A team approach to improving access to Urology Services Trish White Urology NP, BN, MN (Dist) Mr Kim Broome, Urologist Hawke’s Bay DHB Te Papa, Wellington 17 th 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 –ClinicsFSA FU –CommunityCase Management pm –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

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 UrologistsTrish Total % % % (Locum) 10611% % 2009 Overall NP has seen 14.4% of pts on urology OPD contract % of total Urology FU appts

Types of patients 2009 FSATotal 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

Referrals to Urologist 2009 Total to Urologist n=48 –22 Surgery1:5 –5 TRUS –10 Cystoscopy –10 clinical concern W/L 2009 –TURP = 16 –TURBT = 1 –BNI = 3 –Nephrectomy = 1 –Sling = 1 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 surveyANZUNS Inc members 260 responses 41% International Journal of Urology Nursing 2009 White, Crowe, Papps 2008

NZ/Australia Nurse-led Clinics White, Crowe, Papps 2008

NZ/Australia clinics White, Crowe, Papps 2008

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 role White, Crowe, Papps 2008

Advanced clinical skills White, Crowe, Papps 2008

Other advanced skills Lecturer undergraduates Assess urology competencies Train 1 st 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 White, Crowe, Papps 2008

OPD pts – who could see them? White, Crowe, Papps 2008

OPD pts – who could see them? White, Crowe, Papps 2008

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 White, Crowe, Papps 2008

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 study30% (n=27) –Blocked IDC, postop complications 8.6% (n=8) –11 managed in community by NP

Results: ED presentation BOO Admitted to ward Discharged to NP Age Number n = 6641% (n=27)59% (n=39) TURP n = Average Retention vol 1117ml893ml 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 LOS131 days0

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