Department of Human
Services
Acute Health Division
Evaluation of the Relocated HIV/AIDS and Infectious Diseases
Services
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5 Findings 5.2
Infectious Diseases Services at the Royal Melbourne Hospital
While VIDS was unable to replicate the travel medicine links previously provided at Fairfield, arrangements were made for the Travelers' Medicine and Vaccination Centre to establish a private clinic at RMH. The relationship between the Centre and VIDS has been strengthened, with VIDS Registrars attending the clinic on a weekly basis for training and education. Joint research projects have been initiated, including a study on exposure to Hepatitis E. Specific outpatient clinics are also provided for returned travelers at RMH, activity data for which was included in Table 7 above. The Travel Health Service provides specialist advice to medical practitioners with patients who are travelling or who have returned from travelling. The service operates during normal hospital working hours, with after-hour inquiries diverted to a message bank and handled the following day. An audit of services and the time spent on manning the service was conducted in May/June 1998. Results from the audit were provided in the submission from VIDS to the review, (13) and indicated: Number of calls per day:23 (range 15-30) Average time per call:11 minutes (range 3-20) Additional time to research:30 minutes per day (range 1-60) Total time dedicated to answering inquiries:4.7 hours per day The Director of Travel Health played an important role in developing the service, and in establishing guidelines for such conditions as:
Other travel services include the development of a book on travel medicine, and establishing participation in the international surveillance of infections of travelers (the GEOSENTINAL program).
The successful tender for the relocation of VIDRL to Parkville has provided an important basis for the strengthening of laboratory services with VIDS, and enables a greater level of interaction between clinical, investigative and research capabilities at the one site. Discussions with ID specialists at VIDS and staff of VIDRL indicate a developing environment of collaboration and cooperation between the two agencies, with combined meetings held weekly, and plate rounds conducted fortnightly. A number of joint research projects with VIDRL are also under way and more are planned.
5.2.2 Access to and Utilisation of Services Access to ID services at VIDS is regarded by those consulted as being acceptable. Data provided by VIDS on the residence of inpatients admitted in 1997/98 indicate that patients came from 151 postcode areas, of which nearly one third were from rural areas. The services provided at Western Hospital also play an important role in providing access to services from the surrounding population, which has a high proportion of immigrants from south-east Asia. Western Hospital has developed particular expertise in the treatment of tuberculosis and hepatitis, and provides complementary services to RMH, supported by VIDS physicians. The utilisation of the Travel Health Service and travel clinics located at RMH indicate that these services are well known and readily accessible. These services were also highly regarded by community-based providers consulted in the review. Similarly the growth in both inpatient and outpatient activity at VIDS over the past 2 years indicates that more consumers and their referring doctors are becoming aware of VIDS in the delivery of specialist ID services. Notwithstanding these trends, a number of staff at the unit as well as some community service providers consider that VIDS needs to become more active in promoting its existence and capabilities to the wider community. Most of the doctors with whom VIDS has developed relationships are aware of the range and nature of the services it offers and how to access them, and were highly complimentary of the clinical services and associated activities they provide. However, they also expressed the view that there is a need to extend knowledge of the services VIDS offers to a wider audience, including community-based providers in both metropolitan and country areas, and to the general public. Gaining access to the VIDS ward is generally regarded by patients and community service providers as being good during the day, but is more difficult at night when admission is through the A&E Department. VIDS Registrars are generally regarded as being readily accessible, although views varied on this issue among community-based providers. A number of community-based providers and consumers indicated that there were often delays in appointments for outpatient clinics, although this tended to more of a problem in departments other than VIDS. Nevertheless, there is a need to ensure that quality assurance processes are in place to keep waiting times to acceptable levels. Recommendation 13:That VIDS promote the availability of its services through medical practitioners and other media to the general public in order to raise awareness of its services. Recommendation 14:That VIDS continue to review and apply its quality assurance processes to minimise delays to patient admissions and clinic appointments at the hospital. 5.2.3 Consistency with Best Practice Models VIDS has articulated a clear and comprehensive strategy for the development of services, covering clinical care, teaching, training and research, supporting laboratory services, and prevention and information provision which is consistent with models of best practice nationally and internationally. The outcome to date reflects the considerable strategic planning that has underpinned the development of the unit, and the efforts by management to enlist the support, cooperation and collaboration of other key stakeholders in the process. Virtually all those consulted in the course of this review considered that VIDS is now ideally placed to further develop its services and consolidate its position as the pre-eminent ID specialist service in Victoria. VIDS has an active research program, which it is seeking to expand in collaboration with other institutions and individuals in the field. The profile of the services offered, the linkages with other agencies (particularly VIDRL, the Public Health Division of DHS, the University of Melbourne and community-based service providers) and the capacity to draw upon recognised skills and expertise of a range of disciplines are indicative of its efforts in this regard. It has been active in the development and promulgation of service protocols and guidelines, based on national and international standards, and ensuring their availability to staff involved in service delivery in both the inpatient ward and outpatient clinics. These guidelines are periodically reviewed and updated to ensure their consistency with national and international developments. The VIDS model of service is based on evidence-based best practice care, which calls for close monitoring of outcomes of care. Its current database provides information on approximately 3,000 consultations from 1991 to 1998, but there are concerns about the quality and variability of the data. A new database is being developed which will enhance the data collected to date, and provide a more reliable source of information on clinical outcomes and performance indicators. The results of clinical trials and research projects are also used to inform clinical practice. VIDS has also been particularly active in the development and delivery of educational and information sessions in the field of infectious diseases. This has served to expand the knowledge and expertise of its staff and other recipients. This is regarded as being particularly important to ensuring that there is a sufficient pool of expert clinical capacity to respond to disease outbreaks if and when they occur. Extension of these programs and information to community-based providers will further extend this capacity, and is consistent with the leadership role envisaged for VIDS. Staff from VIDS are also members of a number of State, national and international committees and other entities which enable them to both contribute to and learn of developments in infectious diseases, and to ensure that practices at VIDS are consistent with current models of care. 5.2.4 Linkages with Other Services The development of close linkages with a range of experts in related fields has been a fundamental aspect of the development of VIDS. This is reflected in its philosophy of establishing a "web of interacting services for all aspects of research, teaching, training and practice in infectious diseases". Examples of the formal linkages established with other agencies were provided in VIDS submission to the review, (14) and include:
These linkages have provided vehicles for VIDS to extend its knowledge and capabilities to a range of other organisations and service providers. In regard to linkages supporting individual patient care, the HIV Community Care Committee and the VIDS Social Worker have an important role in discharge planning practices and liaising with community-based providers. These were generally well regarded by community-based providers consulted in this review and a number of patients, although variability was commented on in regard to the timeliness of discharge notices, and in ensuring that inpatient service were consistent with treatment being provided in the community. In this regard, there is scope for greater consistency through the application of appropriate quality assurance mechanisms.. Recommendation 15:That VIDS maintain its quality assurance mechanisms to ensure that continuity of care is maintained on discharge of patients.
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