By Will Parsonage, AusHSI Clinical Director and Senior Staff Cardiologist at The Royal Brisbane and Women’s Hospital.
In the field of healthcare, there is increasing interest in research implementation – translating evidence into practice – and rightfully so. If the industry is to manage sharply rising healthcare costs we need to be able to drive innovations and improvements in health services delivery.
Having led, alongside Professor Louise Cullen, the successful Queensland Health state-wide Accelerated Chest pain Risk Evaluation (ACRE) project, I am excited to now join AusHSI and help foster an environment that builds the research and translation capacity for the ongoing innovation of health services.
In this article, I reflect on what I’ve learnt in developing and implementing the ACRE project over the past four years. I believe there is nothing unique that led to the success of this particular project – rather, I believe there are plenty of other good ideas generated by clinicians that could deliver similar outcomes. The challenge is bringing these good ideas to fruition and embedding the innovation.
The ACRE project – creating tangible change
Each year, an estimated 500,000 patients present to hospital emergency departments in Australia with possible cardiac chest pain. These patients make up on average up to eight per cent of all emergency presentations.
Up to 85% of these are eventually diagnosed as having pain of non-cardiac origin, but clinical guidelines dictated extended emergency department stays (>6-8 hours) or admission to hospital for diagnostic workup in the vast majority.
The ACRE project implemented a protocol to safely accelerate care of patients who are experiencing chest pain, but are not suffering a heart attack.
We started the project by approaching the Office of Director General. This led to our undertaking an initial research project, including an extensive pilot study.
Based on the success of the pilot study, we were able and ready when the opportunity arose to secure a grant from Queensland Health’s Healthcare Improvement Unit under the Health Innovation Fund (HIF).
The project has led to a significant service redesign, changing the way Queensland emergency departments assess patients presenting with chest pain, reducing lengths of stay, preventing unnecessary hospital admissions and releasing valuable capacity in Queensland hospital emergency departments.
Evaluations of the project show its rollout has:
- reduced the total average emergency department length of stay by 34 minutes,
- reduced hospital admission rates by 16% (from 68% to 52%),
- improved each hospital’s performance against National Emergency Access Targets, and
- led to cost savings of more than $7.5 million dollars being reinvested in other health services.
Four key factors to enable successful implementation projects
Based on our learnings, I think there are four generic principles that can be applied to any successful implementation project.
- Strong evidence base
The project’s success is due in large part to its strong evidence base and the support this generated. The project was based on the Accelerated Diagnostic Protocol to Assess Patients (ADAPT) study. This was part of a program of collaborative research conducted at Royal Brisbane and Women’s Hospital and Christchurch Hospital, New Zealand. The ADAPT study provided robust, locally derived evidence and had been published in high impact journals, including The Lancet and The Journal of the American College of Cardiology.
We were pleasantly surprised, and then encouraged by seeing how well these studies were received at major, international meetings we attended. There was significant interest in the studies, which gave Louise and I the confidence to put our research into practice.
- Clinician awareness and support
You can only bring about clinical redesign if the clinicians are ready to take it on. As clinicians ourselves, we saw that the time was right and the environment was ready to embrace this change. There was awareness and understanding of the issue among our colleagues.
- Political leverage
Because of the political context of public health services, related policy imperatives act as important levers in enabling clinical change. We were in the process of bringing about this project when the National Emergency Access Targets (NEAT) were introduced for Emergency Departments in 2011. This target helped make Emergency Departments receptive to improving patient flow.
- Timing and preparedness
If you have enough levers moving in the same direction at the same time, there becomes a natural tipping point when an opportunity arises to expedite the change.
We were also prepared having done the initial research project so that when a funding opportunity arose through the Healthcare Innovation Fund, we could move quickly. My learning here is that it’s important to be proactive so that when the opportunity arises you can move quickly.
I believe that AusHSI has a significant role to play in creating an environment where research underpins improvements in health services delivery.
* The NEAT was a national four-hour target which required that by the end of 2015, 90% of all patients presenting to a public hospital Emergency Department (ED) would either physically leave the ED for admission to hospital, or would be referred to another hospital for treatment or to be discharged.