Do supports and barriers to routine clinical assessment for children with cerebral palsy change over time? A mixed methods study

Professor Christine Imms1

Professor of Occupational Therapy, Australian Catholic University

Aim: To investigate changes over time in allied health professional’s (AHP) perceptions of supports and barriers to implementing routine clinical assessment for children with cerebral palsy.

Method: Longitudinal mixed method approach. AHP (occupational therapists, physiotherapists and speech pathologists) employed in five disability service organisations were recruited. Participants completed the Supports and Barriers Questionnaire (SBQ; measuring organisational structures, resources, therapists, assessment tools, children and families) and participated in focus groups at baseline, 6, 12 and 24 months following introduction of routine clinical assessment procedures. Quantitative data were analysed descriptively. Baseline qualitative data were analysed inductively and a thematic framework developed. This framework was applied longitudinally using a constant comparative approach, facilitating identification of framework elements that emerged, or became less dominant, over time.

Results: 447 AHP participated (baseline n=227, 6m n=227; 12m n=224; 24m n=189). Mean SBQ ratings on all domains remained positive over time indicating that overall AHP felt supported in implementing routine clinical assessment. Five themes emerged at baseline: ‘motivated to adopt routine clinical assessment’, ‘ensuring effective ongoing communication’, ‘acquiring and utilising expertise’, ‘availability and distribution of resources’ and ‘therapist perceptions of child and families’ wishes’. Longitudinally, themes demonstrated how routine assessment practices and clinical expertise were embedded and maintained. Critical reflection on the utility and costs of routine assessment were evident over time, attributable in part to national changes in funding of disability services.

Significance of the findings to allied health: Organisational commitment, adequate resourcing and effective communication are required to implement and embed change in AHP services.

iSAP: an innovative case based learning tool to encourage health practitioners to share authentic experiences with future practitioners

Professor Marilyn Baird1

Monash University, Victoria

Aim:
The aim of iSAP is to authentically re-create the emotive experience of the work environment of health practitioners for sharing with future practitioners.

Method:
The case based learning program is based on integrating Science And Practice (iSAP) and employs a design process to engage students in professional issues and clinical decision-making. Learning takes place at the level of pseudo-engagement with the health professional, providing a unique zone for intrinsic feedback modulation. This modelling environment uses the learners’ input of addressing the case professional issues and prompts for a reflective comparison with the model output provided by the expert practitioner. Supported with audio/video interviews, expert practitioner responses evoke the sense of tensions and pressures of the work environment.

Result:
In 2016, we provided access to iSAP within the learning management platform for adoption across disciplines in the Faculty of Medicine, Nursing and Health Sciences. iSAP has been used or is being adopted for use across the disciplines of Radiography, Radiation Therapy, Ultrasound, Health Sciences, Forensic Medicine and Specialist Paramedic Practice.
The use of various media techniques in case scenarios and expert responses has provided the learner with an immersive, authentic practice-learning environment that inculcates all of the work skills required by the future health practitioner.

Significance of the findings to allied health:
Reflective capacity is a critical attribute for certifying professional competence and increasingly described as an essential attribute of the competent health care professional. Through the process of reflection, new knowledge is created daily by allied health practitioners. The iSAP platform encourages future practitioners to bridge the theory practice gap through the use of authentic cases and an iterative learning cycle of investigation, critique and application.

Best practice management of the hemiplegic upper limb: Utilising telehealth to provide education to allied health clinicians in regional Victoria

Ms Jan Quiney1

1 Royal Melbourne Hospital, Victoria

Aims: To develop, implement and evaluate an upper limb management course for regional clinicians using telehealth videoconferencing technologies.
Methods: A pre-existing upper limb management course, with both lecture and practical components, was modified for delivery to regional settings. Regional clinical ‘champions’ were identified and attended training to deliver the practical components of the course prior to the telehealth course. The course presenters delivered the lectures and facilitated the course in real time via telehealth from Melbourne. The practical components were completed simultaneously at respective sites by the regional ‘champions’. Participant feedback was collected following the course and at 3-months follow-up and compared to prior courses run on-site at the Royal Melbourne Hospital.
Results: The upper limb management course was successfully implemented simultaneously at three regional sites, involved the training of 12 regional ‘champions’ and 51 regional course participants. Participant feedback showed high level of satisfaction with the telehealth course; however, several scores were lower than those obtained from prior face-to-face courses, related to presentation quality and course facilities. Three month evaluation demonstrated a change in utilisation of hemiplegic upper limb management modalities.
Significance of the findings to Allied Health:
This study highlights the challenge of delivering clinical education via telehealth for allied health clinicians. The practical components and skill development were reliant on the ‘champions’ to deliver and limited any feedback the experts could provide towards the participants’ performance. Face-to-face delivery of the course was rated more positively compared to the telehealth version by participants and the expert educators in regards to quality for most of the presentations. These findings provide further opportunity to modify the course, to better meet the needs of regional physiotherapists and occupational therapists. A phase 2 study is currently underway.

The organisational benefits of a strong research culture in a health service

Dr Katherine Harding1, Prof Nicholas Taylor1,2, Ms Lauren Lynch1, Dr Judi Porter1,3, Ms Anita Wilton1

1Eastern Health, Box Hill, Australia, 2La Trobe University, Bundoora, Australia, 3Monash University, Clayton, Australia

Aim: A ‘research culture’ within health services is one in which evidence is valued, clinicians are encouraged to participate in research activities, research training opportunities are available, achievements are recognised and there is investment in research activity. Investment in these areas has been shown to increase academic outputs.  This systematic review of the literature aimed to determine whether there a strong research culture is also associated with improved organisational performance outcomes.

Methods: Key health databases were searched, combining the key concepts of “organisational performance” and “research culture”.  Inclusion criteria applied, and study quality appraised. Data were extracted from selected studies and the results were synthesised descriptively.

Results: Eight studies met inclusion criteria. Five compared health services with high versus low research activity, and three evaluated specific interventions focused on the health workforce. All reported a positive association between research activity and organisational performance.  Benefits included lower mortality rates, higher levels of patient satisfaction, reduced  turnover and satisfaction of staff and improved efficiency.

Significance for Allied Health: In recent years there has been significant investment in initiatives within health services to facilitate a culture of research in Allied Health.  This review supports the existence of associations between a strong research culture and benefits to patients, staff and the organisation. However the magnitude of this effect and mechanisms underlying the association remain unclear.  More evidence is needed to determine the return on investment in activities that contribute to a research culture, and the nature of interventions that best achieve this aim.

Allied health inpatient staffing profiles in Victorian hospitals

Ms Lyndell Keating1, Mr James Sayer1

1Healthcare Management Consultant, , Australia

Aim:

To provide information resources regarding Allied Health inpatient staffing profiles, such as the average Equivalent Full Time (EFT) per bed by profession and clinical grouping.

Method:

Victorian public hospitals with multi-day inpatients were invited to participate in macro benchmarking. Consenting hospitals completed a survey regarding the inpatient EFT per classification for each of the Allied Health therapy professions. Of 132 eligible hospitals, 55 hospitals completed the survey (22 acute only, 13 sub-acute only, 20 both acute & sub-acute beds).

Hospitals that rated activity statistics as “good” or “very good” were invited to submit Individual Patient Attributable (IPA) hours mapped to agreed clinical groupings, from which estimated EFT was derived using an established ratio. Statistics data was submitted by 16 hospitals.

Results:

Reports were provided to Allied Health leaders regarding the average EFT per 10 beds for acute and sub-acute, categorised by hospital size and acuity. The reports also outlined the percentage of hospitals with each profession, and the proportion of grades and assistants for each profession.

Further reports included the average estimated EFT per bed by profession and clinical grouping, and additional comparative information such as length of stay and percentage of patients seen.

Significance of the Findings to Allied Health:

Allied Health leaders are required to deliver effective and efficient allied health services within fiscal constraints. The staffing analysis resources have been utilised by managers to assist with decision making regarding workforce profiles, and to modify staffing levels as a result of service change, growth, and other drivers.

The global tracheostomy collaborative: A multi-disicplinary quality initiative improving the lives of children and adults who have a tracheostomy around the world

Ms Tanis  Cameron1,2, Ms  Charissa Zaga1,2, Ms Kristy McMurray1,2, Ms  Jack Ross1, Dr  David Roberson2,3,4

1Tracheostomy Review and Management Service (TRAMS) Austin Health , 2Global Tracheostomy Collaborative, 3Department of Otolaryngology, Boston Children’s Hospital, 4Department of Otology and Laryngology, Harvard Medical School

Aim: The Global Tracheostomy Collaborative (GTC), founded in 2012, is an international multi-disciplinary Quality Improvement (QI) collaborative which strives to improve outcomes in both paediatric and adult tracheostomy care (www.globaltrach.org). Dr David Roberson, ENT Specialist, Boston Children’s Hospital and Harvard is the lead in this world first tracheostomy QI . The GTC works through the following key drivers: Patient and family participation, multi-disciplinary tracheostomy care, a HIPAA-compliant REDCap database to track and benchmark outcomes among member hospitals, creation of institution wide tracheostomy policies and protocols, and coordinated interdisciplinary education for all providers. The aim of this study is to report on the process, outcomes, future directions of this tracheostomy quality collaborative. Austin Health in Melbourne Victoria is a founding member and the Australasian lead site for the GTC with a team led by allied health professionals, nurses and doctors.

Method: Establishing mission and vision, international clinical governance, committee structure, website formation, creation of and reports from international HIPAA-compliant REDCap database, 4 international kick-offs and ongoing global recruitment.

Results: Since April 2014, over 50 hospitals in the United Kingdom, Sweden, United States, Singapore, Qatar, and Australia have joined the collaborative. 770 individuals from 125 institutions attended GTC launch meetings in Boston (April 2014), London (July 2014) Melbourne (October 2014); and Baltimore (April 2016). 1000 additional individuals from over 20 countries attended virtually. All disciplines (anesthesia, critical care, pulmonary, respiratory care, physiotherapy, speech pathology, nursing, social work, and hospital management) were represented at the meetings. Data collection has been successful with 1500 new tracheostomy cases entered into the database by 19 institutions and counting.

Significance of the findings to allied health: This world first global initiative has strong allied health leadership  and membership.  Allied health are key to this specialist healthcare community.

Improving access for foot and ankle patients on an orthopaedic waiting list

Mrs Charlotte Cooke1, Ms Julia Firth1

1Western Health, Footscray, VIC, Australia

 

Aim
This study aimed to determine the efficacy of integrating an Advanced Practice Orthopaedic Podiatry (APOP) clinic to the Orthopaedic Outpatient’s service. Pilot funding was received from DHHS.
Method
The APOP screened referrals received by the Orthopaedic Outpatient department to determine whether they required advanced practice podiatric management or surgical opinion. A clinical governance tool was developed alongside a competency package. Data collection completed October 2015– January 2016. Patients > 18 years of age were eligible. Patient centred outcomes were analysed, patient satisfaction survey, waiting list and referral analysis.
Results
Patient referrals to Orthopaedic clinic between 2013 -2015 were assessed. N = 103, 70% were managed effectively and did not require an orthopaedic opinion for their presenting musculoskeletal pathology. Most commonly assessed condition was Hallux Valgus (51%) followed by 33% with a hind foot pathology. 66% of patients were discharged completely to community providers. Overall satisfaction with APOP visit – 94% strongly agree 6% agree.
Significance of the findings to Allied Health Practice
The aim of this inter-professional model of patient care is to provide seamless movement of patients from one service to another. Shifting resources into prevention and self-management; providing patients with real choices about their treatment options, empowering them to make informed decisions about their health care. Whilst providing them with support, education and tools to improve their understanding of their journey through the health care system.

Implementation of an advanced scope of practice physiotherapist in neurosciences clinics improves patient access to community services

Ms Jan Quiney1, Ms Lucinda  Marr1, Ms Samantha  Plumb1, Mr Scott Edwards1

1Royal Melbourne Hospital, Parkville, Australia

 

AIM: To investigate if the implementation of an advanced practice physiotherapist (APP) within three neurosciences outpatient specialist clinics improves patient care by addressing unmet physical need and satisfaction.

METHOD: Prospective implementation study. APP roles were implemented in three Neurosciences specialist outpatient clinics (Stroke, Neuro Oncology and Neuromuscular). An APP worked alongside the usual specialist medical staff. Quality of care data included number of patients seen; interventions performed (including referrals to community services); and patient and medical staff satisfaction.

RESULTS: Over 4 months, 126 patients were seen by the APP across the 3 clinics (equivalent to 378 per annum). Main interventions included: patient education/advice (73-100%); exercise prescription (50-92%); linking to community services (8-56%) referral to community physiotherapy (27-56%); referral to other community Allied Health discipline (8-33%). All clinic medical staff (100%) believed the APP addressed the physical needs of their patients (rated 10/10) and were supportive for an ongoing role. Patient satisfaction was high, with 100% of respondents (n=9) reporting that the APP assessment benefited them, and addressed all identified problems (44%). Over 69 hours of medical consultant time was freed up by APP over the four months.

SIGNIFICANCE OF THE FINDINGS TO ALLIED HEALTH: The APP in specialist neurosciences clinics improved the quality of care provided through timely physiotherapy interventions and increasing linkages with community based services.  The role enables optimal use of the physiotherapy workforce to free up consultant time and provides an enriching career path for hospital physiotherapists into more senior clinical roles. Further investigations are needed to determine the efficacy on patient outcomes and health economic benefits.

Using audit and feedback to change practice: Embedding clinical practice guidelines in acquired brain injury rehabilitation

Ms Laura Jolliffe1,2, Ms Rebecca Nicks2, A/Prof Natasha Lannin1,2, Prof Tammy Hoffmann3, Ms. Jacqui Morarty1

1La Trobe University, Melbourne, Australia

2Alfred Health, Melbourne, Australia

3Bond University, Gold Coast, Australia

 

AIM: To evaluate the effects of a sustained program of audit-feedback on therapists’ adherence to acquired brain injury (ABI) rehabilitation CPGs.

 

METHOD: Using a periodic service review method, inpatient rehabilitation care was audited fortnightly for 46 weeks (61 cases) against ABI rehabilitation CPGs (137 observable criteria), using medical record review, observation, and staff, patient and family interviews. Each fortnight, a facilitator-led multidisciplinary feedback session provided clinicians with a summary of observed adherence to CPGs, and positive behaviour feedback strategies were used to encourage clinicians to assess and adjust their performance. Three months after withdrawal of the audit-feedback, 20 randomly selected cases were audited to determine if adherence to CPGs was maintained.

 

RESULTS: Immediately following the intervention, there was a significant improvement in adherence to CPG criteria from 47% to 82% (35% improvement, 95% CI 25 to 46) (p=0.0001). Three months after intervention withdrawal adherence was lower and reduced to 73% (9% reduction, 95% CI -19 to 0.5) (p=0.002). Details of the clinical practice areas more susceptible to feedback withdrawal will be discussed.

 

SIGNIFICANCE OF FINDINGS TO ALLIED HEALTH: There are gaps between clinical practice guideline (CPG) recommendations and clinical practice provided. Studies outside of rehabilitation suggest audit and feedback is an effective behaviour-change intervention, however rehabilitation studies have demonstrated only minimal improvements. Our study demonstrates that intensive audit and feedback can improve adherence to rehabilitation CPGs. For sustainable change, audit and feedback needs to be incorporated into usual rehabilitation processes.

The role of allied health leadership in the implementation of an electronic medical record

Ms Jane Carlin1, Mr Adam  Stormont1, Ms Naomi Dobroff1, Dr Suong Le1

1Monash Health, Clayton, Australia

Aim

Electronic Medical Records (EMRs) represent a core strategy for future healthcare delivery. This multidisciplinary study evaluated baseline clinician perception, knowledge and expectation of an EMR on clinical workflow, patient care and research productivity.

Method

A mixed method two phase study was conducted at Monash Health, VIC from March to August 2016.  This consisted of an 18 item, literature derived questionnaire evaluating demographics, satisfaction, clinical workflow, clinical efficiency and qualitative feedback.  This was followed by a time motion study measuring direct clinical time and barriers to clinical workflow.

Results

809 clinicians participated in the survey (89 physiotherapy, 61 pharmacy, 213 medical, 456 nursing and midwifery) across 4 Monash Health hospitals. 64.7% of respondents reported low satisfaction with current workflow on a 5 point Likert Scale.

Domains reported as likely to benefit from an EMR included: improved patient quality of care, reduced medication error and increased research efficiency. Respondents aged over 50 were more sceptical regarding the potential benefits of an EMR (p-value <0.001). The time motion study verified the clinical workflow barriers identified in the survey.

Core challenges identified were: hardware access; handwritten documentation ambivalence; impact on patient rapport; lack of visible leadership; user experience; and staff communication.

Significance of the findings to Allied Health:

This is the first study to characterise the baseline perception, knowledge and expectation of a multidisciplinary workforce towards an EMR. The EMR is a catalyst for clinical workflow reform but Allied Health leadership is essential if we are to realise its true potential to improve patient safety, quality of care and clinical research output.

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