Sunday, 28 February 2010

A case study in nurse practitioners

Let us consider a hypothetical district general hospital, we will call it Fairylandshire NHS Trust (FNT), they have identified a suitable area for the creation of a new nurse practitioner role to help facilitate clinical care and free up the time of doctors to do other tasks. Sounds great doesn't it?

What the managers and senior types at FNT had noticed was that a very large proportion of new referrals to the Medical Admissions Unit (MAU) were suspected DVTs. These took up a lot of doctors time but were generally fairly straightforward to deal with - so much so that a nice little flowchart for how to manage these cases was created.

So how did the MAU work before? Well the triage nurse (a sister/charge nurse) would take a GP referral* and then the patient would, eventually, come in to the unit to be triaged by said nurse (including taking bloods). Once triaged** the patient is seen by a junior doctor who takes a history and examines the patient and then arranges any additional tests that may be needed (x-rays, venous ultrasounds etc.), usually after having waited a little while for the blood results to come back. Once this is done the junior doctor decides on a diagnosis and management plan, then at some later point*** the on-call consultant comes and reviews the patients and management plan.

For suspected DVTs the more experienced juniors (SHOs and registrars) may decide to discharge the patient without consultant review if they do not suspect anything sinister going on and the tests are negative (FY1 doctors can do the same if they discuss it with a more experienced junior doctor first). Once all the management has been decided and if the patient can go home the doctor then writes a discharge summary for the GP, medical notes, and patient, and prescribes any necessary medications to take home and arranges any follow-up. If a patient has a pulmonary embolism (a blood clot that has gone to the lungs) the consultant will need to see them anyway, and all the findings and management plan will be discussed. If it isn't a DVT and isn't serious the junior doctor will discuss the findings and management with the patient and send them home or back to their GP's care. All this takes place on a severly overcrowded ward with a single triage room and a single assessment room (the latter for the junior doctors to use to see the patients), a spare bed may or may not be available on the ward if more than once doctor needs to see a patient at the same time (there are usually 1-4 junior doctors available to see patients depending on the time of day and whether they are needed in A+E or on the wards).

So, what is the wonderful new innovation that will speed up this process? The 'Thromboembolic Nurse Practitioner' (DVT nurse to you or me). She will see any suspected DVT instead of the triage nurse (and see them in the single assessment room usually used by the doctors), take bloods and do obs as the triage nurse does and then...measure the calf circumference on each side. There is a lovely long pro-forma for DVTs with lots of wonderful sections for the doctor to then fill out once the DVT nurse has seen the patient, they have to take a full history, they have to examine the patient (there is even a section for rectal examination findings!), they then have to reach a provisional diagnosis, calculate a Wells score (assessing the pre-test probability that the patient has a DVT), they then have to interpret the D-dimer test (a blood test for DVTs) based on the prior probability, they then have to arrange further investigations such as venous ultrasound if indicated by the 'DVT pathway', then finally they have to interpret all these tests and reach a final diagnosis (most of these patients do not actually have DVTs). If the patient is short of breath or has chest pain then a pulmonary embolism has to be considered and ECGs, x-rays and even lung perfusion scans arranged by the junior doctor (and a much more detailed history squeezed into the tiny history box on the DVT pro-forma).

After all this, if it does turn out to be a DVT the doctor then needs to prescribe low molecular weight heparin for the patient and start warfarin. At this point the DVT nurse will then talk to the patient about the treatment they will be receiving, adds them to a database for 'audit purposes' and arranges a clinic follow-up for them. If if is a PE the patient will be seen by the consultant and if it isn't a DVT then the same process as above will happen with the DVT nurse playing no further part.

So what does the DVT nurse (or rather what do the two DVT nurses) bring to the table? Well she only works 9am-5pm, costs about £10,000 per year more than the triage nurse, she clogs up the single treatment room usually used by doctors to see patients thus slowing them down, she gets an extra office on the same corridor preventing that being used for something more useful (the doctors office has, of course, be converted into bedspace), she harrasses the junior doctors busy seeing sicker patients to see her suspected DVTs as soon as possible, she does some minor counselling and arranging of follow-up for the few patients with DVTs, she does some follow-up clinic work and she undertakes audits and other ephemera to do with 'thromboembolic prophylaxis' around the hospital (note that there are two DVT nurses to do this extra work, one doing the assessments, the other doing the other ephemera). She saves maybe 10 minutes per confirmed case of DVT.

An FY1 doctor could nearly double their salary doing a DVT nurse practitioner role, I wonder if there are any locum jobs going?

* This is madness in itself, massively inflating the number of accepted referrals, having a doctor take the referral would allow them to refuse unsuitable referrals at an early stage decreasing the overall workload - but that isn't my focus here.

** In this unit triage actually means the presenting complaint is briefly noted and bloods are drawn and perhaps a cannula is inserted, and basic observations are taken (blood pressure etc.) No actual triage of severity is undertaken and the patrient is then seen by the next junior doctor available, whether they be FY1 house officer or registrar.

*** This can be very many hours later, and is also madness, since very sick patients can be seen by the most junior doctors without any review by more experienced seniors, and this may even include patients referred from A+E being seen by the FY1 doctors.


GrumpyRN said...

3 thing immediately jumped out from this:-

1) You (or the trust) don't understand the role of a nurse practitioner, and/or
2) The nurse practitioners are being horrendously underutilised.
3) So not triage at all, merely assigning a patient a place in the queue.

From what you write the job does not need a nurse practitioner, it needs a nurse assigned to that job - nurse practitioners are, or should be a whole different kettle of fish.

pj said...

1) Well I have an inkling - stoma and palliative care nurses for instance do a great job. Pain and often diabetic nurses in my experience less so. ITU outreach nurses are very skilled but utilised incorrectly. Night nurse practitioners are a mixed bag.
2) That depends, 'nurse practitioner' being a poorly defined title. If your training doesn't allow you to do any more than this (i.e. you aren't a prescriber or diagnostician) then what more can they do?
3) Not even that - they join the queue in order of arrival (unless they're in neutropenic sepsis or otherwise obviously screwed).
4) I don't think it needs an extra nurse assigned at all. The triage nurse could do it just as well (her workload now consequently decreased). And given the limitations on assessment rooms this would free up the single assessment room for the doctors to use.

pj said...

I think from my perspective what would be useful would be employing another nurse to do the routine nursing aspects of admitting new patients to the MAU - i.e. instead of doing essentially redundant stuff like calculating a Wells score*, checking the d-dimer then chasing me to request a doppler (all things that I still have to do anyway). Having a nurse who could be dipping urine, giving meds, or doing obs after a fluid challenge would be a hell of a lot more useful and actually increase productivity. As it is we have two nurses and 2-4 doctors 'assessing' patients and a single nurse responsible for their care after assessment (not counting those patients who go straight to a bed).

Many of these specialist nurse roles just create more paperwork to be filled in and have minimal impact on clinical care. Maybe when we have enough nurses doing routine nursing we can think about creating these essentially superfluous roles (but doing them properly, not this half arsed way), but until then I have little time for them**.

* This is actually really annoying because the DVT nurse is in no position to calculate the score because she hasn't taken a full history or properly examined the patient and thus can't assess diagnostic probability.

** A similar story can be seen with our chronic and acute pain nurses - they work 9-5, hardly answer their bleeps, are often on leave with no cover, yet we are supposed to refer all sorts of things to them. But when they do see the patients they can offer very little more than we can do (often less - such as the last one who was 'new' and so didn't know anything!), other than allow us to give oxycodone and other morphine alternatives, or to put up PCAs (all things we can do ourselves as well or better, and naturally we still have to prescribe these things and take responsibility for them). Their only advantage is that they can ask for help from the pain consultants directly (i.e. occasionally get epidurals) but largely they actually delay the giving adequate analgesia and make nursing staff reluctant to accept doctor initiated changes to pain relief***.
*** Admittdely the anaesthetists are also bad at this - writing things like 'PCA dosage not to be changed without consultant anaesthetist approval' and then the nursing staff refusing to give top-up analgesia in the middle of the night when there is no hope of getting an anaesthetists to come and fiddle with the PCA.

The Shrink said...

Meh, it's so fucked, you just couldn't make it up, could you? :-(

Nurse Anne said...

"** A similar story can be seen with our chronic and acute pain nurses - they work 9-5, hardly answer their bleeps, are often on leave with no cover, yet we are supposed to refer all sorts of things to them. But when they do see the patients they can offer very little more than we can do "

This is so true. It is the case with the diabetic nurses, tissue viability etc etc etc.

Anonymous said...

u sound like a cunt to me