A/Prof Rebecca Kimble - Royal Brisbane & Women's Hospital - OPENING KEYNOTE ADDRESS | Embedding Behaviours for Quality Healthcare
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A/Prof Rebecca Kimble - Royal Brisbane & Women's Hospital - OPENING KEYNOTE ADDRESS | Embedding Behaviours for Quality Healthcare

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A/Prof Rebecca Kimble delivered the presentation at the 2014 Clinical Audit Improvement Conference. ...

A/Prof Rebecca Kimble delivered the presentation at the 2014 Clinical Audit Improvement Conference.

The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards.

For more information about the event, please visit: http://bit.ly/clinicalaudit14

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A/Prof Rebecca Kimble - Royal Brisbane & Women's Hospital - OPENING KEYNOTE ADDRESS | Embedding Behaviours for Quality Healthcare A/Prof Rebecca Kimble - Royal Brisbane & Women's Hospital - OPENING KEYNOTE ADDRESS | Embedding Behaviours for Quality Healthcare Presentation Transcript

  • Great state. Great opportunity. Department of Health Embedding behaviours for quality healthcare Rebecca Kimble GAICD, MBBS, FRANZCOG, Grad Cert IV Training & Assessment Chair, Statewide Maternity and Neonatal Clinical Network, Queensland Health Director, Queensland Clinical Guidelines, Queensland Health Director, Obstetric Services, Royal Brisbane and Women’s Hospital, Queensland Health Director, Statewide Paediatric & Adolescent Gynaecology Services, Queensland Health Associate Professor, University of Queensland School of Medicine Adjunct Associate Professor QUT Health Sciences Faculty Assoc. Prof. Rebecca Kimble, Dr Brent Knack 4th Clinical Audit Improvement Conference Sydney 25th August 2014
  • THE NATIONAL ENVIRONMENT FOR HEALTHCARE SERVICES National imperative for embedding quality behaviours 2
  • 3 Clinicians Policy Makers Community and Consumers Patients
  • Queensland Maternity & Neonatal Clinical Network Queensland Clinical Guidelines, Queensland Health 4
  • Queensland Clinical Guidelines Program www.health.qld.gov.au/qcg
  • Health Expenditure as a Proportion of Gross Domestic Product (GDP) OECD Countries - 2011 9.29.1 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 UnitedStates France Germany Netherlands Switzerland Canada Austria Denmark Belgium Japan NewZealand Greece Portugal Sweden Spain Norway Italy UnitedKingdom OECDAVERAGE Australia Slovenia Iceland Finland Ireland Hungary SlovakRepublic CzechRepublic Korea Israel Luxembourg Chile Poland Mexico Estonia Turkey HealthtoGDP(%) OECD Health Statistics 2014 – Frequently Requested Data http://www.oecd.org/els/health-systems/OECD-Health-Statistics-2014-Frequently-Requested-Data.xls 6
  • Annual Growth of Health Expenditure and GDP (Australia)- Rising Demand & Resource Constraints 0 2 4 6 8 10 12 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Growth(%) Year Growth in GDP Growth in Government Healthcare expenditure (National Currency Units) 5.4 6.2 8.1 9.1 0 2 4 6 8 10 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Health Expenditureas Percentageof GDP Government Expenditure Total expenditure OECD Health Statistics 2014 http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT# 7
  • AIHW-Mortalities Inequalities Australia August 2014
  • AIHW Report August 2014 Maternal Mortality Australia 2006-2010 Australia 2006-2010 USA 2009 Indigenous 16.4 /100,000 African American 35.6/100,000 Overall 6.8 /100,000 Others 11.7/100,000 Cardiac Mental Health Sepsis Obesity Chronic Diseases Trauma
  • Evidence Based Practices • 30-40% patients do not receive care according to current scientific evidence • 20-25% care medically unnecessary and potentially harmful • Non-compliance: poor information lack of support practitioner resistance 13 Health Care Management Review, March 2011, 36(1),4-17
  • What needs to be achieved? High quality healthcare Efficient and cost effective service delivery Healthcare improvement is the pursuit of these goals 14 Transparency and accountability in governance
  • IMPROVING HEALTHCARE SERVICES Supporting the effectors of quality healthcare 15
  • Improving Healthcare: What works ...? • Good-willed, hard working, highly qualified and autonomous clinicians • Innovative ways to empower and engage clinicians & consumers (Clinical Network activities) • Clinical Networks working together to increase efficiencies 16 Queensland Clinical Guidelines
  • • Everyday decisions, collaborations and communications of clinicians determine: ◦ Quality of healthcare ◦ Efficiency of service delivery ◦ Risk management – clinical and corporate risks • Clinicians working in a clinical capacity hold most power to effect quality, safety and expenditure Improving Healthcare: Why are clinicians important…? Corporate systems exist to lead, support and facilitate better decisions at the bedside 17
  • 18
  • NSQHS Standard 1 Corporate systems that should exist to lead, support and facilitate better decisions at the bedside 19 Governance for Safety and Quality in Health Service Organisations Statement of Intent: Create integrated governance systems that maintain and improve the reliability and quality of patient care, as well as improve patient outcomes.
  • 20 Queensland Clinical Guidelines Corporate Systems Translation, Decision support, Internal controls Clinician decisions Australians receiving healthcare services Queensland Maternity & Neonatal Clinical Network
  • Culture of clinicians and policy makers • But… many clinicians are largely unaware of the big picture Perception: • Clinician focus: Patient care, clinical safety • Policy maker focus: Efficiency of service delivery, risk management A degree of disconnect between clinicians and policy makers
  • Aligning culture of clinicians and policy makers • Align using tools that concurrently shape behaviour of clinicians and policy makers: ◦ Standards and policies ◦ Clinician engagement and leadership ◦ Consumer engagement ◦ Clinical networks ◦ Clinical guidelines ◦ Clinical audit 22
  • SHAPING BEHAVIOUR USING: STANDARDS AND POLICIES A tool for shaping not a stick for chasing 23
  • 24
  • • Assurance for clinicians: ◦ Governance is focused on supporting frontline improvements ◦ Deliver safe, high quality healthcare to consumers • Assurance for policy makers: ◦ Clinician skills and quality systems are able to provide care according to current evidence ◦ Deliver safe, high quality healthcare to consumers Governance for Safety and Quality in Health Service Organisations 25
  • For most frontline clinicians: •Details of standards & policy appear extraneous •Deliver on the principles at the bedside Using Standards to influence the frontline 26
  • Australian Safety & Quality Framework for Health Care Australian Commission on Safety and Quality Health Care (2010) 27
  • My responsibility Using Standards to influence the frontline Frontline clinician Goal: Frontline clinicians consider evidence when making decisions Expectation: Know the standards about using evidence 28
  • My responsibility Using Standards to influence the frontline Frontline clinician Goal: Frontline clinicians consider evidence when making decisions Expectation: Consider evidence when making decisions Queensland Clinical Guidelines 29
  • SHAPING BEHAVIOUR USING: CLINICIAN ENGAGEMENT AND LEADERSHIP Building a majority of clinical leaders 30
  • Creating Strong Foundations for Clinician Leadership • Educate clinicians about teamwork and their roles as leaders. • Genuinely value clinician leadership networks and teams that influence horizontally. 31
  • Clinician Engagement and Leadership • Culture: staff who are engaged and who have high morale deliver a better patient experience, fewer errors, lower mortality rates, less absenteeism and better clinical outcomes • Patient Focus: clinicians have the ability and motivation to keep the needs of patients at the forefront 32 Braithwaite J; Hyde P; Pope C, 2010, Culture and climate in health care organizations, Palgrave Macmillan http://www.palgrave.com/products/title.aspx?PID=353942
  • Clinician Engagement and Leadership • System Complexity: healthcare improvement is complex and those with a deep understanding of the system are best placed to improve it • Microsystems: what makes a difference to patients is the team who delivers their care. The design and running of local teams and systems is critical 33 Braithwaite J; Hyde P; Pope C, 2010, Culture and climate in health care organizations, Palgrave Macmillan http://www.palgrave.com/products/title.aspx?PID=353942
  • How to create a successful improvement culture in health • Make sure overall staff morale is good. Fix hot spots. • Engage the clinicians and give them the leadership and management skills they need • Use “respected colleagues” as change champions • Use the right language : it’s all about the patient • Use teams, groups, networks • Get people to work across silos 34
  • SHAPING BEHAVIOUR USING: CLINICAL NETWORKS Co-ordinating clinical experts and their leadership 35
  • Clinical Networking “Clinicians work best when they are encouraged to flourish in groupings of their own interests and preference, when they are empowered, not directed, and when they are nurtured and influenced by their peers, rather than controlled by others. This is a bottom up situation not readily amenable to top down solutions.” 36 Braithwaite J, Inaugural Australasian Network to Network Conference Melbourne March 2010
  • Clinical Networking “Clinical practice is shaped by the behaviours and attitudes of thousands of practising clinicians who every day make relatively independent decisions.” Networks: • Develop the ideas and knowledge of many clinicians into a culture • Co-ordinate clinician leadership and effort to tackle big picture issues • Advocate and communicate achievements 37 Braithwaite J, Inaugural Australasian Network to Network Conference Melbourne March 2010
  • 38 Clinicians Policy Makers Community and Consumers Patients
  • Network Structure Queensland Maternity and Neonatal Clinical Guidelines Program 39 Governance & Policy Makers Network Co-ordinator Clinical Chair / Director Consumers Clinical Member Network Product Development Teams Remote Area Private Hospitals External Services
  • Developing culture with a network Aligns behaviours by: • Establishing consensus • Providing evidence for decision making • Integrating the consumer perspective • Sharing and extending knowledge • Communicating and advocating for projects and programs 40
  • Developing culture with a network 41 Queensland Clinical Guidelines
  • Integrated electronic medical record
  • Qld Maternity Early Warning Tool Q-MEWT
  • Perinatal social and emotional wellbeing screening
  • SHAPING BEHAVIOUR USING: STATEWIDE CLINICAL GUIDELINES Translating evidence into best clinical practice 45
  • Queensland Clinical Guidelines Program www.health.qld.gov.au/qcg
  • Statewide Clinical Guideline approach by Network Topic Identified by members Evidence Informed Statewide Clinical Guideline Awareness and Marketing Support clinician led implementation
  • Robust Development Process 48 Implementation strategies Scoping and review of the evidence Working party consultation Statewide consultation Working party consultation Queensland Health endorsement Clinician endorsement Communities, consumers Clinicians Policy makers Patients
  • Queensland Maternity and Neonatal Clinical Guidelines Program 49
  • Queensland Clinical Guidelines Translating evidence into best clinical practice Queensland Clinical Guidelines, Queensland Health 50 • Clinical guidelines • Flowcharts • Education • Audit • Implementation checklist www.health.qld.gov.au/qcg
  • • Practical presentation of evidence and statewide consensus • Supports clinicians to meet strategic goals • Facilitated evidence based decision making • Integrates clinicians, policy makers and consumers • Uses multiple concurrent strategies to align behaviours for quality 51 Queensland Clinical Guidelines Translating evidence into best clinical practice
  • 52 Engaging clinicians in quality Dissemination Awareness and Distribution • Notifications (email, newsletters, staff notices) • Presentations & presence (education, professional events & forums) • Accessible information (Posters, flowcharts, web site) • Endorsement – organisational, expert, peer • Clinical champions • Responsiveness to clinician needs • Up to date website Clinical Governance • Table topics at local safety and quality meetings • Clinician orientation • Educational meetings (grand rounds etc) • Opportunities for clinician involvement QCG Statewide desktop icon
  • 53 Education Engaging clinicians in quality • Guideline aligned education • Expert clinician presenters and panels • >1350 individuals over 2 years • 60 sites • Average 22 Sites per videoconference 0 5 10 15 20 25 30 35 40 NeoHypo 29/03/2012 BFI 26/04/2012 Perinealcare 31/05/2012 RespDistress 28/06/2012 IFS 26/07/2012 VBAC 30/08/2012 NormalBirth 27/09/2012 NeoResus 25/10/2012 GBS 29/11/2012 Perinealcare 28/02/2013 PPH 28/03/2013 Jaundice 2/05/2013 NAS 23/05/2013 VBAC 27/06/2013 Neostab 25/07/2013 IOL 29/08/2013 Examinationofnewborn 27/09/2013 Newbornhypoglycaemia 24/10/2013 Obesity 21/11/2013 Diabetesinpregnancy 27/02/2014 SGA 1/05/2014 Numberoffacilities Videoconference education session Participation and reporting of attendance bysession Participating facilities (telehealth record) Facilities reporting participation
  • Importance of statewide approach 54 Queensland Clinical Guidelines Clinician Survey, 2011
  • Uses for clinical guidelines 55 28% 43% 52% 58% 67% 68% Respondents agreed by % Confirmsclinicalpractice Increased clinical knowledge Summary of current evidence Improved patient safety Changes clinical practice More confidence 70%Educational resource (N=348) Queensland Clinical Guidelines Clinician Survey, 2011
  • 92% 87% 98% 98% 84% 87% 96% 91% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Participant agreement (%) Participant agreement (%) regarding videoconference education sessions Knowledge assessments were useful for my learning Topic was relevant to my position Knowledge gained has improved my confidence Education sessions should continue in this format Presenter displayed sufficient knowledge of the topic Course content covered the objectives Overall quality of the session was good The session was well strctured and logical 56 Queensland Clinical Guidelines: statewide videoconference education N = 613 to 1385 Queensland Clinical Guidelines, March 2012-June 2014
  • Pre-videoconference knowledge assessment scores 57 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NeoHypo 29/03/2012 BFI 26/04/2012 Perinealcare 31/05/2012 RespDistress 28/06/2012 IFS 26/07/2012 VBAC 30/08/2012 NormalBirth 27/09/2012 NeoResus 25/10/2012 GBS 29/11/2012 Perinealcare 28/02/2013 PPH 28/03/2013 Jaundice 2/05/2013 NAS 23/05/2013 VBAC 27/06/2013 Neostab 25/07/2013 IOL 29/08/2013 Examinationofnewborn 27/09/2013 Newbornhypoglycaemia 24/10/2013 Obesity 21/11/2013 SGA 1/05/2014 Traumainpregnancy 19/06/2014 PercentageofRespondents Videoconference (Date, Title) >90% 60-89% <60%Score Queensland Clinical Guidelines, July 2014
  • Online knowledge assessments 58 99.5% 99.0% 97.4% 99.5% 99.1% 99.1% 98.9% 98.9% 98.7% 99.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage agreement(%) with statements about online knowledge assessments Will assistme to apply guideline recommendations Easy to use Coverskey aspects of the guideline A useful selfdirectedlearningtool Was easyto findon the QCG website Provide access to appropriate guideline information Couldbe completedina reasonable timeframe Improvedmy knowledge Assistedto consolidate my understanding Well structuredand logical N = 2217 to 2307 Queensland Clinical Guidelines, Jan 2013- June2014
  • Many elements are required to change behaviour 59 Queensland Clinical Guidelines, July 2014
  • Queensland Clinical Guideline: Preterm labour (2009) 60 Introduction of fetal fibronectin test across Queensland (2006)
  • 61 · Positive fFN and/or · Evidence of cervical change and /or · TVCL < 20 mm Increased risk of delivery within 7 days Consider tocolysis Contraindications? Gestation > 34 weeks Labour too advanced In utero fetal death Lethal fetal anomalies Suspected fetal compromise Maternal BP < 90 mm Hg systolic Placental abruption Chorioamnionitis Discuss with Obstetrician and Paediatrician Nifedipine (CTG during tocolysis) give 20 mg oral If contractions persist after 30 mins: Second dose 20 mg oral If contractions persist after further 30 mins: Third dose 20 mg oral · Negative fFN and · No evidence of cervical change and /or · TVCL > 20 mm Low risk of delivery within 7 days Maintenance therapy If blood pressure stable: 20 mg oral Nifedipine every 6 hours for 48 hours Review history · medical · surgical · obstetric Assess for signs & symptoms of PTL · lower abdominal cramping · pelvic pressure · lower back pain · vaginal spotting or ‘show’ · regular uterine activity Physical examination · vital signs · MSU +/- M/C/S · abdominal examination · fetal heart rate +/- CTG · sterile speculum examination · exclude PROM · fFN if not contraindicated · high vaginal swab · assess cervical dilatation by digital VE · low vaginal /anorectal GBS swab Do not perform fFN: With ruptured membranes Visual evidence of moderate bleeding Cervical cerclage insitu Consider TVCL if available Commence corticosteroids YES Transfer In-utero transfer should not be attempted if there is a risk of delivery during the transfer · Call RSQ: 1300 799 127 Contractions regular and painful Contractions infrequent / irregular Persistent painful contractions · Admit and offer analgesia · Administer steroids and commence tocolysis (if not contraindicated) · Commence prophylactic antibiotics for GBS · Continuous fetal monitoring with CTG · Transfer if necessaryDischarge home with follow-up in outpatients within 7 days Admit for observation. Offer analgesia Reassess in 2 hours NO Betamethasone 11.4 mg IM 24 hours later: Repeat dose 11.4 mg IM Prophylactic Antibiotics Penicillin 1.2 g IV bolus; then 600 mg every 4 – 6 hours OR (if penicillin allergy) Lincomycin 600 mg IV every 8 hours or Clindamycin 900 mg IV every 8 hours Cease if GBS screen negative Queensland Maternity and Neonatal Clinical Guideline: Assessment and management of preterm labour: Guideline No: MN09.6-V3-R11 · Positive fFN and/or · Evidence of cervical change and /or · TVCL < 20 mm Increased risk of delivery within 7 days · Negative fFN and · No evidence of cervical change and /or · TVCL > 20 mm Low risk of delivery within 7 days Review history · medical · surgical · obstetric Assess for signs & symptoms of PTL · lower abdominal cramping · pelvic pressure · lower back pain · vaginal spotting or ‘show’ · regular uterine activity Physical examination · vital signs · MSU +/- M/C/S · abdominal examination · fetal heart rate +/- CTG · sterile speculum examination · exclude PROM · fFN if not contraindicated · high vaginal swab · assess cervical dilatation by digital VE · low vaginal /anorectal GBS swab Do not perform fFN: With ruptured membranes Visual evidence of moderate bleeding Cervical cerclage insitu Consider TVCL if available Contractions regular and painful Contractions infrequent / irregular Persistent painful contractions · Admit and offer analgesia · Administer steroids and commence tocolysis (if not contraindicated) · Commence prophylactic antibiotics for GBS · Continuous fetal monitoring with CTG Admit for Queensland Clinical Guideline: Preterm labour (2009) Supporting bedside decision making
  • Obstetric Interhospital Transfers for False Labour (Q1 2003 - Q1 2012) 0 10 20 30 40 50 60 70 80 2003 Q12003 Q32004 Q1 2004 Q32005 Q12005 Q32006 Q12006 Q3 2007 Q12007 Q32008 Q12008 Q3 2009 Q12009 Q32010 Q12010 Q32011 Q1 2011 Q32012 Q12012 Q3 Quarter NumberofAdmissions False Delivered False non-delivered Queensland Clinical Guideline: Preterm labour (2009) Statewide Preterm Labour clinical guideline Statewide Memorandum FFN testing Queensland Clinical Guidelines, June 2013
  • 63 Maternal in-patient cost of Interhospital transfers for False Labour 0 5 10 15 20 25 30 35 40 45 50 Q 1 2003 Q 3 2003 Q 1 2004 Q 3 2004 Q 1 2005 Q 3 2005 Q 1 2006 Q 3 2006 Q 1 2007 Q 3 2007 Q 1 2008 Q 3 2008 Q 1 2009 Q 3 2009 Q 1 2010 Q 3 2010 Q 1 2011 Q 3 2011 Quarter NumberofAdmissions $0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 Cost($) Antenatal admissions Delivery Admissions Antenatal cost Delivery cost post-guideline Period: Q3 2009 - Q2 2011 Pre-guideline Period: Q3 2006 - Q2 2008 Queensland Clinical Guideline: Preterm labour (2009) Queensland Clinical Guidelines, June 2013
  • SHAPING BEHAVIOUR USING: CLINICAL AUDIT Audit as an intervention 64
  • Clinical Audit to Change Behaviour 65 • Frontline clinicians • Clinical champions • Safety and Quality • Consumers • Policy makers • Data specialist / statistician • External stakeholders • Many frontline clinicians • Policy makers • Statistician • Data analyst External expertise & support Policy makers Audit team Data collectors Queensland Clinical Guidelines, July 2014
  • Clinical Audit to Change Behaviour 66 Make decisions considering: · Evidence · Interpretation · Recommendations Communicate decisions Quality Assurance Data Analysis Design Audit Build support for audit Explain imperative Support data collectors · Explain design · Answer questions Communicate summary of results Communicate interpretation of results Make recommendations to policy makers Collect data Respond to decisions Receive interpretations and understand implications Appreciate clinical imperative External expertise & support Policy makers Audit team Data collectors Queensland Clinical Guidelines, July 2014
  • 67 • Benefits: ◦ Aligns clinicians and policy makers ◦ Suited to large audits ◦ Scales of economy ◦ Ownership of outcomes • Limitations: ◦ Longer time to engage appropriate stakeholders ◦ Co-ordination overhead associated with large audits and many people Clinical Audit to Change Behaviour
  • 68 Queensland Clinical Guidelines and Metro North Hospital and Health Service Point of Care Clinical Audit Project March 2014 Pilot Project 2011 Obesity Guideline Clinicians’ feedback: Feasible within daily workloads, worthwhile, would like to be involved again
  • Based on two Queensland Clinical Guidelines > 200 frontline clinicians involved 3 Hospitals auditing @ same time 1x tertiary, 2 x regional Point of Care & Retrospective audits
  • Project benefits • Evidence that clinical practice largely aligns to clinical guideline recommendations (evidence for NSQHS Standard 1.7.2) • Increased awareness and application of clinical guideline recommendations • Improvement in documentation of clinical care – particularly around patient communication • Identification of areas for clinical improvement 70
  • Participant Feedback 71 94% 85% 82% 70% 80% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage agreement Improved documentation Given confidence to apply recommendations Increased knowledge of the guideline Valuable to clinical practice Relevant to the clinicians N=33 Queensland Clinical Guidelines, July 2014
  • Aligning goals using: Clinical guideline based audit • Build audit into regular clinical activity • Engage clinicians • Build leadership capability • Generate evidence for evidence based decision making 72
  • • Build collaborations between clinicians, consumers, policy makers & patients • Multiple concurrent strategies are required to build a culture of quality in healthcare • Leverage Networks, National Standards, Statewide/ National guidelines and audits 73 Governance & Policy Makers Network Co-ordinator Clinical Chair / Director Consumers Clinical Member Network Product Development Teams Remote Area Private Hospitals External Services External expertise & support Policy makers Audit team Data collectors
  • Acknowledgements 74 • Queensland Clinical Guidelines, Queensland Health: ◦ Assoc. Prof. Rebecca Kimble ◦ Ms Jacinta Lee ◦ Ms Lyndel Gray ◦ Dr Brent Knack • Statewide (Queensland) Maternity and Neonatal Clinical Network Funded by: Health Systems Innovation Branch, Queensland Health Contact details: E: Guidelines@health.qld.gov.au | URL: www.health.qld.gov.au/qcg
  • 75 Feedback and contact details: E: Guidelines@health.qld.gov.au | URL: www.health.qld.gov.au/qcg Funding: Queensland Clinical Guidelines is supported by the Health Systems Innovation Branch, Queensland Health. Copyright: © State of Queensland (Queensland Health) 2014 This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the Queensland Maternity and Neonatal Clinical Guidelines Program, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc- nd/3.0/au/deed.en For further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email guidelines@health.qld.gov.au, phone (+61) 07 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email ip_officer@health.qld.gov.au, phone (07) 3234 1479. Copyright