Planning Minor Injury Services The Interdisciplinary Approach

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Planning Minor Injury Services/ The
Interdisciplinary Approach

• Mary Duff
• Director of Nursing and Midwifery Services
• Our Lady of Lourdes Hospital, Drogheda

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Programme

• Background and Process Used
• Consultants Input
• Students Experience
• Questions and Answers

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Hospital Groups within the North Eastern Health
Board

• Louth/Meath
• Drogheda
• Navan
• Dundalk
• Cavan/Monaghan
• Cavan
• Monaghan

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Service Need

• NEHB increase of 12.7 in the population
• Our Lady of Lourdes has seen an increase in
  attendance at the Emergency Department from
  34,807 in 2002 to 36,668 in 2003
• This has resulted in an overall increase in the
  average waiting time for non-life threatening
  injuries
• Review showed that 30 could be classed as a
  minor injury (2002) suitable to be seen by an
  ANP

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Monaghan General

• Unique position in the NEHB with regard to
  emergency services, off call since July 2002
• Monaghan has a treatment room which is the
  designated Emergency Room, 10,747 attendances in
  2003

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Reports

• National Health Strategy (2001)
• St. Pauls HRRI Report (2001)
• St. Pauls Consultancy (2003)
• Bonner Report (2003)
• Comhairle na nOspideal (2002)
• Hanley Report (2003)

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• Strategic regional decision to develop the
  Advanced Nurse Practitioner within the North
  Eastern Health Board
• Drogheda - Trinity Programme
• Monaghan - UCD Programme

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Service Plan

• The decision to introduce A.N.P.s was included in
  the OLOL 2003 2004 service plans
• Monaghan had a suitable physical environment in
  place
• Working Group was established
• National Council framework for establishment of
  ANP service was used to guide the preparation for
  accreditation

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ANP AccreditationWorking Group

• Eddie Byrne Director of Nursing
• Sr. Brenda Matron
• Bernie Reilly Practice Development NMPDU
• Marina OConnor Practice Development
• Isobelle Steenson Practice Development
• Mary Yau CNM3 Emergency Dept
• Pauline Plunkett CNM 3 Emergency Dept
• Conor Egleston Consultant in Emergency
  Medicine
• Siobhan Rothwell Nurse Minor Injury Service
• Margaret Mallen Nurse Minor Injury Service
• Mary Duff Director of
  Nursing/Midwifery

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The Process Used

• Kathleen McLellan Valerie Small met with the
  working group in Our Lady of Lourdes Hospital
  3rd June 2003
• Siobhan and Margaret were one year into the MSc
  programme at this stage
• Margaret was undertaking her 1,000 hrs supervised
  clinical practice in OLOL

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The Process Used (Continued)

• Working Group met on a bi-monthly basis
• Using an interdisciplinary approach goals
  timeframes were identified, set and achieved
  leading to the development of the site
  preparation and job description documents
• Minor Injury service for adults children

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Time Frame

• The Group set their own time frame to have the
  sites accredited to coincide with completion of
  MSc in June 2004
• June 2003 - met with National Council
• Nov 2003 - 1st draft of site prep
• Jan 2004 - 2nd draft to National Council

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• March 2004 - Met with National Council to
  review document and prepare for final
  submission
• April 2004 - Document submitted to
  National Council
• May 2004 - Review by accreditation
  committee
• August 2004 - Submit Portfolios

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Future Plans

• Development of structured educational programmes
  across multi-disciplinary teams
• Involvement in teaching on pre-registration and
  post-registration programmes
• Expansion to the body of emergency nursing
  research
• OLOL as a site for developing A.N.P.s for the
  region

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Developing an ANP service the consultant role

• Conor V Egleston
• Consultant Emergency Medicine
• Our Lady of Lourdes Hospital
• Drogheda

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Previous experience in UK 1

• Southampton University Hospitals Trust
• University Hospital Emergency Department
• 70,000 attendances per year
• 11wte ENPs working in dept
• Active nurse education programme
• I slotted in as one of lecturers, supervisors

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Previous experience in UK 2

• Lymington
• Small community hospital
• ED 15,000 attendances per year
• Bypassed for certain conditions by EMS
• I started training ENPs

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Personal UK experience

• No problems working with ENPs
• Amazed that I could just start training with no
  national standard/vetting procedure
• Too big a task to do solo

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Why do Emergency Medicine want ANP service to
develop?

• Bigger hospitals with consultants based in EDs
• Smaller hospitals with sessional input from
  Emergency medicine consultants

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Why ANPs in NEHB?

• 5 departments
• gt 100,000 attendances per year
• Reorganisation of trauma
• Consultants based in two departments only
• Maintenance of service in two types of hospitals
• Comhairle document re AE services in Ireland

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What do we know about ANPs/ENPs

• As good as SHOs at examination documentation
• As good as SHOs at interpretation of radiographs
• As good as SHOs at prescribing

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What do you need to do? 1

• 1. Talk ED medical staff
• ED nursing managers and nurses
• Director of nursing
• Other clinicians
• Directors of ANP programmes

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What do you need to do? 2

• 2 Support Guidelines
• Supervise
• Develop

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Problems and no problems our experience

• No problem
• Public
• ED nurses
• ED medical staff
• Fracture clinics
• Orthopaedic medics

• Problems
• Radiology

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Caution 1

• ANPS not cheap
• ANPs wont see everything
• ANPs probably wont of themselves be quicker

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Caution 2

• Where are we going to get all the ANPs we need
• If we get all the ANPs we need whos going to
  replace the nurses who change role

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Summary

• Rewarding experience
• Not as many problems as anticipated
• Radiology and prescribing issues to be sorted out
• NOT an ED panacea

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Questions at end of session
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Unfortunately
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PLANNING MINOR INJURY SERVICES-THE
INTERDISCIPLINARY APPROACH

• SIOBHAN ROTHWELL

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OUR LADY OF LOURDES HOSPITAL
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EDUCATION

• MSc Nursing T.C.D.
• Clinical Module St James Hospital
• Clinical Diagnositic Skills for Advanced
  Nurse Practitioners (Emergency Nursing)

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CLINICAL MODULE

• Anatomy
• Theory and Practice of Injury and Wound
  Management
• Documentation and History Taking
• Radiology
• Pharmacology
• 500 Hours Supervised Practice

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SUPERVISED PRACTICE

• 1000 Hours
• 500 Hours St James Hospital (under supervision
  of ANPs
• 500 Hours Our Lady of Lourdes Hospital (under
  supervision of Consultant in Emergency Medicine)

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SCOPE OF PRACTICE

• Adult Minor Injuries
• Paediatric Minor Injuries
• - Significant service need
• - Consultant led education and supervised
  practice
• Clinical Protocols developed collaboratively

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SITE PREPARATION AND JOB DESCRIPTION

• Working group established following a meeting
  with the National Council
• Comprised of DONs both sites
• ED Consultant
• Representative NMPDU
• Practice Development
  Nurse
• Nurse Managers ED
• Nurses pursuing
  Accreditation

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SITE PREPARATION

• Health needs
• Laws, rules, regulations and guidelines governing
  nursing and midwifery practice
• Vicarious Liability
• Guidelines for good practice
• Benefits to patients from the ANP service
• Consistency of service within Organisational
  Philosophy

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SITE PREPARATION cont/d

• How change will meet the service plan
• Location of the service
• Integration of the ANP into the multidisciplinary
  team
• Definition of the role content within the
  framework of nursing
• Resource implications

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MINOR INJURIES UNIT
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MINOR INJURIES UNIT
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JOB DESCRIPTION

• Background to post
• - Generic Background
• - Specific Background
• - Evolution of the role of the Advanced Nurse
  Practitioner
• - Effects of policy changes on Professional
  Practice of the Region

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JOB DESCRIPTION cont/d

• Geographical aspects of the service/demographics
  of the region
• Service Need
• Purpose of the post

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SCHEDULE OF EVENTS

• Guidance from the National Council
• Bi-monthly meetings of the working group
• Goals identified and set
• Time frames highlighted
• Objectives achieved

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SUBMISSION DOCUMENT

• Developed collaboratively
• Different service needs identified
• National Council Framework Document (2001) used
  as a template
• NCNM provided support and direction
• Drafts x 2 submitted before completion of final
  document

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SUBMISSION DOCUMENT cont/d

• Site preparation and job description
• Relevant appendices
• Reference list
• Clinical Protocols
• Application form
• Letters from DON and NMPDU
• Financial approval form
• 2 COPIES 1 BOUND AND 1 UNBOUND

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PHILOSOPHY

• The Advanced Nurse Practitioner will acknowledge
  the individual needs of each patient, and through
  a partnership approach provide a responsive,
  effective service which incorporates advanced
  decision-making and an innovative approach to
  care while retaining the philosophical
  underpinnings of nursing

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PLANS FOR THE FUTURE

• Increase in number of ANPs in Emergency Nursing
  in the North Eastern Health Board
• Expansion of Scope of Practice as determined by
  service need
• Cross-site research and audit to add to the body
  of knowledge and enhance the quality of patient
  care

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Planning Minor Injury Services the
Interdisciplinary Approach

• Part 2
• Margaret Mallen

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Monaghan General Hospital
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Education

• UCD MSc in Nursing (advanced practice).
• Generic programme.
• Pathology, physiology, pharmacology, complete
  physical assessment.
• Documentation and history taking.

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Supervised Practice

• 1000 hrs supervised practice under care of
  consultant in emergency medicine.
• Review clinic Mon, Wed, Fri.
• Weekly teaching sessions with emergency
  department SHOs.

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Supervised Practice cont/d

• Individualised teaching as deemed appropriate by
  consultant.
• All patients seen are presented to consultant or
  registrar prior to discharge.

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Clinical Protocols

• Scope of clinical practice collaboratively
  agreed.
• All adults with minor injuries are treated.
• All children with minor injuries except children
  under four who present with a head injury are
  treated by the nurse in minor injury service.
• Clinical protocols developed collaboratively.

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Clinical Protocols cont/d

• Collaboratively agreed that the clinical
  protocols would be used across all sites in NEHB.
• Research based.
• Adult and Paediatric clinical protocols were
  developed with ED consultants. Paediatric
  clinical protocols were reviewed by
  paediatricians and senior paediatric nurses

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Framework.

• Guidelines to Nurses and Midwives on the
  Development of Policies, Guidelines and
  Protocols.
• An Bord Altranais 2000.

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Sample List of Protocols

• Abscess
• Bites
• Corneal abrasions
• Fractures
• Elbow injuries
• Foreign bodies
• Tetanus

• Hand injuries
• Foot injuries
• Ankle injuries
• Shoulder injuries
• Minor head injuries
• Lignocaine
• Wounds

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REFERRALS FROM THE MINOR INJURY SERVICE
PRIMARY CARE
NURSE-MINOR INJURY SERVICE
SPECIALIST TEAMS OR CLINICS
ALLIED HEALTH PROFESSIONALS
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Liability

• Important to consider liability when developing
  the service.
• Clinical Indemnity Scheme (CIS) were contacted
  through Risk Management department.
• Letter received showing nurse covered by CIS.

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Core Concepts
EXPERT PRACTITIONER

RESEARCHER
AUTONOMY IN CLINICAL PRACTIC
PIONEERING AND PROFESSIONAL LEADERSHIP
NCNM 2001
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Challenges

• Time Management
• Meeting Targets for MSc and Working Group
• Hard Work

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Strengths

• Team Building
• Support
• Combining MSc with Site Accreditation
• Ownership of the process
• Sense of achievement