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Nurse Practitioner-led Outreach Rapid Response Acute Aged Care Service
Shin Hwa, Kang-Breen, Nurse Practitioner – Acute Aged Care, RN, MNP, MHSciEd (Hon.)
Emergency Department, Coffs Harbour Health CampusMid North Coast Local Health District
Background§ The Nurse Practitioner (NP) – led Outreach Rapid
Response Acute Aged Care service was implemented in March 2012
§ The service is delivering a patient-centred and Integrated Health model of Care framework
§ It’s effectiveness was recognised and selected as the winner of Integrated Care for 2015 Mid North Coast Local Health District (MNCLHD) Quality Awards.
§ It has been also awarded for Integrated Care Finalist for 2015 NSW Health Innovation Awards
Purpose§ The purpose of the service is to minimise incidents of unnecessary acute care hospital presentations through,
§ providing timely access to acute care§ reducing unnecessary complications to older
persons, &§ increasing the satisfaction of the older persons and
their families
Method: Appropriate care in the right place at the right time§ The service is available to RACFs, GPs, older persons & families in the Coffs Harbour region
§ The service is also accessed by ED, discharge planners as well as the community health care services to provide appropriate care to older persons in the right place at the right time
§ Monthly data of the NP’s monthly total occasions of service (OOS) (Fig. 1) shows that on average patients are being seen by the NP on 92 occasions
§ The OOS for the avoidable hospital presentations (Fig. 2 & 3) demonstrate that the average monthly hospital avoidance achieved by the NP is 71 occasions (Fig.2), which is up to 79% of the monthly OOS received the appropriate care in the right place at the right time.
Figure 1: Monthly occasions of NP service 2013-2014
Figure 2: Monthly occasions of Hospital Avoidance 2013-2014
Nov-14
Sep- 14
Jul-14
May-14
Mar- 14
Jan-14
Nov- 13
Sep-13
Jul-13
May- 13
Mar-13
Jan-13
140
120
100
80
60
40
20
0
Date
Individual Value
_X=71
UCL=139
LCL=2.4
Total Occasions of services of Hospital AvoidanceJanuary 2013 - December 2014
Figure 3: Monthly occasions of Hospital Avoidance 2012 - 2013
020406080
100120
1
2
3
4
5
6
78
9
10
11
12
13
Monthly Numberof OOS
HospitalAvoidances
NP led Rapid Response Outreach Service for Elderly Express Community Care Clinic (ECCC) NP
What is a NP?
The NP for Acute Aged Care Outreach Rapid Response Service is making a significant differences in hospital avoidance / unnecessary hospital presentations from the Coffs Coast Community to CHHC. ECCC NP also had made a positive differences in patient throughput as well as bed utilisation in ED including access block. These outcomes indicate that there is a need for an expansion of the NP role including recruiting more NPs and promoting succession planning within the workforce to provide positive consumer -centered health care service s to the Coffs Harbour Community.
Conclusions
The NP led Acute Aged Care service is implemented to prevent avoidable presentations to the ED / hospital admissions from Residential Aged Care Facilities (RACFs) and the Coffs Harbour elderly community by providing a flexible and rapid response service, with a consumer-centred approach. This is being achieved by delivering the service in collaboration with ED Staff specialists, Geriatrician, General Practitioners (GPs), RACFs’ nursing staff and various other Health & Allied professionals from CHHC, providing the right care to the elderly population at the right time, and in the right place. The NP provides an outreach service to the Coffs Harbour community including Woolgoolga, Nambucca and Bellingen areas.
A primary aim of the NP led service was to reduce the rate of ED presentations and the graph below is an evidence of hospital avoidance during 2012 - 2013
The ECCC NP provides fast – tracked health service by conducting a
timely assessment, treatment and discharge of patients.
This role has created several benefits to ED, which are, 1 Reductions in patient length of stay in the ED; 2 A reduction on the number of patients leaving before being treated; 3 improved patient throughput and bed utilisation across the ED; 4 Reduce access block; and, 5 Improvement in patient satisfaction and ED staff satisfaction
Nurse practitioners (NPs) are registered nurses with additional educational preparation and experience who possess and demonstrate the competencies to
autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals and
perform specific procedures within their legislated scope of practice
The NP role is grounded in the nursing profession’s
values, knowledge, theories and practice and provides innovative and flexible health care delivery that complements other health care
providers (ANMC 2006)
NPs practice collaboratively as an interdependent member of the multidisciplinary health care team and provide autonomous, consumer - centred care
NP is a protected title
The graphs & diagrams below are some of evidence / outcomes of ECCC NP activities:
� Changes in length of stay
� Fast Track Presentations
1–31 Jan 2011 Pre-Fast Track Model
& NP
1–31 Jan 2014 Post-Fast Track Model &
NP
Fast Track Presentations
640 906
Average Arrival to Discharge Time 3.11 hours 1.45 hours
Patients >2 hours to Discharge 398 287 Percentage of Patients Meeting
Benchmark 37.18%
68.32%
Number of Patients who did not wait for treatment
281 89
� Ministry of Health Key Performance Indicator Benchmarks Category 1: 100% <= 2 mins Category 2: 80% <= 10 mins Category 3: 75% <= 30 mins Category 4: 70% <= 60 mins
Category 5: 70% <= 120mins
Poster presented on 11 July 2014 at the Nursing & Midwifery Symposium: Engaging, growing and celebrating on the NSW Mid North
Coast | Venue: Southern Cross University, Coffs Harbour
Background
Emergency Department (ED), Coffs Harbour Health Campus (CHHC) developed an innovative alternative strategy to meet the ever-increasing health care demands of Coffs Harbour community by recruiting two Nurse Practitioners (NPs) for the provision of consumer-focused health care.
The first NP was recruited in March 2012, for the Acute Aged Care Rapid Response Outreach service, and the second NP was appointed in 2013 for Express Community Care Clinic
(ECCC) in the ED to provide fast - track health service for the population who present to ED with minor injuries or non-urgent health care needs, which Australian triage score (ATS) categories of 4 and 5.
NURSE PRACTITIONERS & CONSUMER-CENTERED APPROACH IN HEALTH SERVICE DELIVERY FROM EMERGENCY DEPARTMENT
SHIN HWA KANG-BREEN,1 MN(NP), MHLSCIED (HON) & DAVID MCKIERNAN,2 MN (NP), BN
1 & 2 EMERGENCY DEPARTMENT, COFFS HARBOUR HEALTH CAMPUS, COFFS HARBOUR, NSW 2450, AUSTRALIA
Triage / Assessment History taking, physical examination, investigations for consideration
Diagnosis / Interpretation
Management plan Treatment options to consider: referrals or NP treat or health promotion or Non-pharmacological approach or pharmacological option
Follow-up Review as appropriate, test results, monitor progress
Independently assessed by NP
Admit for surgical intervention
Discharge home for follow up surgery/outpatient
review
Injury reduced/mobilised in ED (in consultation with ED Staff Specialist if required)
Direct referral to orthopaedic team
Discharge home with relevant education, analgesia +/-
support services for follow up in outpatient clinic
Patient identified for Fast Track with
orthopaedic injury
General approach to a patient assessment by NP
Typical journey through ED Fast Track Model of Care with the NP as a Care Provider
Results…So farOlder Person – Centred Care:
§ The NP-led Outreach Rapid Response Service has made an impact in bettering older persons care outcomes particularly in RACFs
Efficiency of the NP-led Service:
§ 86% in 2013 and 74% in 2014 of RACF residents received their medical care and end-of-life care from the NP in their home environment
§ Total 900 / 1046 OOS of hospital avoidance in 2013
§ Total 791 / 1067 OOS of hospital avoidance in 2014
§ Above figures translate to many avoided bed days & $$$
§ Anecdotally, in addition to the statistical data, there has been a significant reduction in older persons presenting in ED from RACFs as frequently claimed by staff specialists and nursing staff in ED, CHHC
Collaboration | Integrated Health Care Service:
§ The hospital avoidance DRGs and geriatric syndromes are being assessed and treated in RACFs in collaboration with the GPs including older persons & their families
Empowering | Capacity Building in RACFs:
§ Education / training sessions are delivered by the NP
§ Communication & Collaboration with / via
§ ISBAR style in communication
§ Emergency Decision Guidelines booklet
§ Recognising the deteriorating older persons educations
§ 6 out of 13 RACFs capable of administering IV antibiotics & hydration at the RACFs
§ 2 out of 13 RACFs capable of cannulation autonomously
§ Timely coordination of end-of-life | advance care directives, ensuring a person-centred good death for older person & his/her family
§ IDC, SPC & PEG change independently
§ Complex wound management
Conclusion & Implications§ The NP- led Outreach Rapid Response Acute Car
Service is making positive efficiencies in limiting unnecessary hospital presentations from the Coffs Harbour Community to CHHC.
§ The concept of this NP-led model of care in Coffs Harbour has been taken up by multiple hospitals from Toowoomba Health, Grafton, and Goulburn as well as a few others formally and informally.
§ Therefore, demonstrating the practically and transferability of the NP-led model of care.
§ This illustrates that there is a need for future planning for the education and training of RNs for the NP role
References§ Avoidable admissions, Preamble (2007). NSW Health
§ Kang-Breen, S H. (2012). Nurse Practitioner for Outreach Rapid Response Acute Care Service Scope of Practice, ED, CHHC
§ Nurse Practitioner Activity Data, from 2012 – 2014, Ed, CHHC
§ Ouslander, J & Berenson, R. (2011). Reducing unnecessary hospitalization of nursing home residents. New England Journal of Medicine, September 29, 1165 – 1167
§ Stefanacci, R & Haimowitz, D. (2014). The perfect interactions to reduce hospitalizations, Geriatric Nursing, 35, 466 – 470
Acknowledgements
§ Thanks to Ms. Helen Ganley – Data Sanity for her contribution
Contact
§ Shin Hwa, Kang-Breen, NP
§ Mobile: 0427 909 583
Poster presented on 3 December 2015 at the Mid North Coast Research Conference: The future of Health is in Your Hands: Research Driving Better Outcomes | Venue: Port Macquarie Shared Health, Research & Education Campus (PMSHREC), Rural Clinical School, University of New South Wales, Highfields Cct, Port Macquarie NSW
