Information Services Division NURSE-LED OUTPATIENT ACTIVITY PROJECT (Phase 1) Sponsor ISD Data Development Programme Authors Jenni Muir Richmond Davies September 2005
Document History Version Date Amendment Comment 1.0 30 Sept 2005 First draft 2
1.0 INTRODUCTION 1.1 Setting the scene In 2002, Audit Scotland announced that the follow-up to their earlier 2001 report on Outpatients would include a week long count of planned clinics, actual numbers of patients seen, numbers of DNAs, etc, across the full spectrum of possible clinic leads (e.g. nurses, specific AHPs, consultants). ISD then offered to investigate an additional data collection phase that would give indicative figures of planned clinics in advance of main report. Both the ISD findings and the Audit Scotland report provided evidence of the large number of people seen at clinics run by non-medical staff. Also evidenced was the fact that the information and medical staff were not always aware of the existence of clinics run by nonmedical staff. Many lessons were learnt and set the scene for groundwork for further initiatives. The service was advised of the extension of SMR00 by ISD in February 2003. Few nurse-led SMR00 records were submitted to ISD and a change of tack was necessary. In October 2003, ISD issued guidance advising health board areas of the introduction, from January 2004, of a new monthly requirement for aggregate statistics on nurse-led clinics using the ISD(S)1 approach. The process of reporting the nurse-led clinic and AHP and Other technical Departments attendance data has essentially become an established routine exercise and is published in the data developments section of the ISD website. It is important to note that ISD is aware of areas where pressure has been exerted by consultants to cease or prevent recording of nurse-led activity so that their activity levels are maintained. Until these issues can be better quantified, it may be prudent to avoid any assumption that the nurse-led figures can simply be added to the existing figures for consultant-led outpatients to provide a total. The Scottish Executive s Centre for Change and Innovation (CCI) has been investing in the biggest ever change programme in outpatient services to improve patient access and help NHS systems reduce waiting times and sustain these reductions. The programme is complimented by the National waiting Times Unit investment to tackle historic backlogs that have arisen. The CCI is engaged in a strategy for supporting NHS Boards in redesigning their services and facilitating local interventions based on evidence and best practice. The CCI has selected specialties cardiology, dermatology, ENT, general medicine, general surgery, gynaecology, neurology, ophthalmology, orthopaedics, plastic surgery, respiratory medicine and urology - that represent the majority of all referrals from primary to secondary care. 1.2 Rationale ISD s ability to meet the challenge of providing fuller answers to questions about NHS activity and deliver new and improved information depends hugely on collaborative working with others, particularly NHSScotland Health Boards and the Scottish Executive Health Department. Central to the success of this endeavour is the clinical community. Clinical leaders and the champions of clinical information must engage with their colleagues to bring about greater understanding of the importance of information to the ongoing improvement of all aspects of patient care. The aim of this exercise is to provide preliminary insight into the activities that are carried out in a small selection of nurse-led outpatient services in providing care for the patient during their journey. At the time of the survey, dermatology, ENT and orthopaedic redesign were in progress as a result of CCI investment in the service. It was therefore decided to focus on these specialties. It must be emphasised that the clinics selected are not statistically representative of all nurse-led clinics in NHSScotland. These are just a few clinics that have good quality local information that the CCI uses to monitor the effects of their investments. 3
The reasons for undertaking the exercise are as follows: - ISD has gathered, anecdotally, that the figures for attendances and procedures at nurse-led clinics that are submitted routinely to ISD do not reflect the magnitude of work carried out by nurses in outpatient nurse-led clinics. - The CCI has been investing money in developing outpatient nurse-led services in order to make clinicians work more smartly, reduce the waiting times for outpatient appointments and ease the burden on consultant-led services. - In the future, there may be a requirement to monitor waiting times for outpatient nurse-led clinic appointments and ISD would like to have a flavour of the issues involved in recording activities that take place in these clinics. - ISD is aware that, in some of these clinics, nurses receive direct referrals, diagnose, treat, refer onwards and discharge, but the clinics continue to be labelled consultantled, thus giving an inaccurate picture of what is actually happening in the service. - ISD would like to understand the issues involved in ensuring accurate data are collected to inform robust national information for the journey of patients through outpatient nurse-led clinics. 2.0 OBJECTIVES The objectives of this project are: 1. To identify activities undertaken by nurses leading a selection of CCI funded outpatient nurse-led services across orthopaedics, ENT and dermatology. 2. To ascertain the administrative operating procedures receiving and triaging referrals, discharging and referring undertaken by nurses in a selection of nurse-led services. 3. To examine how nurses work alongside other healthcare professionals in multidisciplinary and joint services for outpatient clinics. 4. To present the issues that will affect the robustness of nurse-led activity data. 5. To make recommendations for developing and expanding the project. 3.0 METHODOLOGY A descriptive approach to describe and quantify the activities of lead nurses in outpatient nurse-led clinics was adopted to meet the above objectives. The sampling method was judgement sampling, which involved a deliberate choice of a sample. This is good for providing illustrative examples and is prone to bias; so samples are small and one cannot extrapolate from the sample. Representatives from ISD s National Data Development Programme and SE s CCI met to discuss the issues of lack of robust nurse activity data and the type of redesign work being sponsored by the CCI. The CCI subsequently provided contact names and addresses of Project and Service Managers involved in redesigned nurse-led services. It was decided to visit these clinics and interview the lead nurses and project managers. In some cases, due to the unavailability of the lead nurse at the clinic, the nurse was contacted by telephone or invited to ISD s premises in Edinburgh. Questionnaires were developed to serve as a guide for unstructured interviews. They comprised the following questions: - What is the service? Is it an outpatient service? - How was the service set up? - Roughly, what numbers of patients (new and returns) do you see per week or per month? - What is the frequency of the service? - How many and what grades of staff run the service? - Why is it called a nurse-led service? 4
- Is the nurse in charge registered on the ISD reference files and are they awarded activity for this clinic? If no, why? - Does the nurse have clinical responsibility for the patient and are there any procedures to determine how this responsibility is allocated? - Are there any procedures for setting up a nurse clinic and how is it registered with the information department? - Where a nurse has continual follow up patients, sometimes over many years, is the source of referral always recorded as original referrer or as the HCP at the previous appointment? - Are there any qualifications or other requirements for a nurse to run a clinic? - How do you handle referrals (appropriate and inappropriate) to the service and who triages the referrals? - What are the procedures for appointments and do you have administrative support for handling this? - Do you sometimes refer the patient on to another HCP? If yes, how do you do this? - Do you work as part of a multidisciplinary team? If yes, in whose name is the clinic registered with the information department? - How do you record activities that are carried out? Are they all submitted to your information department? Do you record data on ISD(S)1 and SMR00 forms? - What activities do you carry out both procedures and non-procedures? - Did consultants previously carry out some of the activities? - What are the procedures for discharging patients from the service? Is the nurse empowered to do this? Brief notes were recorded during each interview and, in some cases follow up telephone calls were made. 4.0 FINDINGS 4.1 CCI funding Most clinics visited were in operation before funding from CCI was available. Clinics have however, on receiving funding, used it to expand and develop their existing services. For example, funding has been used to refurbish clinics, improve room availability, provide nurses with training in specific fields to improve their knowledge, pay the overheads of extra staff required on a secondment basis while permanent staff are training or conducting clinics, and recruit new permanent nursing staff. 4.2 Services provided As mentioned in the objectives, the focus of the study was on 3 specialties orthopaedics, ENT and dermatology. The nurse-led services and the location within each of the 3 specialties covered by this study are shown in the table below: Specialty Location Nurse Clinic/Service Orthopaedics 3 sites within Glasgow Royal Infirmary Fracture clinic Post operative Ankle fracture clinic Post operative foot clinic Post operative hand clinic Dupuytren s assessment clinic Elbow clinic Hand & Wrist lumps and bumps clinic ENT Crosshouse Hospital Crosshouse & Ayr Hospitals Crosshouse Hospital Heathfied Clinic at Prestwick Fracture clinic Joint arthroplasty nurse service Naso-fracture review clinic Aural care clinic Joint (Nurse/Speech & Lang Therapy) voice box valves Review clinics Minor surgery clinic 5
Crosshouse Hospital Inverclyde Royal Hospital Falkirk Royal Infirmary Aberdeen Royal Hospital Wishaw, Monklands & Hairmyres Hospitals Follow up photodynamic therapy clinic New patient clinic Nurse biopsy clinic Photodynamic therapy Review clinic New patient clinic Chronic disease clinic Patch testing clinic minor surgery clinic Cryotherapy clinic Phototherapy clinic 2 nd Line drug monitoring clinic Photodynamic therapy clinic 2 nd Line drug monitoring clinic Cryotherapy clinic Open access return clinic Phototherapy review clinic Leg ulcer management clinic Cryotherapy clinic Photodynamic therapy clinic Phototherapy clinic Review clinics Psoriasis clinics across 3 hospitals Phototherapy clinic Dressings clinic Surgery clinic Chronic disease management clinic Drop-in advice service liaison nurse service A combination of new, new & return and return patients is seen in the nurse-led clinics above. Some clinics are run jointly by a nurse and an allied health professional but attributed to the nurse because the hospital systems cannot support activity by allied health professionals. For a number of clinics, the nurse receives direct referrals from the GP/GDP or another referral source, manages the treatment and either discharges or refers the patient to another healthcare professional. Nevertheless, some of these clinics are attributed to a Consultant who would never have contact with the patient. 4.3 Activities As at end April 2005, the nurse activities across dermatology, orthopaedics and ENT in completed SMR00s submitted to ISD across Scotland are as follows: - Other excision of skin - Curettage of lesion of skin - Other destruction of lesion of skin of head or neck - Other destruction of lesion of skin of other site - Other biopsy of skin - No operation The table below shows that no nurse procedures were recorded and submitted to ISD for orthopaedics and ENT, and only 7 locations reported activities in the 3 specialties. 6
Number of procedures at nurse-led clinics in, Orthopaedics and Since 1st April 2003 Specialty Operation 1A Orthopaedics ENT Heathfield Clinic (A246C) S06 Other Excision Of Lesion Of Skin 7 - - S08 Curettage Of Lesion Of Skin 2 - - S10 Other Destruction Of Lesion Of Skin Of Head Or Neck 6 - - S11 Other Destruction Of Lesion Of Skin Of Other Site 2 - - S15 Other Biopsy Of Skin 16 - - Glasgow Royal Infirmary (G107H) No Operation 1A 2727 1799 90 Stobhill Hospital (G207H) S06 Other Excision Of Lesion Of Skin 2 - - No Operation 1A 12478-107 Western Infirmary/Gartnavel General (G516H) No Operation 1A 243 305 434 Raigmore Hospital (H202H) No Operation 1A - 290 362 St John's Hospital At Howden (S308H) S15 Other Biopsy Of Skin 1 - - No Operation 1A 365 18 - Lauriston Buildings (S374C) No Operation 1A 555-190 Source: SMR00 Date: 29 April 2005 The study found that the following nurse activities are being carried out across the 3 specialties at the locations visited. This is not a definitive list because, for instance, we were unable to obtain a full list of procedures from the only ENT site visited. - Excision of lesion of skin NEC - Punch biopsy of skin - Cryotherapy to lesion of skin NEC - Skin sample for organism - Shave biopsy of lesion of skin NEC - Curettage and cauterisation of lesion of skin NEC - Percutaneous transluminal cannulation of vein - Light therapy - Photodynamic therapy - Phototherapy 7
- Doplar assessments - Pulse assessments - Applying dressings - Topical treatments - Venepuncture - Teledermatology - Removal of sutures / skin clips / Kirshner wires / external fixators / dressings - Removal of casts and splints - Applying casts and splints - Irrigation of external auditory canal and removal of wax. - Other non-procedure activities such as education, advice, health promotion, physical examination, ECG, manage patient helpline, collect data for research, demonstrate/supervise exercises, refer for diagnostic tests, refer to other health professional, and assessments. For comparison, SMR00 data for March 2004 April 2005 were interrogated to show the recorded procedures by consultants as follows: BIOPSY OF LESION OF SKIN OR HEAD OR NECK,N.E.C. BIOPSY OF LESION OF SKIN, NOT ELSEWHERE CLASSIFIED CAUTERISATION OF LESION OF SKIN OF HEAD OR NECK,N.E.C. CAUTERISATION OF LESION OF SKIN, NOT ELSEWHERE CLASSIFIED CRYOTHERAPY OF LESION OF SKIN OF HEAD OR NECK CRYOTHERAPY TO LESION OF SKIN, NOT ELSEWHERE CLASSIFIED CURETTAGE AND CAUTERISATION OF LESION OF SKIN OF HEAD OR NECK CURETTAGE AND CAUTERISATION OF LESION OF SKIN, N.E.C. CURETTAGE OF LESION OF SKIN OF HEAD OR NECK,N.E.C. DESTRUCTION OF LESION OF LIP EXCISION OF LESION OF EXTERNAL NOSE EXCISION OF LESION OF EYELID EXCISION OF LESION OF LIP EXCISION OF LESION OF SKIN OF HEAD OR NECK,N.E.C. EXTIRPATION OF LESION OF NIPPLE INJECTION OF STEROID FOR LOCAL ACTION, NOT ELSEWHERE CLASSIFIED INJECTION OF STEROID INTO SUBCUTANEOUS TISSUE INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT INJECTION OF TRIAMCINOLONE FOR LOCAL ACTION INSERTION OF THERAPEUTIC SUBSTANCE INTO SUBCUTANEOUS TISSUE, N.E.C. OTHER SPECIFIED CURETTAGE OF LESION OF SKIN OTHER SPECIFIED DESTRUCTION OF LESION OF SKIN OR OTHER SITE OTHER SPECIFIED EXCISION OF LESION OF SKIN OTHER SPECIFIED INTRODUCTION OF SUBSTANCE INTO SKIN OTHER SPECIFIED PHOTODESTRUCTION OF LESION OF SKIN PUNCH BIOPSY OF LESION OF SKIN OF HEAD OR NECK PUNCH BIOPSY OF LESION OF SKIN, NOT ELSEWHERE CLASSIFIED SHAVE BIOPSY OF LESION OF SKIN, NOT ELSEWHERE CLASSIFIED SHAVE EXCISION OF LESION OF SKIN OF HEAD OR NECK SHAVE EXCISION OF LESION OF SKIN, NOT ELSEWHERE CLASSIFIED UNSPECIFIED BIOPSY OF SKIN UNSPECIFIED EXCISION OF LESION OF SKIN UNSPECIFIED OPERATION ON SKIN 8
UNSPECIFIED PUNCH BIOPSY OF SKIN BIOPSY OF LESION OF EAR, NOT ELSEWHERE CLASSIFIED BIOPSY OF LESION OF SALIVARY GLAND BIOPSY OF LESION OF SKIN OR HEAD OR NECK,N.E.C. BIOPSY OF LESION OF THYROID GLAND CAUTERISATION OF LESION OF SKIN OF HEAD OR NECK,N.E.C. CAUTERISATION OF LESION OF SKIN, NOT ELSEWHERE CLASSIFIED CRYOTHERAPY TO LESION OF SKIN, NOT ELSEWHERE CLASSIFIED DIAGNOSTIC ENDOSCOPIC EXAMINATION OF NASOPHARYNX, N.E.C. DRAINAGE OF LESION OF SKIN OF HEAD OR NECK EXCISION OF LESION OF EXTERNAL NOSE EXCISION OF LESION OF SKIN OF HEAD OR NECK,N.E.C. EXCISION OR BIOPSY OF CERVICAL LYMPH NODE, NOT ELSEWHERE CLASSIFIED INCISION OF EAR DRUM, NOT ELSEWHERE CLASSIFIED INSERTION OF VENTILATION TUBE THROUGH TYMPANIC MEMBRANE MANIPULATION OF FRACTURE OF BONE, NOT ELSEWHERE CLASSIFIED OTHER SPECIFIED CLEARANCE OF EXTERNAL AUDITORY CANAL OTHER SPECIFIED OPERATIONS ON EAR OTHER SPECIFIED OPERATIONS ON FRONTAL SINUS OTHER SPECIFIED OPERATIONS ON NOSE REMOVAL OF SUTURE FROM SKIN OF HEAD OR NECK REMOVAL OF SUTURE FROM SKIN, NOT ELSEWHERE CLASSIFIED REMOVAL OF VENTILATION TUBE FROM TYMPANIC MEMBRANE REMOVAL OF WAX FROM EXTERNAL AUDITORY CANAL, N.E.C. REPAIR OF EXTERNAL EAR, NOT ELSEWHERE CLASSIFIED SUCTION CLEARANCE OF MIDDLE EAR UNSPECIFIED EXCISION OF LESION OF SKIN ASPIRATION OF JOINT CHANGE OF PLASTER CAST CURETTAGE OF LESION OF BONE, NOT ELSEWHERE CLASSIFIED DRAINAGE OF LESION OF SKIN, NOT ELSEWHERE CLASSIFIED DRESSING OF SKIN NEC INJECTION INTO BURSA INJECTION OF STEROID FOR LOCAL ACTION, NOT ELSEWHERE CLASSIFIED INJECTION OF THERAPEUTIC SUBSTANCE INTO JOINT MANIPULATION OF FRACTURE OF BONE, NOT ELSEWHERE CLASSIFIED OTHER SPECIFIED EXPLORATION OF BURNT SKIN OF OTHER SITE OTHER SPECIFIED OPERATIONS ON FASCIA OTHER SPECIFIED OPERATIONS ON SHEATH OF TENDON OTHER SPECIFIED OPERATIONS ON TENDON OTHER SPECIFIED OPERATIONS ON UNSPECIFIED ORGAN REMOVAL OF INTERNAL FIXATION FROM BONE, NOT ELSEWHERE CLASSIFIED REMOVAL OF PLASTER CAST REMOVAL OF SKELETAL TRACTION FROM BONE REMOVAL OF SUTURE FROM SKIN, NOT ELSEWHERE CLASSIFIED UNSPECIFIED EXCISION OF LESION OF SKIN UNSPECIFIED INJECTION OF THERAPEUTIC SUBSTANCE UNSPECIFIED INTRAMUSCULAR INJECTION UNSPECIFIED OPERATION ON UNSPECIFIED ORGAN 9
4.4 Recording of Information A lot of very good comprehensive information is held in the local departments but not all filtered through to their central information and medical records departments. The reasons are lack of computer systems, inability to track case notes due to the hospitals having many sites, hospital information systems unable to accept the information and nurse-led clinics being attributed to the consultant so rich nurse procedures are not centrally recorded. Information is either recorded on outcome sheets devised by each area with no common standards or is dictated by the nurse and typed up by the secretaries. SMROO forms were being completed for several clinics but many of these were attributed to the consultant and not to the nurse, who had actually received direct referrals, diagnosed, treated, referred on, or discharged. Only in a few areas were the clinics coded to the nurse who had run/led the clinic. In many cases there were no agreed standards for identifying what a nurse-led clinic is. While it was clear, in many cases, that the nurse had total responsibility for patients attending their clinic and that the patient would not se a doctor during their journey through the clinic, many of these clinics were still being recorded as consultant. In other cases, the nurse was told to attribute the new patients as attending a consultant-led clinic and the review patient as attending a nurse-led clinic. In some other cases, while the nurse recorded all activities carried out in their clinic, they were unsure of what actually was taken forwarded and recorded in the returns to ISD. They felt excluded in the process. Some had no knowledge of the term SMR00. There was an example of a joint clinic being run by a nurse and an AHP. Although either professional had 50% input to the clinic, the clinic was attributed to the nurse and recorded as nurse-led because their hospital computer systems cannot record AHP activity. In some other areas, the nurses and AHPs developed their own local paper system for recording activity and number and characteristics of patients seen but were aware that this information was not being submitted centrally. Some mentioned that they would like to submit but there was no interest in their information. Some nurse-led clinics were designed to see only return patients but some of the nurses cited many instances of seeing new directly referred patients in between seeing review/return patients. 4.5 Definition of nurse-led Agreeing who has overall clinic responsibility for a clinic is a matter of local judgement. This was recommended by ISD. ISD had also informed the service that this local judgement must be made according to local guidelines. While some nurses were clear that their nurse-led service was rightly attributed to the nurse, others wondered why their nurse-led service was attributed to a consultant when the consultant had no input in the care of the patients. Other nurses explained that they had received directive that all their clinics must be attributed to the consultant and as a result they were fighting hard to make their clinics be recognised at nurse-led. 4.6 Volume of clinics and numbers seen It was difficult to obtain a breakdown of numbers seen at the individual clinics by new and return patients because of the widespread use of paper diaries rather than local computer records. Also some of these clinics are run in different sites during the week and because paper records are kept at the site of the clinics, the figures can only be collated if the records at every clinic site are brought together. However, during meetings with the nurses, they were able to give estimates of numbers of patients seen per month and they emphasised the impact of the nurse services on reducing numbers of patients waiting to see consultants. In 10
Glasgow Royal Infirmary for instance, nurses were seeing just under 1500 new and return patients per month in orthopaedics outpatients. Not all of these were being recorded and submitted to ISD. Data submission to CCI from their nurse-led funded clinics is at its infancy and because they are data in development it would not be wise to quote them. 4.7 Staffing Most of the clinics visited were all nurse-led. However some clinics were multi-disciplinary to provide well-rounded assessment and treatment. Some of the clinics had access to consultants should the nurse require another professional opinion. Most of the nurse-led clinics had administrative and clerical support and in others, the nurse had to deal with all the referrals to the clinic including triaging of referrals, and appointments and discharge procedures. Other nurses such as E and D grade staff nurses support the lead nurse in the running of the clinic. 5.0 DISCUSSION & CONCLUSION It was difficult to obtain a detailed picture from the lead nurses of what was being recorded and submitted because most were unaware of the information reporting requirements of their clinics. The full picture of the patient s journey was being blurred because of the significant gaps in data reporting. A lot of information was being held in local clinics in paper diaries because of lack of networked computer systems and the inability of central hospital information systems to capture this information. It was sometimes difficult to determine which clinics were CCI funded and which ones were not because, in some instances, the CCI funds were used to refurbish accommodation used by a variety of clinics. It was clearly obvious that the nurses valued the funds they received from the CCI and explained that, with the setting up of these clinics, triaging of referrals was more effective and patients were not all having to wait to attend consultant clinics. It was evidenced in the study that a lot of nurse procedures are not recorded in SMR00 returns or are attributed to a consultant who did not have overall responsibility for the clinic. Local guidelines for labelling nurse-led clinics vary and in some instances are non-existent. It was interesting to note that while some clinics were labelled nurse-led, all the activities were attributed to the consultant. This raised the question of why can t these clinics be properly labelled consultant clinics. It was also interesting to note that, in some instances, the nurses were trying to make a case to their consultants and their information departments that their clinic should be attributed to the nurse. The study revealed that nurses spend a significant portion of their time engaged in activities that are not classed as procedures and therefore cannot be coded and submitted. These activities include health promotion, telephone consultancy, clinic administrative tasks, advice and health education, physical and other assessments, and carrying out diagnostic tests. Multidisciplinary or joint clinics are an area that requires clarification. Where a nurse and an AHP are jointly running a clinic with equal input, it is obvious that if an SMR00 were to be raised, the clinic will be classed as nurse-led. This is a situation that gives the wrong picture of nurse activity in some instances. It is unfortunate that many systems are not geared to collecting patient level AHP data. 11
As stated in the introduction, the 2002 Audit Scotland report that revealed that, in some areas, medical and information staff were unaware of the existence of clinics run by non-medical staff. As a result of the visits to the selective clinics, one wonders whether there have been improvements to this situation. To improve the robustness of nurse information, the following should be considered: 1. Map the SMR00 nurse returns to individual clinics and do a quality assurance exercise on a random selection of returns. 2. Determine which sites have local guidelines for defining and setting up nurse-led clinics. Compare these guidelines and make recommendations. 3. Develop a clear definition for a procedure. 4. Determine which procedures would be mandatory for nurses to submit and provide a long list of procedures and their codes for all specialties by working closely with the nurses. 5. Start preparing the ground for the collection of AHP data on SMR00 returns and determine how their specialties could be mapped to the consultant specialties. 6. Maintain a database of all nurse-led clinics with a small dataset, publish them and develop a system for updating the details of the clinics. This project has hopefully set the foundation for more work in the area of nurse-led clinic activity. 12