Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2025
CEQ Showcase 2025 - City to Bush: Transforming Post-operative Care
Summary
PODSS is a nurse-led telehealth service that is transforming surgical patient experiences and outcomes across metropolitan and regional Queensland during the first 30 days following hospital discharge.
Dates: 1 November 2023 - October 2024
Implementation sites: Cairns Hospital, RBWH, Rockhampton Hospital and, STARs
Aim
To improve post-operative outcomes and reduce avoidable emergency department (ED) presentations by delivering expert, community-based care through a scalable, nurse-led telehealth model.
Outcomes
Review of two metropolitan and two regional PODSS sites:
- Rapid and reproducible model implementation within approximately four weeks
- STARS reduced ED rates by 40%. This includes all hospital ED's in Queensland health.
- RBWH reduced ED rates by 18% (May 2024 - October 2024). This includes all hospital ED's in Queensland health.
- 78% average reduction in ED presentations for targeted surgical specialties at regional sites. Cairns had an 81% reduction (October '24 - March '25)
- Rockhampton had 75% reduction. This does not include other hospital ED's within Queensland health.
- Over 93% of patients provided a 5-star rating in Patient Reported Experience Measures (PREMs)
- More than 85% of care delivered via telehealth
- Average of 1.5 Clinical Nurse Consultant (CNC)
Background
Queensland emergency departments are under increasing pressure due to rising patient volumes, greater complexity, and challenges with access block. Sample data from five hospitals involved in the National Surgical Quality Improvement Program (NSQIP) revealed that 10% of surgical patients in Queensland return to the emergency department within 30 days of discharge. Many of these visits are for low-acuity issues that could be prevented with timely follow-up or better discharge planning.
This highlights a significant gap in transitional post-operative care. Patients, especially those in regional areas, often struggle to access outpatient follow-up or primary care, increasing their risk of unnecessary ED visits. To address this, the Post-Operative Discharge Support Service (PODSS) was created. Piloted at the Surgical Treatment and Rehabilitation Service (STARS) in November 2023, PODSS provides a flexible, nurse-led model offering virtual and in-person support (in some locations) for the 30 days following hospital discharge.
Led by CNCs, the service offers rapid access to expert telehealth advice, monitors for complications, and escalates concerns where needed. The model improves continuity of care, facilitates early intervention, and provides reassurance for patients, serving as a vital safety net.
Supported by the Healthcare Improvement Unit (HIU), PODSS has now expanded to 13 sites across Queensland, including six Department of Health-coordinated sites. While the core model remains consistent, each site has adapted it to meet local needs. For example, one regional site embedded culturally appropriate care for Aboriginal and Torres Strait Islander peoples, while another supported outpatient follow-up despite not having a local PODSS clinic.
This evaluation focused on four PODSS sites: two metropolitan and two regional. The core question addressed was:
How can low-acuity ED re-presentations be safely reduced and patient experiences improved in the 30 days following surgery across diverse Queensland settings?
Methods
This evaluation reviewed the implementation and outcomes of PODSS across four sites: two metropolitan and two regional hospitals. The foundational model, developed at STARS, was replicated at each site with adaptations to meet local needs. Implementation was supported by mentoring from experienced PODSS teams and prioritised high-risk surgical specialties using data from the Operating Room Management Information System (ORMIS) and Surginet.
Each site established its own workflows, clinical escalation protocols, and educational materials. Referrals to PODSS were received from ED triage, general practitioners, QAS (at one regional site), self-referrals, acute care teams, and community services. Key evaluation metrics included ED presentation rates before and after implementation, escalation rates to medical officers, and patient experience via PREMs.
CNCs from some sites worked with data analysts to monitor outcomes. Regional sites showed high adaptability, introducing weekend coverage and expanding to include broader patient cohorts such as paediatrics and obstetrics. One regional site successfully integrated QAS referrals, reflecting strong community engagement and significant socioeconomic need. Metro sites, on the other hand, faced challenges such as limited clinic space and the absence of nearby EDs for escalation.
Across all four sites, more than 85% of care was provided via telehealth, demonstrating strong accessibility. The success of the model was supported by robust clinical governance, flexibility in local implementation, and culturally safe care. Site-specific challenges, including variation in escalation processes, were addressed through ongoing stakeholder collaboration and iterative improvements.
Regional sites achieved significantly greater reductions in ED presentations, likely due to a combination of higher unmet need and the availability of in-person clinic options. At metropolitan sites, targeted quality improvement initiatives were implemented. One site introduced proactive calls to patients following laparoscopic cholecystectomy, resulting in zero ED presentations in that cohort (for a two-month period). Another site reported a substantial reduction in ENT-related ED presentations.
Discussion
The PODSS model has demonstrated significant impact in improving post-operative care across Queensland. Building on its origins at STARS and led by experienced CNCs, it has offered a patient-centred and telehealth-enabled solution that enhances recovery and reduces pressure on emergency departments.
Critical to success has been strong engagement from multidisciplinary teams, including surgeons, ED staff, Indigenous Liaison Officers, general practitioners, and ward-based nurses. Local adaptation allowed teams to tailor the service to specific community needs, reflected in high PREM ratings and measurable outcomes.
Key insights from the rollout include the importance of early access to data and informatics support to enable real-time evaluation and responsive service adjustments. Workforce remains a limiting factor, especially in expanding the model to seven-day coverage and a broader range of surgical specialties. Recruiting and retaining CNCs with skills in surgery, telehealth, and data analysis is an ongoing challenge.
Regional sites achieved greater reductions in ED presentations, likely influenced by higher baseline need, physical clinic access, and closer community engagement. Conversely, metro sites faced constraints related to infrastructure and service overlap yet still delivered measurable reductions and high patient satisfaction.
PODSS teams continue to address common discharge-related challenges, including incomplete documentation, fragmented community services, and gaps in medication or certificate provision. These are mitigated through proactive follow-up, education on surgical wards, and improved coordination with community providers.
Patient feedback strongly supports the model's value:
- "Being a long-distance patient, I found the service invaluable. It also makes me feel I'm not lost in the system once discharged."
- "The nurses were excellent. Efficient, very helpful, and caring. I felt safe and cared for. I couldn't speak more highly of the service. Essential service and support were outstanding."
- "The best post-op service for the region. Living remote can make things difficult; this makes things so much more comforting."
Future expansion would benefit from pre-arranged CNC backfill, dedicated clinic space, and automated data collection. Although the current focus is surgical, the PODSS model could be adapted to medical specialties and cancer care pathways. It is essential that it remains nurse-led, maintains clinical rigour, and continues to support structured handover to community services.
In summary, PODSS is improving patient outcomes and experiences across Queensland. Regional results suggest even greater impact where need is high and physical access supports virtual care. The model is 'practical, scalable, and compassionate ' an effective response to the modern demands of post-operative care.
References
Queensland National Surgical Quality Improvement Program (NSQIP) - Growing focus on surgical outcomes - Clinical Excellence Queensland, Queensland Health