa Saweirs

Dr Walaa Saweirs
Consultant Nephrologist, Northland DHB

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Telerenal Services in Northland Telerenal Services in Northland Presentation Transcript

  • Telerenal Services in Northland Establishing an integratedregional dialysis service and clinical networks Dr Walaa Saweirs (2012), Whangarei Hospital, New Zealand
  • Outline Background  Regional service  Rurality/travel times  Cost of travel  Tertiary referral Current use of telehealth  Within the region  Links with other centres Lessons learned Future plans
  • Background View slide
  • Geography Total population: 148, 470  Whāngārei: 74,460  Far North: 55,842  Kaipara: 18,135 Hospital locations:  Whangarei (Regional Base)  223 in-patient beds  36 haemodialysis stations  Kaitaia  26 in-patient beds  8 haemodialysis stations  Kawakawa (Bay of Islands)  15 in-patient beds  8 haemodialysis stations  Dargaville  16 in-patient beds View slide
  • Population Density (2008)< 1 person/ km2 1-5 persons/ km2 5-10 persons/ km2 Kaitaia 10-50 persons/ km2 Kawakawa 500-750 persons/ km2 Whangarei 750-2000 persons/ km2 250-500 persons/ km2
  • Socioeconomic Deprivation (Dep2006)
  • Kaitaia to Whangarei – 2¼ hrsKawakawa to Whangarei – 1hrWhangarei to Auckland – 2¼ hrs
  • Travel Costs Ambulance transfer to Whangarei Base Hospital  From Kaitaia costs NDHB roughly $350  From Bay of Islands costs NDHB roughly $150 Patient transfer by taxi to Whangarei Base Hospital  From Kaitaia costs NDHB roughly $200  From Bay of Islands costs NDHB roughly $100 NTA allowance of 28c/km  From Kaitaia to Whangarei (155km) - $43.40  From Bay of Islands to Whangarei (71km) - $19.90 Hidden costs  Social eg support person travelling, child care, isolation from whanau  Staffing eg need for nurse escort
  • Tertiary Referral – Auckland Renal specific:  Vascular radiology including interventional  Vascular surgery  Renal transplant  Pathology General:  Interventional cardiology  Specialist radio-oncology
  • Impetus for a Telehealth solution…
  • Kaitaia Hospital
  • Bay of Islands Hospital (Kawakawa)
  • Issues: Opening of new satellite dialysis unit at Kaitaia hospital in November 2010 Lack of permanent Clinical Nurse Manager  Contingency for BOI CNM to oversee KTA satellite No on-site specialist physician  Planned for 2 visits per month for clinics Travel times for both patients and staff movement  Weekly multidisciplinary team meetings would prove challenging Staff isolation and training issues Support for existing satellite unit at BOI …etc
  • ..other options? Don’t open the Kaitaia unit…  Health pressures  Community pressure etc Increased staffing…  Financially and logistically not viable Skype-based system initially discussed...  Security  Logistics  Ease of use  Future adaptability
  • Equipment Polycom HDX7000 with 32" LCD TV screen on a mobile cart in each of the 3 units Panasonic SD50 handheld videocamera in each of the 3 units QD700 Document Camera in each of 2 satellite units HP Elitebook Pro tablet in base unit  Total set-up cost - $70k  Monthly cost (of 3 renal units) - $1000
  • Current Use of Telehealth
  • Multidisciplinary Meeting Weekly meeting with all units involved Medical handover Review of:  Difficult/problematic cases within each unit  Dialysis access issues  New patients Forward planning  Patient transfers/logistics between units over the coming week for eg planned procedures  Patient transfers/logistics to Auckland over the coming week for eg vascular procedures
  • KTABOI
  • “Paper round” - Summary Monthly review of individual haemodialysis patient results with primary nurse/nursing team leader by patient’s primary renal physician Adjust dialysis prescription as needed Adjust medication as needed and advise GP Review any vascular access issues Review any on-going concerns
  • “Paper round” - Logistics Individual patient electronic folders:  Excel spreadsheet of cumulative monthly labs  Excel spreadsheet of dialysis BPs & weights  Word document with current medication record  Above prepared by nurses in advance of round ECGs and individual dialysis session notes can be transmitted using the document camera Brief round note dictated to GP Medication/dialysis record changes updated, signed & dated using Tablet PC Potential room for further efficiency:  Electronic renal IT system collating patient lab results, BPs, weights  Electronic medication record linked to GP and Pharmacy
  • Sample Spreadsheet – Results Chart
  • Sample Spreadsheet – Weight gain/BP Weight UF BP & Pulse (sitting) BP (standing) date pre post Targ IDW Achiev set pre di p Pos di p *Hypo pre post comment 2nd 78.5 76.8 77.0 1.7 134 86 84 143 87 77 no 125/79 136/81 4th 77.0 76.9 77.0 0.2 0.1 0.3 122 75 95 154 85 73 no 119/79 135/81 6th 77.8 76.5 76.5 0.9 1.3 1.6 154 91 102 160 90 78 no 140/89 151/86 9th 76.8 75.9 76.0 0.3 0.9 1.1 161 73 94 158 75 81 no 150/81 129/80 11th 75.8 75.9 76.0 -0.1 -0.1 0.3 155 79 93 153 78 76 no 142/83 130/70 13th 77.0 75.9 76.0 1.1 1.1 1.3 131 69 93 152 79 77 no 125/65 133/73 January 16th 79.1 77.1 76.5 3.2 2.0 2.9 135 72 108 139 78 88 yes 123/64 126/64 UF ach 2420mls 18th 78.2 76.6 76.5 1.1 1.6 2.0 143 67 97 155 84 84 no 142/66 159/80 20th 77.0 76.0 76.0 0.4 1.0 1.3 153 84 110 159 87 81 no 161/75 145/87 23rd 75.6 76.2 76.0 -0.4 -0.6 0.0 139 83 89 157 80 72 no 139/76 144/78 25th 76.2 76.1 76.0 0.0 0.1 0.5 131 86 90 155 79 72 no 110/75 149/98 27th 75.8 75.9 76.0 -0.3 -0.1 0.0 128 59 83 150 71 75 no 133/76 128/95 30th 77.6 76.0 76.0 1.7 1.6 1.9 166 78 81 146 75 72 no 167/80 133/70 average 77.1 76.3 0.7 0.7 1.1 142 77 94 152 81 77
  • Sample Spreadsheet – Dialysis Chart
  • Sample Spreadsheet – Medication Flow Chart
  • Patient Assessment As needed basis Medical assessment  Acute review of issues arising on dialysis eg vascular access, skin lesions  Use of handheld digital camera  Allows collegial support of non-specialists at satellite unit  Allows streamlined transfer to tertiary centre without detour via base hospital  Reduces unnecessary travel for patients and family  Discussion of complex management plans with patient & carers  End of life discussions Dietetic assessment Social work review Psychiatric review
  • Other uses (within the region) Family meetings – for those about to start or on dialysis Weekly nurse in-service training sessions Staff performance appraisal Collegial support of satellite team
  • Tertiary Links – “BVC” Vascular & vascular radiology  Vascular access nurse-led paper referral sent to VA team at ADHB  Outcome of discussions relayed back to Northland team without direct discussion with Northland team  More crisis management than planned Renal transplant  Monthly telephone discussion with Auckland transplant team of Northland patients on transplant waiting list Regional meetings  Ad hoc – inconsistent attendance due to travel time issues and impact on clinical load
  • “Asymmetry of need - the incentive for telehealth is greater for those who receive it than those who provide it”
  • …Perceived barriers by tertiary centre… Time  Meeting times stretched already  “Current system works fine” (Tertiary team) Money  Stretched resources  Who would fund?...  “Northland - as its for their patients” (Tertiary team) Effort  Set-up of system  IT Support  “We don’t need it” (Tertiary team) Impact on Auckland patients  “Aucklanders have the lowest intervention rate” (Tertiary team)  ..implying they are usurped by regional centres it serves..
  • X
  • Tertiary Links – “AVC” Vascular & vascular radiology  Weekly meeting with vascular surgery, radiology, vascular access team (ADHB and NDHB)  Real-time two-way patient discussions with review of radiological investigations and previous intervention  Collaborative planned approach Renal transplant  Monthly meeting which now feels as though one is talking with the whole team Regional meetings  Improved ability to attend eg weekly transplant meetings  Potential for larger group discussion encompassing eg Waitemata, Middlemore, Waikato etc
  • Lessons learned
  • Benefits Quantifiable:  Reduced staff and patient travel costs  Increased productivity  Estimated $8700 per month of additional revenue (on paper anyway!)  Additional 30 patients per month can be seen in clinic  Travel cost savings low, but productivity gain from time released is large Non-quantifiable:  Far greater value than quantifiable benefits  Include:  Team cohesion  Enhanced communication  Improved staff morale  Enhanced education and training  Improved ability and speed to adapt to new priorities and demands  Anticipated reduction in error rate  Safe and supported working environment for staff
  • Issues - Local Location  Ideally need a dedicated consulting room which is soundproof  Patient areas also need to be private Security of units  Lockable, yet useable Ease of use  Units initially appeared to reset themselves  Slow start-up Bandwidth KEYS TO LOCAL ISSUES:  Initial Telecom issues Medical and nursing champion Power issues Dedicated IS support Team engagement and enthusiasm  Surge protector Communication
  • Issues – Tertiary Link ?KEYS TO ISSUES: Medical and nursing champion Dedicated IS support Team engagement and enthusiasm Communication Incorporate into service plan as part of tertiary provision Recognise cost through purchaser/provider codes Recognise the benefit and potential
  • Future plans..
  •  Patient hand-over  Satellite transfer  Vascular access Acute patient assessment Dialysis equipment troubleshooting  Use of hand-held camera – “live” and “store & forward”  Importance of camera stability +/- lighting Link to renal pathology review meetings in Auckland? Regional and national meetings???
  • Acknowledgements:Cheryle Kiwi – Northland Renal Service Nurse ManagerRoy Davidson – Telehealth Programme LeaderSue Wyeth – GM Mental Health and District HospitalsNeta Smith – Kaitaia Operations ManagerPhilip Jarvis – CNM Bay of Islands dialysis unitLaurie Francis – Previous acting CNM Kaitaia dialysis unitJill Rengatch – CNM Kaitaia dialysis unitThe nursing and medical staff of the Northland Renal TeamSimon Hayden and the team at Vivid Solutions