Clinical Excellence Showcase

As always, we’ll see out the Showcase with The Great Debate. Known to entertain more than inform, this year’s debate asks whether Australia is the best place for clinicians to live and work.

Joining us this year is another stellar line up of some of Queensland’s best and brightest (and unusually, most are surgeons!)

Affirmative team (yes, Australia is the best place to live and work):

Dr Emilia Dauway, Director of Surgery at QEII Jubilee Hospital

Dr Bernie Whitfield, Director of ENT at Logan Hospital

Dr Rob Franz, Medical Director General Surgery at The Prince Charles Hospital.

Negative team (no, Australia is not the best place to live and work):

Associate Professor Robyn Littlewood, CEO Health and Wellbeing Queensland

Dr Diana Tam, Consultant Breast and Endocrine Surgeon

Associate Professor Cath McDougall, Chief Medical Officer for Queensland Health.

Chaired by the Deputy Director-General herself, Dr Helen Brown, this year’s Great Debate is sure to highlight the pros and pitfalls of our beautiful country!

Climate change is one of the most important challenges the world is facing currently. Climate change negatively impacts on health worldwide. To address climate change is our professional obligation.

SWAPNET has established an Environmental Accountability Working Group with the aim to engage clinicians, HHSs and facilities to promote change and to develop comprehensive resources to support improvement and to lead the way to encourage other networks to also take up the challenge.

Traditionally long-term antibiotic therapy for significant infections has been given intravenously (IV). Current evidence now supports the utilisation of highly bioavailable oral antibiotic (HBOA) therapy substituting for most of the IV course. This includes quinolones, sulphonamides, tetracyclines, macrolides, azoles, lincosamides, rifamycins and oxazolidinones classes of antibiotics.

HBOA therapy allows the patient to receive treatment in their own home, potentially return to work, removes the risk of long lines, and achieve therapeutic goals. However, treatment may be for several months and side effects may arise at any time; some potentially avoidable with early recognition.

We established a Complex outpatient antibiotic therapy (CoPAT) service that monitor’s patients on HBOA at home. This manages in a timely fashion any adverse outcomes to allow ongoing achievement of therapeutic goals, prevention of hospital admission and reduction of overall care costs. It also allows standardisation of the follow-up care provided.

Obesity places a significant burden on Australia’s healthcare system. Currently at The Princess Alexandra Hospital (PAH), local antimicrobial guidelines do not provide advice on dosing for obese patients. Instead, clinicians are directed to utilise standard dosing advice which has been developed and tested in non-obese patients, thus adopting a one-size-fits-all dosing mentality. The aim of this project was to determine the proportion of admitted patients at the Princess Alexandra Hospital receiving antimicrobial therapy, who are classed as obese (BMI >30kg/m2) as well as audit the current prescribing patterns of antimicrobial dosing in obese patients at the PA Hospital. As a result of the audit findings, it was clear there was a severe lack in dosing advice in this cohort of patients and that antimicrobial dosing most commonly followed standard dosing guidelines with no consideration for the patient's weight. Therefore, guidelines for the dosing of antimicrobial recommendations in obese patients were drafted and are currently awaiting publication.

Children’s Health Queensland Hospital and Health Services (CHQHHS) has empowered its workforce, young people, families and care partners to pursue innovative ways to minimise their environmental impact of our health care service. We have established an Environmental Stewardship Network, the ‘CHQ Green Team’, which has grown to over 200 active members who work together to meet the targets set out in the CHQHHS Environmental Sustainability Plan 2021-2024.

CHQ Green Team initiatives have resulted in emission reductions, improved energy efficiency and waste reduction at the Queensland Children’s Hospital (QCH) in South Brisbane.

This has established QCH as an international example for sustainable healthcare service delivery, both financially and environmentally.

CHQ Green Team initiatives support local businesses and circular economy jobs while also shifting current practices and improving Queensland’s environmental performance.

CHQ showcases sustainable leadership that has successfully diverted 491 tonnes of waste from landfill and generated and saved over $580 000 in 2021/22. Our sustainability success story can be shared and adopted across other Queensland Health Hospitals and Health care services.

Borderline Personality Disorder (BPD) is a complex and serious psychiatric condition with significant morbidity and mortality. It is often characterised by a severely and persistently impaired psychosocial functioning and a high risk for self-harm and suicide, resulting in the high consumption of healthcare resources.

Access to evidence-based interventions for Borderline Personality Disorder (BPD) is still highly limited in the current Australian health service system. Specialist mental health services are dominated by a generic case management model, with a lack of specific treatment modalities and staff struggling to provide psychologically focussed interventions. Similarly, non-government organisations (NGOs) report a lack of capacity, competence and confidence when working with consumers living with BPD.

Despite people with BPD commonly having multiple contacts with mental health services, an audit within Metro South Hospital and Health Service (MSHHS) found that access to evidence-based treatment for this group of patients was highly limited in the Brisbane South region. The need for all workers to be able to therapeutically respond to consumers needs, and better access to appropriate intervention intensities was required.

Using a stepped workforce capability framework the project aimed to increase the overall workforce capability to intervene effectively. In addition to develop higher level skillsets across NGO and public mental health and greater treatment access across the spectrum of care needs.

Outcomes were significant and have directly impacted the ability of staff to provide good care from thsoe with BPD and related disorders. Over 350 NGO and MSHHS frontline staff completed training to achieve a practice-informed level of DBT capability.

The project’s activities were highly valued in terms of content and presentation. Most participants reported greater use of and capability with Dialectical Behaviour Therapy (DBT)-informed practice and improved care coordination after training attendance.

The significant improvements in the self-efficacy of participants that were identified immediately following training attendance appear to have been maintained in the short term.

Almost 100 people attended advanced forms of training that will enable them to run DBT-informed groups, and in some cases provide individual comprehensive therapy. These individuals will serve as DBT leaders and champions who can support the maintenance of each service’s improved capability. There are new programs accessable to those with BPD in the region.

Healthcare services continue to face significant challenges to providing access to care and delivering care. Acceptance and utilisation of virtual options during the last three years has expanded as a result of the COVID pandemic. Conversely, waiting lists for surgical care have increased as a result of the pandemic. Leveraging these two competing factors, a multi-disciplinary team reimagined the surgical patient pathway to create efficiencies and improved access to care. Key stakeholder engagements across multiple business units were undertaken to inform each aspect of the implementation plan, including modifications to systems (iEMR, scheduling, booking), development of decision-making resources and frameworks, re-imaging workflows to maximise care value and virtual care opportunities, reviewing and reducing the physical footprint (through transition to virtual care touchpoints).

Where and how we care for preterm babies in South-East Queensland requires urgent review. Increased demand for service, improved survival rates, increased complexity of premature and sick newborns and a specialist nursing shortage has seen burgeoning pressure on large tertiary units, such as ours: The Grantley Stable Neonatal Unit (GSNU) at the Royal Brisbane and Women’s Hospital (RBWH). Emerging evidence indicates that early discharge of physiologically stable, pre-term neonates is safe and cost-effective when appropriate in-home supports are in place (Brooten 1986; Cruz 1997; Collins et al, 2015). Given the comfort and psychological safety of the home environment, we anticipated enhanced parent-infant bonding. Health system level improvements, such as increased capacity within the Neonatal Unit would also result if we adopted similar models.

In late 2021, the Women’s and Newborn Service, Hospital in the Home project (NeoHOME and MatHOME) was successfully granted SEED funding from the Metro North Hospital and Health Service (MNHHS) Innovation Program. With their support and guidance, two arms of the project were developed (maternity and neonatal) and NeoHOME was born. The objectives of NeoHOME are:

safe and effective care in the home for preterm neonates

improved parental satisfaction, wellbeing and self-efficacy in addition to reduced financial burden, associated with long-term hospitalisation

reduction in occupied bed days with anticipated improvements to capacity and staffing demands

Clinical implementation commenced 4-months ago, and 61 neonates have been cared for in the home.

Preoperative pathology is an important component of the assessment of patients prior to elective surgery. Ordering routine preoperative pathology is listed by bodies such as the Australian and New Zealand College of Anaesthetists (ANZCA) and Choosing Wisely Australia as one of the top five practices anaesthetists should avoid (Choosing Wisely Australia 2017). The aim of this project was to evaluate current local practice for preoperative pathology at the Pre-Anaesthetic Evaluation Unit (PAEU) at the Sunshine Coast University Hospital (SCUH). The priority for improving patient care was to ensure local practice was in line with evidence-based guidelines, was sustainable and patient focused.

Intravenous iodinated contrast is commonly and routinely used in abdominal imaging computed tomography (CT) to demonstrate patient’s anatomy and visualise and pathology.

Historically, a fixed volume of contrast is used for abdominal CT. However, this fixed dose approach means small patients are typically overdosed, resulting in excessive enhancement of the abdominal organs. Conversely, larger patients are underdosed which results in scans that have less than ideal enhancement. The idea of a simple weight-based contrast regimen was proposed by our team as a solution to this problem.

A review of other Queensland Health sites indicated that most medical imaging departments were using fixed volume or simplified 2- or 3-step volume protocols (e.g., small, medium, and large patients). A thorough literature review was conducted to see if there was evidence to support a more tailored approach. The literature suggested that a weight-adjusted contrast dosing protocol can objectively provide more consistent vessel and solid organ enhancement and subjectively improve image quality across a spectrum of body weights. In addition, it could reduce the amount of total contrast used, saving money and reducing waste.

The issue with the current body of literature is that there is no consensus as to the ideal enhancement of the image, in other words how the image should look. It is largely dependent on the country of the study and the patient demographics of that region. As a result of this, our team decided to conduct our own study to determine if the patient specific approach could work at our site.

Our team consisted of radiographers, radiation physicists and radiologists. A weight-based contrast protocol was established by our team based on 1ml of contrast per kilogram of patient weight in 10kg increments and was rolled out across the department. Quantitative and qualitative data was collected to compare the fixed dose vs weight-based methods and analysed.

The main aim of this clinical audit was to determine whether a weight-based contrast regimen in abdominal CT can provide more consistently enhanced images for our clinicians across the spectrum of patient sizes. In addition, can the change in practice reduce contrast wastage and therefore costs. If so, the weight-based protocol could be implemented across more Queensland health sites to improve the quality of the abdominal CT scans we perform statewide.