Deborah Lenaghan Extended Scope Physiotherapist Dr Paul Bowe Director ED Robina

1. Deborah LenaghanExtended Scope PhysiotherapistDr Paul BoweDirector ED Robina Extended Scope of Physiotherapy Emergency Department Health Workforce Australia (HWA) Funded Project 2012-13

2. Purpose of this Presentation Report on extended scope of practice as an emerging model of care Discuss the process of implementation Key lessons learnt Demonstrate the impact of this service on organisational throughput and quality

3. Background HWA • National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015 • National Partnership Agreement on Improving Public Hospital Services (the National Partnership Agreement) • Whole of system change • Mandate to address known areas of workforce shortage in the Australian health system • Expanding the scopes of practice of nurses and allied health professionals

4. National Emergency Access Target (NEAT) • Also known as the 4 hour rule. • By 2015 90% all patients will leave the emergency department within 4 hours. • Overcrowding & LOS associated with poorer outcomes for patients • Richardson 2006; Spivulis et al 2006; Forero et al 2010;Baggoley 2011; Geelhoed 2012

5. NEAT Targets to be phased in 2015

6. Project • HWA nominated 2 lead sites- • Alfred and ACT Health • Partnered each with 3 implementation sites • Two lead sites – have different education pathways • In-house competency vs in-house competency + university qualification

7. Background: Robina ED • Pre-project Staffing: 0.5 FTE secondary contact Physiotherapist. • Proposed Project model: • 1 Extended Scope Physiotherapist • 5 days week for 10 months • 7 day service for 4 months. • 0.5 Project manager

8. Objectives

9. Objectives • Primarily to successfully implement and evaluate a locally adapted model of the ESP Physiotherapist working within the ED at Robina Hospital by Jan 2014.

10. Secondary objectives : demonstrate • Increased productivity- • by demonstrating a change in patient flow and waiting times as measured against the National Access and flow Targets. • Workforce reform- • by measuring workflow impacts particularly for medical practitioners and cost effectiveness of this model. • Transferability/Sustainability- • by developing and implementing (in partnership with Lead Sites) policy, governance standards, resources and frameworks for training future ESP Physiotherapists in ED.

11. Implementation

12. Steps taken to Implementation • Secure Funding • Develop project plan. • Staff Recruitment • Determine KPI’s Measurement Data- Establishment of Informatics and Data • Form Advisory Committee through invitation • Adaptation of Lead Organisation Model • Governance and Quality Assurance • Develop and communicate implementation, training ,competency frameworks and tool kits • Staff training- • Communication Strategy: • Ethics approval.

13. Key Milestones

14. Professional Operational Advisory District Director of ED HWA Program Manager HWA Liaison Officer Assistant Director of ED Robina District Director of Physiotherapy Lead Organisation Project Manager Local Project Advisory Group Delegated Medical Consultants and Mentors Local Project Manager ESPPhysiotherapist Governance UOW Evaluators

15. Recruitment Criteria Qualifications/Professional registration/Other requirements • >5 years experiencein Musculoskeletal or Sports Physiotherapy or Emergency Physiotherapy, • Masters Qualificationin MSK/Sports • Be available to work a weekend roster • Be available to undertake a training program in Extended Scope Physiotherapy. Clinical Practice: • Provide primary ‘first contact’ specialist musculoskeletal physiotherapyservice. Communication / Team Participation • Provide authoritative clinical counsel. • Provide expert contribution to the professional body of knowledge. Leadership / Service Development • Provide leadership, direction and change management skills.

16. Training Pathways and Competencies • Lead Site (ACT Health) Model of training: • Formal Tertiary Training • University of Canberra- Graduate Diploma – Extended Scope of Physiotherapy. • Identified areas included: • Pharmacology • Radiology • Injecting/aspirating • Research/evaluation/management and leadership • Local Training: • Weekly training with a Consultant Radiologist and Orthopaedic Consultant. • Daily input with the ED Consultants.

17. Extended Scope of Practice Activities • Imaging interpretation • Fracture management • Direct referral to Specialist OPD • Digital blocks-Joint relocation • Medicine prescriptions (simple analgesics) Activities being developed

18. Highlights • (SOP) for Paracetamol and Ibuprofen • Chief Health Officer sign off- S4 medications – Nitrous and Lignocaine • Written instruction, possession, administration and obtaining

19. Chief Health Officer

20. Health Professionals Prescribing Pathway: 8/11/13 Ministers today approved the Health Professionals Prescribing Pathway which will provide a way for health professionals, other than medical practitioners, to prescribe medications. The pathway sets out the steps required for a health professional to achieve safe and competent prescribing of medicines within their scope of practice

21. Patient Journeys

22. Patient Journey-1 Nursing input** Orthopaedic technician Allied Health***

26. ESP Patient Journey Consultant Orthopaedic registrar Radiology yes no Orthopaedic technician Nursing

31. Patient Flow

32. Presentations at Robina

33. Percentages of through put

34. Top 10 Oct12- Sep 2013

35. Length of Stay (2/10/12-30/09/13)

36. Average Length of Stay for Top 10 ESP Patient diagnosis per day of week. • ESP- LOS n= 651 • ≈ 2x LOS • 4141 patients in total

37. LOS for TOP 10 diag. • Average LOS on Sunday since Deb has been working has decreased by: 1hr 55mins

39. Clinical Quality Indicators - ED Effectiveness of care • 1. Ambulatory care – no inappropriate admissions • 2. Unplanned re-attendance rate • 3. Total time spent in the A&E department- average 90mins Patient experience • 4. Left without being seen rate- Robina trending to 6% • 5. Service experience- >95% satisfied or very satisfied Patient safety • 6.Time to initial assessment – average 20mins • 7. Time to treatment - • 8. Consultant sign-off – relates to higher acuity patients

40. October 2013 represents

41. Enablers • The Districts focus on NEAT performance • Austerity measures. • State wide Ministerial Taskforce on Expanded Scope of Practice underway. • Networks

42. Challenges/Obstacles • Governance – Credentialing • Staff cover • Data extraction delays • Access to finance and data managers • Culture and fear of role replacement • Communication to the multiple key stake-holders difficult

43. Future sustainability • Uncertainty - HH& S restructuring to service line management model • Funding

44. Acknowledgement • Dr Paul Bowe- Director ED • Bruce Morton- NUM ED • Consultants • Dr Tom Torpie- Emergency • Dr Craig Buchan- Radiology • Dr Haig Lennox- Orthopaedics • Dr Michael Thomas- Orthopaedics • Dean Blond A/Director emergency services (ecass) • Rod Ellem- A/director physio • Morven Gemmil- Allied health exec director • Brad Job -Director Radiography • Leonie Warren- BPIO • Lauren Patching-Pharmacy • Therese Kelley- DSS • Lynn Massey- Access & Flow • HWA • University of Wollongong • Cristina Thompson • ACT Health • Jo Morris • Katie Vine

45. Thank you

46. Skills required by staff • Knowledge, experience and confidence, • practise proactively in a self-directed role with awareness of the role scope and boundaries • maintaining good communication with other ED team members. • balance of judgment and the assertiveness to seek assistance when required • Demonstrated ability to interact and respond to others • personable and professional manner • takes into account unexpressed concerns. • requires well-developed listening and questioning skills and the ability to negotiate for desired outcomes. • Working knowledge • local service delivery models • appropriate referral pathways.

47. Re-presentation rates

48. Embedding the Role • Recognised and reported on at an Executive Level. • Supported verbally at a local level by the Directors of ED. CEO and COO • Continued positive feedback from ED staff and Patients. • Local and National Evaluation being undertaken.