nps 1960, usa to provide primary health care in...

NPs 1960, USA to provide primary health care in under

resourced/disadvantaged communities. Loretta Ford and

Henry silver

(Walsh, Crumbie and Revely 2003)

Western Australia

1997, investigation (Judge Antoinette Kennedy) into the role of remote area nurses recognised many were working outside their scope of practice.

Implementing the NP role could legitimise those activities

Change in political climate= desire to expand the role

Supported by the AGPC report on the Australian health

care workforce Australian Government Productivity Commission (2005) Australia’s Health Workforce Position

Paper Canberra: Productivity Commission

Despite the support many challenges

› Medical resistance

› Pharmacology and prescribing resistance and law

changes

› Accredited courses

› Designation

“A Nurse Practitioner is a registered nurse educated to function in an advanced clinical role.

The scope of practice of the Nurse Practitioner will be determined by the context in which the Nurse Practitioner is authorised to practice and will include legislative authority not current within the scope of nursing practice”

National Nursing Organisation 2000

Dynamic practice that incorporates application of

high-level knowledge and skills in extended

practice across stable, unpredictable and

complex situations.

Advanced comprehensive health assessments

High level of clinical proficiency in procedures,

treatments and interventions

Extended practice competencies

Professional efficiency whereby practice is structured in a

nursing model and enhanced by autonomy &

accountability.

Established therapeutic links

Applies extended practice competencies

Clinical leadership that influences & progresses clinical care,

policy & collaboration through levels of health service

Engages in, and leads clinical collaboration that

optimises outcomes for patients /clients and

communities

Nurses Act 1992, Nurses Amendment Act 2003

Medical Act 1984

Misuse of Drug Act 1981

Pharmacy Act 1964

Poisons Act 1964

Radiation Safety Act 1975

Road Traffic Act 1974

Registration (AHPRA)- Endorsed

Nurse Practitioner Code of Practice

Designation of Practice Area (Director General or Department of Health)

Clinical Protocols

Drug formulary

Monitoring and evaluation

Enrolled Nurse

Registered Nurse

Clinical Nurse

School Teacher

Clinical Nurse Specialist

Nurse Practitioner

Bachelor of Nursing

Post Graduate Studies

Orthopaedic Certificate

Graduate Diploma Education

Graduate Diploma in Clinical Nursing

Master of Nursing (Nurse Practitioner) Flinders South Australia/ECU

Identifying the need-clinical expertise Increasing complexity of the patients

Increasing presentations, admissions,

support of orthopaedic patients in outlying areas

(ICU, NOSA, General wards, ED)

increasing needs of the community-early

discharge

A business case

Role • Coordinates the clinical management of all minimal trauma fractures

• Mx. complex acute medical conditions/co-morbidities timely manners

Peri-operative management optimising pt. condition

Maintaining consistent and comprehensive approach

Encouraging compliance/education #hip pathway

Facilitates discharge planning

Enhance rehabilitation outcomes

› Cost effective- Reducing length of stay

Peri-operative Mx › Pre and post op x-rays/bloods/ECG/Fluid

Mx/Transfusions/Benzodiazepine withdrawal nicotine, insulin infusion, prophylactic AB’s

Pain Mx

VTE prophylaxis

UTI

Constipation

Nausea and vomiting

Osteoporosis

Scope Outcomes

Nurse Practitioner All medically stable orthopaedic patients requiring surgery. All medically stable minimal trauma patients

being conservatively managed.

Identify patients suitable for Ortho NP CPG

MEDICAL PRACTITIONER +/- Nurse

Practitioner

Exclusion Criteria Complex orthopaedic patients (e.g. multi-trauma

patients) Medically unstable orthopaedic patients Palliative Intent

Identify patients not suitable for Ortho NP CPG→ exit CPG refer orthopaedic +/- Orthogeriatric team

ASSESSMENT & INTERVENTION

Primary Survey Airway Breathing

Circulation

Identify patients not suitable for Ortho NP CPG→ exit CPG refer orthopaedic

+/- Orthogeriatric team

Scope Outcomes

History Presenting injury/condition Planned orthopaedic surgical interventions Risk factors1

As per Risk Ax Tools (VTE/Falls/Pressure areas,

withdrawal drug/alcohol) Relevant past medical history medication use (including anticoagulants/anti-platelets) Renal function Weight

Allergies


Focused clinical assessment

Haemodynamically stable Trauma injuries- open wounds Fracture type

Potential compartment syndrome Muscular skeletal examination General examination Vital signs

Differential diagnosis→ exit CPG refer to Orthopaedic +/- Orthogeriatric Team.

Scope Outcomes

Working diagnosis and Investigations

Imaging X-ray suspected fracture Pelvic X-ray (suspected hip #) Chest X-ray Post-op X-ray

Abdominal X-ray (Constipation protocol) Bone densitometry (DXA) (OP protocol)

Differential diagnosis→ exit CPG refer to Orthopaedic +/- Orthogeriatric Team. Routine pre and Post-op x-rays Facilitate early diagnosis and rehab goals (post –op)

Scope Outcomes

Pathology Laboratory Test Clinical biochemistry tests Blood glucose Serum urea and electrolytes Serum calcium

Cardiac markers Thyroid function test LFTs: alanine transferase (ALT), gamma glutamyl transpeptidase (GGT), alkaline phosphate (AP), bilirubin and albumin Therapeutic drug monitoring -digoxin Haematology test

Full blood count Coagulation profile Erythrocyte sedimentation rate and C-reactive protein Blood transfusion testing Blood group, antibody screen and crossmatch (as

per routine pre-op and post-op guidelines Microbiology Urine microscopy, culture and sensitivity Blood Cultures Osteoporosis Bloods Ca, Vitamin D, LFT, Creatinine/eGFR, PTH, TFT

Identification of abnormalities and initiate treatment refer to Orthopaedic +/- Orthogeriatric Team. Implement

VTE Risk assessment and Mx Therapeutic Mx as per anticoagulation chart Transfusion protocol Ab’s as per UTI protocol

OP medications as per OP protocol

Scope Outcomes

Other ECG Routine pre-op Early identification in Dx cardiac event (e.g. AF ACS)

Working diagnosis and Investigations

Imaging Confirmation of fracture Confirmation of good alignment post-op

Identification of chest abnormalities (consolidation/PO)

Early identification of abnormalities → refer to Orthopaedic +/- Orthopaedic Team facilitate early mobilisation

Interpretation of results (diagnostic features) and management decisions

Pathology and clinical features

Identify abnormalities and notify Orthopaedic +/-Orthogeriatric Team Implement treatment modalities

Differential diagnosis→ exit CPG refer to Orthopaedic +/- Orthopaedic Team Implement VTE Risk assessment and Mx Therapeutic Mx as per anticoagulation

chart Transfusion protocol Ab’s as per UTI protocol OP medications as per OP protocol Correct dose charted

Scope Outcomes

Associated Care Patient education/family education Pre and Post –op care Discharge planning Rehabilitation goals and referral to rehab

facilities OP education and referral


Acute Referral Referral to Orthopaedic +/- Orthogeriatric Team Duty Anaesthetist APS

Interpreter Allied Health

Prompt referral Improved pain management Early identification of D/C Requirements for rehab

Referrals As appropriate to allied health team members Referrals may be made for specific patient problems or as required to

-HITH - Interpreter -Pharmacist -- Physiotherapist - Occupational therapist -Social work - Aboriginal liaison officer

-Drug and alcohol counsellor

Medications

Analgesia

Antibiotics Antacid Anti-emetics

Aperients Antifungal

As per NP Pain management protocol

As per UTI protocol As per orthopaedic surgical prophylaxis (IV cephazolin/ mupirocin) Mylanta As per nausea and vomiting protocol

As per constipation protocol Fluconazole (oral) Nystatin (Nilstat) Oral Clotrimazole (Canestin Cream) (topical)

Assist in effective pain relief

Prompt treatment of infections identified Improve compliance with prophylactic protocol Relief of indigestion Assist in effective nausea and pain management Prevent and treat constipation

Treatment of simple Candida infections (throat and vagina)

Medications

Benzodiazepine

Drugs for eye infections Intravenous Fluids Nicotine

Diazepam (As per drug/alcohol

withdrawal chart, Benzodiazepine withdrawal chart, Amphetamine withdrawal Chart, Cannabis Withdrawal chart) Chloramphenicol 1% ointment Chloramphenicol 0.5% eye drops

Normal Saline Red blood cells

As per SCGH Withdrawal guidelines and nicotine Dependency Assessment

Assist in management of reducing

withdrawal symptoms Treatment of conjunctivitis and

simple eye infections common to the elderly patient Assist in maintaining hydration Assist in treating hypovolaemia as per orthopaedic transfusion

protocol Encourage cessation of smoking whilst undergoing surgery. Reduce the incidence of aggression related to withdrawal

Medications

Osteoporosis

VTE prophylaxis protocol

As per OP protocol

As per Risk Assessment Tool for

Venous Thromboembolism (VTE) and Department of

Orthopaedics VTE Prophylaxis (Jan 2011)

Assist in improving initiation of OP

treatment and prevention Reduce incidence of VTE Improve compliance of risk assessment and prophylactic administration

References

A guide for assessing older people in hospitals(2004) Developed by the Centre for Applied Gerontology, Bundoora Extended Care Centre, Northern Health. Commissioned on behalf of the Australian Health Ministers’ Advisory Council (AHMAC) by the AHMAC Care of Older Australian Working Group. Australian Medicine Handbook Pty. Ltd. July 2011 Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings: Update 2007 Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings (2004) British Orthopaedic Association (2007) The Care of Patients with Fragility Fracture Brown, A.F.T and Cadogan, M.D. 2006. Emergency Medicine emergency and Acute Medicine: Diagnosis and Management (5th. Ed), Hodder Arnold, London. Dandy, D., Edwards. D. Essential Orthopaedics and Trauma 3rd. Ed (1998) eTG Complete Therapeutic Guidelines 2011 (http://online.tg.org.au.qelibresources.health.wa.gov.au/ip/) Management of hip fracture in older people. A national clinical guideline (2009) Scottish Intercollegiate Guideline Network. MIMS Online 2011 SCGH Withdrawal Guidelines and Nicotine Dependency Assessment SCGH Alcohol Withdrawal Chart SCGH Amphetamine Withdrawal Chart SCGH Benzodiazepine Withdrawal Chart SCGH Cannabis Withdrawal Chart

AUTHOR(S) ENDORSEMENT

This CPG was written by: Sharon Pickles

Nurse Practitioner

Orthopaedics

Sir Charles Gairdner Hospital

Dr Denise Glennon

Geriatrician

Rehabilitation and Aged Care Department


Reviewed & Authorised by: Dr Gerard Hardisty

Head of Orthopaedic Department


_________________________________

Dr Denise Glennon

Geriatrician

Rehabilitation and Aged Care Department


________________________________

Jennifer Benzie

Chief Pharmacist


________________________________

Michael Bynevelt

Head of Radiological Department Sir Charles Gairdner Hospital

________________________________

Dr Ee Mun Lim

Head of Department Clinical Biochemistry

PathWest QEII

Consultant Endocrinologist


_______________________________

Date written: December 2011 Review date: December 2013

Analgesics

Aspirin Tablet

Buprenorphine Transdermal Patch (Norspan)

(5mcg, 10mcg)

Buprenorphine sublingual immediate release (200mcg-400mcg) (As per

APS)

Hydromorphone HCL prolonged- release tablet (Jurnista PR) 4mg

Hydromorphone immediate release tablet

(0.5mg-4mg)

Oxycodone hydrochloride controlled release tablet (Oxycontin- 5mg,

10mg)

Oxycodone hydrochloride immediate release tablet/capsule (Endone

IR/Oxynorm 2-5-10mg)

Oxycodone hydrochloride liquid (1mg-10mg)

Oxycodone hydrochloride & Naloxone hydrochloride dihydrate

controlled release tablet (Targin CR)

(5/2.5, 10/5mg)

Paracetamol PO/PR/IV

Paracetamol Osteo (665mg)

Paracetamol /Codeine Tablet (500mg/8mg) (Panadeine)

Paracetamol/Codeine (500mg/30mg)

(Panadeine Forte Tablet)

Tramadol PO/IV (50mg-100mg)

Antacids Mylanta Aperients Bisocodyl tablets/suppository

Benefibre Coloxyl and Senna Epson salts Fleet enema Glycerine suppository Microlax enema Movicol

Picoprep Sorbitol

Antibacterials

Amoxycillin Amoxycillin with clavulanic acid Flucloxacillin Phenoxymethylpenicillin (penicillin V) Cephalexin Cephazolin Doxycycline Roxithromycin Metronidazole Trimethoprim Mupirocin ointment/cream (*As part of Hip pathway and all orthopaedic metal work implantation)

Antiemetic Metoclopromide hydrochloride Ondansetron Prochlorperazine

Antifungal

Fluconazole (oral) Nilstat (oral) Canestin Cream (Topical) Benzodiazepines Diazepam (as per withdrawal protocols) Drugs for eye infections Chloramphenicol ointment Chloramphenicol eye drops

IV Fluids Normal Saline 5% Dextrose Red Blood Cells (Transfusion as per Orthopaedic Transfusion Protocol)

Insulin Actrapid (as per fasting protocol) Patient’s usual insulin dose

NSAIDS Diclofenac Ibuprofen Indomethacin Naproxen

Osteoporosis Medications Vitamin D Cholecalciferol 25mcg

Vit D2, D3 Calcitriol Calcium Supplements Calcium Carbonate 600mg Calcium Citrate 500mg Bisphosphonates

Alendronate (patient’s usual meds) Fosamax (patient’s usual meds) Strontium(patient’s usual meds) Actonel Combi D (patient’s usual meds)

Pre admission clinics

Anaemia management

Outpatient clinics

Fragile bone clinic- Management of OP

Falls Clinic

Private consultant rooms

Funded until 2014

Annual report

Justify cost saving benefits

Justify clinical needs

Patient outcomes

nps 1960, usa to provide primary health care in...

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