Avoid waiting room woes

The phone line’s running busy at the local medical centre. Doctor’s appointments are as scarce as hen’s teeth.

Some patients needing to see somebody that day don’t even bother to phone any more and head straight to their local drop-in afterhours centre whether it is afterhours or not.

It is meeting the demand for same day primary health care that is the prime motivation for MidCentral’s acute care nursing programme for practice nurses, says Debbie Davies, lead clinical nurse specialist in primary health care for MidCentral District Health Board.

MidCentral was one of nine business cases given funding blessing in late 2009 to transform primary health care services to meet the government’s Better Sooner More Convenient (BSMC) vision.

The business case is a collaboration between the region’s district health board and primary health organisations, and one of the four target areas is improving acute demand management.

Davies says a casual survey of patients fronting up to a local 12-hour accident and medical centre in office hours had brought home the need to better manage the demand for same day acute care.

“Seventy per cent had not even bothered trying their local GP team as they knew the response would be most likely that they couldn’t get in.”

Stakeholder workshops looked at what practices were already doing to manage same day demand and showed widely varying practices including some centres literally turning people away at the front desk and sending them home to phone the triage nurse.

Runny noses, cut fingers & UTIs

The team looked at the top presentations for same day acute care and decided that registered nurses could handle many of them with the right training and support. So they developed a core set of knowledge and skills to upskill practice nurses on ‘top-to-toe’ triage assessment for children and adults and then acute care nurse management of the most common presentations.

Once nurses are trained the aim is for all practice teams to work with Debbie and her MidCentral team towards offering nurse-led acute care walk-in clinics with nurses assessing and deciding which patients are within their scope to treat and which need to see the GP.

First off the block was Tararua Health that was already offering acute care walk-in clinics in Dannevirke for a number of years, thanks to GP Tom Gibson, to counter frustrated patients and stressed-out doctors unable to meet demand.

The morning clinics – with a GP and nurse assigned to work with walk-in patients – had been underway for about three years when Kathleen Brown started working for Tararua as an acute care clinical nurse specialist in late 2010. A clinic in Pahiatua had also been underway for some time.

But up until recently the triage process was ad hoc, if at all, with most of the practice nurses stepping into the acute care role with little preparation apart from some practical on-the-job skills teaching by GPs. “There was no formalised training that gave nurses the knowledge and skills they could stand on as a foundation and be confident and competent in assessing acute patients when they walk in,” says Brown.

Now, thanks to the MidCentral acute care nurse training programme, Brown says the nurses are skilled to not only assess whoever walks in the door but also to treat those that fall within their scope, and the initial vision of a nurse-led acute care clinic is being fulfilled.

She says the numbers of people seen in the walk-in clinic has just increased and increased until they now average 40-45 patients a morning and sometimes up to 50 – and this is on top of the patients with booked appointments to see their GP or nurse.

As many as 20 people can turn up at 9am for the walk-in clinic with conditions ranging from a runny nose to appendicitis or a cut little finger to a heart attack.

The clinic’s triage nurse has to keep a safe waiting room by scanning the waiting patients for anyone looking short of breath, sweaty and pale (or has presented to reception with chest pain or some other high end acute presentation) but usually people are seen on a ‘first come first seen’ basis. And after the triage assessment the clinic nurse will either refer the patient on to the clinic’s assigned GP (or Brown who is a nurse practitioner intern) or continue to assess and treat the patient themselves.

‘Bread & butter’ work of an RN

Brown, who hopes to become the first NP specialising in acute care in primary health settings, helped oversee the training. She is adamant that the walk-in clinic work does not require clinical nurse specialist or NP-level training and just requires an experienced RN to work at the top of their scope.

This is echoed by Davies who says it is a bonus not a requirement that MidCentral has NPs and NP interns working in a number of the six primary health sites involved in the project. “But we didn’t want the RNs to perceive this as only the business of advanced pathways. The majority of this is the bread and butter work of a level two competent RN.”

Davies says it is fair to say that the rollout of the project had not been without its pitfalls – much of it to do with the ‘busy-ness’ of general practice but also resistance from some to changing the model of care.

“For some of them it’s quite a mindshift – actually having to push themselves outside of their comfort zone of what they are currently doing.”

The acute care training programme (see box) has been trimmed down from an initial eight sessions to six sessions of two hours each presented in the workplace at a time to suit the practice – for some that is within work hours and others evenings.

Davies says the biggest area that nurses lack confidence in is assessing sick children. “Sick children are very scary”. But the training is pitched at the level of minor illnesses, minor injury and minor exacerbations of chronic conditions, with nurses referring on any patient beyond their scope and competency level.

Trust also has to be built between GPs and nurses – so GPs don’t feel the need to redo nurse assessments and nurses aren’t reluctant to do them. “Because what you found was that most of these practice nurses weren’t doing the initial assessment on children because they knew darned well the GP would do it again and for the child that’s not pleasant.”

Some nurses are also initially uncomfortable with having to have their existing or newly gained knowledge and skills validated, and there have been some challenges with getting a peer assessor or GP to carry out the on-the-job assessment. (Davies says offering the acute training package has also seen an interesting trend of other training needs emerge – such as for IV (intravenous) cannulation, plastering and suturing – as general practices seek to take on work once the realm of ED.)

Over 120 Registered Nurses across the MidCentral DHB are now involved in the acute care training programme but the most advanced, and first to finish, has been Tararua. Davies says a key to this has been the buy-in of the local clinical excellence group which supported and mandated Kathleen Brown and the programme’s nurse educator to work alongside the nurses to assess and sign off their skills or build their competence in a particular skill they identified as needing help in.

The other sites are at different stages along the project’s phase one training pathway and phase two stage of analysing their current acute care processes and further refining them to make the most of nurses working at the top of their scope and improving same day acute care demand.

Triage and standing orders

The MidCentral project team has also been working with Tararua to develop a triage template tool to provide consistent documentation and decision-making on whether a patient sees a nurse or a GP. Plus a tool kit to guide an organisation on developing standing orders to help deliver the new model of care for their general practices.

Brown says in Tararua they have revised and released a number of new standing orders so nurses working in the acute care roles can initiate and give medications like paracetamol, ventolin and oxygen.

Next off the block – once approved by the Tararua clinical excellence group – is to be a standing order setting out criteria for uncomplicated urinary tract infections (UTIs) and, if a patient fits the criteria, nurses will be able to supply them with a pharmacy prepackaged medication for single use only.

Brown believes one of the strengths of the acute care training programme has been unifying standards across the practice so all are “singing from the same song sheet”.

Surveys on nurses skills before and after the training also show an upswing in confidence in nurses of their acute care knowledge and skills which is having spin-offs not only for the walk-in clinics but also telephone triaging and general assessment skills.

For the public there is the spin-off of knowing they are able to get their acute care needs met on the day in their own general practice. Novel roles like Brown’s proposed acute care in primary health NP role will make this even more likely.

Not total answer says GP and NP intern

David Hill, a GP at Tararua for the past year who also works in ED, for one believes the clinic’s popularity with patients does not mean it is a success in addressing ongoing patient demand. “All I think you are doing by bringing in nurses (to acute care walk-in clinics) is increasing patient demand … if you lessen waiting times you increase demand”.

He sees while the clinics and acute nursing role have value he believes what is really needed is a reform of the current flawed general practice model to look at better collaborative models of funding and delivering planned and unplanned care.
Tararua is a progressive practice Hill agrees but he personally sees the busy walk-in clinic as not addressing the fundamental issue of patient demand. And having up to 50 patients turning up in a morning meant patients didn’t get a good deal and neither did the nurses and doctors.

Brown agrees that the general practice model as it stands is probably not working with the increasing demand for the acute clinic almost unmanageable. People who can’t get a GP appointment just present to the clinic and wait until their needs are met. For example she had a week recently where two of the GPs rostered to the acute clinic were sick and she as the NP intern was “it”. “Forty-three people presented for that day – a lot were minor illnesses but in amongst them were a few rather sick people and three were referred to ED.”
She also says there needs to be a change in how health professionals work so care is better planned to minimise acute care needs and the demand for acute clinics.

But Brown sees beauty of her role – and also of the walk-in clinic – is that patients who might otherwise have had to head to an after-hours clinic or ED can be see in their own practice so herself and others can ensure continuity of care and monitoring of their acute condition (including exacerbations of any long term conditions). Plus keeping emergency departments free for those most in need.

An aspirational target of the MidCentral business case is to reduce ED admissions by 30 per cent. “Which is actually a very big ask,” says Davies.

“But we’ve actually just reached that target with 0-4 year olds and started to make some traction in the up to 18 year olds.”

Collaborative teamwork in the community and more nurses working at the top of the scope appears to be making some mark but not without some impact on the demand for general practice too. With more acute care walk-in clinics to follow it could be a matter of watching this space to see whether that target is just aspirational or achievable.

Community nurse prescribing a good fit? Yes but ….

Community RN prescribing is a logical next step for models like the Tararua acute care walk-in clinic, agrees Kathleen Brown.

“RNs running nurse-led clinics in a number of areas around NZ are already practicing independently and competently diagnosing and treating uncomplicated minor ailments and infections using standing orders in alignment with the legislation and guidelines.”

Being able to prescribe for those minor ailments and injuries would make better use of those nurses skills, be more efficient for patients and could enhance the effectiveness of both GPs and NPs working in the primary health care setting.

But, adds Brown, more clarity is needed about what the Nursing Council means by community RN prescribing as the model as currently proposed raises some concerns for the NP intern. Particularly around the suggested qualification timeframe (up to six theory days and three days supervised practice), which she thinks, looks totally inadequate to ensure competent and confident community RN prescribers. “The knowledge community RNs would need to prescribe requires training in pharmacology, pharmacotherapeutics, clinical assessment diagnostic reasoning, writing prescriptions, teaching and more”. Brown also has concerns about the drug list as currently proposed (see additional comment and Nursing Council response in main prescribing story).

Tararua GP David Hill reiterates that while he thinks community nurse prescribing could be helpful – and nurses working in collaborative teams with GPs would lessen the risk – he says it is the flawed general practice model as a whole that needs to be addressed first if future patient demand is to be catered for.

“I don’t see nurse prescribing lessening the load of the GP unless we change the structure of the way we work.”

Brown still believes RN extended prescribing will be a key part of stepping up to meet future health care needs. But she also agrees with Hill that the current model is not sustainable and is not delivering on reducing health disparities.

“Health professionals don’t work together, we exist in silos, care is disjointed, duplicated at times, not co-coordinated, we have to start working together collaboratively, integrating the resources/capacity we have.”

She also believes that collaborative practice across all disciplines and greater integration of primary and secondary services is needed if primary health care is expected to meet more and more health needs of the communities. “If this is achieved we will start to make a difference using all resources available in the community not in competition with each other but working together.” Integrated Family Health Centres could make a key difference and the RN role must expand to meet the challenges ahead.