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OOH The Way Forward. Sally Gardner Nurse Consultant Out of Hours. Nurse Development in OOH. WHY? Workforce Issues (nGMS). Evidence from Literature. Nurse Practitioners existed in North America many years Reviews suggest Nurse Practitioners equivalent to GP ( Horrocks et al 2002)

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Ooh the way forward

OOH The Way Forward

Sally Gardner

Nurse Consultant

Out of Hours


Nurse development in ooh

Nurse Development in OOH

  • WHY?

  • Workforce Issues (nGMS)


Evidence from literature

Evidence from Literature

  • Nurse Practitioners existed in North America many years

  • Reviews suggest Nurse Practitioners equivalent to GP (Horrocks et al 2002)

  • Same day consultations – no differences in outcomes. (Kinnersley et al 2000)


Evidence from literature1

Evidence from Literature

  • Patients seeing Nurse Practitioners – are more satisfied

  • Nurse Practitioners offer longerconsultations

  • Evidence has compared mainly minor illness


International models

Denmark

GP Care - free

Resembles old GP system UK.

Telephone based medical advice by GP

Demand rising

Netherlands

Medical Insurance

OOH Co-operatives

Many co-located with A/E

Triage Nurses

Professional self- regulation

International Models


International models1

USA

Medical Insurance

Large variation

Call handling service

Signposting

Nurse Triage

90% referred to GP

Urgent care centres

Australia

Consultations paid for 85% refunded

Variable models

Nurse Call centres

GP Telephone triage

Health Direct – nurse led service

Performance indicators

International Models


United kingdom

Scotland

NHS 24

OOH Centres

Staffed by mixture clinicians

Quality standards

Accessibility availability, safe & effective care

Audit

Wales

Commercial providers

NHS Acute Trust

Mainly GP led

Some Nurse Triage

NHS Direct – Wales has call handling and Nurse Triage service

United Kingdom


Ooh models

OOH Models

  • Varies across UK

  • Some GP led

  • Some Nurse led

  • Some multidisciplinary

  • No one seems to know what is the ideal skill mix

  • Varies according to Geographical area


What is the ideal model

What is the ideal Model

  • Nobody Knows………………………

  • Systems in place

  • Processes

  • Standard Procedures

  • Performance Reporting

  • Clinical Governance

  • Training Programmes


Primary care foundation

Primary Care Foundation

  • Swift Response

  • Highly trained staff

  • Streaming patients

  • Local bases

  • Skilled mixed professionals

  • Effective Advice and treatment


Activities

Activities

  • Urgent Care Course

  • Skill Mix Development

  • Patient streaming project

  • Evaluation of dental triage

  • ECP Pilot

  • Nurse triage Pilot

  • Home Visiting Pilot


Define skill set

Define Skill set

  • General Practitioners

  • Nurse Practitioners

  • Minor Illness Nurses

  • Emergency Care Practitioners

  • GP Registrars

  • Trainee minor illness nurses

  • Trainee N/P

  • Trainee ECP

  • Trainee Radiographers


Nurse practitioner

Can assess all patients

via telephone or face to face

Orders investigations

Can treat and complete around 90% of cases

Nurse Practitioner

Diagnoses

Prescribes from

formulary

and can use PGD’s

Provides treatment

Refers

Nurse Practitioner


Minor iilness nurse ecp

Assesses a range of common conditions

via telephone or faceto face

Can complete 50% of cases

Can initiate some treatment

Minor Illness Nurse

ECP

Diagnoses from list of common presentations

Reports to Nurse Practitioner or GP

Can administer medication via PGDs

Unable to prescribe

Can not produce prescriptions for signing

Minor iIlness Nurse/ECP


Trainee minor illness nurse paramedic

Directly and then indirectly

Supervised to Assesses a range of common conditions

via telephone or faceto face

Working towards completion of 50% of cases before able to work as

Minor Illness Nurse

Directly and then indirectly

Supervised Can initiate some treatment

Trainee Minor Illness Nurse

Training to diagnose from list of common presentations

Reports to Nurse Practitioner or GP

Directly and then indirectly

Supervised administer medication via PGDs

Unable to prescribe

Can not produce prescriptions for signing

Trainee Minor Illness Nurse/Paramedic


Projects

PROJECTS

  • Review of Consultations and analysis of competencies

  • Review of Consultations re completion rates

  • Audit – comparing Nurse's GP,s NP’s


Review of consultations

Review of Consultations

  • Levels were identified ABCDEF

  • A/B = HCA’s / Paramedic

  • C = Nurse’s / ECP

  • D = Nurse Practitioner

  • E = GP Registrar

  • F = GP Principle

  • Consultations were marked with the clinical grade considered competent to complete the consultation


Exclusions

D Level (NP)

Palliative Care

Verification of Death

Neonates (under 3/12)

Repeat Prescriptions

Pregnancy (over 3/12)

Mental Health Sectioning

Pathology Results

C Level (Nurses/ECP’s)

All plus Under 5’s

B (HCA/Paramedic)

All of the above plus

Cardiovascular

Respiratory

Gastro-intestinal

Some Genitio Urinary

EXCLUSIONS


Reliability

Reliability


Ooh the way forward

Graph To Show Average Competency Development Over a Two Year Period


Review of consultations1

Review of Consultations

  • Aim was to determine the skill mix required to deliver the service

  • 100 consultations were reviewed

  • Different shift patterns were selected

  • TCN competency framework was developed with classifications


Ooh the way forward

Completion Rates of non-medical Clinicians

Analysis of 100 consultations


Ooh the way forward

Completion Rates of non-medical Clinicians

Analysis of 100 consultations


Ooh the way forward

Completion Rates of non-medical Clinicians

Analysis of 100 consultations


Results

Results

  • F level could complete 100% (GP)

  • D level could complete 83% (NP)

  • C level could complete 52% (Nurse/ECP)

  • B level could complete 12% (HCA Paramedic)

  • Case Mix varies midweek evenings/weekends


Skill mix review

Skill Mix Review


Results1

Mid Week evenings

Saturday AM

Sunday PM

More complex problems

CDF levels required

Scope to use a variety of skill mix

C level utilised to full potential with lower ratio of NP/GP

D level utilised high ratio to GP

Results


Audit

Audit

  • Three groups

  • GP’s

  • Nurse’s

  • NP’S

  • Compare Three Months data


Audit1

Audit

  • Extrapolate Three months data from HMS

  • Identify Clinicians who meet the following criteria

  • 1) Have undertaken 100 Telephone triages in the time period

  • 2) Have undertaken 50 base consultations

  • 3) Have undertaken NO home visits


Audit2

Audit

  • Comparisons made

  • Triage Performance Outcomes

  • Length of time of Triage Consultation

  • Length of time of Base Consultation

  • Admissions

  • Bench marked against company averages for the time period


Triage performance outcomes

Triage Performance Outcomes


Consultation times admissions rate

Consultation Times AdmissionsRate


Consultation times admissions rate gp vs np

Consultation Times Admissions RateGP vs NP


Evaluation minor illness nurse v gp

EvaluationMinor Illness Nurse v GP

  • Nurses perform longer consultations

  • Nurses have low admission rates probably as they tend to select less unwell patients.

  • They tend to work within their competency to avoid duplication so outcomes are similar to other clinicians

  • The nurse results for triage may be biased as it was not possible to exclude the dental triage from these stats.

  • (Most of the dental outcomes will be advice)


Evaluation np vs gp

EvaluationNP vs GP

  • Nurse Practitioners consultation times are slightly longer than a GP’s

  • Triage difference = 0.17 secs

  • Base difference = 2.48 mins

  • Admissions very little difference 0.21%

  • This could be attributed to the holistic framework that nurses deliver care from and the more rigorous documentation


Audit conclusion

Audit Conclusion

  • N/P and GP perform to similar performance levels

  • N/P cost approximately 50% less to employ

  • Nurses are working productively according to their competency

  • It would appear that it is both cost effective and safe to change the skill mix in OOH delivery.


Audit completion of calls

Audit Completion of Calls

  • Aim was to determine if nurses are able to complete cases without referral to GP’s

  • One weeks nurse consultations reviewed

  • Various Nurses with various skills

  • Various Shift times

  • Different days of week


Results2

Results

  • 92.6% of consultations completed by the nurse

  • 7.4% referred to GP

  • OOH nurses on various clinical shifts can complete the vast majority of consultations

  • Appropriate levels of skills used in service delivery results in patients being seen and completed in one consultation

  • Lower grade clinicians refer more patients to GP’s


What do we want

What do we want?

  • Efficiency

  • Drive down costs

  • Effectiveness

  • ensure safe practice with clinical governance central to delivery

  • Collaboration

  • stakeholder engagement

  • Team Working

  • create climate of mutual respect through clear roles, responsibilities.

  • Common vision


Future model

Future Model

  • Explore skill mix

  • Determine safe efficient model

  • Develop GP light OOH service

  • Develop other clinicians

  • ? IT support system

  • Competitive tendering

  • Successful new business.


The way forward

The Way forward

  • Patient focused quality service

  • Delivering to agreed specification

  • Working with all stakeholders

  • Understand and resolve any service issues

  • Developing new services for the benefit of patients.

  • Exploring future options in skill mix


Thankyou

THANKYOU

Contact Details

Sally Gardner

Nurse Consultant

Take Care Now

Telephone – 01473 299531

  • Email – [email protected]


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