Alfred Health PEG Credentialing Program - The Alfred … · Alfred Health PEG Credentialing Program...
Transcript of Alfred Health PEG Credentialing Program - The Alfred … · Alfred Health PEG Credentialing Program...
Alfred Health PEG Credentialing Program
Lisa Murnane
Senior Dietitian, Alfred Health
Management of Gastrostomy Feeding Tube’s in Adults
Friday 11th December, 2015
Acknowledgements
• A/Prof Ibolya Nyulasi; Manager, Nutrition Services, Alfred Health
• Professor Stuart Roberts; Director Hepatology & PEG service, The Alfred
• Vanessa Carter & Allison Lauder; Founding Dietitians, Formerly The Alfred
• Georgina Calder; Senior Nurse Clinician, MATS Gastrostomy service
• Dr Eva Kipen; Geriatrician, Aged Care Service, The Alfred
• Kathryn Collins & Lorraine Gaffney; former Enteral Nutrition Portfolio Leads
Presentation Overview
• Background – Alfred Health
– Gastrostomy feeding tubes
– Home enteral nutrition (HEN) patient management
– Alfred Health HEN Service profile
• Extended Scope of Practice (ESoP) program – Gastrostomy tube credentialing program overview
– Brief history of the credentialing program’s development
– Who can be credentialed?
– Credentialing Process
– Competency & clinical governance
• Measures of success – Key Performance Measures
– How does this ESoP program enhance the ED?
– Why the model works
Southern
Eastern
0 10 20
Kilometres
North and West
Broadmeadows Health Service
Bundoora Extended Care Centre
Heidelberg Repatriation HospitalSunshine Hospital
Western Hospital
Healesville & District Hospital
The Peter James CentreWilliamstown Hospital
Mercy Werribee Caulfield General Medical CentreAngliss Hospital
Monash Medical Centre, Moorabbin Monash Medical Centre, ClaytonHampton Rehabilitation Hospital
Sandringham & District Hospital Kingston Centre
Queen Elizabeth Centre Dandenong Hospital
Frankston Hospital
Rosebud Hospital
The Northern Hospital
Cranbourne Integrated Care Centre
Casey Hospital
Rosebud Rehabilitation Unitp
The Mornington Centre
Golf Links Road Rehabilitation and PCUp
pYarra Ranges Health
O'Connell Family Centre (Grey Sisters) Inc.
Melton Health
Craigieburn Health Service
Wantirna Health
Sunbury Day Hospital
Austin Hospital andMercy Hospital for Women
Royal Melbourne Hospital, Royal Park
Tweedle Child & Family Health CentreRoyal Talbot Rehablilitation Centre
Maroondah Hospital
Calvary Health Care Bethlehem Ltd
The Alfred
Box Hill Hospital
St George's Health Service
Hospitals current as at 1 June 2011
Southern
Eastern
0 10 20
Kilometres
North and West
Broadmeadows Health Service
Bundoora Extended Care Centre
Heidelberg Repatriation HospitalSunshine Hospital
Western Hospital
Healesville & District Hospital
The Peter James CentreWilliamstown Hospital
Mercy Werribee Caulfield General Medical CentreAngliss Hospital
Monash Medical Centre, Moorabbin Monash Medical Centre, ClaytonHampton Rehabilitation Hospital
Sandringham & District Hospital Kingston Centre
Queen Elizabeth Centre Dandenong Hospital
Frankston Hospital
Rosebud Hospital
The Northern Hospital
Cranbourne Integrated Care Centre
Casey Hospital
Rosebud Rehabilitation Unitp
The Mornington Centre
Golf Links Road Rehabilitation and PCUp
pYarra Ranges Health
O'Connell Family Centre (Grey Sisters) Inc.
Melton Health
Craigieburn Health Service
Wantirna Health
Sunbury Day Hospital
Austin Hospital andMercy Hospital for Women
Royal Melbourne Hospital, Royal Park
Tweedle Child & Family Health CentreRoyal Talbot Rehablilitation Centre
Maroondah Hospital
Calvary Health Care Bethlehem Ltd
The Alfred
Box Hill Hospital
St George's Health Service
Inner South Inner East
North East
Hume Whittlesea
HealthWest
Inner North WestOuter East
Kingston-Bayside
South East
Frankston-Mornington
Moonee Val l ey - Mel bour ne
Inner EastHealthWestCaritas Christi Hospice
Dental Health Services VictoriaRoyal Women's HospitalRoyal Children's Hospital
Royal Melbourne Hospital, City
St Vincent's Hospital Royal Victorian Eye & Ear Hospital
Peter MacCallum Cancer Centre INSETINSET0 500
Metres
1000
Department of Health regional boundariesPrimary Care Partnership
Metropolitan Melbourne public hospitals
Kingston – North (S)
Kingston – South (S)
Glen Eira – South (S)
Bayside – South (P)
Bayside – Brighton (P)
Glen Eira – Caulfield (P)
Port Phillip – St Kilda (P)
Port Phillip – West (P)
Stonnington
- Prahran (P)
Stonnington
- Malvern (P)
Melbourne – Inner (S)
Melbourne
– S’bank
- D’lands (S)
Melbourne –
Remainder (S)
•
•
•The Alfred
Caulfield Hospital
Sandringham Hospital
Kingston – North (S)
Kingston – South (S)
Glen Eira – South (S)
Bayside – South (P)
Bayside – Brighton (P)
Glen Eira – Caulfield (P)
Port Phillip – St Kilda (P)
Port Phillip – West (P)
Stonnington
- Prahran (P)
Stonnington
- Malvern (P)
Melbourne – Inner (S)
Melbourne
– S’bank
- D’lands (S)
Melbourne –
Remainder (S)
•
•
•The Alfred
Caulfield Hospital
Sandringham Hospital
Alfred Health inpatient sites
The Alfred Caulfield
Hospital
Sandringham
Hospital
Hospital type Acute Sub-acute Acute (community)
Bed # ~470 ~255 ~45
Dietetic EFT 26 6 1
Services include Tertiary referral
hospital
Specialist services:
Trauma / Burns,
Emergency & ICU,
Cancer, Respiratory
including CF, HIV,
Heart / Lung
transplant, Bariatric
surgery
Aged care, rehab
(including ABI) &
residential care
Surgery, acute aged
care, emergency &
maternity
Alfred Health HEN Service Profile
• Insert ~130 Gastrostomy tubes per year
• ~80 HEN clients currently
• All HEN patients reviewed in-person every 3 months by the Dietitian via:
– PEG clinic
OR
– Mobile PEG service
• Nutrition Service holds HEN budget including formula, equipment & replacement feeding tubes
Stroke 23%
Head & Neck Ca
26% Trauma 25%
Neuromusc Disease/ Dementia
10%
HIV 3%
Cystic Fibrosis
3%
Other 10%
Gastrostomy tube Credentialing Program
• Extended scope of practice program for Dietitians & RNs
• Advanced role: independently manage patients with Gastrostomy feeding tubes including tube replacement
• Includes inpatients & those living in the community
• Developed collaboratively by: – The Alfred Gastroenterology Unit
– Alfred Health Nutrition Service
– The Alfred Mobile assessment & treatment service (MATS)
• Commonly Medical practitioner role
(stomal therapist/outreach RN in some organisations)
Gastrostomy ‘PEG’ Clinic established
Problem Identification
ED presentations
16 week waiting list for PEG clinic
Residential care patients: distress & transport difficulties
Mobile Gastrostomy Service established
Approval of credentialing program by:
Clinical Risk Committee
Legal Counsel
Hospital insurers
Alfred Health Executive
Model of care for Mobile Gastrostomy service &
Gastrostomy tube Credentialing program developed
Gastrostomy Credentialing Program commenced
1997
2002
2004
2005
Process of Credentialing Program Development
Who can be credentialed?
• Required professional qualifications:
- Dietitian: minimum 3yrs experience with enteral nutrition
OR
- Registered Nurse working in the AH MATS program
• Must be an Alfred Health employee
• Dietitian with high HEN caseload credentialed as a priority
e.g. Head & neck cancer, CF, stroke, trauma
Credentialing process Part 1: Experience
• The trainee must attend a minimum of 10 Alfred PEG clinics (or have equivalent
experience) and be able to:
– Identify current feeding tubes used across AH including removal method(s)
– Identify possible risks / complications associated with tube removal / replacement and be
competent to manage these if they arise
– Identify situations where it is not appropriate to manage the patient in the community &
when escalation to Gastro team required
– Identify when it is clinically appropriate to order a PEG-o-gram via the AH Radiology
Credentialing process Part 2: Supervised practice
• The trainee must complete:
– 5 supervised BALLOON gastrostomy tube
replacements including: > 3 supervised by the Consultant Gastroenterologist (minimum)
> 2 supervised by Credentialed Dietitian or RN who is an
approved supervisor
– 5 supervised EXTERNAL-TRACTION gastrostomy
tube removals with balloon replacement
(supervision as above)
Note: An ‘approved supervisor’ is a Dietitian or RN who has significant experience in independent / safe tube replacement (minimum 25
replacements) & has written approval to supervise from the Consultant Gastroenterologist
Credentialing process Part 3: Infection prevention
• The trainee must:
– Read & understand the AH Infection Control guideline on ‘Standard
precautions’
– Completed AH eLearning package on ‘aseptic technique’
Competency & Clinical Governance
• Prior to independent practice, the trainee must:
– deem themselves competent
– be deemed competent (in writing) by the Consultant Gastroenterologist
• Annual re-evaluation of competency occurs by the Consultant Gastroenterologist via:
– Completion of independent practice for the past 12 months,
– May require supervised Gastrostomy replacement(s) at the discretion of the
Consultant Gastroenterologist
• Development & review of the competency standards are the responsibility of the
Gastro Unit
• Credentialing/re-credentialing of staff & ongoing management of the credentialing
program is the joint responsibility of Gastro Unit and Nutrition Service
Key Performance Measures Pre-credentialing Program Currently
Credentialed Staff None ~19 Dietitians
(6 employed currently)
8 MATS RNs
(4 employed currently)
ED admissions > 1 per month ~1 every 6 months
PEG Clinic waiting list 16 weeks 1 weeks
Mobile Gastrostomy Service
Dietitian FTE
0.1 FTE Senior Dietitian 0.2 FTE Senior Dietitian
NB: nil other dedicated FTE
Clinical incidents relating to
tube replacements
Unknown Nil to date
How does this ESoP program
‘enhance’ the ED?
1. Reduction in ED presentations
• Minimum 3 monthly tube reviews via PEG clinic OR MATS PEG service (including
proactive tube replacement where indicated)
• Systems to prevent ED presentation if tube dislodges or concerns with tube / stoma:
– 24 hour on-call service for patients on the MATS PEG program (7 day service for
emergency tube replacements / review)
– ‘on-call’ PEG Dietitian available during business hours for drop-in service where required
– Dietitian able to troubleshoot non-urgent issues over the phone
• Training & education of local aged care facilities have
improved their capacity to manage residents with
Gastrostomy feeding tube with less reliance on ED
2. ED consultation by credentialed staff
Excerpt from TAH
E&TC’s Gastrostomy
tube dislodgement
guideline (Oct 2011)
Dietitian able to
managed
all aspects of
HEN care
Wide
organisational
support
Primarily utilises
existing FTE
Enhanced Dietetic
profession
Clear,
thorough
& well
governed
Patient-centered
Why the
model works
Why consider this ESoP program elsewhere?
• Patients come first!
• Utilises existing resources
• Sustainable
• Shares workload
• Improved recognition of dietetic profession
Thankyou.