Guest Editorial Anna Carey Chair Of The Health Of Older People Service Level Alliance
28 Oct 2020
Anna Carey, Chair of the Health of Older People Service Level Alliance.
As the South Island ACP (Advance Care Plan) facilitator role – supported by the South Island Alliance – comes to an end, I thought it was timely to reflect on the progress we have made with advance care planning.
Advance care planning is one of several priorities across the South Island. With the recent COVID-19 pandemic, it has brought the need for ACPs into sharper focus both for health teams, and for a person and their whānau. International evidence has found that advance care planning leads to less unwanted aggressive medical care, better quality of life near death, decreased rates of hospital admission – especially age residential care residents – and those who have completed an advance care plan are more likely to receive care that is aligned with their wishes.
For the past few decades, ACP conversations have evolved. In the early days, there was a focus by many on the document. These days, there is better recognition of the value of the process in supporting people to understand and share values, goals and preferences regarding future medical care. Given this, the process of advance care planning is usually a series of conversations, often with whānau and different providers. People’s goals and values change to reflect changing health, and the system to support advance care planning in the South Island aims to support this.
In addition to having a digital ACP, which can be shared across the South Island for those with access to Health Connect South/HealthOne, a new South Island digital solution was developed this year – ACP Progress Note. The tool provides the option to use a dropdown box and record a targeted advance care planning conversation using the serious illness conversation guide framework, or health teams can use the free text format to record the interactions and discussions that happen during the advance care planning process.
As of September 2020, we now have 4982 ACPs on Health Connect South – 869 completed by four DHBs who commenced their digital journey on 1 May 2019. Canterbury DHB has been using the digital system for seven years and has completed 4113 so far. All these plans can be accessed across the South Island health system. Such progress has been achieved by collaboration and alliance working. Regional leadership through the Health of Older People Service Level Alliance (HOPSLA) has contributed to working in a broadly similar manner across the South Island. While there are many regional projects to complete, these are on hold, awaiting resource.
Meanwhile, the more we can support people who live in the South Island to have these conversations, document them if they wish and share them electronically on Health Connect South/HealthOne, the more we’re able to be truly person-centred in our approach.
Sharing And Collaborating Between South Island ICUs
18 Sep 2020
Richard Whitticase, ICU Charge Nurse Manager, South Canterbury DHB.
Since the South Island Intensive Care Unit (ICU) Project Group was formed two years ago, communication between ICUs has increased dramatically, resulting in more collaboration and collegiality across the region.
“The group has achieved our hopes and expectations in spades,” says Richard Whitticase, ICU Charge Nurse Manager, South Canterbury DHB. “We get to exchange ideas, policies, procedures – and you know your problems are the same as everyone else’s. In the past, others might have thought we weren’t a proper ICU because we’re small. Now, everyone realises our work is the same as other ICUs, and we have great mutual respect and confidence.”
The South Island ICU Project Group is responsible for sustainably planning and improving intensive care services, across the five DHBs. Chaired by Nelson Marlborough DHB CMO Nick Baker, the group meets monthly and consists of each ICU clinical director and charge nurse manager, and a selection of duty nurse managers, operations managers, planning and funding, as well as allied health scientific and technical representatives.
Richard is based at Timaru Hospital, where he originally trained as a Registered General and Obstetric Nurse, from 1984-87. After a stint in Australia working in a high dependency environment, he realised he enjoyed the unpredictability and adrenalin of a more intensive nursing style.
In 1991, during a holiday in Timaru, he was approached about a maternity leave cover role in ICU – and he’s been there ever since. Richard became the Charge Nurse Manager of the Level 2 Intensive Care Unit in 2000. He relishes the environment. “You never know who is going to come through the door, you must have a broad practical skillset and then you can stretch it.”
He learnt the trade alongside experienced nursing colleagues, especially during seven years of night shift. “It’s about the nuances of assessment and clinical judgment, and when something just doesn’t feel right, it’s important to be able to communicate succinctly, coherently and persuasively to nursing and medical colleagues – who also may be on call off-site.”
Some of the project group’s achievements include the development of an automated dashboard to display what’s happening in each ICU environment, as well as daily and weekly status reports. “We look at the reports every day, and contribute our data, so that we know what’s happening and where the pressures are in the system. If we can provide support, we will and do.”
The sharing of information between ICUs is invaluable, he says. “We really appreciate the short communications chain about ICU-related issues and our collective ability to get things done, such as the COVID-19 response, when we were having meetings three times a week. We had access to information early and could make sure our organisation responded, and we got our voice heard at local, regional and national levels. And the ability to share information shapes policy here in South Canterbury. We get inspiration about models of care, changes that will make our own system better.”
Being able to air common issues in a forum with colleagues who can take those concerns further is another benefit, he says. “We have never had this before. It gives us the confidence to know we’re heading in the right direction, we’re not out on limb, we’re part of a system. It will be good when we can all get back together in the same room – virtual meetings are great, but it’s also good to meet in person.”
Richard believes South Canterbury plays an important part in the South Island health system. “The work we do takes pressure off Canterbury. Our first option is to keep patients in South Canterbury if it’s clinically safe, because it’s best for the person and their family. Things change in ICU all the time, and the work we’re all doing together is the best way of collaborating.”
Streamlining Service Delivery Across the South Island with ePharmacy
Some of the ePharmacy implementation team in Wairau: (From left) Eliza Hooper (Pharmacist), Sharon Elrick (Pharmacist), Helen Martin (Pharmacy Technician), Rachel Powell (Pharmacist), Abby Edwards (Pharmacy Technician), Liz Jones (Pharmacy Technician) and Caro Aberhart (Pharmacist).
An electronic pharmacy management solution is now live across the five South Island DHBs, enabling hospital pharmacy inventory to be managed within a single system, improving service delivery and saving time.
ePharmacy provides full inventory management, dispensing, compounding, and repacking functionality for hospital pharmacy services, and integrates with patient management systems, financial systems, and MedChart prescribing and administration software.
Developed in close consultation with hospital pharmacy expertise, ePharmacy replaces end-of-life software, WinDose. The upgrade will allow more efficient and productive ways of working, improved functionality and regional patient information sharing to pharmacy services.
Since August, all five DHBs are now using ePharmacy. For Nelson Marlborough DHB and West Coast DHB, the project involved ‘on-boarding’ to a Canterbury DHB hosted instance of ePharmacy, which was already live. The Southern DHB and South Canterbury DHB ePharmacy projects were configured separately and hosted by Southern DHB. Pharmacy workflows and business requirements were standardised and aligned across the regional instances.
Anna Mitchell, Regional ePharmacy Programme Specialist, says despite project delays due to Covid-19, the go-lives across the South Island went smoothly and are a credit to the dedication of the teams. “The project involved a real regional collaboration and I personally formed valuable working relationships with the project teams. It was nice to share the knowledge I gained with others and learn technical aspects of the software, and also learn how other DHB pharmacies work. The project teams worked really hard to configure the software, which involved setting up each medicine kept at their pharmacy, testing the software multiple times and implementing it on top of their regular work.”
Sonja van Alphen, Team Leader at Nelson Hospital Pharmacy, says the go-live transition was seamless and the new system provides multiple levels of functionality. “It’s a better, more collaborative way of working and it’s nice to know we are part of a wider, supportive community of ePharmacy users.”
Electronic Acp Solution Live Across The Region
09 Sep 2020
A digital solution designed to capture conversations around Advance Care Planning (ACP) has gone live across the South Island.
The ACP Progress Note provides a single, regional solution for clinicians to document and access important discussions with patients about their future health care planning and end-of-life wishes.
Canterbury Initiative ACP Facilitator Jane Goodwin says it’s a consistent way for clinicians to log those conversations, which can then be electronically shared securely. “Advance care planning conversations don’t always lead to a person creating or completing an ACPlan. So, the ACP Progress Note allows clinicians to document discussions in a consistent location that can be accessed by other health care staff across the sector.”
Canterbury DHB initially had a locally-developed version of electronic progress notes. The improved South Island version enables health care professionals using HealthOne and Health Connect South to record or document ACP conversation with the patient.
Conversations about what’s important to a person and their priorities for care if they become unwell are even more important in the current environment – especially if a person has underlying medical conditions, Jane says. “For example, a man with terminal melanoma was referred to our team for support to create his ACPlan. We used the ACP Progress Note to capture our phone conversations ahead of the home visit.
“Unfortunately, a couple of days before that appointment, he had a significant stroke and could no longer communicate his wishes. Discussions with his whānau and the information captured in the ACP Progress Note helped the medical team ensure his care aligned with his preferences.”
The ACP Progress Note was fast-tracked during the pandemic to include the newly-released national Serious Illness Conversations Guide (SICG), providing a consistent regional solution to the electronic capture of these important discussions – either as a free text electronic record or using the SICG template (embedded in ACP Progress Notes) to support the conversation. This could include discussions with critically ill patients during COVID-19 restrictions.
Helen Sawyer, Palliative Care Clinical Nurse Specialist at Southern DHB, says the tool provides a convenient way to document a conversation that couldn’t be formalised in any other way at the time. “It’s easy to use, find and read – so we can easily record discussions with our patients, that will contribute to the development of their ACPlan.”
Congratulations Ehealth It All Stars Ryan Papps And Aleisha Whitehead
Congratulations to the recently announced eHealth IT All Stars, not least to our own all-round superstars Ryan Papps and Aleisha Whitehead.
As part of the COVID-19 response, Ryan, a programme specialist with the South Island Alliance Programme Office (SIAPO), developed a daily ICU dashboard for South Island DHBs and infographic summary of the national COVID-19 picture.
The dashboard is largely an extension of the regional ICU capacity dashboard established last year but includes additional information not consistently available electronically across all sites (such as ventilated, isolated or high acuity patients, as well as staffing levels). Ryan had been working with the regional ICU group since July 2019 and his relationships with key stakeholders and the trust he had developed were critical in getting manual data entered every day to complete the dashboard.
Ryan also set up an infographic summary of the national COVID-19 picture (example below), with an additional focus on South Island information. This was initially included in the daily ICU updates but quickly gathered a larger audience as a ‘one-pager’ of useful information covering the national picture.
Ryan was nominated as an eHealth IT All Star by Janice Donaldson, on behalf of the South Island ICU Project Group.
Aleisha, portfolio quality assurance lead at SIAPO, was also acknowledged for the support she provided to the SIAPO team during the COVID-19 response. The team needed the ability to facilitate meetings, collaborate and communicate effectively from their homes all over the South Island. For consistency and ease of use, Microsoft Teams was chosen as the single solution for all Alliance meetings.
While working remotely and facilitating virtual meetings was familiar to some, there was still a lot of technical support required get the whole team up and running. Aleisha’s time, patience and perseverance in this area was invaluable.
Aleisha was nominated by Mark Leggett, SIAPO General Manager.
Ryan’s daily Covid-19 infographic
New South Island Service Provides Relief For Kids With Drug Resistant Epilepsy
07 Nov 2019
Zachery Dunn, 4, has drug-resistant epilepsy and his health has been greatly improved through ketogenic dietary therapy. The service has recently been expanded South Island-wide.
After beginning ketogenic dietary therapy (KDT) to control Zachary Dunn’s drug-resistant epileptic seizures two years ago, he went from having four hospital admissions and two helicopter transfers within three months, to a happy four-year-old with greatly reduced seizure frequency and no further admissions.
Zachary’s parents Danielle and Hamish Dunn had trialled five epilepsy medications that did very little to help him. “We were in and out of hospital and the medication doses were increasing, but Zach was still having a lot of seizures at home,” Danielle says. “He also had terrible side effects. It got to the point where he couldn’t move, sleep or feed himself and he was crying inconsolably. His quality of life was pretty poor and it was a really awful, stressful time for us as a family.”
The Dunn family live rurally in Alexandra, Central Otago. They are one of the families being assisted by the South Island Paediatric Ketogenic Dietary Therapy Service, led by Charlene Tan-Smith, South Island Clinical Lead (Ketogenics) and Paediatric and Ketogenic Dietitian, Canterbury DHB. The service, originally only available privately and in Canterbury DHB since 2016, has now expanded to cover all five South Island DHBs as a hub-and-spoke model (with Christchurch Hospital as an online hub).
Zachary’s seizures began when he turned two. Danielle says they had noticed his development was delayed at around one year of age and after his seizures started it was thought that he had a rare, underlying genetic syndrome that was causing the epilepsy. Danielle and Hamish found out about the use of KDT as therapy for refractory epilepsy through an internet search. After researching what was available in New Zealand, they were informed about Charlene’s clinic through another parent in an online epilepsy support group.
Zachary is now solely on KDT to control his epilepsy, after being gradually weaned off the medication he was resistant to. “We were lucky we found Charlene when we did, as Zach was so sick and all our DHB had to offer was more drugs. Many kids with refractory epilepsy spend their life on drug trials without being offered a ketogenic diet trial, while still having seizures and suffering the side effects. And once you’ve exceeded two to three ineffective drug trials, the chances of further trials being effective for controlling seizures falls exponentially, whereas the ketogenic diet – which has been used to treat epilepsy for a century – has a higher success rate.”
Danielle, Hamish and Zachery Dunn, of Alexandra. Photo credit: Emily Kerse Photography
About a third of children with epilepsy will eventually develop refractory epilepsy – meaning medicines don’t work well, or at all, to control the seizures. In the most severe cases, hundreds of seizures can occur each day, impacting on the quality of life of children, parents, siblings, grandparents, schools and the wider community. There has been no improvement in the rate of refractory epilepsy, despite the addition of over 10 new antiepileptic medications to the market in recent years.
KDT is a treatment used internationally for children with refractory epilepsy who don’t respond to anti-epilepsy drugs. It is not to be confused with the fad ‘keto diet’ and must be medically prescribed and monitored. KDT can significantly reduce seizures for some patients, with some even becoming totally seizure-free, says Charlene. “KDT is an evidence-based mainstream treatment, using medical nutritional ketosis to simulate a starvation state and provide the brain with fuel from ketones, rather than glucose from carbohydrates. It’s a very specific, tightly controlled diet. All the components have to be carefully calculated, weighed and measured, which is why it’s registered dietitian-led.”
For children and their families in the South Island who live outside of Christchurch, the service is available remotely via Zoom sessions, email and phone calls. Charlene provides families with the total amounts of fat, protein and carbohydrates their child needs each day and teaches them how to measure each meal and snack, depending on their specific KDT prescription. The family’s lifestyle and food preferences are incorporated into the prescription, which is also carefully adapted as the child grows. Ketone levels are measured at home using a funded blood/glucose monitoring machine and frequent blood tests keep track of nutrition levels to ensure there are no deficiencies.
“It’s a whole new skill we had to learn as parents,” Danielle says. “There’s so much more involved than just dishing out medication a couple of times a day. There’s a lot of effort involved in creating a diet that’s so precise and requires a huge amount of compliance from both the child and the parent. Learning to use the keto calculator to make all the macronutrients in each recipe balanced down to 0.1g took a bit of practice and it has been great to have Charlene’s support to get me up to speed. It’s a big change in lifestyle but parents will go to great lengths to help their sick child become well. The diet is our life saver and it’s so much easier spending some time in the kitchen than living with poorly controlled epilepsy.”
Charlene Tan-Smith, South Island Clinical Lead (Ketogenics) and Paediatric & Ketogenic Dietetian, Canterbury DHB.
Danielle says while the diet itself is a lot of work, the convenience of not having to travel to Christchurch is a huge help. “Once we had initiated the diet we were talking to Charlene every few days, as it takes a while for the ketones to rise and get to a steady state. Now that he is stable, we stay in touch every few weeks. It’s completely feasible to do it all from a distance.”
KDT is a highly specialised service. Charlene trained to become a ketogenic dietitian in Canada and at Matthew’s Friends UK Keto College, and has travelled to hospitals all over the world learning about how different countries use the therapy. She is part of the Ketogenic Dietitian Group in the USA, UK and Canada. “I’m very blessed to have connections with the major keto centres around the world and I’m so excited about our service for the South Island – we want to help as many families as we can.”
The service is not only benefiting patients and their families but is also saving health resources by reducing emergency department admissions and hospital overnight stays. The service was extended South Island-wide in August 2019, after Canterbury DHB put forward a case to the South Island Alliance’s Child Health Service Level Alliance, requesting improved access and equity for patients, no matter where they live in the South Island. The average time a patient may need to be on the diet is between two and five years.
Danielle and Hamish were one of the families who had written letters to the Ministry of Health and Canterbury DHB asking for the service to be offered across the South Island. “Zach has done really well with the diet, which probably helped the case,” says Danielle. “Within two months of starting, his tonic clonic and atonic seizures stopped. Now, he only has focal seizures, which are a lot smaller and usually triggered by illness or when he is really tired. Just to see the difference it’s made in his development is huge. He started walking earlier this year, at three and a half years of age. Obviously, that’s really delayed compared to a healthy child but I don’t think he would have achieved walking with the kind of protocol he was on before, with frequent convulsive seizures and drug side effects.
“His communication is increasing and he is just so much happier within himself. Seeing him smiling and playing again and his character come back is amazing. It’s greatly improved his quality of life and for our family as well, it’s just been massive. Opening the service up across the South Island for other families to benefit from it as we have, is great and definitely a step in the right direction.”
Faster Treatment For South Island Stroke Patients
From left: Dr Teddy Wu of Canterbury DHB, and West Coast DHB stroke physician Dr Daniel Salazar.
The South Island’s new telestroke service has been launched between the West Coast and Christchurch, giving more people faster access to potentially life-saving acute stroke treatment.
Using dedicated video-conferencing and CT image technology, the telestroke service enables neurologists and stroke specialists to provide advice and support via video link to doctors treating stroke patients in smaller centres and after hours.
Dr Teddy Wu, one of six neurologists at Christchurch Hospital, says the service has transformed stroke care. “This is real-time care – it’s like watching a movie and giving instructions. While we can’t touch the patient, we can ask the doctor to examine them on our behalf. Potentially, one of the key aspects is deciding whether we need to fly them to Christchurch Hospital for a clot removal procedure. What this means is, more people who experience paralysis from a major stroke will be able to walk out of hospital within a few days.”
Following the successful 2016 telestroke pilot between Wellington and four smaller centres, including Nelson and Wairau in the South Island, the Ministry of Health provided funding for the equipment and implementation costs for a similar service across the South Island. Through the South Island Alliance, the five South Island DHBs developed a hub-and-spoke model, comprising six ‘spoke’ hospitals (Grey Base, Timaru, Oamaru, Dunedin, Dunstan and Southland) supported by a ‘hub’ hospital (Christchurch). If a person presents to a ‘spoke’ hospital emergency department (ED) with a suspected stroke, the local ED team can notify an on-call neurologist or stroke specialist at Christchurch Hospital, who can then read the patient’s CT scan, provide advice and make a diagnosis.
The South Island telestroke service will help to ensure smaller communities can access the same 24/7 neurological expertise and care as city patients. Ideally, it will also lead to more South Islanders receiving the life-saving clot retrieval procedure, which is currently available only at Christchurch Hospital.Dr Wu anticipates the remainder of the South Island telestroke service will be linked up by the end of the year.
300000 Ereferrals And Counting
The eReferrals programme, that is moving paper-based patient referrals to an electronic format, has processed its 300,000th successful South Island eReferral.
eReferrals, a combination of the Electronic Request Management System (ERMS) and Orion Health’s Referral Management System (RMS), is one of four main programmes being implemented by the South Island Alliance, a collaboration of the five South Island DHBs working toward more innovative and efficient health services for improved population health outcomes.
Following three years of development effort between the Canterbury Initiative, Pegasus Health, and Orion Health, eReferrals has been rolled out to Canterbury, Nelson Marlborough, South Canterbury, and West Coast DHBs. Planning is now underway to include Southern DHB to complete the regional eReferral solution.
Southern DHB-based Chair of the Information Services Service Level Alliance (IS SLA) Dr Andrew Bowers said eReferrals improves the reliability of the referrals process while providing greater transparency in the way DHBs prioritise patients.
“By reducing administrative burden and improving clinical process we can focus more on patient quality and care than ever before.
“For our patients, this means an improved transition between health care providers and better access to care when they need it,” he said.
Referrals will go directly from GPs to secondary care; the system is secure and auditable, ensuring patients’ privacy, as well as the ability to monitor the progress of the eReferral through the referral process.
“This is one of many electronic systems and tools that will improve patient centred care as health care providers from the community through to hospitals will be better connected,” said Dr Bowers.
Simon Wynn-Thomas, a General Practitioner at Mount Pleasant Medical Centre in Christchurch and Senior Clinical Leader at Pegasus, said ERMS has received positive feedback from many of the Canterbury General Practitioners who have used it.
“Most say the time taken to write a referral letter has been reduced because ERMS pre-populates the letter with relevant demographic and clinical information.”
As the rollout continues across the South Island, work has begun on additional referral management functionality that will allow for both electronic triage and internal referrals.