1. Multimedia Health Education Can It Change Clinical Practice? Assoc Prof Leo Donnan Director of Orthopaedics Chief of Surgery RCH

2. What is DDH? ■ A condition of the childs hip where there is incomplete development ■ Range of disorders including - instability, subluxation and dislocation

3. ■ If unstable hips are not detected and treated they may - not develop properly and eventually fail

4. 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

5. Victorian Screening Program ■ 72,000 births per year ■ Geographically Spread 4.0 million in Melbourne 2.0 million in the “bush”

6. ■ Clinical examination at birth six weeks regular intervals up to age two ■ Ultrasound abnormal clinical findings risk factors at six weeks

7. The Problem ■ Poor documentation ■ No uniform standard of examination ■ Inconsistency in terminology ■ Increased reliance on imaging ■ Unclear referral mechanisms ■ Multiple examiners

8. 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

9. 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

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

11. Learning Ability ■ Education level ■ Cultural background ■ Social class ■ Literacy skills ■ Trust in the information ■ Emotional state

12. information flow Challenge Skill LowHigh ANXIETY BOREDOM

13. ■V■Visual ■A■Auditory ■W■Written ■K■Kinesthetic Learning Types

14. Words PicturesSound

15. Developing the Module ■ Focus groups ■ Literature review ■ Educational objectives ■ Outcome measures ■ Script development ■ Story board ■ Animation ■ Testing

16. Testing the Module ■ Maternal and Child Health Nurses ■ Range of municipalities ■ 203 recruited

17. Information easy to understand

18. Recommend the use of the module

19. Module met educational needs

20. Knowledge

21. P< 0.001

22. Confidence

23. p < 0.001

24. Change in Clinical Practice

25. Desired Change PreThree Months Two Years How frequently do you examine for DDH? (n=164) 99%100% How often do you perform the examination from the side of the infant? (n=164) 34%23% >0.05 21% >0.01

26. Do you refer all infants with “clicks” in isolation for further assessment? (n=162) 88%46% >0.001 34% >0.001 Do you fully unclothe infants to examine their hips? (n=162) 99%91% >0.001 90% 0.003 Desired Change PreThree Months Two Years

27. Desired Change PreThree Months Two Years Hip creases are the most important physical feature of DDH (n=164) 42%24% >0.01 19% >0.01 In a relaxed baby it is important to push firmly in testing for hip instability (n=162) 43%60% >0.01 46% 0.77

28. The relationship between delayed motor development and untreated DDH is very strong (n=161) 57%60% 0.5 58% 0.5 Desired Change PreThree Months Two Years

29. 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

30. Swaddling ■ Recent trend for settling babies ■ What’s old is new again!! ■ High risk for DDH if not practiced safely

31. ■ Navaho Indians

34. Has it made a difference? MOR at RCH (year to date)

35. 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

37. Take Home ■ Refresh your knowledge ■ Update your skills ■ Use the resources