Advanced Clinical Practitioner working with older patients with Sarah Goldberg Associate Professor in Older Persons Care University of Nottingham School of Health Sciences frailty Caroline Barclay Consultant Nurse Advanced Practice Leicester Community Healthcare Trust Gill Fletcher Lead Advanced Clinical Practitioner DME & clinical co-ordinator FEAT Derby Teaching Hospitals NHS Trust
Introduction i) What is Advanced Clinical Practice? ii) Case study 1: ACPs working in acute geriatrics iii) Case study 2: ACPs in community hospitals iv) Case study 3: ACPs working in a frail elderly assessment team v) Discussion and Questions
What is Advanced Clinical Practice? In small groups discuss: i) What is your experience of Advanced Clinical Practitioners ii) What is their role iii) How are they trained iv) What benefits/challenges do they bring to the service
What is Advanced Clinical Practice?
What is an Advanced Clinical Practice? Registered Healthcare professionals More than 5 years clinical experience. MSc Advanced Clinical Practice
Advanced Nursing Practice
Role of Advanced Clinical Practice Roles traditionally performed by doctors: history taking, physical examination, creating a differential diagnosis and problem list, ordering and interpreting diagnostic tests, prescribing medication and other treatments, and discharging patients. Making professionally autonomous decisions Comprehensive Geriatric Assessment Advanced communication with patients, their families Leadership and consultancy
Why do we need ANPs Increasing prevalence of frail older patients in hospitals Increasing need for clinicians skilled at CGA Insufficient medical doctors. Additional benefits of experienced nurses taking on these roles.
ANPs working in acute geriatrics at Nottingham University Hospitals 8 Healthcare of the Older Person Wards Acute Medical Unit 6 ANPs training: 5 registered on MSc, one completed MSc. First two years and project management generously funded by Nottingham Hospitals Charity Tailored teaching programme Competencies and role determined by Delphi study
Meeting Competencies Three years Masters in Advanced Clinical Practice Two year period following MSc for older patient specific competencies. Experiential learning working with geriatricians. Programme of bedside teaching sessions provided by consultant geriatricians. Junior doctor teaching sessions. Rotation around a variety of Healthcare of the Older Person wards including Medical and Mental Health Unit. Additional courses and opportunities for learning as required. All competencies signed off by one of two geriatricians.
East Midlands ANP network Monthly meetings: ANPs, consultants, head of service, matron, project manager. Fortnightly ANP meetings Support Peer support from HCOP ANPs and other ANPs in trust.
Benefits Highly experienced and skilled nurses, 80% clinical Bridging the gap between nursing and medicine Bedside teaching of nurses and junior doctors. Communication skills.
Challenges Pressure of service/time to learn Expectations Retention of nursing role not junior doctor substitute. Investment needed to train Recruitment to post Ongoing teaching and learning of ANPs. Clinical accountability
Experiences of a trainee ANP
Role of ANPs in Service Delivery Caroline Barclay Consultant Nurse Advanced Practice
Leicester, Leicestershire and Rutland
Distribution of Beds 248 48 126 MHSOP ICS Community In-patients
LLR Medical Model OOH Consultant Geriatrician ANP MSHOP GP
Patients and Public Lack of understanding of ANP role Media very medically focused Be open and clear of roles Examine processes Publicise
Patient Case Mix Understand your case mix and requirements Examine your ANP skill mix Generalist v Specialist Be aware of future developments short/long term
Policies Review main policies Medicines Management Interventional Policies Monitoring Death Certification On-Going!!
Communicate Establish Pathways with Providers Review Effectiveness Establish KPIs Listen to feedback Be prepared to change
No Blame Culture
Is It Worth It?
Discharge Letters 2012 2013 2014 Primary diagnosis 100% 100% 100% Comorbidities/ Risk factors 90% 93% 98% New treatments commenced 75% 85% 90% Treatments discontinued 82% 85% 92% Summary of outcome 96% 96% 98% Is there a DNAR in place? 13% 31% 75% If yes, is this documented in discharge summary 30% 38% 100% Relevant investigations & results documented 90% 94% 98% Any actions expected of GPs are documented 95% 95% 98%
Antibiotic Prescribing Appropriate indication (state specifically if choice driven by Culture & Sensitivity) 2012 2013 2014 88% 96% 96% Appropriate dose 90% 94& 96% Appropriate frequency 80% 92% 98% Appropriate length of course 88% 94% 95% Allergy status documented 90% 97% 100%
VTE Assessment Criteria 2012 2013 2014 Was the patient s mobility assessed? 72% 95% 90% If Yes was the mobility reduced relatively to normal state for the patient? 43% 88% 90% Was the VTE assessment completed? 36% 88% 98% If Yes was it done using the tool? Was the patient found to be at risk of VTE? 93% 100% 100% 49% 85% 94% Was the intervention made for prophylaxis (stockings & medicines)? 0% 85% 90% Was the patient given the information leaflet? 0% 90% 96%
Admissions 4000 3500 3000 2500 2000 1500 1000 500 0 ADMISSSIONS ANP 2012/13 2013/14 2014/15
Length of Stay 30 25 20 15 10 5 0 ANP 2012/13 2013/14 2014/15 LOS
Current Position in Derby TOTAL 40 ACP s (inc. 17 trainees) 1. Rehab & DME (Dept Medicine Elderly) = 6 2. Speciality Medicine = 6 3. Adult ED = 14 4. MAU = 4 5. Children's ED / Neonatal ICU = 9 6. Oncology = 1 Surgery Looking to recruit by Aug 2015! We currently have 2 Physiotherapists & 3 Paramedics in ACP posts.
Medical Student /FY1 FY 1 / 2 CT1/2 CT3 CT3/CT4+ Derby ACP Model tacp Year1 tacp Year 2 / 3 ACP (year 4) Senior ACP Lead ACP
ACP Framework Standardises ACP role across the Trust: Title Definition Accountability, roles & responsibilities Competency framework: - Core - Specific (per clinical area of practice) Job descriptions /Person Specifications Identity new uniforms!!! Recruitment process Training and assessment process
Work based Assessments Mini clinical evaluation exercise (mini-cex) 4 every 6 months Case based discussion (CbD) 2 every 6 months Directly Observed Procedural Skills (DOPS) 6 every 6 months Acute Care Assessment Tool (ACAT) - x5 for Band 7 upwards prior to progression to Band 8a) Requirement to maintain a CPD Portfolio. - 25% sample randomly selected and audited annually Annual IPR with Medical supervisor (Consultant) & Line manager (Lead ACP)
Acute Rehabilitation Wards ACP s role in DME MAU DME Rotation Acute Geriatric wards FEAT team
ACP Role in MAU Working alongside the On-call DME Consultant reviewing all the new admission patients allocated to Medicine for the Elderly. Independent Clinical assessment. Providing expertise re management of elderly patients in the acute setting to MAU staff. Facilitating transfers to appropriate ward beds as required.
ACP Role in FEAT The Frail Elderly Assessment Team comprises of an ACP, Therapy (Physio & OT), Pharmacy, Acute Medicine and DME Consultants, along with daily input from Mental Health, Social services, SALT and Dietetics as required. The team is available everyday 8am 8pm. The team work within ED, MAU, and the Short Stay wards. The aim is to provide CGA to all frail elderly patients and facilitate same day discharge to the most appropriate location (e.g. home, rehab, respite etc.) for those that are medically fit.
ACP Role in FEAT Physical assessment Performing clinical skills Requesting investigations and reviewing results Directing management plans Prescribing medication Completing comprehensive discharge summaries Communication with patients, relatives, & community colleagues Referring to appropriate specialist services (in-pt and out-patient) Team co-ordination Auditing of patient outcomes Assisting with strategic development of the FEAT service development of Dementia friendly environment on MAU including creation of FEAT activity lounge; creation of Frailty register; development of FEAT ethos into all medical wards.