Supporting an allied health workforce to facilitate complex implementation projects: lessons learned from the SIMPLE project

Dr Adrienne Young1, Prof Heather Keller2, Ms Rhiannon Barnes1, Ms Jan Hill3, Dr Merrilyn  Banks1, A/Prof Tracy Comans4, Dr Jack Bell5

1Royal Brisbane And Women’s Hospital, Herston, Australia, 2University of Waterloo, Waterloo, Canada, 3Princess Alexandra Hospital, Woolloongabba, Australia, 4Metro North Hospital and Health Service, Herston, Australia, 5The Prince Charles Hospital, Chermside, Australia

Aim: Allied health clinicians are often recruited to project positions to facilitate the implementation of complex interventions into practice. Facilitation is a key implementation strategy, but how it might be operationalised, particularly by clinicians, has not been well explored. This study aims to advance understanding of implementation science, by describing the function of novice clinician facilitators, and barriers and enablers they experience while implementing a new model of care for managing hospital malnutrition.

Methods: Semi-structured interviews were undertaken with local facilitators (six dietitians, one occupational therapist; each funded 0.2FTE for six months) involved in implementing The SIMPLE Approach (Systematised Interdisciplinary Malnutrition Pathway Implementation and Evaluation) in six hospitals in Queensland, Australia. A hybrid approach to analysis was used, with deductive framework approach used to identify facilitator activities, and inductive analysis to identify barriers and enablers to fulfilling their role.

Results: Key functions of the facilitator role over the six-month project were building relationships and trust; understanding the problem and stimulating change through data; negotiating and implementing the change; and measuring, sharing and reflecting on success. Facilitators appeared to focus efforts on the ‘clarifying and engaging’ stage, and experienced challenges in building an improvement team and creating a common vision for change.  ‘Dedicated role, time and support’ was identified as a theme encompassing key barriers and enablers to successful facilitation, with time referring to adequate duration of implementation phase and need for protected time from clinical tasks.

Conclusions: When implementing complex interventions within short project timelines, it is critical that novice clinician facilitators are given adequate and protected time within their role, and have access to regular support from peers and experienced facilitators. Without these structures in place, facilitators may experience difficulties in building trust and relationships, co-designing strategies with teams, and developing capacity for change, compromising the success of implementation.


Biography:

Dr Adrienne Young is an Accredited Practicing Dietitian, and is currently Principal Research Fellow, Allied Health Professions at the Royal Brisbane and Women’s Hospital. Her PhD research on improving nutritional intake of older medical inpatients has been of interest nationally and internationally, with Adrienne awarded the Health Practitioner Researcher of the Year at the Royal Brisbane and Women’s Hospital research symposium in 2018, and New Researcher Award at the International Congress of Dietetics in 2012. Adrienne has continued to research in the area of malnutrition in older people, with recent work also focused on workforce development to prepare allied health professionals to translate research into their practice.

Are you ready for this? – reflecting on the implementation journey of electronic medication management system (eMMS)

Mrs Bryanna  Lawrie1, Ms Heidi  Wong1, Miss Sarah  Fuller2

1Children’s Health Queensland, Brisbane, Australia, 2Clinical Excellence Queensland, Brisbane , Australia

Background: Previous literature had captured doctors’ and nurses’  views and perceptions on eMMS but none focused specifically on pharmacy staff despite our heavy involvement. This study aims to describe pharmacy staff’ change journey through the implementation of eMMS at a tertiary paediatric hospital early 2018.

Method: All pharmacy staff were invited to participate in a series of three online surveys released at 3 different time points during eMMS go-live period (namely pre-training, post-training/pre go-live and post go-live). The surveys were designed, distributed and collated using SuveryMonkey™ and results were further analyzed using Excel™.

Results: Respondents for survey 1 (n = 69), survey 2 (n= 60) and survey 3 (n = 50) included pharmacists, pharmacy interns, pharmacy assistants and pharmacy administration officers of age range from 18 to 45 years. Some overall trends were identified:

  • Confidence and proficiency in the use of eMMS increased by 20% post training and was sustained post go-live
  • Apprehension towards ieMR Advanced increased by 10% after training but the actual impact to individual workload decreased by 10% post go-live
  • Perceived level of support increased by 10% with each respective survey with pharmacy being heavily involved in the implementation

Discussion: Our research highlights the importance of practical and relevant end-user training in improving staff’ confidence and proficiency in using eMMS. Individuals’ age, role, prior change experience, use of social media, project involvement, amount of training also influenced their readiness towards eMMS implementation. Using eMMS implementation as an example, our research provided insights on considerations and factors that may contribute to successful change management.


Biography:

Bree currently works as resident pharmacist at Queensland Children’s Hospital after completing her internship at Children’s Hospital at Westmead. Bree was seconded to the ieMR Advanced project to provide staff training on the new system. With human resource management background, Bree decided to undertake this project to observe the change journey that pharmacy takes during implementation of Cerner ieMR

Improving rural health through implementation of a pharmacist-led post discharge and high-risk medication service in a rural community

Ms Michelle Rothwell1, Ms Sarah Tinney2, Dr Neil Cottrell3

1Queensland Health, Cairns , Australia, 2Cairns and Hinterland Hospital and Health Service, Atherton , Australia, 3University of Queensland , Brisbane, Australia

Introduction: The 2019 report ‘Medicine Safety: Take Care’ states that 250,000 hospital admissions each year are a result of medication-related problems (MRP’s) costing $1.4 billion with 90% of patients having at least one medication-related problem post discharge from hospital. This study determines the impact of a pharmacist-led post discharge and high-risk medication service on medication misadventure.

Methods: Conducted as part of the Queensland Allied Health Rural Generalist Pathway initiative this is a descriptive study utilising quantitative methodology to collect data prospectively as well as pre- and post-intervention. The intervention is a comprehensive pharmacist medication review for patients identified at risk of medication misadventure Primary outcomes are the subjective and objective measured change in medication adherence and the SF-12 health survey quality of life (QOL) score compared to baseline at three and six months post intervention. Secondary outcomes include the number of identified medication-related problems (MRPs), the number of resolved MRPs and the grading of clinical significance of the MRPs.

Results: 81 patients consented with a complete data set presented so far for 50 patients. Preliminary results show an increase in subjective medication adherence for post discharge patients at three months continued through to six months, with the mental component summary of QOL data considerably lower for patients at discharge compared to the high-risk patients and to baseline. 430 MRPs were identified which is an average of 5.31 MRPs per patient.

Conclusions: The high number of identified MRPs per patient emphasises the risk of medication misadventure. Preliminary data suggests the pharmacist intervention improves medication adherence and the effect is sustained. QOL mental component summary data may contribute to evidence that patients in the immediate post discharge period are at most risk of medication misadventure. Further work on this study will complete evaluation data and measure the impact on acute service use.


Biography: 

Sarah Tinney is a hospital pharmacist who has been working in rural hospitals since 2013. She is passionate about improving medication services in rural areas, with particular interests in antimicrobial stewardship, medication safety and deprescribing. Among her achievements, Sarah has implemented a rural multidisciplinary antimicrobial stewardship round at Atherton Hospital, which was highlighted at the 2018 SHPA Medicines Management conference.

Five-year review of a regional Allied Health Graduate Program: What value do graduates perceive?

Mrs Kathryn Vick1

1Barwon Health, Clinical Education & Training, Geelong, Australia

For new allied health professionals, there are many challenges during the transition from student life to working as an employee in a busy client-focused setting. Whilst graduates may perceive they are ready for practice, very few feel well prepared, especially regarding tasks such as interacting with other healthcare professionals(1). To aid this transition, the Clinical Education and Training team at Barwon Health (BH) have run an Allied Health Graduate Program (AHGP) since 2014. Invitations are extended to all graduates employed in a cluster of Barwon-South West region health services in Victoria.

The AHGP is designed to enhance peer learning across disciplines and enable individuals going through a similar experience to share and debrief common issues and challenges, becoming a support to each other as they settle into the workforce. Two intakes run annually with seminar topics including: supervision, self-care, sources of support; teamwork and collaboration; understanding roles and responsibilities; interpersonal communication and conflict management; setting career goals; and the importance of safety and quality in healthcare.

Between 2014 and 2018, 111 graduates from 13 professions participated. Three-quarters of the graduates represent Therapy professions, whilst one-quarter represent Sciences(2). The majority of graduates were employed by Barwon Health (85%).

Qualitative analysis of graduate feedback revealed 4 themes as to the perceived benefits of the AHGP: (a) Interprofessional learning; (b) Acquiring new knowledge and skills; (c) Debriefing and discussing experiences with facilitators; and (d) Meeting other graduates and accessing peer support. The most frequently cited benefit perceived by graduates was (d), followed by (c). In their own words:

  • “[The program] is really helpful to meet other grads, especially if you’re new to a town.”
  • “Good content. But the most beneficial part for me was meeting the other grads and being able to debrief / share experiences.”
  • “The program helped me find a sense of belonging in such a big organisation.”

(1) Gray, M., et al. (2012). New graduate occupational therapists’ feelings of preparedness for practice in Australia and Aotearoa/New Zealand. Australian Occupational Therapy Journal, 59, 445–455.

(2) Victorian Department of Health and Human Services. (2016). Allied health categories position paper.


Biography: To be confirmed

Optimising scope for pharmacists – a case of initiation of Orkambi(TM) treatment in paediatric patients with cystic fibrosis

Ms Heidi Wong1, Ms Elouise Middlemiss1

1Children’s Health Queensland, Brisbane, Australia

Background: Orkambi® is a potentially life-changing medicine for patients over six years of age who have two copies of the f508del mutation in the CFTR gene. The medication has been shown to improve lung function and BMI, and reduce pulmonary exacerbations by up to 40%. Orkambi® was introduced on the Pharmaceutical Benefits Scheme (PBS) on 1st October 2018 and it is only available via hospital pharmacy. Prescribers are required to provide an extensive list of documentation to fulfil PBS authority restrictions. Being a strong enzyme inducer, Orkambi® has very high potential to cause many drug interactions; many of which are not well documented.

Method: Cystic Fibrosis Service identified 200 patients (both local and regional) currently under their care as eligible. We approached these families to undertake comprehensive medication history; with the aim to identify potential drug interactions and other medication related problems, formulate pharmaceutical care plans, and provide medication counselling. The number of service occasions, drug interactions identified and drugs involved were recorded for analysis.

Result: Between October 2018 and January 2019, we completed 120 comprehensive medication histories and 91 medication counselling sessions via face-to-face discussion at CF clinics, telephone and telehealth channels. Twenty-nine significant drug interactions (Orkambi vs drug or patient or condition) were identified, among which 55% were with prescription-only medications, 35% were with over-the-counter or complementary medicines and 10% were with medical issues (e.g. impaired liver function). Upon review, we found that medication histories taken by non-pharmacy staff were mostly incomplete (particularly with respect to complementary medicines) or without a documented plan to manage the impact of identified drug interaction. The feedback from families and CF team on this pharmacy service was very positive; they appreciated the opportunity to speak to a pharmacist and asked many questions unrelated to Orkambi®.

Discussion: Pharmacists have expertise in medication management.In this case of Orkambi® initiation, we helped streamlining the PBS authority application process by undertaking comprehensive medication histories. We kept our patients safe by identifying and managing potential drug interactions. We improved family experience by being proactive and empowering. Our value in patient care has been realised.


Biography:

Heidi currently works as the pharmacist medical lead at Queensland Children’s Hospital. She has over 15 years’ experience in paediatrics and represents paediatric pharmacists at statewide and national forums. Her research interests include general paediatrics, professional education and training, paediatric medicines and system improvements.

Investigating multidisciplinary team management of pressure injuries in sub-acute care

Ms Alice Doring1, Ms Juliette Mahero1

1Qld Health (TPCH), Brisbane, Australia

The prevalence of pressure injuries (PI), both hospital acquired and present on admission, is a worrying concern. The 2016-2017 financial year attracted $510,000 in PI penalties at The Prince Charles Hospital alone. Evidence-based policies for the prevention and management of pressure injuries describe the benefits of a multidisciplinary team(MDT) approach1.

This project aimed to investigate MDT management of PI in the Rehabilitation and Acute Stroke (RAS) Unit at a tertiary hospital in Brisbane, QLD. A four-week prospective audit was conducted on patients who were admitted to the RAS unit with a PI(N=9) or obtained a hospital acquired pressure injury during their admission(N=0). Documentation including that at point of handover of care, discharge planning processes and communication of pressure injuries at weekly MDT meetings were audited. Clinical staff were engaged via surveys(N=13) to assess current practice and perceptions of responsibility for care.

Results showed that 12.5% of the time, PI were documented on handover to the sub-acute ward via medical admission summary. 62% of clinicians did not routinely note a PI in departmental handover processes. 66% of patients had their pressure injury documented on summary pages as per local hospital protocol. PI progress discussions at weekly MDT meetings were conducted in 3.7% of the cases (N = 9). 22% of patients were discharged with no documentation of PI healing status on medical discharge summary.

Results were presented with the MDT and a unit pressure injury week was held to improve awareness and increase education around PI care. Changes were made to local handover and case conference templates. In future, audits will be conducted annually to reassess management and address key areas for improvement.

While structured management plans for MDT PI care exist, lack of awareness, documentation and communication amongst the MDT and on transfer of care is compromising patients PI care.

References:

1)            Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Abridged Version, AWMA; March 2012. Published by Cambridge Publishing, Osborne Park, WA.


Biography: To be confirmed

The Allied Health workforce paradox: The coexistence of oversupply and unmet need

Professor Susan Nancarrow1, Dr Anna Moran2

1Southern Cross University, Coolangatta, Australia, 2University of Melbourne, Albury / Wodonga, Australia

In 2005, the Australian Productivity Commission predicted an impending allied health (AHP) shortfall. Subsequently, numerous new allied health training courses have been introduced nationally for almost every discipline. Thus, over the past decade, the supply of AHPs has increased exponentially for some disciplines, without a commensurate increase in positions for new graduates. In Victoria alone, occupational therapy graduates increased by 39% between 2010 and 2015; dietetics by 95% (2010 – 16); and speech pathology by 221% (2010 – 13).

This paper reports the results of the Victorian Allied Health Workforce Research Project, which involved an environmental scan of 27 allied health disciplines and in-depth analysis of 11 disciplines in Victoria between 2015 and 2018. A primary concern of the majority of professions was the impending over-supply of AHPs. However, the in-depth analysis presented a far more complex picture of supply and demand for AHPs in Victoria. There was strong evidence of new graduates in some disciplines experiencing difficulty finding employment; large numbers of applications for junior positions; and high proportions of participants agreeing that “there are too many graduates in my profession”. Despite these findings, there was also evidence of large pockets of unmet need for AHPs services in specific segments of the community (particularly paediatrics and chronic disease management) as well as in regional and rural areas. The challenges AHP face are to ensure funding models support appropriate AHP distribution; that new graduates receive adequate supervision and support in the workplace; and they can access appropriate career pathways.

The allied health workforce paradox of AHP oversupply coinciding with unmet service need is compounded by a lack of AHP workforce planning tools and business models to support the provision of allied health services where they are most needed.


Biography:

Susan is Professor of Health Sciences at Southern Cross University. Susan has nearly 20 years’ international experience as a health services researcher with expertise in health workforce reform, service delivery and organisation. In particular, she works with health services to help them think differently about how they organise and deliver care to provide solutions to enhance health care from the patient’s perspective. She is particularly committed to regional and rural health issues, community health, and capacity building. Recent research projects have explored the use of the NBN to provide telehealth to keep older people independent at home; primary health care integration; the use of social media to engage with health service users; and the recent Victorian Allied Health Workforce Research Project.

Promoting men-inclusive maternity services at Royal Brisbane & Women’s Hospital

Dr Gai Harrison1, Ms Kristy Fitzgerald1

1RBWH, Herston, Australia

Background: There is growing recognition of the importance of men’s inclusion in antenatal care and childbirth to optimise outcomes for maternal and newborn health. However, programs aimed at involving fathers tend to focus on how men can best support their partners rather than addressing their own expectations and needs. Fathers commonly report feeling excluded or marginalised during antenatal appointments and childbirth. This exploratory study, led by social workers, was undertaken to generate data to inform a plan for promoting men-inclusive maternity services at Royal Brisbane and Women’s Hospital.

Method: An environmental audit tool was developed to examine visual depictions of men in maternity services. The audit was administered by two social workers who documented and photographed posters, pamphlets, art work and signage on display. Qualitative analysis was used to elicit the dominant images of men portrayed in this data.

Results: The audit revealed that men are not often visually represented and when they are it is predominantly as supports for their partners or perpetrators of violence (e.g. domestic violence posters).  Visual materials focusing on fathers’ needs and experiences as men were scarce. Signage similarly omitted reference to men.

Discussion: The limited visual depictions of men coupled with their negative portrayal in domestic violence literature may deter men’s attendance at maternity services. Although men were positively portrayed as support persons, these representations may promote the idea that their own needs are secondary to their partners and that they are not entitled to health professionals’ support. Future research will build on these findings by eliciting men’s perceptions of the environment of maternity services and whether they experience a sense of inclusion while attending services. The findings will inform a plan for cultural change to enhance men’s sense of inclusion in maternity services.


Biography:

Kristy has 16 years of social work experience in hospital and health settings and is currently the team leader of the Maternity and Neonatology Social Work Team at the Royal Brisbane and Women’s Hospital. Kristy’s particular interest is in the area of surrogacy, with other research interests including projects to promote men-inclusive maternity services.

Nutrition intake early after stroke is poor: Investigating nutrition within an Enriched Environment

Ms Samantha Robertson1, Dr Rohan Grimley2,3, Dr Chris Anstey2,3, Dr Ingrid Rosbergen1,4

1Allied Health Medical Services, Sunshine Coast Hospital and Health Service, Birtinya, Australia, 2Sunshine Coast Clinical School, Griffith University , Birtinya, Australia, 3Department of Medicine, Sunshine Coast Hospital and Health Service, Birtinya, Australia, 4Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia

Background: Malnutrition is common after stroke. Nutrition intake and malnutrition were investigated within the novel intervention of an Enriched Environment (EE) in an acute stroke unit.

Methods: We performed a before-after study observing standard care (n=30) versus EE (n=30) participants.  Standard care participants ate meals at the bedside whilst EE participants were provided the opportunity of communal mealtimes at breakfast and lunch. Both groups received nutrition supplementation if indicated. Mealtime intake was observed and remaining daily intake calculated using food charts across 6 days per week. Nutrition requirements were calculated for total energy (ratio method) and protein (1g/kg) and proportion of requirements met (%).  Malnutrition was assessed using the Subjective Global Assessment (SGA) and admission and discharge body weights. Stepwise multivariable logistic regression was performed assessing predictors of nutrition outcomes adjusting for intervention group, age, gender, stroke type and severity, length of stay, admission weight, and dietary modification.

Results: Neither standard care (n=30, age 76.0 ±12.8) nor the EE group (n=30, age 76.7 ±12.1) met daily requirements for energy (70.7% ±16.8 vs. 70.7% ±17.3, p= 0.94) or protein (73.2% ±18.6 vs. 69.8% ±17.3, p= 0.70). Data was stratified into stroke severity showing a trend toward improved intake in moderate stroke patients (NIHSS 8-16) (Energy 63.7% ±13.7 vs. 76.8% ±15.2, p=0.55 and Protein 66.2% ±14.5 vs. 77.3% ±16.2, p=0.11). Mean body weight dropped (0.92kg standard care vs. 0.64kg EE) and malnutrition rates increased: standard care (3.3% to 26.6%) and EE (6.6% to 13.3%).  Predictors of malnutrition on discharge in logistic regression models were: length of stay (p<0.01), and protein (p<0.01) or energy intake (p<0.05).

Conclusion: Overall, acute stroke patients were not meeting nutrition requirements and losing body weight. The enriched environment had no effect on nutrition intake. Malnutrition was associated with lower energy and protein intakes and increased length of stay.


Biography:

Samantha qualified as an Accredited Practicing Dietitian (APD) at Queensland University of Technology in Brisbane, Australia graduating with Honours. Samantha began her career working for the NHS in London, gaining experience in a broad range of areas and is now based at the Sunshine Coast University Hospital, specialising in acute stroke for the past 7 years. Samantha has an interest in research and has presented study results internationally in 2017 at the Stroke Society of Australasia (SSA) conference in New Zealand and also locally at the Sunshine Coast Hospital and Health Service (SCHHS) Research Days. Samantha was recently awarded a Runner Up prize at the Allied Health Translating Research into Practice (AHTRIP) 2018 Queensland State-wide program and received an Excellence in Patient Care award by the SCHHS Chief Executive in 2018. Samantha’s work has featured in local research reports, social media and Dietitian Association of Australia newsletters. Samantha is currently the Senior Stroke Dietitian at the Sunshine Coast University Hospital, Australia.

 

Cognitive impairment in a tertiary hospital: Prevalence and carer experience

Mrs Prue McRae1, Ms Elise  Treleaven1, Ms Karen Lee-Steere1, Mrs Margaret Cahill1, Dr Simon  Finnigan1,3, Associate Professor Alison Mudge1,2

1Royal Brisbane And Women’s Hospital, Brisbane, Australia, 2QUT, Brisbane, Australia, 3UQ Centre for Clinical Research, Brisbane, Australia

Introduction: Cognitive impairment (CI) is common in older hospital inpatients, and associated with poorer outcomes. High quality care requires partnership between patients, healthcare professionals and carers. Hospitalisation can be a stressful experience for people with CI and their carers. The aims of this study were to: 1) To identify the prevalence of CI in patients aged 65 and older; 2) Explore the carers’ experience of involvement in hospital care for patients identified with CI.

Methods: This observational study was conducted at Royal Brisbane and Women’s Hospital on March 14 2018. We performed a cross-sectional study of all ward inpatients (excluding intensive care, emergency department and mental health units) aged 65 years or older using the 4As test, a validated measure of cognitive impairment. We defined score ≥1 as CI, with score ≥4 likely to be delirium. For patients identified with CI, we undertook a brief structured survey of carers, in person or by telephone within 3 days of the audit date.

Results: We screened 218 older patients in 21 wards; 90 (41%) screened positive for CI, with 45 of these likely delirium.  Fifty two (58%) carers completed the survey; most were spouse or child, and 41 (79%) identified as a main carer for the participant. Most carers (44/52, 85%) strongly agreed they felt welcome on the ward (44/52, 85%) and confident leaving their family member on the ward, and 35 (67%) definitely agreed that they were listened to by staff. Only 28 (54%) had been asked about change in cognition and only 8 (15%) had received information on delirium prevention.

Conclusion: CI was prevalent across a broad range of acute and subacute wards. Understanding the carers’ experience will inform strategies to enhance their involvement in delirium prevention and management for their family member in partnership with clinical staff.


Biography: 

Prue Mcrae is the Eat Walk Engage Program Manager at the Royal Brisbane and Women’s Hospital

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