Multimedia Health Education Can It Change Clinical Practice?

Assoc Prof Leo Donnan Director of Orthopaedics Chief of Surgery RCH

What is DDH?

 A condition of the childs hip where there is incomplete development  Range of disorders including - instability, subluxation and dislocation

 If unstable hips are not detected and treated they may - not develop properly and eventually fail

The Impetus to do something

 In Victoria children are still presenting with a late diagnosis of hip dislocation despite screening programs and use of ultrasound  Children facing lifelong disability from a condition that is easily managed if detected early

Victorian Screening Program

 72,000 births per year  Geographically Spread  4.0 million in Melbourne  2.0 million in the “bush”

 Clinical examination  at birth  six weeks  regular intervals up to age two  Ultrasound  abnormal clinical findings  risk factors at six weeks

The Problem

 Poor documentation  No uniform standard of examination  Inconsistency in terminology  Increased reliance on imaging  Unclear referral mechanisms  Multiple examiners

The Scale of things

   72,000 births per year Expect  72 frank dislocations  720 unstable hips  ???? dysplastic hips 1012 MCH nurses in full/part time positions  large work force  dispersed  will see very low rates of dislocation  hrad to maintain skills

The Solution ?

 Target the front line clinicians  Understand their difficulties  Define the barriers to early detection  Develop evidence based practice guidelines  Standardise the clinical examination  Apply education theory principles

Objectives

 Knowledge - terminology, anatomy, pathology, associations, risk factors, examination, imaging  Change practice - improve clinical skills, confidence and referral procedures  Standardise approach health professionals - consistency across all

Learning Ability

      Education level Cultural background Social class Literacy skills Trust in the information Emotional state

Challenge

High

ANXIETY

Low

BOREDOM

High

Skill

Learning Types

    Visual Auditory Written Kinesthetic

Pictures Words Sound

Developing the Module

        Focus groups Literature review Educational objectives Outcome measures Script development Story board Animation Testing

Testing the Module

   Maternal and Child Health Nurses Range of municipalities 203 recruited

Information easy to understand

Recommend the use of the module

Module met educational needs

Knowledge

P< 0.001

P< 0.001

Confidence

p < 0.001

Change in Clinical Practice

How frequently do you examine for DDH? (n=164) How often do you perform the examination from the side of the infant? (n=164) Desired Change Pre Three Months Two Years 99% 100% 100% 34% 23% >0.05

21% >0.01

Do you refer all infants with “ clicks ” in isolation for further assessment? (n=162) Do you fully unclothe infants to examine their hips? (n=162) Desired Change Pre 88% 99% Three Months Two Years 46% >0.001

91% >0.001

34% >0.001

90% 0.003

Hip creases are the most important physical feature of DDH (n=164) In a relaxed baby it is important to push firmly in testing for hip instability (n=162) Desired Change Pre Three Months Two Years 42% 43% 24% >0.01

60% >0.01

19% >0.01

46% 0.77

The relationship between delayed motor development and untreated DDH is very strong (n=161) Desired Change Pre 57% Three Months Two Years 60% 0.5

58% 0.5

What now?

   Increase accessibility of module  online resource  roll out to other clinical groups  general practitioners  midwives  paediatricians Update the module  response to feedback Watch for changes  swaddling module developed

Swaddling

  Recent trend for settling babies What ’s old is new again!!

 High risk for DDH if not practiced safely

 Navaho Indians

Has it made a difference?

MOR at RCH (year to date)

Summary

 This initiative is aimed at improving the health and well being of children by facilitating early diagnosis and referral of DDH  The module significantly improves the clinicians knowledge, skills and confidence in making the diagnosis  Aim to ultimately reduce the need for complex surgery due to late diagnosis

Take Home

   Refresh your knowledge Update your skills Use the resources