Transcript presentation ( format)

Stephen J. Hughes, MD, Nianne
VanFleet, RN, Martha Williams, RN
Gannett Health Services, Cornell
University
Describe how to set up a Nurse
assessment/dedicated clinician team
for rapid assessment/treatment of
patients
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Expectations of patients
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Selection of team members
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Development of trust within the
team
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Logistics
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More rapid assessment/treatment of
relatively uncomplicated patients
Dedicated clinician available to RNs
for consultation
Dedicated clinician for review of U/As,
etc.
Other clinicians not distracted by need
to consult with RNs
Team-building experience
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Private/Public Institution – 7 colleges,
Graduate School, Law School, Business
School, Veterinary School –( Medical
School is 250 miles away)
• ~ 22,000 students , ~ 1/3 graduate and
professional
• “centrally isolated” – school is in
central NYS – significantly-sized cities
60+ miles away
• Highly stressed - higher expectations
for RAPID, HIGHest Quality care
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~ 27,000 visits with physicians, NPs,
PAs
~ 10 FTE MD/DO,NP,PAs
~ 9.5 FTE RNs
~ 22,000 immunizations/Tb testing
(RN)
~2000 Travel Clinic (RN)
~ 2400 Allergy Clinic (RN)
Patients would have appointments with
clinicians or alternatively could see an
RN for simple URIs, dysuria(women),
contraceptive 3 mo. F/U or extensions,
Emergency Contraception (“old” days),
suture removal, wound care, HIV testing,
preliminary visit prior to Fullbright,
Peace Corps , other Physicals
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Nurses would “spin” seeking clinician
consultant
Clinicians would be interrupted
NP/PAs would compete with RNs for
physician consulting time
Some clinicians would become
“favorites”, some were avoided
RN EXAMINING PATIENT
RN USING ASSESSMENT SKILLS
Daily number of ILI patients with visits or collateral care
70
60
50
40
30
20
10
0
Returning ILI patients
New ILI patients
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1725 flu/ILI pts seen at Gannett of 1837
1 student death
Website information
Beefed up phone assessment/ F/U availability
– 5178 calls
Trial of SPIDER – physician or NP or PA – no
patients booked with clinician – as many as 5
RNs with very good assessment skills
assigned to floor designated for “respiratory
illnesses”
•ILI threshold was set pretty low by CDCultimately “fever or perception of fever” and
cough or sore throat.
•These patients were presented to the Spider
clinician by the RN, many were examined
by the clinician, including patients with
higher-risk medical conditions, who made
decisions about home care, medications,
CXRs, etc.
•Telephone follow up was done by nurses,
Health Educators, other Health Center staff
and campus volunteers
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Expectations of patients
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Selection of team members
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Development of trust within the
team
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Logistics
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Best diagnostician in the world hanging on a
hook in my closet that I can bring out whenever I
feel the need.
Ability to diagnose my problem by listening to
whatever I have to say without doing tests,
asking more than three questions, or
contradicting anything I have read on ANY
website or anything my parents or friends have
told me
Ability to successfully treat – and completely
cure – my problem(s) at essentially no out-ofpocket cost to me – within three days – sooner, if
I have an exam, paper or social function coming
up in one or two days
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A staff dedicated to providing the best care
possible given the constraints under which
we work
Rapid, accurate, minimally invasive
assessment of problem
Comprehensible explanation of diagnosis and
plan
Rapid communication of lab tests, x-ray
reports, etc.
Willingness to work with patients to provide
best possible outcome
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Excellent Assessment Skills
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Must be willing to expand these skills
and add to knowledge of illnesses,
treatment options
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Must be able to adapt to different
clinicians’ styles
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Must be able to communicate well with
patients and clinicians
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Must be comfortable letting go of a certain
level of control
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Must trust the assessment skills of the
nurse but be prepared to re-examine
patient
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Must be willing and able to teach nurse
about physical exam, disease entities,
treatment options
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Must be comfortable with multi-tasking
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Cornell uses Point and Click EHR – there are
ways to “Share” a note or “Send” a note. We
can “drop in” a Spider consult section –
(custom made by us) – to facilitate
documentation. We can order lab tests, x-rays,
medications in the EHR.
We can Secure Message a nurse to follow up
(call or secure message or both) with a patient
the next day
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Allow rapid communication between RNs
and clinicians
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Allow ordering of labs, medications, possibly
x-rays – with E-signing by clinician
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Allow Sharing and/or Sending of notes
between nurses/clinicians
Pass the paper chart around
The Clinician – NP/PA or
Physician
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Swift
Proficient
Integrated
Decisive
Effective
Resourcing
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Time
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Shared experience
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Communication
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De-selection of certain members
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Appropriate space
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Set expectations for the team
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Appropriate rules
Three types of nurse visits on Level 4:
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Nurse managed - no consult necessary - nurse
completes note
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Needs Consult - (ex: sinus pain, flu, ear
infection, etc.) – shared note between nurse and
clinician. (Use the Spider drop in template)
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Complicated Case -consult with Spider who
may request it be moved to an appointment
with them if possible or another clinician.
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All Virtual Dysuria and Contraceptive Only
consults
Nursing orders for immunizations or a rabies
series (for a non-bite type exposure, such as a
Bat)
Patients with cough/cold/sore throat visit that
are seen on Level 6 (this is only done if Level
4 is backed up), the nurse will come to Level 4
to consult with Spider.
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Other types of nurse visits that are
scheduled on Level 6 (wound check, suture
removal, etc.) that need a consult can be
done by the Spider if she is not busy and is
available for a consult. Otherwise consult
with a Level 6 clinician.
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The AM Spider will be available for consult
from 8:30 - 1:00pm
The PM Spider will be available for consult
from 1:00 - 5:00pm
The Spider should never be scheduled as the
late clinician.
The Spider should not have meetings or
blocks scheduled during their Spider time.
The team leader on Level 4 will monitor the
Spider’s schedule, if the Spider is not busy,
she may schedule non-complicated
appointments with the Spider.
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RNs really appreciated decreased waiting time to
consult with a clinician
Clinicians who had full schedules of patients
really appreciated not being interrupted by
consults
Able to set RN appointments on a different floor
for many pre-bookable issues (contraceptive f/u,
wound care, etc.) so patients not “stuck” waiting
behind many with sick visits
More physician time for consult with NP/PAs
Continuing to refine Spider concept
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Know ahead of time what the parameters are
Agree on the approach
Improves team – morale/spirit
Decrease wait time
RN satisfaction
Patient satisfaction
Freed up physicians to do higher level care
Clinician satisfaction
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Can be inefficient, repetitive evaluations, duplication
of documentation
Can have a disparity of patient loads
Often a swamp of labs next day – esp. Strep Cultures
ordered during Spider time and sent to NP/PA when
not Spider is cumbersome
Can have high intensity and complicated visits
rather inappropriate for RN visits (due to lack of
clinician appointments)
Liability / RN scope of practice (NY), evolving
protocol, provider liability for RN “curbside”
consult
One additional layer of triage/evaluation which can
extend time in clinic
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Allows for more rapid
assessment/treatment of large numbers
of patients in an “outbreak” scenario
(e.g. flu, norovirus)
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Allows for more patients to be seen than
you would have available clinician
appointments
Allows more complicated patients to be
seen by the higher level clinicians in a
more timely manner
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