Introduction of an advanced practice nurse endoscopist program to Victoria Melodie Heland, Director Surgical Clinical Services Unit Sylvia Constantinou, Program Manager, State Endoscopy Training Centre
Presentation Overview Prevention opportunity: Colon cancer The volume challenge Merits of nurse endoscopy Programs underway in Victoria Lessons learned in introducing workforce change Impact of NE role at Austin Health service and quality Cost comparison
Background Colorectal cancer is the second most common cancer in men and women in Australia One of the most preventable cancers Screening improves early detection, treatment and survival It is now easy, cheap and socially acceptable to do the test
Health promotion message
National Bowel Cancer Screening Program Between July 2012 and Dec 2015, 4.8 million eligible Australians will have been offered free bowel cancer screening 40% uptake 7.8% positivity rate for FOBT = 1.9 million people tested = 149,000 over a 3.5 year period Approximately 42,000 FOBT positive patients annually nationwide These are just the NBCSP numbers!
NBCSP and future referrals Positive FOBT 7.8% (42,000 people a year) Polyps, adenomas, cancer found in 55% 23,000 people join the list of those who need a repeat colonoscopy every 3 5 yrs
Victorian NBCSP Add 60 yo: +32% Add 70 yo: +55% Add biennial screening: +90% Public colonoscopies +369% of the 2011 figures
Feels a bit like this.. Need to do something different
The merits of nurse endoscopy
1994
Nurse Endoscopist role..gradual development over past 3 years Workforce Innovation grant program 2011 Health Workforce Australia funding 2012 State Endoscopy Training Centre 2014
From little things big things grow. 1. Austin Health successful grant application to Victorian Dept of Health Workforce Innovation Program. Trained Nurse Endoscopist from the program scoping independently since Feb 2013 2. 2012 Health Workforce Australia Nurse Endoscopy Project Austin Health:- Lead site in Victoria. 4 NE trainees Victorian Implementation sites:- Austin, Alfred, Monash & Western Logan Hospital:- Lead site in Qld. 2 NE trainees
State Endoscopy Training Centre State Endoscopy Training Centre (SETC) established:- Jan 2014 Funded by Department of Health Victoria Funds secured for four years. Goal:- 10 Public Hospitals, with at least one Nurse Endoscopist, in the next four years Working in partnership with Victorian Public Hospitals to implement a training program based on the training pathway arising from the HWA project
State Endoscopy Training Centre (SETC) Austin Health Addition of new NE Health Services planned in 2014-15 UK University for theoretical component Structured training program consisting of:- Post Grad level study Personal Development Legal and regulatory status Simulation Training Observational Training Communicating effectively with patients Performing Colonoscopy Ongoing support and assistance
Lessons learned Workforce change creates uncertainty Underestimate the politics at your peril Communication, commitment and understanding of the program across all participating departments Tortoise vs the Hare Selection of candidate Site readiness
Lessons learned Health Service readiness is critical to success Organisational readiness (developed by the Victorian Department of Health)» The health service has established the need for a NE service and identified the benefits for the organisation, staff and consumers.» The health service has developed a service delivery model for the NE service» The health service is committed to providing a NE service that is sustainable over the longer term» The health service has established the clinical governance structures and arrangements required to support a NE service» The health service has identified and engaged relevant stakeholders required to support a NE service» The health service is able to provide supervised medical clinical practice for NE trainees» The health service is to ensure program management skills are available to support the establishment phase of a NE service» The preparedness of the health service to reform on behalf of the system and drive national and state-wide transferability of the new workforce model» The willingness of executive staff, medical and nursing clinicians and surgical services staff to learn with and accept support from others including SETC, other participating health services, the Department, training organisations and consumers and carers
Nurse endoscopist role - in Victoria NOW Total of 7 people across these programs 2 fully trained Nurse Endoscopists (Austin & Monash) 3 NE trainees approaching sign off (Western, Austin, Alfred) 2 new trainees Melbourne Health Eastern Health Theoretical training component supplied via University of Hull UK Practical training provided by participating Health Services and Austin Health SETC
Complication Rates First Victorian Nurse Endoscopist Total colonoscopies: 1083 (579 as trainee; 504 as a NE) Complications: 0 Four trainees across Victoria (Jan 13 to May 14) Total colonoscopies: 1216 Complications: 2 One perforated diverticulum 84 y.o. right hemicolectomy Post-polypectomy PR bleeding - Settled spontaneously
Impact of Nurse Endoscopy at Austin Nurse commenced independent list in Feb 2013 12.6% of total colonoscopies Without adverse events High completion rate High polyp detection rate
Nurse Endoscopy Procedural Data:02/13-07/14 Parameters Number Total Austin Health colonoscopies 3694 Numbers of colonoscopies (NE) 504 (12.6%) Patients with polyps 260 Patients with cancer 9 Patients with adenoma 174 Patients with hyperplastic polyps 64 Polyps not suitable for processing 3 Assistance requested from supervising consultant Incomplete procedures (due to looping, obstruction, poor prep etc) 6 15 Patients sent for advanced endoscopy 13
Indications for referral to Nurse Endoscopist Indications Number Abdominal pain 1 ABH:- Blood group expression 7 Anaemia 3 Previous CRC:- Screen 4 Diverticular Disease 4 Diarrhoea 3 Family history screening 148 Faecal Occult Blood Test 88 NBCSP patients 76 Polyp surveillance 103 PR Bleeding 63
Benchmarking: Adenoma detection rate Adenoma detection rate (ADR) Adenoma has a higher rate of progression to cancer than other polyps Indicator of quality of procedure Overall risk of progressing to cancer for unchecked adenoma is 5% Can be as high as 10% in 55yr old females, 43% in 55yr old males UK NBCS targets for proceduralists 32% ADR Austin Health s Nurse Endoscopist 34.8% ADR
Benchmarking: Procedure Colonoscopy completion rate form 25-02-2013 to completion 25-02-2014 rates 100% 99% 98% 97% 96% 95% 94% 93% 92% 91% 90% 89% 88%
Benchmarking: Polyp detection detection rate rates 80 70 60 56.41 50 40 Average polyp detection rate 30 20 10 0 AA AB AC AD AE AF AG AH AI AJ AK AL AM AN AO AP AQ AR AS AT AU AV AW AX NE AY AZ
Nurse led Out patient clinics Total number of Patients Pre-procedure assessment patients Post-procedure review patients Patient declined nurse endoscopy procedures 219 164 55 5
Budgetary impact / Service continuity» Difference in salary Nurse Endoscopist, staff member $43.54 /hr VMO Yr 5 $131.50 /hr One session per week annually = $16,000 savings in salary» Leave coverage 29 gastroenterologists and colorectal surgeons x 5 weeks p.a. 145 weeks leave Opportunity taken up for NE to cover lists with agreed criteria» WIES $1290 WIES per colonoscopy $6450 income for no extra cost if full time NE is used
Number of Procedures number of patients waiting Austin Hospital Colonoscopy waiting list and performance Number of Procedures number of patients waiting 6000 3000 5000 2305 2568 2198 4000 1577 1686 2000 3000 2000 1000 1044 1062 862 500 2564 2215 1749 1747 2645 2657 2758 2509 2553 *Projected, Based on 9 th Sept12 Data 2006 2007 2008 2009 2010 2011 2012 2013 2014 1000 0
Victorian Public Healthcare Awards 2013 Health Leader s Award for achieving a highly capable and engaged workforce
Summary Early detection can reduce morbidity & mortality from cancer Waiting list and waiting time is significant now for public colonoscopy NBCSP moving to full roll-out with biennial screening demand and waiting times will increase Nurse endoscopy utilized safely with high standards & satisfaction in Europe and USA Has been a successful workforce change for Austin Health, govt support for ongoing program When benchmarked - Quality of service is high Is enabling us to seize the opportunity to support an excellent public health initiative and prevent cancer
Acknowledgements The Advance Practice Nurse Endoscopy Project was funded by HWA The State Endoscopy Training Centre is supported by the Victorian Government.
Thanks for the opportunity