5 Findings

5.2 Infectious Diseases Services at the Royal Melbourne Hospital
5.2.1 Compliance with Service Objectives in Health Service Agreement (cont)

• Focal Point for Management of Exotic and Infectious Diseases

The model adopted by VIDS in its role as a focal point for the management of exotic and infectious diseases has been to develop its own clinical services for direct patient care allied to strong education and research activities undertaken in collaboration with other relevant agencies in the field. It has described its approach as a "web of interacting services" built on a foundation of tertiary patient care, linkages and support services to community-based providers, an ongoing emphasis on education and research, and a commitment to best practice evidence-based medicine. It has used this approach to develop and maintain a core of expertise in infectious diseases, and to have the capacity to respond to outbreaks if and when they occur.

The VIDS model is depicted in the figure below.

Figure 1: Model for Victorian Infectious Diseases Service (VIDS) (12)

VIDS has established close relationships with the University of Melbourne, other educational institutions and the Walter and Eliza Hall Institute to support its educational and research activities, and the Network was successful in winning the tender for the Victorian Infectious Diseases Reference Laboratory (VIDRL), which has relocated to a nearby building, with extensive laboratory and research capabilities. These activities have strengthened the interaction of clinical, epidemiological and public health activities, and increased the critical mass of specialists in ID. It is also a member of a consortium recently nominated as the preferred tenderer for the management of the Melbourne Sexual Health Centre, which, when finalised, will further extend its linkages with community-based services and service providers. Linkages to the Department of Human Services have been strengthened through the joint appointment of a Public Health Research Fellow.

Travel health services are provided to returning and prospective travelers and their doctors through a dedicated telephone line service manned by one of three ID Registrars or an ID Resident, and arrangements were made with the Travelers' Medical and Vaccination Centre for a private clinic to be established on-site at RMH. Representatives from VIDS are also members of a number of committees at both State and national levels which contribute to the identification and management of infectious diseases. It is also involved (with the University of Melbourne) in the establishment on-site of the Australian International Health Institute to promote interactive health activities in immunisation, public health and education. VIDS is also one of the few centres outside the USA to participate in the GEOSENTINEL program for the global surveillance of illness in travelers. Staff of VIDS have also been active in the publication of a number of books on travel medicine, clinical parasitology and a text book of infectious diseases medicine.

These activities are indicative of the efforts by VIDS in establishing its profile and capacity as the focal point for infectious diseases in Victoria, a significant component of which is the provision of a wide range of advice and support services which are not directly related to direct patient care. Consultations with a range of stakeholders, including community-based service providers, staff of VIDS, the Public Health Section of DHS, other hospitals, VIDRL and tertiary institutions revealed a high level of knowledge of and support for the work undertaken by VIDS to date, and confidence in their capacity to continue providing a leadership role in infectious diseases in the future.

• Consultative Service for the Management of Infectious Diseases

Consultative services are provided by ID specialists in outpatient clinics at both RMH and Western Hospitals, at the dedicated inpatient ward at RMH, and through consultative services to patients in their "home" ward in the hospital. Typically, patients admitted for conditions other than an infectious disease but who require services by an ID specialist (e.g. orthopaedic surgery patients with osteomyelitis, or diabetic patients with chronic foot ulcers) are not transferred to beds in VIDS, but are treated by the ID specialist in their normal ward. ID specialists also provide advisory and in-servicing services to other hospital staff.

State/Commonwealth funding arrangements prevented the reproduction of the travel medicine links that existed at Fairfield where patients paid for services. In response, arrangements were made for the Travelers' Medical and Vaccination Centre to establish a private clinic on-site at RMH. In addition to direct patient care, VIDS Registrars attend the clinic weekly for training and education. The Centre has established an excellent relationship with VIDS, and a number of joint research projects have commenced.

• Dedicated Infectious Diseases Inpatient Unit

Funding was provided for a renovated ID Ward. While an 18 bed facility was originally planned, in fact a new 20-bed ward was constructed, comprising 14 single rooms and 2 three-bed rooms, including 4 beds for patients with suspected haemorrhagic fever. As previously noted, not all ID patients are necessarily admitted to this ward, and receive ID services at their "home" ward as appropriate.

Activity in the VIDS ward for 1996/97 and 1997/98 is summarised in the following tables. It should be noted that services provided to inpatients in other wards are not included in these data:

Table 5: Summary of Inpatient Activity at VIDS, 1996/97, 1997/98

Major DRGs represented in the above admissions were:

Table 6: Separations by Major DRGs at VIDS, 1996/97, 1997/98

Policies within the inpatient facility promote services of a particularly high standard, and are sensitive to patient needs and concerns, particularly in regard to privacy and confidentiality. Protocols for the treatment of patients with suspected viral haemorrhagic fever were not available from Fairfield, so VIDS developed its own using international guidelines. These are reviewed six-monthly to ensure that they are appropriate to changing conditions. Procedures have also been developed in association with the Australian Animal Health Laboratory at Geelong in the event of staff being exposed to Equine Morbilli Virus. Day care is also available to patients requiring this service.

Feedback from patients (see Section 5.2.5) on the quality of inpatient services indicated a high level of satisfaction with these services, and a number were particularly complimentary about the quality of care provided. Staff at VIDS were also enthusiastic about the facilities provided, and the opportunities for on-site education and professional development.

• Clinical Examination Facilities

Examination facilities at RMH are provided through an outpatient facility located adjacent to the inpatient ward. The facility was funded through internal sources and from private donations. It includes six clinical rooms for patient consultations, an area for tutorials and clinical teaching and two rooms with negative pressure capability for obtaining induced sputum or for minor procedures.

Clinics are conducted daily and provide for a range of specialties, including hepatitis, tuberculosis, leprosy, general IDs (mainly travel related), and HIV/AIDS. Patients may be seen in any clinic, but are generally referred to particular clinics according to their specific needs. Details of outpatient activity in these clinics are provided in the table below.

• Isolation Beds at the Western Hospital

The availability of negative pressure beds has continued at the Western Hospital which are used extensively by tuberculosis patients. The hospital has also established a clinical room for the examination of patients referred directly to the ward. Physicians from VIDS also support the hepatitis and tuberculosis clinics at the Western Hospital.

• Outpatient Clinics at RMH and Western Hospitals

As previously described, outpatient clinics are conducted daily at both RMH and the Western Hospitals with weekly specialist clinics in hepatitis, tuberculosis, leprosy, general IDs (mainly travel related), with two clinics per week for patients with HIV/AIDS. One clinic is provided as an after-hours service. Details of attendances at the RMH clinics are provided in Table 7 below.

Data on the hepatitis and tuberculosis outpatient clinics at Western Hospital which are supported by VIDS physicians are less comprehensive, because hepatitis patients were included initially with the gastroenterology clinic, while tuberculosis patients were included in the respiratory clinic. Data for 1997/98 indicate that 657 encounters occurred in the tuberculosis clinic, and 431 in the hepatitis clinic. Because of the changes in counting rules, these data should be treated as lower estimates of actual activity.

Table 7: Summary of Outpatient Activity at VIDS, 1996/97, 1997/98