A recent 4 Corners program has highlighted the risks faced by Remote clients with Rheumatic Heart Disease. (RHD) (ref)
RHD is a disease now all but unknown in “polite society” ie the rest of Australia. But it remains common in Remote communities. The risk factors are well known – poor housing with the resultant overcrowding and poor hygiene. As a result of this Skin Sores are common. These are colonized or caused by Group A Streptococcus which drives the high incidence of Rheumatic Fever. The Housing issue has been described in many Government reports over many years but appears to be as immutable as ever.
The 4 Corners Program describes the journey or four patients with RHD in a Queensland Clinic – there appears to have been a delay in managing the deterioration of the condition.
Similar cases are occur regularly in all Remote environments.
As ever it is tempting to blame the individual clinicians for the poor outcomes. But are there systemic issues in our health system that are contributing to the problem?
Deterioration in RHD is an unusual but not rare presentation. It may mimic other conditions such as Pneumonia with cough, shortness of breath and fever. The deterioration may be due to a further attack of Rheumatic Fever and Carditis (inflammation of the heart) causing heart valve damage, or perhaps bacterial infection of an implanted valve prosthesis. An unsophisticated Clinician may mistake this for a more common condition such as Chest Infection, particularly if the relevant information about the RHD is not prominent in the record.
Remote places are difficult to staff – most initial encounters occur between a client and Remote Area Nurse (RAN) or Aboriginal Health Practitioner (AHP). Doctors are not resident in most Remote places but visit on an intermittent basis for planned consultations. Remote staff perform sterling work in the face of difficult conditions. They provide a very competent emergency service. However nonmedical staff do not have the sophisticated clinical training that doctors undergo. They are are less able to manage an unusual or nontypical presentation.
The “Anonymous Consultation”
Staff turnover is accepted as normal in Remote practice. Typical figures in Remote Clinics are in the order of 150% turnover each year. It is estimated that reducing this turnover by half would save $32M per year in NT (ref). In spite of these costs, policy makers seem content to accept the current situation – staff turnover is not a “KPI” or even actively measured. There do not appear to be active programs to reduce it.
But what are the risks of rapid staff turnover to clinical standards and safety? Was this a relevant factor in these cases? In my own personal experience a large proportion of consults in Remote practice are “anonymous” – ie the client and clinician have not met before. My own personal surveys in various Remote locations have found consistently that for every 10 consultations, a client sees 6-7 different clinicians.
If the clinician assessing the case had met the client before and knew them previously, would they have seen a deterioration in their condition? Would they have ensured that they had received notice of appointments and that the client attended? Would the client have been able to communicate better? Would the clinician have taken more notice of their story?
In my view a relationship with the client is important in managing long term conditions, and the answer to these questions is yes. It also means that there is less reliance on electronic systems of recall and administration.
The Record and Data Visibility
Health is ever more complex, with new treatments and subspecialties appearing all the time. There is a push to standardize and systematize clinical interaction with Careplans and treatment protocols. In theory this will “commoditize” clinical encounters, allowing them to be conducted by any clinician with the relevant training. A personal relationship between client and clinician is at least in theory less important. Care is compartmentalized with different clinicians dealing with different issues. The role of the General Practitioner “Expert Generalist” has been devalued.
Of course, all this creates complexity in the medical record with Careplans, referrals, appointments, treatment items and letters. The Medical Record is now Electronic – if this system is not well designed, relevant information can lost in the “noise” of all this process. In many systems interface design has not been high priority – there are redundant dialogs and headings, critical data may be hidden in poorly labelled secondary dialogs. The noise is further exacerbated by administrative information such as travel and appointment letters cluttering the record.
There may be further administrative problems, with relevant letters never reaching the record or appointments never being notified.
These systemic administrative failures are safety issues which should be part of Quality and Safety reviews, but are not addressed as such. Reviews focus on the performance of individual clinics and clinicians but rarely address systemic issues.
In general Remote Health Services provide a high quality response in Primary Care and Emergency Care under difficult conditions.
However, the combination of an unusual but serious presentation, an “anonymous” clinical encounter and poor administrative and record systems can be deadly.
Administrative and management performance should be part of Safety and Quality Review. In particular the massive staff turnover which is routine in Remote Health should be measured and addressed as a priority. The content and interface design of Electronic Medical Record Systems should also be regarded as a safety issue, with more effort being put into this part of their design.
Remote health workforce turnover and retention: what are the policy and practice priorities?
John Wakerman 1 , John Humphreys 2 , Deborah Russell 3 , Steven Guthridge 4 , Lisa Bourke 5 , Terry Dunbar 6 , Yuejen Zhao 7 , Mark Ramjan 8 , Lorna Murakami-Gold 9 , Michael P Jones 10