With more than 630,000 residents, Waitematā District Health Board (WDHB) is located on the North Island of New Zealand and is the largest, and one of the fastest growing DHBs, in the country with an expected increase of 100,000 to their population over the next decade. Servicing the areas of the North Shore, Waitakere and Rodney, the DHB employs more than 7,400 staff throughout its hospitals and community sites.
WDHB provides child disability, forensic psychiatric services, school dental services and alcohol and drug services to the residents of the overall Auckland region on behalf of the other DHBs. It contracts other DHBs to provide some tertiary services, e.g. cardiac surgery and radiation oncology services and have contracts with approximately 600 other community providers.
WDHB operates North Shore Hospital on the shores of Lake Pupuke in Takapuna and Waitakere Hospital in West Auckland. It provides emergency, medical, surgical, maternity, community health and mental health services locally as well as a range of services for the Auckland region, including child rehabilitation and respite at Takapuna’s Wilson Centre, forensic psychiatric services at the Mason Clinic in Point Chevalier, oral health services for children and young people from multiple locations through the Auckland Regional Dental Service and Community Alcohol and Drug Services.
WDHB had a vision for an ‘eVitals’ solution. It wanted a solution that could provide clinical decision support capabilities, help identify deteriorating patients by automatically calculating an Early Warning Score (EWS), alert appropriate clinicians and provide prompts to the clinician for follow up actions. This information needed to be available for nurse managers and nurses to identify overdue or incomplete observation sets or assessments; and provide access for other clinicians to view patient status onsite or remotely.
Alcidion (formerly MKM Health) was selected to implement Miya Assessments and Miya Observations (formerly Patientrack) at North Shore Hospital and Waitakere Hospital. The solution would replace paper-based observation recording as well as automate EWS calculations. It would also be delivered on devices for use at the bedside where assessment details could be recorded and available to all users anywhere, any time.
The eVitals project is part of the WDHB Leapfrog Program, which was intended to fast-track key initiatives that support the organisation’s purpose, values and strategic priorities. The program aimed to increase efficiency, provide real-time access to clinical information, better integrate primary and secondary care and lay the ground-work for long-term, intelligent continuous quality improvement across the organisation. The program helped to instil the culture of improvement and innovation; demonstrating that WDHB is prepared to lead in these areas, learn from exemplars internationally and able to rapidly implement.
“The new real-time system means we will no longer rely on paper charts to search for records and identify patterns, which ultimately means safer care and more clinical time to focus on the patient.”
– Jenny Parr, Associate Director of Nursing
Prior to use of the Alcidion solution, physiological vital signs and assessments were paper-based and held in patient folders and on charts. EWS calculations were performed manually by nurses who would then follow a written protocol for appropriate response and escalation. This system relied heavily on accurately measuring a full set of vital signs, correctly calculating the EWS and prompt follow-up actions based on the written protocol. Manual compliance audits showed variations in standards and knowledge across individuals, teams, days of week and time of day.
These patient paper-based records needed to be accessed by various multi-disciplinary team members and were sometimes not returned in a timely fashion. In turn, nurses were unable to record vital signs directly to the patient chart; they did not have access to the EWS protocol; and other relevant documents were not available to record or assess risk. This approach also presented challenges that come with managing multiple folders and impacted the effectiveness of handovers and ward rounds.
Some of the key drivers for change were to:
- Improve patient outcomes:
- Facilitate early identification of deteriorating patients
- Provide a hospital-wide view of at-risk and deteriorating patients for response
- Increase consistency, appropriateness and timeliness of responses
- Increase identification of patients at risk through completion of assessments
- Improve productivity and release time to care for patients:
- Reduce time spent looking for paper charts
- Facilitate communication between nurses, doctors and other clinical groups
- Provide real-time audit information and reduce time spent in manual collation
- Improve the experience of patients and families through timely intervention and support
- Improve staff experience with better communication across teams and timely response to support requests
- Improve the assurance of care standards through real-time reporting and improved compliance with reduced variation improved audit capability
“Now, all the doctor needs is access to any computer or one of the tablet devices stationed in the ward and immediately they can read the patient’s chart simultaneously. Also, the outreach nurse can be elsewhere in the hospital and still be aware of who are the sickest patients and re-prioritise their work based on EWS scoring and other observations.”
– Peter Groom, eVitals Clinical Lead & Clinical Nurse Specialist
The Alcidion solution, encompassing Miya Observations and Miya Assessments, was the solution chosen by WDHB to deliver the objectives of the eVitals project. It is a complete digital and mobile bedside solution proven to improve patient safety, quality and efficiency of care in one easy-to-use application.
Alcidion worked closely with the project teams from WDHB and healthAlliance to configure the solution in accordance with WDHB policies and clinical protocols. It was released to an initial ward for assessment, before a progressive roll-out across Waitakere and North Shore.
The solution delivered included:
- Observation profiles with defined schedules for taking a patient’s set of observations
- Calculation of adult EWS scores based on observation data to identify patients at risk of deterioration
- Assessments and related charts to monitor a patient’s condition including neurological, fluids, stools, weight, PIVC and smoking history
- Ability for WDHB administrators to create additional observation profiles for the hospital due to feedback received from nursing staff
- Flags to support end-of-life care and non-resuscitation identifiers for patients
- Customised views (My Views) based on user needs
- Automated alerts to notify recipients of a patient’s condition as and when required
The engagement commenced late 2015 and went live on the first ward in mid-2016. Since the implementation began, the solution has been rolled out across over 400 beds on two acute sites, with 70 beds being added every two weeks. Over 800 health professionals are logging in using a variety of devices to access clinical data. iPad minis are being carried by clinical staff and offering mobility for data access and capture.
WDHB is experiencing a 100% completion rate for observations captured on the ward. Through the use of the My Views feature, the Outreach Team is more aware of a patients’ conditions.
Wards using the solution are experiencing consistent improvements in clinical audits such as 100% compliance for cannula and bowel assessments, which had never been achieved before.
The fast uptake and perceived benefits of the solution were immediately realised by nursing staff, managers and clinicians. The project team received numerous suggestions for new assessments and features to help further streamline processes and enhance workflow. Additional assessments WDHB planned to include were sepsis, glucose, Venous Thromboembolism (VTE), Morse falls and Malnutrition Universal Screening Tool (MUST).
Subsequent work includes automating the comprehensive nursing assessment. The aim is to improve the nursing assessment process by offering the potential to screen the ‘well’ patient, reduce the requirement for repeated assessments, save nursing time and direct nurses to areas of concern.