Health Council of Canada: Health Human Resources Summit Scope of Practice Issues for Nurse Endoscopi

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Health Council of Canada Health Human Resources
SummitScope of Practice Issues forNurse
Endoscopists23 June 2005

• Mark Dobrow, PhD
• Cancer Quality Council of Ontario
• Department of Health Policy, Management and
  Evaluation
• University of Toronto

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Outline

• Context
• Colorectal Cancer Burden
• Colorectal Cancer Screening
• Non-physician endoscopy
• Scope of practice issues in Ontario

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Context
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Colorectal Cancer Burden

• 3rd most common form of cancer in both men/women
  in Ontario
• 2nd most common cause of cancer death in Ontario
  (after lung)
• In 2005, it is estimated that
• 7500 Ontarians will be diagnosed with colorectal
  cancer
• 3050 Ontarians will die of colorectal
  cancer Canadian Cancer Statistics, 2005

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Colorectal Cancer Screening

• Non-Endoscopic Tests
• Fecal Occult Blood Test (FOBT)
• Double Contrast Barium Enema (DCBE)
• Endoscopic Tests
• Flexible sigmoidoscopy
• Colonoscopy
• Emerging Tests
• Virtual colonoscopy
• Fecal DNA test

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Expert Recommendations

• Numerous national and international expert bodies
  have recommended colorectal cancer screening for
  adults over the age of 50
• Australian Health Technology Advisory Committee
  (1997)
• Ontario Expert Panel on Colorectal Cancer
  Screening (1999)
• Canadian Task Force on Preventive Health Care
  (2001)
• National Committee on Colorectal Cancer Screening
  (2002)
• U.S. Gastrointestinal Consortium Panel (2003)

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Colorectal Cancer Screening Rates in Ontario
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Increasing Colorectal Cancer Screening in Ontario

• FOBT Pilot Project
• Ontario Task Force on Large Bowel Endoscopic
  Services
• Objectives
• Determine the feasibility of training
  non-physicians to perform flexible sigmoidoscopy
• Explore new funding and delivery models to expand
  the delivery of large bowel endoscopic services
  in Ontario

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Non-Physician Endoscopy
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International Experience

• USA Colon Cancer Prevention Program (CoCaP
  Kaiser Permanente)
• UK NHS National Endoscopy Project
• International research shows that nurses can
  safely and effectively perform flexible
  sigmoidoscopy
• No clinically significant differences between
  gastroenterologists or general surgeons and
  nurses
• Polyp detection rates
• Complication rates
• Patient satisfaction
• Non-physicians more cost-effective

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Local Experience

• Scarborough Hospital
• Nurse performed flexible sigmoidoscopy with video
  review by gastroenterologist
• Showed that a nurse could safely and effectively
  perform flexible sigmoidoscopy
• Project terminated due to uncertainties
  surrounding professional regulatory and
  reimbursement issues

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Scope of Practice Issues in Ontario
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Scope of Practice Issues for Non-Physician
Endoscopists in Ontario

• Competency Profile
• Regulatory Framework
• Recruitment
• Training/Assessment/Licensing Requirements
• Remuneration
• Delivery Settings

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Competency Profile

• A non-physician endoscopist is expected to
  possess the required knowledge, skill and
  judgment to
• Provide necessary patient teaching and
  counselling prior to and following the
  sigmoidoscopy and biopsy
• Understand the indications and contraindications
  of sigmoidoscopy and biopsy
• Understand the risks involved in, and the
  expected outcomes of, performing the procedure
• Perform the technical aspects of sigmoidoscopy
  and any biopsy safely, effectively and ethically
• Make decisions and take appropriate action based
  on information gained during the course of the
  procedure
• Recognize when additional skill knowledge and
  expertise is required
• Understand the role of, and collaborate with
  other health care team members and
• Evaluate the effect of the sigmoidoscopy and
  biopsy on the overall status of the patient

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Possible Human Resource Pools

• Nurses
• Registered Practical Nurses (RPNs) NO
• Registered Nurses (RNs) (general class) YES
• Nurse Practitioners Registered Nurse in the
  Extended Class RN(EC) NO
• Technicians NO
• Foreign medical graduates NO

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Regulatory Framework (1)

• Performing Controlled Acts
• Regulated Health Professions Act and Nursing Act
  allow RNs to perform flexible sigmoidoscopy for
  assessment purposes
• Medical Directives
• Required for RNs to perform flexible
  sigmoidoscopy and biopsy
• Physician Availability
• Physician must be available within an appropriate
  time frame

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Regulatory Framework (2)

• Biopsy
• College of Nurses of Ontario allows RNs to
  perform routine biopsies
• Communicating Assessment of Findings
• RNs do not have authority to communicate
  diagnoses refer to physician to communicate
  findings
• Professional Liability Protection
• In hospital setting nurses covered by Healthcare
  Insurance Reciprocal of Canada (HIROC)
• Nurses who are members of the Registered Nurses
  Association of Ontario have occurrence based
  liability coverage through Canadian Nurses
  Protective Society

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Recruitment

• Skill enhancement and specialization
• Improve retention
• Part-time vs. full-time endoscopy
• Performing flexible sigmoidoscopies daily not
  likely sustainable
• Expect nurse endoscopists to perform flexible
  sigmoidoscopies for approximately 30-40 of their
  work time (e.g. 3-4 half days per week)
• Nurse endoscopy positions need to be coordinated
  with other nursing positions

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Training, Assessment and Licensing Requirements

• Change Foundation Grant
• Training Curricula
• Cognitive, simulation, technical/practical
• Assessment Criteria
• Knowledge of anatomy, physiology and
  pathophysiology
• Depth of insertion
• Duration of procedure
• Size, location and type of polyps removed
• Complication and adverse event rates
• Patient satisfaction
• Credentialing/Licensing
• Successful completion of training program
• Maintenance of competencies

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Human Resource Remuneration

• Nurses
• Training (salary?)
• Ongoing practice (salary?)
• Physicians
• Trainer (stipend?)
• Ongoing backup (stipend, fee-for-service?)
• Communication of findings (fee-for-service,
  sessional fee?)
• Support staff
• Endoscopy suite (salary?)
• Administrative support (salary?)

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Delivery Setting Requirements

• Onsite physician collaboration/back-up
• Necessary endoscopic equipment
• Infection control equipment/procedures
• Access to colonoscopy services for positive
  results from flexible sigmoidoscopies
• Appropriate insurance coverage for nurses

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Possible Delivery Settings

• Hospital-Based Settings
• Colonoscopy Hubs (proposed)
• Non-Hospital Based Settings

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Summary

• Colorectal cancer presents a significant health
  burden
• Unrealized opportunities exist to screen for
  colorectal cancer
• International evidence and experience suggests
  that non-physicians can perform flexible
  sigmoidoscopy safely and effectively
• Flexible sigmoidoscopy is within the scope of
  practice for RNs in Ontario
• Training, assessment, licensing and remuneration
  processes and delivery settings are being
  developed to make nurse endoscopy a viable option
  to increase screening and reduce the burden of
  colorectal cancer in Ontario