A team approach to improving access to Urology Services Trish White Urology NP, BN, MN (Dist) Mr Kim...

A team approach to improving access to Urology Services

Trish White Urology NP, BN, MN (Dist)Mr Kim Broome, Urologist

Hawke’s Bay DHBTe Papa, Wellington 17th November 2010

Introduction

• All started back in 2004!– Completion of MN advanced practicum, Kim as

clinical mentor – Application for NP registration 2005 – Application to MOH Elective Initiatives Fund to

establish NP role

• Urology NP role in elective services– Clinics FSA FU– Community Case Management 80-100pm– Hospital/ED

HBDHB Clinics

• Two clinics per week • Patients triaged by Urologist

– Predictable outcomes– Prostate or LUTS, UTI, continence, voiding disorders, oncology

surveillance, follow-up

• Assess, investigate, diagnose, treat and evaluate • FSA and FU patients• Refer, discharge as appropriate • Most seen within two months• Evidence based clinical guidelines • Collaborative practice • Excellent clinical support from Urologist

MOH KPI

020406080

100120140

Oct

Nov

Dec Ja

n

Feb

Mar

ch

Apr

il

May

June

July

Aug

Sep

t

2004 2005

No

. o

f p

ts

Patients waiting more than 6 mths for an FSA at end of period



MOH Feedback

“The NP Service has allowed the Urologist to focus on high acuity patients and use his expert skills

where they are needed most. Urology patients have benefited through the

good example of effective interdisciplinary care. The success of this project highlights the

benefits of having more NPs working in acute and elective services.”

Jane Craven, Senior Advisor, MOH, February 2006

Urology FSA

Total

FSA

Urologists Trish Trish

Total %

2006 751 680 71 9%

2007 721 643 78 11%

2008 940 827(Locum)

106 11%

2009 896 787 109 12%

2009 Overall NP has seen 14.4% of pts on urology OPD contract

2009 15.5% of total Urology FU appts

Types of patients 2009

• FSA Total 109– LUTS/Voiding disorders– Recurrent UTI– Continence – Raised PSA

• Follow-up 306– Post-op– Oncology Surveillance – General Follow-up

• Approval from urologist to see appropriate pts from his recall FU list – Reviewed list with ACN – 50 selected – Only seven referred back to urologist

Outcomes NP FSA

0%

10%

20%

30%

40%

50%

60%

NP

2006 2007 2008 2009

Referrals to Urologist 2009

• Total to Urologist n=48

– 22 Surgery 1:5– 5 TRUS– 10 Cystoscopy– 10 clinical concern

• W/L 2009– TURP = 16– TURBT = 1– BNI = 3– Nephrectomy = 1– Sling = 1

0%

5%

10%

15%

20%

25%

30%

2006 2007 2008 2009

n=16 n=18 n=27 n=22

W/L Referrals

Pick-ups

• Prostate cancer in 59 year old • Prostate cancer in 62 year old • Renal cancer• Bladder cancer

All presented with LUTS

Research

Defining Urology nursing practice roles in Australia and New Zealand

• Postal survey ANZUNS Inc members• 260 responses 41%

International Journal of Urology Nursing 2009

White, Crowe, Papps 2008

NZ/Australia Nurse-led Clinics

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LUTS n=60 Voiding Disordern=78

Continence n=96 Haematurian=64

Competency

Informal

Self taught


NZ/Australia clinics

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

UTI n=72 Postop n=66 ED n=35 Oncology Surveillancen=21

Competency

Informal

Self taught


Advanced Skills

• Cystoscopy– n =7

• 5 under direct medical supervision 1 NZ, 4 Australia

• 2 independent 1NZ, 1 Australia

• 2 ward, 2 OPD, 2 OT, 1 combination role

• All specialist nurses

• Cystoscopy – diathermy– n = 1: Australia, specialist nurse

• Cystoscopy – stent removal – n = 5: All Australia

• 3 ward, 1 OT, 1 combination role

• 1 non-specialist, 3 specialist, 1 other roleWhite, Crowe, Papps 2008

Advanced clinical skills

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cystoscopy n=251 CystoscopyDiathermy n=247

TRUS n=244 Insert SPC n=252

Dr

NP

CNS

RN


Other advanced skills• Lecturer undergraduates• Assess urology competencies• Train 1st year medical students• Biofeedback, faecal incontinence• Teach urology procedures• Monitor/interview post-op pts• Educate clients & staff• Equipment expertise• Bladder training clinic• Assess & train manual bladder

irrigation• Urodynamics• Intravesical chemotherapy• Intracavernosal injection therapy• Education for health professionals• Oncology surveillance• Laser operator

• Continence management & bladder training

• Insert haematuria type catheter• Teach self-catheterisation• Complex post-op clinical care• Assist other specialties with

urological problems• Organise community supports• Urostomy management• Protocol development• Health promotion continence• Review results, triage referrals• Urethral dilation• Maintain bladder cancer database• Trial of void at home• Sexuality discussions with pts &

partners• Uro & gynaecology assessments


OPD pts – who could see them?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LUTS n=194 Voiding Disordern=205

Continencen=208

Haematurian=203

Dr

NP

CNS

RN


OPD pts – who could see them?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Postop n=205 ED n=204 Urodynamics n=206 OncologySurveillance n=196

Dr

NP

CNS

RN


Opportunities for Urology Nurses

• Experienced – 79% worked in Urology >5yrs

• Well educated– 47% PG qualification, 60% specialist nurses PG

qualification, 10% undertaking tertiary study• 29% working towards an advanced role (n=74)

• Professionalism– 70% presented a paper, 5% published, 31% research

• Role confusion – 35 job titles identified, 26% jobs created independently,

33% no guidelines for role development


Discussion

• Overall aging population • Aging workforce! (80%>40yrs)

• New technology• Higher demand

“Any expansion in a nurse’s practice should be informed by a philosophy rooted in improving the

quality of patient care”

Greenwood, 2003

Strengths of my role in OPD

• Contributed to decreased waiting times – 87%

• Similar clinical outcomes

• Providing quality and effective care for Urology patients using nursing clinical expertise

• 55% FSA managed by NP

• Urologist receives appropriate referrals, with full assessment completed

Strengths

• Contributing positively to health outcomes, responsive to needs & crosses boundaries

• Evidence based practice

• Collaborative, interdisciplinary

• Health promotion, education, self management

• Prescribing

• Informed Consent

Challenges

• Some see role as a threat, impact of role on contracts

• Radiology – unable to order some tests • Disjointed service – up to 7 admin staff• Horizontal violence • Little support for nurses in roles as “not enough

resources”– Leave, backfill, non-clinical time, succession

planning

Acute Urinary Retention

Example of hospital to community based NP care

Aim of Study

• To review service provided to men presenting with UR to ED

• Review effectiveness of ED protocol to establish criteria for discharge

• Is use of the NP role effective in providing quality, cost effective care

Methodology

• Retrospective review of men over 50, admitted to ED with UR over one year period (1/7/09 – 30/6/10)

• IT provided list using ICD codes for Urinary Retention • NP review of ED/ward electronic discharge summaries to

gather information on:– ED discharge plan

• Either Ward or community with NP follow-up

– Diagnosis– TURP?– Retention Volume – LOS

• Establish cost savings on early discharge programme

Results

• Total 336 visits for men >50 with Urology diagnosis

• Average age 73.8

• Primary diagnosis UR 28% (n=93)– Average Age 77.5yrs– Included in study men with BOO

• Exclusions from study 30% (n=27)– Blocked IDC, postop complications 8.6% (n=8)

– 11 managed in community by NP

Results: ED presentation BOOAdmitted to

wardDischarged to

NP

Age 80 74.2

Number n = 66 41% (n=27) 59% (n=39)

TURP n = 24 18 6

Average Retention vol

1117ml 893ml

Deceased by end of year

25% (n=7) 8% (n=3)

Outcomes

Admitted to ward

Discharged to NP

Cost

Based on $470 per day in ward

$61,570

ALOS 4.8 days

Estimated prevent 1 day LOS = $11,700 saving

19 FSA appts

LOS 131 days 0

Outcomes

• Safe discharge of community patients with no readmissions

• As expected the NP group is: – Younger – Lower retention volumes – Less overall deaths – Less TURP required

• Financial saving demonstrated • Cared for in own home • Less pressure on DHB resources eg beds• Single contact – GPs often refer directly

Teamwork always wins!

References

Dellagiacoma, T. (2007). Eight essential factors for successful nurse-led services. Australian Nursing Journal p28-31

White, T., Crowe, H. & Papps, E. (2009). Defining Urology nursing practice roles in Australia and New Zealand: IJUN

Greenwood, J. (2003). Nurse-led clinics for assessing men with lower urinary tract symptoms. Professional Nurse 19 (4) p228-32

A team approach to improving access to Urology Services Trish White Urology NP, BN, MN (Dist) Mr Kim...

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