Episode 17: Supporting clinicians to provide safe and quality health care

Voiceover:

Welcome to the NPS MedicineWise podcast, helping health professionals stay up to date with the latest news and evidence about medicines and medical tests.

Steve Morris:

Hi, I'm Steve Morris, CEO of NPS MedicineWise, and welcome to another episode of our podcast. I would like to introduce Dr Robert Herkes. Dr Herkes is the Chief Medical Officer at the Australian Commission on Safety and Quality Health Care and was previously Director of Intensive Care at the Royal Prince Alfred Hospital in Sydney. Welcome, Robert.

Robert Herkes:

Thanks, Steve. And thanks for having us.

Steve Morris:

Yeah. Thank you for joining us. And look this podcast series is focused on issues related to the impact of COVID-19 on the conditions, clinical care, and ultimately patients and our listeners are mainly health professionals. So can you just take us through what the Commission has identified as the biggest issues during this time and what the Commission has been doing in supporting clinicians to address these issues?

Robert Herkes:

Yes. Thank you. So one, of course, the biggest issues is understanding how to prevent transmission of COVID. And we thought as with all new diseases, there's actually, especially at the start of the pandemic, a sparsity of data around what you should do to try and prevent transmission in the community and transmission within the hospitals and aged care facilities. So one of the first things the Commission did was looked at our Standards to see whether the Standards are fit for purpose and whether there was appropriate advice for health services within the Standards to allow them to appropriately practically consider the preventative aspects of COVID. So within our Standard Three, which is preventing and controlling healthcare-associated infections. It's fair to say that historically, this was a Standard that really didn't look at staff or visitors or patients bringing in an extremely contagious virus into the hospital and then spreading it within the hospital. So we spent quite a lot of time looking to see what we could do to add resources to that Standard, to make it more robust.

So we developed resources in consultation with each of the states and territories around PPE, around environmental cleaning, around issues of protection from droplet and aerosols spread of disease, looking at how you might screen visitors and staff coming into your facility to try and screen for COVID, what you might do around recommencement of elective surgery when there's still COVID within the community, what you might do about screening elective surgical patients before they come into hospital to try and keep the hospitals safe.

Now, a lot of that work was done in conjunction with the new national bodies that have been set up to help National Cabinet make decisions around the COVID response. So that's the Infection Control Expert Group and the AHPPC that both feed advice up the cabinet. So we developed a rapid evidence unit to get evidence rapidly for High Care Infection Control Expert Group so that they could be informed about issues as they came along. And so we undertook a series of quick literature reviews, looking at things that might decrease the risk of COVID, therapies for COVID, usual medicines, and usual medicines’ effect on the risk of COVID to try and support our clinicians.

Steve Morris:

Yeah, I think thanks for the overview Robert, and obviously, given the pace at which things were changing, how did the Commission determine kind of which resources needed to be prioritised or produced first?

Robert Herkes:

So often it was in consultation with the jurisdiction. So all the jurisdictions were initially very keen to get information about personal protective equipment out around how you might don and doff personal protection equipment safely, and then information about what levels of PPE were required in different circumstances. And so that work was done with the jurisdictions. And it's fair to say, it's evolved as the pandemic’s continued and as careful consideration of workforce issues have become more and more important, particularly in Victoria where there was more COVID than elsewhere.

Steve Morris:

Yeah. Thanks, Robert. Just a couple of other things in terms of, you talked about working in conjunction with other national agencies, how does the work of the Commission dovetail with, say, the National COVID-19 Clinical Evidence Taskforce?

Robert Herkes:

So the Clinical Evidence Taskforce and the Commission have regular meetings, the Clinical Evidence Taskforce takes some of our work and as you'll be aware, Steve, the Commission, as I was saying has done some literary reviews around essential therapies for COVID, has looked at normal therapies. So ACE inhibitors and what have you and their effect on the risks of getting COVID and having severe COVID. So we've published those and they have also been distributed to the National Clinical Evidence Taskforce. The Clinical Evidence Taskforce has regular meetings with us so that we understand what each other's doing. And so far we haven't ended up having contrary positions, which has been useful. So there's been this cross-fertilisation.

Steve Morris:

So are the jurisdictions still identifying new issues that require kind of some national scrutiny, or a review of the evidence, rather?

Robert Herkes:

So I think one of the lessons out of Victoria is around how you might want to care for patients who are delirious or demented where their behaviours potentially expose staff to infection with COVID outside of their normal environment, outside of the residential aged care home and into a hospital. And so there issues like that really need ultimately considering it at national level about how to best look after sick but not critically ill elderly patients because bringing them out of their usual environment exacerbates their confusion and causes issues.

Steve Morris:

So the work continues in terms of the role of Commission in this area then Robert?

Robert Herkes:

Yes, it does indeed. And in fact, we've just set up a taskforce to look at making sure that all the recent lessons out of Victoria are reflected appropriately within our Standards, particularly the Standards through the preventing and controlling healthcare-associated infections.

Steve Morris:

Where can people find the Commission resources?

Robert Herkes:

So all our resources are available on our website and that's www.safetyandquality.gov.au and there are tabs there to our COVID resources.

Steve Morris:

Okay. And just to switch tack slightly, I suppose with the lens of the clinicians working in the sector, what sort of issues and problems have you observed personally and how do you think these have changed over time?

Robert Herkes:

I think it's fair to say that even places like intensive care hadn't practiced donning and doffing, putting on and taking off PPE extensively enough in the past. Fit testing of N95 masks is another important issue. To wear an N95 mask appropriately, it's not to leak and the only way to assure yourself that it's not leaking is to properly fit test it. Even in hospitals that have a range of multiple different sizes and styles of N95 masks. Still a small proportion of the workforce can't get a mask to fit and therefore have to use a hood or a powered respirator.

So there are lots of issues like that, that have emerged during the pandemic that if we sat back and thought about how we deal with the pandemic, I'm sure we would have imagined that there would be problems but practicing up on PPE and properly putting it on and properly putting it off and all sorts of old fashioned things like arriving at work and changing into scrubs. And then at the end of the day, changing and having a shower and changing out of your scrubs into your civilian clothes. Things that have often dropped by the wayside are now important again.

Steve Morris:

Yeah. Despite everything, all the challenges that the COVID-19 pandemic has presented, there's always some positive changes in healthcare which have been facilitated because of the impact of the pandemic. Do you have any reflections, stories on innovations that have come about in response to these issues and problems?

Robert Herkes:

I think exactly the same as in the influenza pandemic, the system has flattened. So a lot of the levels of bureaucracy have disappeared and there's much more transparency between the public health people and the frontline clinicians within the hospitals which has been really useful. I think on reflection both the state and territory and the Commonwealth chief medical officers have done a fantastic job trying to keep up to date with the evidence and bringing the community along with them. So I think that's been really useful. I think there have been a whole series of committees set up that have historically not been there. So things like a medicine shortage committee, and there's a national stockpile committee and those committees have engaged with say, the hospital pharmacist association in ways that haven't historically happened. So the whole series of work around preparedness of hospitals with stockpiles or with adequate supplies of say, COVID medicines for intubated and ventilated patients, has been taken, has occurred across the whole of Australia and that's been a really useful engagement at a clinical level with the national bureaucracy and clinicians.

Steve Morris:

Yeah. And let's hope that some of those ways of working and solutions are continued beyond this period.

Robert Herkes:

Yeah, I think they will. I think the other thing that's been from my point of view as being stark is the way states that historically were rivals have pulled together. So the Commission has had 20 or 25 of our staff doing contract tracing, and that's been done mostly for New South Wales, but also for Victoria, all the other States have been sending Victoria masks and PPE when there were shortages of masks and PPE. There's a national process now to share medicines when there's medicine shortage in one particular area. So those are really positive developments that have overcome some of the ‘us and them’ stuff where a jurisdiction would be disinclined to help their neighbour.

Steve Morris:

I fully understand, look I'm just going to shift finally to one final topic, the not insignificant challenge of medication safety. And I’ll end with a big question for you Robert. Why do you think the challenge of medicine safety has proved over the years to be such a difficult challenge?

Robert Herkes:

So I think the first thing is we've got a very disconnected system. And so if you just think about the disconnects between a doctor or a nurse practitioner ordering a medicine, putting it on a piece of paper, or now hopefully onto an electronic script, they're disconnected in the community from the local pharmacy where the pharmacist has to dispense those medicines. Lots of the process is manual and not electronic still, in hospitals the pharmacy supplies mostly not fully integrated into the electronic medicines management systems. So they're not using barcodes, they're not using all the things that you would imagine in the 21st century should be part of assuring safety. And then I think there's inadequate decision support for both the prescriber, the dispenser, and the person who administers the medication, reminding them of things to look for and not putting people accidentally on a NOAC and conventional warfarin and so on.

And so I think a whole set of those electronic tools that can aid each stage of the medication prescribing, dispensing, and administering just aren't there yet and they should be.

Steve Morris:

Is this about to some extent, some systematic adoption of those types of systems?

Robert Herkes:

Yes, exactly. And you know, you look at the wicked problems, say of opioids and opioid stewardship. There's so many things that could be connected up to allow people to understand the person who's in front of them, what they may have had in the past, and what issues they may have to allow a better prescribing and dispensing of medicines that just aren't there yet. So we're on a journey, unfortunately.

Steve Morris:

Thank you, Robert, and thank you for your time.

Robert Herkes:

It's my pleasure.

Steve Morris:

If you want to hear more about ‘rising to the challenge of medication safety’, Robert and myself will be a part of a panel of the NMS virtual symposium on the 7th of December 2020. I encourage you all to sign up to this event. We'll give you ideas, thoughts from other professionals and organisations about how we can all act differently to rise to the challenge of improving medication safety. Thank you and thanks for listening.

Voiceover:

For more information about the safe and wise use of medicines, visit the NPS MedicineWise website at nps.org.au