Bonne Lee (Prince of Wales Spinal Unit)

MHA, FAFRM, MBBS, MMED (Clin Epi), Gcert Info Tech

PhD

Research Sponsored by:

ARC Discovery Grant for 2004: (DP0450773) RA Iedema, J Braithwaite, R Sorensen, RK Kerridge, BB Lee

ARC Discovery Grant for 2007:(DP0879002 ) Prof RA Iedema; A/Prof E Manias; Dr BB Lee; A/Prof MD Buist; A/Prof GA Caplan; Dr M Kornberger; Ms

JF Carthey; Dr R Sorensen; Dr CM Jorm; Prof FD Becker

SPCC POWH

Holistic Pressure Care From Research to Clinical Practice

(and back again) 2 contrasting

cases – in and out of the comfort

zone

The Clinical Problem of

Pressure areas in established

spinal patients Spinal Cord Injuries is associated with an

increased risk of pressure areas (50-80% SCI

persons will develop a Pressure Area

Rodriguez 1981).

Established patients develop pressure ulcers

particularly as they age. Prevalence 9% at 1

yr post D/C vs 32% 20 yrs post D/C. (Yarknoy

etal 1995 - Model USA data systems)

Costs

Estimated average cost per patient for

pressure ulcer treatment is b/w $70,000

(Braun 1992) and $150,000 (USA

dollars - Garber 2003 - EXCLUDING

surgical costs).

Spinal Pressure Care Clinic

In people with a spinal cord injury, a pressure

area is often a marker of complex underlying

problems – the resolution of which is closely

tied to the success of any intervention.

The SPCC is a multidisciplinary outpatient

initiative which aims to provide this service to

spinal cord injured patients in the community.

It is part of a state-wide pressure

management service.

Spinal Pressure Care Clinic

Baseline pre intervention data suggests that

when you DON’T manage patients in this

manner in hospital length of average LOS

stay varies between 104* days and 264& days

for grade 4 pressure areas (Local data

estimates).

October 1998-October 2000* For Myocutanoeus flap

2003-2005&

Spinal Pressure Care Clinic

Holistic PRE-Assessment of pressure area risk factors weeks or months before any surgical intervention. (Standard questionnaire + SF36 + ANSI – nutritional screen)

Gives the best opportunity for conservative management and secondary prevention.

Mobilises community resources (eg. nursing, care agencies, community groups, advocacy services).

Mobilises capital resources (equipment, nutritional supplementation)

THE POW SPCC Intervention *Recurrent NSW Health Funding from July 1 2004.

Resources: BIWEEKLY INTERVENTION

Spinal Occupation Therapist (Victoria Sim, Jenny Nicholls)

Spinal Physiotherapist (We are unfunded for this but still miss Lyndall Katte!)

Spinal Clinical Nurse Consultant and Clinic Coordinator (Margaret Samson)

Spinal Rehabilitation Specialist (B Lee)

Orthopaedic Surgeon (R Stanford)

Dietitian (S Nelan)

Plastic Surgical Registrar

Infectious Disease Consultant (K Clezy)

Social Worker (Beverley Berelowitz)

Clinic

Interactions

REFERENCE

Iedema R, Long D, Forsyth R and Lee B (2006)

Visibilising Clinical Work: Video Ethnography in the

Contemporary Hospital. Health Sociology Review

15

B B Lee, R Iedema, S Jones, O Marial, J Braithwaite

and D Long (2007) Recognizing and Enabling

Clinician-led Quality Improvement Initiatives: the

Spinal Pressure Care Clinic (SPCC). Asia Pacific

Journal of Health Management

Case Study 1: Frontloading

our interventions - an operable

case. A 27y.o gentleman who has had

longstanding pressure areas for 3 years.

Strategy

Front load our interventions

Predict resource use such as equipment and

discharge destination

Line those ducks up pre op as much as you

can. It takes work but is not rocket science.

wound status

“The right trochanter is undermined

2cm it is of Grade 4. The dimensions

are 3cmx3cm. The left trochanter is

likewise a Grade 4 pressure area

dimensions of 4cmx2cm. The left

heel is a Grade 4 area again

approximately 3cmx3cm.” Ralph Stanford

PREOP Infectious Diseases

Intervention

Dicloxacillin 500mg qid orally would be

appropriate given the staph and strep

infections currently in the wounds.

May need to add additional cover through

either the addition of metronidazole or

replacing the antibiotics regimen with

clindamycin.

(Kate Clezy – Infectious Disease Specialist)

PREOP Restricted seating

times

On our recommendation he has reduced his

sitting hours from 8 hours a day to now only

half an hour every second day.

Social isolation

Quality of life

(lower numbers indicate poorer scoring)

Tetraplegic and paraplegic Australian spinal injury norms Ref: Haran M, Lee B, King M, Stockler M “Health Status Measured by SF36 in people with Spinal Cord Injury”.

Education and

appropriateness of response

Checks his skin for red areas although does

not check it everyday. Some ongoing

education issues to target here.

Appropriate response to any new pressure

areas.

PREOP Physical Plan

Musculoskeletal Shoulder issues (pain):

Impacts on transfers and the ability to

pressure relieve both PRE and POST

operatively.

PREOP shoulder program prescribed.

Nutritional issues

Smokes 6 to 10 cigarettes a day and has been smoking for 9 years. He does not drink alcohol.

Height: 189cm

Weight: 65kg (patient’s estimate)

Weight history: patient reports recent weight gain

IWR (paraplegic): 65.5 – 82.5kg

MAC: 27cm

Using ANSI assessment toolL at risk of malnutrition.

PREOP Nutritional Supplementation Plan Prescribed

PREOP Infrastructure and

equipment Assessment.

Electric wheelchair

Manual wheelchair

Wheelchair cushion Quadtro/Roho

Bed Turns/ Mattress/overlay

Shower commode.

Commode chair

PREOP Occupational Therapy

Plan

Appropriate mattress and cushions.

Need to arrange loan commode Roho cushion for him given the poor state of his commode and we also need to arrange slow memory foam bolster to be made for his left leg so that we can get clearance of that left heel above the bed.

PREOP Wound Care

Interventions

The left heel will require daily dressings of Jelonet

The bilateral trochanter pressure areas require daily vacutex dressings to wound base, covered with combine and tegaderm.

Community Liaison Nurse has spoken to the community nurses at Kingswood community health centre regarding increasing dressings from second daily to daily.

PREOP Social risks

The level of care that he has in the community are

probably insufficient to cope with the post-operative

requirements.

Respite post op is likely

Social risks/support/home situation explored by social

worker to identify potential problems.

Summary Plan

This gentleman will probably need surgery.

Needs a post-surgical discharge destination with

A community spinal nursing service.

Make sure that the wounds in the interim are

improving.

In particular heal that left heel!

Surgical Plan

AIM: Bilateral Myocutaneous Flap

operations on both sides probably

without any bony debridement

necessary.

Confirming the POST

operative plan

SPCC have been in preliminary contact

with the Spinal Nursing Accomodation

and timing of surgery seems OK (as

best anyone can plan these things).

INPATIENT SUMMARY

Left GT Myocutaneous Flap

Right GT Flap (week 6)

SSG Left distal Flap (week 10)

Discharge

LOS 100 days for Bilateral

myocutaneous flaps (Right and Left

Trochanters)

*note averages from previous work 104

days per MC Flap pre-intervention.

What does this case highlight?

Blurred margins between community and the hospital. Community issues such as ability to comply, available equipment and home care NEED to directly influence our in hospital decisions.

A need for a coordinated forward planning clinical intervention.

Bringing traditional hospital based resources like discharge planning, allied health, specialist nursing and specialised equipment into the community (weeks or months before surgery) makes sense!

The timing of surgery takes place when the patient’s physical and nutritional conditioning is optimal, and where acute and potential discharge infrastructure and social issues are addressed, or processes to address them are underway.

Communication!!

Paranoia.

Case 2: A non operable case

– out of the comfort zone.

The patient was 27years old when he was

injured in a motorcycle accident in 1990,

which left him with C4 Quadriplegia. He

was independently mobile using a

power wheelchair with chin control. His

pressure areas reportedly developed in

1999 when his ROHO pressure cushion

deflated leading to him sitting on the

hard board of his wheelchair seat.

Non curative surgical

intervention

Between 2003 and 2008 the patient had

multiple admissions to POWH for

conservative management and surgical

intervention on his pressure areas

(including VAC therapy, flap repairs, a

girdlestone procedure) in an attempt to

heal his pressure areas and control his

osteomyelitis. He was prescribed

lifelong antibiotics for his non-curable

osteomyelitis.

No definitive surgical options

In August 2008 an orthopedic surgeon

involved in the management of the

patient’s pressure areas stated the

following:

“He is beyond any hope of a curative

resection. He will continue to have a

discharging sinus indefinitely. He should

continue to be managed non-

operatively”

A Palliative approach

Following this report, it was agreed

amongst the SPCC team members that

the patient should be managed by way

of a palliative care approach.

Palliative liason

Due to the team’s inexperience in

dealing with palliation, they

acknowledged they were in need of

support and guidance from other health

care providers.

Kahren Whyte Palliative care OT was

invaluable – Thank you!!

Formal Palliative Care N/A

The SPCC team at POWH contacted

the patient’s local Palliative Care Team

with the aim of gaining support in goal

setting and symptom management.

However, the patients local palliative

care team were unable to offer any

service to him at that time, as he did not

meet the Palliative Care criteria.

The patient’s Quality of Life

Goals

To sit up in his wheelchair

To visit and stay with family members

he had not seen for some time.

To go swimming at Clovelly beach,

which has wheelchair access

Visiting the bioscope

Repairing his motor vehicle

The SPCC Team’s

Intervention:

In November and December 2008, the

patient was seen in the seating clinic at

POWH for assessment and prescription

of a new seating system for his (hardly

used) 11 year old power wheelchair –

he had previously been on 5+ years

bedrest awaiting the “healing” of his

wounds. This was the SPCC Team’s

priority to assist the patient in achieving

4 of his 5 goals.

Getting him mobile

Over a number of seating appointments,

a custom foam on ply backrest was

fabricated and fitted to the patient’s

power wheelchair. His final seating

appointment to hand the finished chair

back to the patient for use in the home

and community, was booked for 17th

December 2008.

Medical complications

The patient was admitted to ICU in his

local hospital on the 12th December

2008 with a collapsed lung and possible

permanent ventilation.

He was discharged home in late

January 2009 however, he was never

well enough to attend his final seating

appointment.

In May 2009 the patient’s carer found

him unconscious at home. He died in

hospital 2 days later from pneumonia.

This patient was never able to achieve

any of the quality of life goals he had

set.

What does this say?

Palliative services do not have the

resources to assist patients who do not

meet strict inclusion criteria.

We need to be mindful of quality of life

and react faster when prognosis is poor.

It is hard to have these conversations if

you are not used to having them.

No surgery does not mean no SPCC

intervention – it sometimes means

more.

POW SPCC Operative

Outcomes

Note small sample. Non randomised allocation. Staged vs Non Staged procedures.

Both Non SPCC and SPCC were a mix of procedures (myocutanoeus flaps and debridements: SPCC included one shoulder procedure)

System Aim: to reduce and eventually eliminate Non Staged Procedures through referring through SPCC pre-op and aggressive primary and secondary prevention.

SPCC Myocutaneous flap only LOS: 73 days.

Non SPCC Myocutaneous flap only LOS: 300 days.

LOS (days): SPCC vs NON SPCC Mx at

Prince of Wales Hospital 2003-2005

264

59

0

100

200

300

NON SPCC (n = 5) SPCC (n = 11)

LOS (days)

POW SPCC Outcomes

264 inpatient days @ $750.00 per day is approximately $198,000 per

procedural admission compared to SPCC associated costs of (56

inpatient days @ $750.00 per day) of approximately $44,000 per

procedural admission. The total direct SESAHS costs of managing 5

patients NOT using the SPCC model was almost 1 million dollars. The

total direct SESAHS costs of managing 11 SPCC model patients was

under $483,000 dollars. This cost does NOT include direct surgical,

equipment, and community costs, nor indirect and societal costs such

as time out of the work force.

Cost of SPCC vs NON SPCC Mx at

Prince of Wales Hospital 2003-2005

$198,000

$1,000,000

$44,000

$483,000

$0

$500,000

$1,000,000

$1,500,000

Cost/admission Cost of Cohort

NON SPCC (n = 5)

SPCC (n = 9)

The research Loop

Theories behind the current

model of care

UNSW - Health Service Management

Division: Rick Iedema and Jeffrey

Braithwaite Masters project.

Analogies in the business literature to

the computing environment with

software development.

We are not making

Hamburgers or building cars

Post-Fordism: Not a production line (e.g. Scientific Management systems).

We decided we needed a small, closely knit, fast moving team with blurred job margins, a high level of interdisciplinary awareness.

We wanted the clinic structure to support not hinder these goals.

New Work Order

The framework of the intervention was to directly

apply New work Order (NWO) and

organizational learning techniques to a defined

part of a clinical outpatients department in a

major tertiary teaching hospital. These

management models stem from the commercial

business world.

Structural dimensions of the NWO

are: Flatter

Flatter management structures with less emphasis on hierarchy and consequently a blurring of social, organisational and professional boundaries occurs. Morgan talks about a “holographic” approach to job design where within the team roles are broadly defined and individuals are multi-skilled. This theoretically leads to the workers being considered “committed partners” who can supervise themselves. The role of management instead becomes one of empowerment and providing workers with tools (information, training, authority) and accountability “Facilitators”.

Clinical Design Implications: Flat structure. Blurred Margins. We know each others roles, know where we specialise, but importantly can recognise errors outside our sphere and can directly refer to achieve this.

Structural dimensions of the NWO

are: Smaller

There is also the implication that smaller more locally in touch organisations will be better in tune with the needs and wants of their customers (environmental niches).

Clinical Design Implications: Small teams with clinical facilitation and cross disciplinary referral patterns.

Globalisation

Organisations are becoming global in perspective, harnessing information technology to facilitate and accentuate performance and integration. Morgan calls this “networked intelligence”, which allows even those in remote locations to become participants in an evolving system of organisational memory and intelligence. This has a profound effect on organisations, management, workers, social relations and definitions.

Clinic Design Implications: Teleconferencing, (POWH Jan 2004-present) TRY to develop an Electronic (if possible) Patient Medical Summary for goal planning.

Communisation

Communisation is how people establish new ways of living and working together. How people perceive their working relationships (and at times blur their work and personal relationships) is a profound element of the NWO paradigm.

Clinic Design Implications: Physical design: Do not encourage separate assessment areas. People HAVE to interact. IT design: Make all E-Notes universally accessible IF POSSIBLE.

Improving the Model of Care

ARC Discovery Grant for 2004: (DP0450773) RA

Iedema, J Braithwaite, R Sorensen, RK

Kerridge, BB Lee, Preventative health care: how

compatible are clinicians’ identity and practice

with transition to the new roles that health reform

requires? 2004: $120,000, 2005: $120,000, 2006:

$120,000; Category: Public Health and Health

Services, Administering Institution: The

University of New South Wales.

VIDEO ETHNOGRAPHY

AIM: To identify how the current clinical

structure is operating.

To allow clinicians to self reflect on

clinical practice.

To allow the good parts about current

approaches to be SYSTEMATISED and

problems to be addressed.

LOOKING IN THE MIRROR

What do I see? Potential for multiple looks at

the clinic from different perspectives utilising

the inherent skills of the multidisciplinary unit.

EXAMPLES

Infection Control (GTP: Kate Clezy, Giulliana

Pontovivo)

Systemisation of Care (GTP: R Iedema,

Debbi Long)

INFECTION CONTROL

Video footage analysed with regard to:

the patient group

the clinician group

equipment issues

specific clinic geography

INFECTION CONTROL

International standard best practice

applied to unique specificities of the

clinic.

INFECTION CONTROL

Bedrails were identified as potential vectors of

transmission …….

INFECTION CONTROL

….. as were bins, overflowing with Personal

Protection Equipment (Gowns/gloves etc).

INFECTION CONTROL

Clinicians in wheelchairs presented a

unique challenge, with few infection

control protocols designed to meet their

needs

INFECTION CONTROL

Video footage allowed infection control

specialists to make effective risk

management recommendations based

on actual clinical practice.

It is intended that recommendations

(individualised to clinician role) will be

integrated into future clinical behaviour.

Video tools and clinician

feedback to clarify existing

barriers in the system Mapping of information flows and

relationships.

Identifying Vortices.

USING information flow

diagrams

A greater understanding of the complexities of the interactions within the clinic environment and other clinicians roles.

Addressing barriers.

Plan and improve how we allocate resources to address these barriers.

Other uses important to this clinic: “Data Flow Diagrams” programmers can use to capture clinical data for data systems.

Physical Layout: Reflecting

ideas (A shiny mirror?)

consult

consult A

procedures B

procedures A

pan room

office

store room

desk

1

23 corridor

Physical Design and

Communication

Conversations most frequently take place

in the corridor space between the

procedures room and the office (1),

outside consult rooms A and B (2), or

around the desk at the end of the

corridor (3). Informal communications in

the relatively casual space of the

corridor became identified as an

important component of a flexible and

reactive communication structure.

Spinal cord injury patients often

succumb to bed sores By Liz Szabo, USA TODAY

.

“Christopher Reeve dedicated his final years to promoting cutting-edge research in paralysis,

including stem cells and experiments aimed at regenerating the spinal cord.

In the end, though, the star who portrayed the Man of Steel succumbed, like so many people with

spinal cord injuries, to an age-old problem: an infected bed sore.”

"It seems like such a piddly thing to take down Superman," says Jean de Leon of Baylor Specialty

Hospital in Dallas. "But this is the type of injury that people with spinal cord injuries get every day.“

But treating bed sores — which sometimes take more than a year to heal — can be both daunting

and disruptive. Patients may have to stay in bed for weeks or even months — a challenge for busy

people such as Reeve. Pressure sores can leave paralyzed people further disabled and isolated,

says Gerard Kelly, executive director of the United Spinal Association. "It stops your life," Kelly

says.

The elephant in the room

This approach in large part does not

exist in NSW for Spina Bifida.

Complexities are similar.

Interventions are unsustainable with

current resources.

This is an practical and ethical dilemma.

References

Iedema R, Long D, Forsyth R and Lee B (2006) Visibilising

Clinical Work: Video Ethnography in the Contemporary Hospital.

Health Sociology Review 15

Long D, Iedema R and Lee B (2007) Corridor Conversations:

Clinical communication in casual spaces. In R. Iedema (Ed.),

Communicating Hospital Work: Professional, managerial and

organizational discourses and practices in tertiary care.

Basingstoke: Palgrave-Macmillan

Long D, Iedema R, Lee B B and Braithwaite J (2007)

Attempting Clinical Democracy: Enhancing multivocality in a

multidisciplinary clinical team. In C.R. Caldas-Coulthard, & R.

Iedema (Eds.). Anonymous Identity Trouble: Discursive

Constructions. Basingstoke: Palgrave –Macmillan. Forthcoming.

Iedema R (2006) (Post-)bureaucratizing medicine: health reform and the

reconfiguration of contemporary clinical work. In: Meyer F, Gotti M,

editors. Advances in medical discourse analysis: oral and written contexts.

Gottingen: Peter Lang; p. 111-31.

B B Lee, R Iedema, S Jones, O Marial, J Braithwaite and D Long (2007)

Recognizing and Enabling Clinician-led Quality Improvement

Initiatives: the Spinal Pressure Care Clinic (SPCC). Asia Pacific Journal

of Health Management

References

END