Shared competencies and delegation practice in the Mackay Health Services District Emergency Department: A Randomised Controlled Trial

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Demographic trends resulting in increased longevity and an increasingly aged population, combined with the current economic climate, indicate that there will be rising demand placed on already stretched health resources. This is accentuated by the rural location of the Mackay Health Service District (MHSD) which leads to a disproportionate amount of patient and clinician time being spent on travel, as compared to metropolitan services. Within Mackay Base Hospital there are pressures on bed availability (average 96.5% bed occupancy), necessitating innovative early discharge / admission prevention strategies. In addition, patients may be admitted unnecessarily because; they are nearing their emergency department (ED) wait limit target; there are limited and variable Allied Health (AH) services available for ED referrals; or existing ED staff do not have a detailed awareness of community services available to address these patients’ rehabilitation needs. Compounding this, anecdote suggests that there are inefficiencies within existing AH service delivery models; that tasks are duplicated by health professionals, that patients are frustrated by repeating information to AH staff involved in their care, that Allied Health Assistants (AHAs) are under utilised and that services are often fragmented. Increasing pressures on services, staff shortages and lone working, common in regional areas, has led to clinicians informally skill sharing, albeit in an ad-hoc and unstructured fashion, often without the requisite training and competence to enable them to be effective, or to recognise when they are out of their depth. There is inherent risk in this practice, unless a rigorous process has been followed to identify and risk analyse tasks for their appropriateness to share across professional boundaries or delegate. There is subjective information indicating that many tasks are undertaken by qualified practitioners that could be delegated to AHAs, and that there are tasks that can’t be delegated but don’t require highly specialist knowledge and skills to perform, for example routine assessments / interventions. In these instances, it is intuitively sensible to identify which tasks could be delegated / shared across professional boundaries, to use the skill set of the multi-disciplinary team (MDT) more effectively. The Calderdale Competency Framework is a systematic approach to identifying tasks carried out in teams, deciding which can be shared across professional boundaries, or delegated, and assessing competence. Following implementation of the Calderdale Framework, AH practitioners share professional skills across AH disciplines and increase delegation of tasks to AHAs, reducing the number of professionals involved in a patient’s care and minimising duplication of interviews, assessments, interventions, documentation and travel. The Calderdale Competency Framework has numerous potential benefits for the patients, clinicians and organisations, including: Patients are able to form a rapport with 1 individual who can meet most needs, reducing the number of visitors to their home or bedside - more rounded, holistic knowledge of the patient Access to a wider range if interventions for patients living in rural / remote areas Reduced repetition of personal details, condition history and assessments - reduced travel costs and duplication of tasks / roles Closer MDT working - Multi skilled staff - effective team built around the patient Increased awareness and respect of one another’s roles - more issues are identified and addressed - awareness of when staff need to seek the involvement of their colleagues Each discipline’s areas of expertise are identified - guides focus of resources Safe skill sharing / transferable skills Multi skilled workforce using the full scope of practice and delegating appropriately Increased job satisfaction – clarified roles and responsibilities - reduction in staff absence Less ‘hand offs’ - No need for patient handover Improved service productivity / patient flow Management of increased demands Although this framework has been applied in many settings in the UK, it has not been used previously in Australia and the clinical effectiveness of this model of care (MoC) has never been evaluated. In Queensland Health, this model of care is known as shared competencies and delegation practice (SCDP). The proposed study aims to examine the clinical and cost effectiveness in SCDP in relation to its current implementation in the Mackay Health Service District. All AH tasks carried out within the Emergency Department (ED) in the Mackay Health Services District will be identified and, using a risk management decision tool, tasks will be categorised into those that should be delegated to support staff, those that could be professionally skill shared and those which should remain uni-disciplinary. Competencies will be written / sourced and multi-disciplinary team (MDT) staff will teach each other skills, which have historically been considered their role. An Occupational Therapist and a Physiotherapist will then operate Shared Competencies and Delegation Practice within the ED setting. MDT staff will be fully engaged at all stages of the process to ensure sign up. The model is likely to enable patients, triaged to ED categories 2/3/4 (n=27,156 July 2010 - February 2011), to be assessed by AH staff quickly and admission avoided or length of stay reduced, as MDT assessments would have already been completed and discharge planning initiated. The nursing and medical input to patients will not be affected by this study. Aim(s) of project/study This study aims to determine the clinical and cost effectiveness in implementing a SCDP MoC with older people presenting to the ED. Research questions Is Shared Competencies and Delegation Practice (SCDP) clinically effective in enhancing patients’ functional independence, in an Emergency Department (ED) setting, as compared to usual care? Is SCPD cost effective? A prospective Randomised Controlled Trial design will be used with blinding of participants, outcome assessors and statistical analysts. Data will be collected at baseline, on discharge from Allied Health intervention and at 4 months post randomisation. The Cost Utility Study will be carried out from a societal perspective with both direct and indirect costs identified. The primary measure of benefit will be quality of life as measured by the Euroqol. Clients who attend the ED between the hours of 8am – 6pm Monday to Saturday, meet the study inclusion criteria and provide written informed consent to participate will be randomised to the intervention or control groups. The intervention group will receive AH input from clinicians trained in Shared Competencies and Delegation Practice whilst in ED, with follow-up on the ward or in the community if required. The AH clinicians based in the ED will be an occupational therapists and physiotherapists, by clinical background, but will be additionally trained in occupational therapy / physiotherapy / speech pathology / dietetics / podiatry and social work competencies. Thus, clinicians will be able to complete a more a rounded assessment and target intervention to meet the client’s complex needs. Intervention will aim to maximise functional independence, prevent admission and minimise the number of AH clinicians involved in a client’s care. An intervention protocol will be developed to ensure consistency in this approach. The control group will receive standard care, which comprises of clients being referred to individual disciplines, as the need is identified by the Community: Hospital Interface Programme (CHIP) nurses in the ED. Individual disciplines will then intervene with the clients using existing uni-disciplinary approaches and refer on to other services as indicated. Standard care will be documented via an audit prior to trial commencement to ensure that it can be clearly defined at the outset.

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