Dr Walaa Saweirs Consultant Nephrologist, Northland DHB

1. Telerenal Services in
Northland
Establishing an integrated
regional dialysis service and
clinical networks
Dr Walaa Saweirs (2012),
Whangarei Hospital,
New Zealand

2. Outline
 Background
 Regional service
 Rurality/travel times
 Cost of travel
 Tertiary referral
 Current use of telehealth
 Within the region
 Links with other centres
 Lessons learned
 Future plans

3. Background

4. Geography
 Total population: 148, 470
 Whāngārei: 74,460
 Far North: 55,842
 Kaipara: 18,135
 Hospital locations:
 Whangarei (Regional Base)
 223 in-patient beds
 36 haemodialysis stations
 Kaitaia
 26 in-patient beds
 8 haemodialysis stations
 Kawakawa (Bay of Islands)
 15 in-patient beds
 8 haemodialysis stations
 Dargaville
 16 in-patient beds

5. Population Density (2008)
< 1 person/ km2
1-5 persons/ km2
5-10 persons/ km2
Kaitaia 10-50 persons/ km2
Kawakawa
500-750 persons/ km2
Whangarei
750-2000 persons/ km2
250-500 persons/ km2

6. Socioeconomic Deprivation
(Dep2006)

7. Kaitaia to Whangarei – 2¼ hrs
Kawakawa to Whangarei – 1hr
Whangarei to Auckland – 2¼ hrs

8. Travel Costs
 Ambulance transfer to Whangarei Base Hospital
 From Kaitaia costs NDHB roughly $350
 From Bay of Islands costs NDHB roughly $150
 Patient transfer by taxi to Whangarei Base Hospital
 From Kaitaia costs NDHB roughly $200
 From Bay of Islands costs NDHB roughly $100
 NTA allowance of 28c/km
 From Kaitaia to Whangarei (155km) - $43.40
 From Bay of Islands to Whangarei (71km) - $19.90
 Hidden costs
 Social eg support person travelling, child care, isolation from
whanau
 Staffing eg need for nurse escort

9. Tertiary Referral – Auckland
 Renal specific:
 Vascular radiology including interventional
 Vascular surgery
 Renal transplant
 Pathology
 General:
 Interventional cardiology
 Specialist radio-oncology

10. Impetus for a Telehealth solution…

11. Kaitaia Hospital

12. Bay of Islands Hospital
(Kawakawa)

13. Issues:
 Opening of new satellite dialysis unit at Kaitaia
hospital in November 2010
 Lack of permanent Clinical Nurse Manager
 Contingency for BOI CNM to oversee KTA satellite
 No on-site specialist physician
 Planned for 2 visits per month for clinics
 Travel times for both patients and staff movement
 Weekly multidisciplinary team meetings would prove
challenging
 Staff isolation and training issues
 Support for existing satellite unit at BOI
 …etc

14. ..other options?
 Don’t open the Kaitaia unit…
 Health pressures
 Community pressure etc
 Increased staffing…
 Financially and logistically not viable
 Skype-based system initially discussed...
 Security
 Logistics
 Ease of use
 Future adaptability

15. Equipment
 Polycom HDX7000 with 32" LCD TV screen
on a mobile cart in each of the 3 units
 Panasonic SD50 handheld videocamera in
each of the 3 units
 QD700 Document Camera in each of 2
satellite units
 HP Elitebook Pro tablet in base unit
 Total set-up cost - $70k
 Monthly cost (of 3 renal units) - $1000

16. Current Use of Telehealth

17. Multidisciplinary Meeting
 Weekly meeting with all units involved
 Medical handover
 Review of:
 Difficult/problematic cases within each unit
 Dialysis access issues
 New patients
 Forward planning
 Patient transfers/logistics between units over the coming
week for eg planned procedures
 Patient transfers/logistics to Auckland over the coming
week for eg vascular procedures

18. KTA
BOI

19. “Paper round” - Summary
 Monthly review of individual haemodialysis
patient results with primary nurse/nursing team
leader by patient’s primary renal physician
 Adjust dialysis prescription as needed
 Adjust medication as needed and advise GP
 Review any vascular access issues
 Review any on-going concerns

20. “Paper round” - Logistics
 Individual patient electronic folders:
 Excel spreadsheet of cumulative monthly labs
 Excel spreadsheet of dialysis BPs & weights
 Word document with current medication record
 Above prepared by nurses in advance of round
 ECGs and individual dialysis session notes can be transmitted
using the document camera
 Brief round note dictated to GP
 Medication/dialysis record changes updated, signed & dated
using Tablet PC
 Potential room for further efficiency:
 Electronic renal IT system collating patient lab results, BPs,
weights
 Electronic medication record linked to GP and Pharmacy

21. Sample Spreadsheet – Results Chart

22. Sample Spreadsheet – Weight gain/BP
Weight UF BP & Pulse (sitting) BP (standing)
date pre post Targ IDW Achiev set pre di p Pos di p *Hypo pre post comment
2nd 78.5 76.8 77.0 1.7 134 86 84 143 87 77 no 125/79 136/81
4th 77.0 76.9 77.0 0.2 0.1 0.3 122 75 95 154 85 73 no 119/79 135/81
6th 77.8 76.5 76.5 0.9 1.3 1.6 154 91 102 160 90 78 no 140/89 151/86
9th 76.8 75.9 76.0 0.3 0.9 1.1 161 73 94 158 75 81 no 150/81 129/80
11th 75.8 75.9 76.0 -0.1 -0.1 0.3 155 79 93 153 78 76 no 142/83 130/70
13th 77.0 75.9 76.0 1.1 1.1 1.3 131 69 93 152 79 77 no 125/65 133/73
January 16th 79.1 77.1 76.5 3.2 2.0 2.9 135 72 108 139 78 88 yes 123/64 126/64 UF ach 2420mls
18th 78.2 76.6 76.5 1.1 1.6 2.0 143 67 97 155 84 84 no 142/66 159/80
20th 77.0 76.0 76.0 0.4 1.0 1.3 153 84 110 159 87 81 no 161/75 145/87
23rd 75.6 76.2 76.0 -0.4 -0.6 0.0 139 83 89 157 80 72 no 139/76 144/78
25th 76.2 76.1 76.0 0.0 0.1 0.5 131 86 90 155 79 72 no 110/75 149/98
27th 75.8 75.9 76.0 -0.3 -0.1 0.0 128 59 83 150 71 75 no 133/76 128/95
30th 77.6 76.0 76.0 1.7 1.6 1.9 166 78 81 146 75 72 no 167/80 133/70
average 77.1 76.3 0.7 0.7 1.1 142 77 94 152 81 77

23. Sample Spreadsheet – Dialysis Chart

24. Sample Spreadsheet – Medication Flow Chart

26. Patient Assessment
 As needed basis
 Medical assessment
 Acute review of issues arising on dialysis eg vascular
access, skin lesions
 Use of handheld digital camera
 Allows collegial support of non-specialists at satellite unit
 Allows streamlined transfer to tertiary centre without detour
via base hospital
 Reduces unnecessary travel for patients and family
 Discussion of complex management plans with patient &
carers
 End of life discussions
 Dietetic assessment
 Social work review
 Psychiatric review

28. Other uses (within the region)
 Family meetings – for those about to start or
on dialysis
 Weekly nurse in-service training sessions
 Staff performance appraisal
 Collegial support of satellite team

29. Tertiary Links – “BVC”
 Vascular & vascular radiology
 Vascular access nurse-led paper referral sent to VA team
at ADHB
 Outcome of discussions relayed back to Northland team
without direct discussion with Northland team
 More crisis management than planned
 Renal transplant
 Monthly telephone discussion with Auckland transplant
team of Northland patients on transplant waiting list
 Regional meetings
 Ad hoc – inconsistent attendance due to travel time issues
and impact on clinical load

30. “Asymmetry of need - the incentive for telehealth is greater for those who receive
it than those who provide it”

31. …Perceived barriers by tertiary centre…
 Time
 Meeting times stretched already
 “Current system works fine” (Tertiary team)
 Money
 Stretched resources
 Who would fund?...
 “Northland - as its for their patients” (Tertiary team)
 Effort
 Set-up of system
 IT Support
 “We don’t need it” (Tertiary team)
 Impact on Auckland patients
 “Aucklanders have the lowest intervention rate” (Tertiary team)
 ..implying they are usurped by regional centres it serves..

33. X

34. Tertiary Links – “AVC”
 Vascular & vascular radiology
 Weekly meeting with vascular surgery, radiology, vascular
access team (ADHB and NDHB)
 Real-time two-way patient discussions with review of
radiological investigations and previous intervention
 Collaborative planned approach
 Renal transplant
 Monthly meeting which now feels as though one is talking
with the whole team
 Regional meetings
 Improved ability to attend eg weekly transplant meetings
 Potential for larger group discussion encompassing eg
Waitemata, Middlemore, Waikato etc

36. Lessons learned

37. Benefits
 Quantifiable:
 Reduced staff and patient travel costs
 Increased productivity
 Estimated $8700 per month of additional revenue (on paper anyway!)
 Additional 30 patients per month can be seen in clinic
 Travel cost savings low, but productivity gain from time released is
large
 Non-quantifiable:
 Far greater value than quantifiable benefits
 Include:
 Team cohesion
 Enhanced communication
 Improved staff morale
 Enhanced education and training
 Improved ability and speed to adapt to new priorities and demands
 Anticipated reduction in error rate
 Safe and supported working environment for staff

38. Issues - Local
 Location
 Ideally need a dedicated consulting room which is
soundproof
 Patient areas also need to be private
 Security of units
 Lockable, yet useable
 Ease of use
 Units initially appeared to reset themselves
 Slow start-up
 Bandwidth KEYS TO LOCAL ISSUES:
 Initial Telecom issues Medical and nursing champion
 Power issues Dedicated IS support
Team engagement and enthusiasm
 Surge protector
Communication

39. Issues – Tertiary Link
?KEYS TO ISSUES:
Medical and nursing champion
Dedicated IS support
Team engagement and enthusiasm
Communication
Incorporate into service plan as part of
tertiary provision
Recognise cost through purchaser/provider
codes
Recognise the benefit and potential

40. Future plans..

41.  Patient hand-over
 Satellite transfer
 Vascular access
 Acute patient assessment
 Dialysis equipment troubleshooting
 Use of hand-held camera – “live” and “store &
forward”
 Importance of camera stability +/- lighting
 Link to renal pathology review meetings in
Auckland?
 Regional and national meetings???

42. Acknowledgements:
Cheryle Kiwi – Northland Renal Service Nurse Manager
Roy Davidson – Telehealth Programme Leader
Sue Wyeth – GM Mental Health and District Hospitals
Neta Smith – Kaitaia Operations Manager
Philip Jarvis – CNM Bay of Islands dialysis unit
Laurie Francis – Previous acting CNM Kaitaia dialysis unit
Jill Rengatch – CNM Kaitaia dialysis unit
The nursing and medical staff of the Northland Renal Team
Simon Hayden and the team at Vivid Solutions