Reducing low value and unnecessary care

Nurse getting blood from on a female donor

A national scale-up of an initiative to reduce low value care and reduce unnecessary treatment was the focus of a nationwide meeting recently.

The Choosing Wisely Australia national meeting was held in Melbourne in late May and showcased innovative projects both national and international.

A nurse discontinuation protocol of telemetry implemented at Johns Hopkins Hospital, Maryland USA found a significant decrease in telemetry hours with no increase in the number of codes or rapid response team (RRT) calls.

There was a significant decrease of 19.38 hours per month following implementation of a nurse discontinuation protocol of telemetry in October 2015. It was found that protocols could effectively decrease the amount of telemetry; that codes/RRT do not increase with less use of telemetry; and that nursing or physician protocols could be equally effective.

Choosing Wisely Australia was launched by NPS MedicineWise in 2015 aimed to consider tests, treatments and procedures where evidence shows they provide no benefit, or may even lead to harm.

Insights from a year-long Safe Care Victoria scaling collaboration of Choosing Wisely in 11 health services were shared with more than 200 delegates at the national meeting held in Melbourne.

NPS MedicineWise CEO Adjunct Associate Professor Steve Morris said Victoria was the first state to fund the expansion of Choosing Wisely Australia across its hospital network. Thirty health services had implemented Choosing Wisely to help reduce unnecessary tests, treatments and procedures and to prioritise high value healthcare.

“It’s concerning to hear people willingly have tests, take medicines and undergo surgeries without even asking basic questions about necessity, risks or other options.

“The ultimate goal is to create long-term sustainable change in our hospitals, within primary care and among consumers in relation to reducing low-value and unnecessary healthcare practices.”

The Victorian roll out in 11 health services of Choosing Wisely through the Better Care Victoria (BCV) Innovation Fund is being independently evaluated with full results expected in September.

The Department of Critical Care Medicine St Vincent’s Hospital in Melbourne undertook a multidisciplinary (MD) project on unnecessary clinical observations in continuous cardiac and respiratory monitoring and blood gas analysis on ward-ready patients.

Continuous Improvement Coach at St Vincent’s Hospital, Melbourne, Clare Hammer said there had been three reasons for ongoing testing of ward-ready patients.

“The culture, that it has always been done this way; fear of missing clinical deterioration; and there was no tool to guide decision making.”

A six to 10 month audit gauged a percentage of patients that received testing when ward-ready. Cardiothoracic patients were exempt due to a postop clinical pathway. The MD team developed a standard and a pre- and post- audit.

Results found a 62% reduction in blood gas analysis in ward-ready patients; testing only occurred when clinically indicated. There was a 53% reduction in unnecessary clinical observations.

“We had significant results with no adverse events to patients or to staff,” Ms Hammer said.

Other positive outcomes included: improved staff morale; patients less dependent on nursing staff; and critical care nursing staff had time to provide support to other colleagues, Ms Hammer said.

Areas now under review include: coagulation testing in the ED; chest x-ray following chest drain removal of cardiology patients; and daily blood cardiology.

“The approach of Choosing Wisely is to create a system of thought and process that embeds in health services’ and clinicians’ very core the mantra of giving the right patient the right test at the right time,” BCV Board Chair Doug Travis said.

Choosing Wisely Australia is encouraging clinicians and consumers to start a conversation about what care is truly needed – identifying which practices are helpful and which are not.

Consumers Health Forum of Australia CEO Leanne Wells said advocates, such as nurses, could play an important role in ultimately helping to reduce low-value and unnecessary healthcare practices.

“Having good conversations about healthcare options is critical to shared decision making between healthcare providers and consumers.”

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