Implementing a Collaborative Acute Pain Service (APS) Model of Care in a Private Hospital Setting: What have we done well and what could we have done better?

Jill Kelly Nurse Practitioner, APS

Objectives

-Background of the Acute Pain Service

-Implementation of the APS NP role

- Identify challenges in a private hospital model

-Where are now?

St John of God Subiaco Hospital

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St John of God Subiaco Hospital

-2012 activity: over 70,000 admissions

-Elective surgery -over 50,000 cases performed

-Main surgical specialties: orthopaedics, neurosurgery

colorectal, gynaecology, plastics, urology and obstetrics

Acute Pain Service: APS

-APS commenced in 1996 as a nursing only model

-2007 sessional based pain specialists joined service

-2010 Director of Anaesthesia took over responsibility for the medical APS

Aim: Collaborative medical and nursing team

Highlighting a Service Gap

-Anaesthetist’s are a transient population

-No anaesthetic registrar

-Pain Consultants are also transient- single round per sometimes after hours

-Limited RMO/ registrar cover

-No emergency department on site

Highlighting a Service Gap

It was identified: -Patient’s pain needs were increasingly more complex

-Timely intervention was challenging

-Strong reliance on interim phone orders

Implementing the NP Role

-March 2012, SJOGSH Designated APS NP site

-April 2012, SJOGSH implemented APS NP role

Clinical Leadership Coordinator

APS Nurse Practitioner

Director of Anaesthesia and Pain Medicine

Director of Nursing and Midwifery

APS Consultants and Anaesthetists

Organizational Chart

APS Clinical Nurses

APS NP Model of Care

-Collaboration and referral

-Guided by clinical protocol -Link between medical colleagues hospital wide and APS -Support for nursing and midwifery colleagues

-Early patient access to pain management and review

Additional NP roles

-Research

-Consultation on Policy Development

-Education

-Leadership

APS Nurse Practitioner Triage

APS Consultant or Anaesthetist

APS Team Consultant, Nurse Practitioner,

Clinical Nurses, Clinical Pharmacist

Specialist Anaesthetist Physician

Surgeon,RMO

APS Referral

APS Nurse Practitioner

Early Successes

-Hospital wide nursing/ midwifery support of APS NP role

-NP able to provide RMOs with support in relation to treatment of complex pain

-Medicare rebates for NP outpatient consults

Important Aspects of NP Role

- Collection of service data

- Ongoing mentorship and support

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Patterns of NP prescribing

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Number of NP prescriptions July 2012- Jan 2013 = > 400 prescriptions

Number of Prescriptions

Hallmarks of APS NP practice

-Collaboration with the multidisciplinary team

- Communication and interpersonal skills

- Accessability

-Patient follow up

-Non pharmacological input

-Thinking “outside the square”

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Challenges

-Inpatient Billing

-Private insurance inpatient gap payments

- Succession planning

Where are we now?

December 2012, Implementation of NP led Acute Pain Discharge Clinic

APS’s across Australia have striven to improve analgesia for patients, but by doing so: Is there potential to create problems for our GP colleagues? Time shortages, inadequate funding and manpower are challenges to providing follow up for these patients.

Kumar, 2011

Rationale for a Timely Implementation

- “The painkiller oxycodone also known as oxycontin has overtaken heroin as the drug of choice among injecting users , but the bulk of its victims are middle aged pain sufferers ”(Herald Sun 2012)

- 465 Oxycontin related deaths in Australia between 2001- 2009

- 2,611,531 dosages of oxycodone hydrochloride recorded on the PBS in 2012- almost double the number than in 2006-2007 (Medicare 2012)

Clinic Goals

-Reassessment of patient analgesic needs post discharge

-Reviewing the patients progress in weaning prescribed opioids

-Providing the GP with a written estimated duration of opioid therapy, and a suggested dose reduction schedule

-Referral to a pain clinic for ongoing follow up if required

Additional Outcomes

-Reducing length of stay

-Reducing amount of discharge analgesics dispensed for discharge

Moving the APS NP Role Forward

- Review and extend SJOGSH APS NP clinical protocol

- Increase number of APS discharge clinics

- Pursue Medicare rebates for NP inpatient visits

- Evaluation

Thank you

Research Proposal

“Towards an Understanding of the Role of the Nurse Practitioner in an Acute Pain Service in a Private Hospital Setting’’

Literature Review

- Lack of publications describing and critiquing NP roles in the private hospital sector nationally and internationally- contributing to a lack of clarity in the service that the NP role can provide in a private hospital setting

- Limited available literature relevant to NP role in acute pain

A Collaborative Study

-SJOGSH APS NP research study in collaboration with Curtin University

- Approval from St John of God Health Care and Curtin University ethic committees

Study Objectives

- Describe the patterns of practice of the APS NP role

- Elicit NP service satisfaction from patient, nursing, medical and pharmacy perspectives

-Inform decision relating to the implementation of additional NP roles at SJOGSH

Participant Recruitment

-Patients treated by the APS NP as an inpatient, outpatient or both

-Medical Practitioners referring to the NP

- Nurses, midwives and pharmacists at all levels working collaboratively with the APS NP to deliver everyday patient care hospital wide

Study Methodology

- Mixed methods Quantitative/Qualitative

- Multidisciplinary Team Questionnaire – “Perceptions of the Acute Pain Service Nurse Practitioner Role”. - to elicit referring medical practitioners , pharmacists and nursing views relevant to the APS NP role (Adapted from AUSPRAC Tool Kit, 2011)

- NP Patient Satisfaction Questionnaire.- “Perceptions of the Acute Pain Service Nurse Practitioner Role” - to elicit patient satisfaction with the care provided by the NP (Adapted from McCabe, 2011)

- “IBA” data management system and “Fred Dispense” pharmacy data collection system

Study Design

- Conducted in two stages over a 12 month period. During each of the two stages the data shown in the table below will be collected concurrently

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- Multidisciplinary Questionnaire Patient Questionnaire IBA/ Prescribing Data

Stage 1: Retrospective data collection October 2012 to

January 2013 Stage 2: Prospective data collection August 2013 to October

2013

Data Analysis

- Quantitative data - Recorded on an Excel data base comprising patterns of service data, number of patients contacts and the reason for contact and the number and type of pharmacological agents prescribed

- Qualitative data- Common themes will be highlighted, analysed and reported

Research Methods-Timeline

Research Project Oct 2012 April 2014 Develop Research Proposal

Develop Research Tools

Obtain Participants

Gather Data Stage 1

Stage 1 Data Analysis

Gather Data Stage 2

Stage 2 Data Analysis

Research Report

Publish Research Findings