Telehealth-based model of care redesign to facilitate local fitting and management of patients with a spinal fracture requiring a thoracic lumbar sacral orthosis in rural hospitals in New South Wales.

OBJECTIVE: To develop and implement a telehealth-based model of care for spinal fractures requiring management with thoracic lumbar sacral orthoses that eliminates the need for transfer to a metropolitan tertiary referral hospital. DESIGN: Pre-post design observational study evaluating model of care implementation. SETTING: Rural referral hospitals in a large NSW region covering metropolitan, rural and remote hospitals. PARTICIPANTS: Patients presenting with a thoracic or lumbar spine fracture requiring thoracic lumbar sacral orthoses management and rural clinicians caring for them. OUTCOME MEASURES: Number of patients managed in rural hospitals without transfer to a metropolitan tertiary referral hospital; length of stay and related cost efficiencies; clinicians' perceived skills, knowledge and confidence levels. RESULTS: Model of care was implemented with clinical and system governance processes; and educational workshops across eight rural hospitals. A total of 81 patients managed in rural hospitals under this model between July 2013 and June 2016 without transfer were included in this study. Mean length of stay reduced from nine to four days. Hospital transfers were eliminated from the patient journey, totalling 24 324 km. Workshops were attended by 71 clinicians from nine rural hospitals and survey findings indicated a significant increase in staff knowledge, skill and confidence post education. Cost efficiencies were gained by eliminating 162 inter-hospital transfers and 405 patient bed days. CONCLUSION: This model has streamlined patient journeys and reduced transfers and travel, enabling rural clinicians to provide specialised services in local communities and facilitating timely evidence-based care in local communities without any adverse events.

Tracheostomy management in acute care facilities--a matter of teamwork.

AIM: Implement and evaluate an inter-disciplinary team approach to tracheostomy management in non-critical care. BACKGROUND: Trends towards early tracheostomy in intensive care units (ICU) have led to increased numbers of tracheostomy patients. Together with the push for earlier discharge from ICU, this poses challenges across disciplines and wards. Even though tracheostomy is performed across a range of patient groups, tracheostomy care is seen as the domain of specialist clinicians in critical care. It is crucial to ensure quality care regardless of the patient's destination after ICU. DESIGN: A mixed method evaluation incorporating quantitative and qualitative approaches. METHOD: Data collection included pre-implementation and postimplementation clinical audits and staff surveys and a postimplementation tracheostomy team focus group. Descriptive and inferential analysis was used to identify changes in clinical indicators and staff experiences. Focus group data were analysed using iterative processes of thematic analysis. RESULTS: Findings revealed significant reductions in mean hospital length of stay (LOS) for survivors from 50-27 days (p < 0.0001) and an increase in the number of tracheostomy patients transferred to non-critical care wards in the postgroup (p = 0.006). The number of wards accepting patients from ICU increased from 3-7 and there was increased staff knowledge, confidence and awareness of the team's role. CONCLUSION: The team approach has led to work practice and patient outcome improvements. Organisational acceptance of the team has led to more wards indicating willingness to accept tracheostomy patients. Improved communication has resulted in more timely referral and better patient outcomes. RELEVANCE TO CLINICAL PRACTICE: This study highlights the importance of inter-disciplinary teamwork in achieving effective patient outcomes and efficiencies. It offers a model of inter-disciplinary practice, supported by communication and data management that can be replicated across other patient groups.