Resources

Dr. Stephen Warrillow, Director of ICU at Austin Health discusses the level of collaboration it took to get a real-time view of all ICUs to help those responsible for deploying and co-ordinating resources during COVID-19.

Disclaimer

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The Challenge

A lack of situational awareness across hospitals, regions and countries that could lead to a whole region being overwhelmed by COVID positive ICU patients, as we have seen overseas (00:01:48). 

The Solution

CHRIS: Critical Health Resource Information System.

• High levels of collaboration across Australia and New Zealand between various stakeholders resulted in hospitals leveraging a comprehensive data sharing and reporting system.
• This system is updated twice daily, ultimately providing a heat map of intensive care bed utilisation that uncovered pressure points and informed resourcing (00:07:39).

The Impact

CHRIS ensures that regardless of postcode, people are able to receive high quality intensive care, whether COVID positive or not. This approach has applications far beyond COVID-19 and can inform the coordination and deployment of resources for future crises, even outside of healthcare (00:10:00).

Video transcript

Melanie Hay:

Welcome, everyone to another issue of Connecting Clinicians, where we interview a clinician across the country who is or has been facing, within their organisation, a challenge in light of the COVID pandemic, the solutions that they've put into place, and also the outcomes or the impact that they've seen from implementing those solutions. Today we'd like to welcome Stephen Warrillow, who is the Director of Austin Health.

Stephen, I'd like to welcome you today. Stephen will be sharing with us something quite exciting which is happening at the moment. It's around system level data sharing to better understand ICU capacity, not only here within the state of Victoria but across the country and also across in New Zealand. Thank you, Stephen.

Dr. Stephen Warrillow:

Thank you very much for the opportunity to share the story with you, Mel. I appreciate it. As everyone will recall back in January and February, when we were getting reports from overseas about this novel coronavirus that was causing severe respiratory failure in a range of patients, there was considerable concern here in Australia that we similarly might be overwhelmed. Individual units were spurred into action at the behest of departments of health at a jurisdictional level to develop their own surge response plans and the ability to meet this increasing demand for capacity. And so all intensive care units across Australia and New Zealand did that. That's served us very well, and we have in fact been enacting those capacity and surge plans at that time, and also more recently here in Melbourne over recent weeks, as people might be aware.

(00:01:48) But at another level, certainly from the Australia and New Zealand Intensive Care Society and those of us involved in other elements of the governance of intensive care, we were concerned that there may be a lack of situational awareness potentially across not just hospitals and cities, but also regions and at a federal level and indeed, by a national level. And there was a concern that hypothetical scenarios we could think of included one particular hospital or region or one particular site being entirely overwhelmed as we had seen occurring in Northern Italy and parts of the United Kingdom. And that was really very worrying for all of us. So we wondered, how could we have a strategy whereby there could be close to real time information sharing to guide those responsible for the deployment of our resources who might have the ability to call in additional help, such as, for example, from the Australian defence forces and similar, and coordinate personnel, equipment and bed availability at a citywide, statewide and even countrywide level.

And there really wasn't any instrument with which we could do that. We weren't starting from a zero point. We did have some data sharing. So with ANZICS, we've had quarterly reporting of intensive care outcome benchmarking and annual resource reporting whereby we would share information on personnel and bed numbers and acuity, but we certainly didn't have anything that was real time. Individual directors knew what was going on in their unit, and then their circuit managers understood, and maybe even hospital executives had some concept, but there wasn't a strong awareness outside of that very localised knowledge of what the acuity and capability of that particular unit was.

(00:03:44) So we wondered how we could solve this problem. How could we do it quickly? So initially it was easy to feel somewhat daunted by the challenges that designing such a system would involve. The idea that we could, in near real time, report the number of patients in a given intensive care unit across the entire country, how many of them might be COVID-affected, what their care needs might be in terms of things like mechanical ventilation and kidney dialysis, those sorts of things, what our stores of personal protective equipment might be in real time at a local and regional level, and also how we're managing personnel.

Do we have enough nurses and medical staff and other health stuff able to care for these high numbers of patients? I think as anyone that has been involved in cross-jurisdictional engagement will attest, trying to get even a really good idea up and running between different jurisdictions is quite a challenge. And yet we recognise that we really had a matter of weeks or maybe at most months in which we could get this underway in a meaningful manner. So we had a lot of conversations, often on a Saturday and Sunday morning, and often at strange times because we had to involve colleagues from Western Australia as well as New Zealand. And we worked really hard with those at a federal level. So we had Nick Coatsworth, for example, and Brendan Murphy who immediately recognised the need for engagement of this kind. We also spoke to state-based health department personnel and state ministers for health.

And also, as if it wasn't challenging enough to do it within Australia, we had conversations with our Kiwi colleagues because we've got a strong history of collaboration with them at an intensive care level. And we also had to get every director of every intensive care unit in all of those regions to also agree to do this and really, in a way, that was quite inspiring actually. Everyone recognised that this was not just a good idea, but it was essential. And that certainly - I won't suggest made things easy - but it made them easier and there was a great deal of enthusiasm for wanting to make this work and to make it work quickly. So ordinarily an endeavour of this kind would take months, perhaps even years, to organise. And we set ourselves a timeline, which was ridiculously ambitious in some respects, of three or four weeks.

That meant a lot of people were working pretty long hours. It wasn't just clinical teams, obviously, but we had data experts, IT experts. We had a lot of back room discussions with people that were quite influential that could help promote the idea of the work that we were trying to do. People that had corporate experience, they could really bring their expertise and context to the table. And we ended up having a really remarkable engagement between Ambulance Victoria. We had a platform called Reach, which had some of the characteristics of what we were hoping to do. We involved Telstra and their health division, and they contributed expertise and a lot of useful practical guidance and also most importantly at a political level, and it certainly caught the imagination of the national cabinet. I think, without a doubt, that was a high point of getting things done in terms of our COVID response and was incredibly important for developing this new system.

Finally, there's a lot of coordinating work within the Australian and New Zealand Intensive Care Society itself. I know that our executive and office team we're pulling similar hours to those of us in the clinical space to make this work.

(00:07:39) Ultimately what was developed was a system called the Critical Health Resource Information System, or CHRIS. I'd love to take credit for that, but that actually came from the feds. That allowed us to piggyback on a comprehensive data sharing and reporting system that works very close to real time, it's updated twice a day, onto systems that clinicians were already using. So for example, in Victoria, the associate nurse unit managers in every intensive care unit were sharing their bed availability on a twice daily basis with that system. And so given that was already an established work practice and work flow, it seemed logical to expand that slightly and utilise skills that people already have and utilizsng data that they already have access to, to make it a binational program.

And so now we have a system whereby at a federal level, whether it's in New Zealand or in Australia, the government can see what are the pressure points within the system. They can get, essentially, a heat map of what is intensive care bed utilisation, both from COVID and non-COVID, because it's important to remember we're caring for a lot of critically ill patients that don't have COVID. People still have heart attacks and overdoses and trauma in their life. But it allows the people who are in a position to influence where personnel might be deployed or where resources are spent to know what each hospital's activity is and how they may be impacted and what support might be necessary. And that's really true to our initial premise that it's not the patient's fault where they live when they get critically ill, and it's not their fault of which hospital they're taken to by ambulance or where their family bring them to.

And that if that hospital is very busy, once the initial resuscitation and care has been administered, that we can either provide that organisation with additional resources if they need to, to accommodate the surge demand, or move the patient to another hospital that does have bed capacity such that the quality of care of that patient's the same, or as close as we can get it, regardless of the postcode that they live in or the hospital that's closest to them.

(00:10:00) It's now been running since April and the data has been updated twice a day, every day. Every hospital, to all intents and purposes, just about every hospital with an intensive care unit in Australia and New Zealand contributes. And it's actually open to any authorised clinician or a registered individual who has a log-in so that I can see not only my data here at the Austin, but I can also get a sense of what's happening with my colleagues in nearby hospitals and also at a state and binational level.

And that is quite informative for those who have to make high level decisions. But it also makes me recognise as a clinician that we really are all in this together and that no unit is left alone. This idea that no unit will be allowed to drown in demand, I think makes the whole process feel incredibly collegial and a lot safer than it might have otherwise felt, that no one's being left to their own devices. And so I think it's been a really inspiring example that is very patient-centred, that was inspired by a concern that we have to serve all of our patients to the best of our ability regardless of where they were. And also all the barriers that one usually might imagine will come up with trying to do this cross-jurisdictional engagement.

Really, I'm not saying they were easily overcome, but everyone was incredibly committed to overcoming them and to have people from ANZICS, the Federal Department of Health, the state Departments of Health in all jurisdictions and New Zealand, as well as data experts and the corporate sector come together in a time of crisis really was an example of how we can make things happen on a quite short timeline when we all work together and recognise the imperative to do so.

I think one of the challenges going forward is to realise that this approach has application far beyond COVID. There will no doubt, unfortunately, be future pandemics, we believe, but also things like bushfires, floods, major trauma events, natural disasters and the like. This same platform, now that it's established, we're firmly of the view is a great way to ensure equitable deployment of resources where the need arises going forward. So we're very hopeful that this is now a benchmark of engagement and that in due course, it becomes the standard of how we coordinate our response to future crises. We never want to see anything like COVID-19 ever again, but if we have anything like this going forward, I think these preparations and these systems will serve us and our patients really very well in the future.

Melanie Hay:

Thank you, Stephen. I really appreciate you sharing that with us today, and it's quite inspiring to hear about the inter-jurisdictional collaboration that has come forward in a very short timeframe and just what that means for the future. So not only thank you for today, but also just to extend that thank you to yourself as a clinician at the Austin and also your staff who are working tirelessly to help all of us in the community. So, I thank you.

Dr. Stephen Warrillow:

That's very kind of you. Thank you for your support, Mel.

Melanie Hay:

So just for others who might be interested to also come on board and share some of the challenges that they've been facing and also to be able to highlight some of the innovation which is really coming to the forefront in what I think everyone is appreciating as very short timeframes and at speed. So if you'd like to connect in, please email info@aicg.edu.au. On that note, stay safe and kia kaha.