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Drogheda Nurse led initiative eliminates delays

Advanced Nurse Practitioners  Karen Carragher, Anthony Dillon and Mary Savage.

Advanced Nurse Practitioners  Karen Carragher, Anthony Dillon and Mary Savage.

A nurse-led initiative has been helping to eliminate lengthy delays for many patients waiting on medical assessment and treatment.

The Acute Medical Assessment Unit (AMAU) in Our Lady of Lourdes Hospital, Drogheda has introduced a service led by Registered Advance Nursing Practitioner Karen Carragher. The aim of this service is to divert patients with lower acuity medical illnesses from the queue waiting on medical assessment and to expedite unwell medical patient’s to first line interventions on the busy emergency floor. Karen and two Advanced Nurse Practitioner Candidates, Mary Savage and Anthony Dillon, with the support of an on-site medical team and consultants, can triage, diagnose and come up with a treatment plan towards hospital discharge or admission for those lower-acuity patients in a timely fashion.

“This is a new approach to service delivery within the specialty of Acute Medicine which is nurse-driven and nurse-led. It demonstrates that the nursing profession can provide the frontline leadership required to enhance and improve service delivery to meet the needs of the increased demand on healthcare services,” explained Karen.

Karen is one of four Registered Advanced Nurse Practitioners (RANP) in Acute Medicine operating around the country. The three others are based in Dublin and 21 ANP candidates are presently undergoing training in the speciality of Acute Medicine.

Advanced nursing and midwifery practitioner roles are developed around the country as a direct response to population health need and organisational requirements.

“While this service is clinically managed by an RANP Acute Medicine since July 2018, the developmental journey evolved in 2014 just four years after the unit first opened. Over this four-year period, the ANP Acute Medicine service was shaped to streamline the journeys for certain patient cohorts, allowing for expedited patient experience times, expedited and improved access to certain diagnostics and overall improving patient flow within the AMAU,” she explained.

“This service has improved the overall efficiency of assessment for all service users. By streaming the lower acuity presentations to the ANP service a reduced queue is waiting on assessment by the medical colleagues. This improves efficiency for the more acutely unwell service users.”

Karen said that the patient experience times are averaging between three-and-a-half to four-and-a-half hours between check-in and discharge. On average 85-89pc of patients managed by the ANP team are discharged home on the same day. She explained how the organisation and delivery of the AMAU services allows for such quick assessment and treatment.

I clinically manage each patient’s assessment/diagnostic journey and discharge/admission plans. As a Registered Nurse Prescriber I can prescribe and administered treatment interventions as required. The ANP Acute Medicine role and service is supported by the consultancy and medical team here in keeping with the recommendations from the National Acute Medicine program. The Consultant team are a constant supportive structure within our AMAU and have provided endless supports during the developmental stages of this ANP service,” she said.

“Many patients like the reassurance of knowing that their case has been looked over by a consultant so it is a major bonus to have them as a constant resource here on site.”

The ANP Acute Medicine service deals largely with lower acuity patients with less complex medical conditions or medical history.

“For example, I assessed a lady this morning and she was discharged in a couple of hours having seen a Medical Consultant with a provisional new diagnosis of asthma. This lady had bloods taken, had a chest x-ray, full respiratory assessment, was educated in the correct use of inhaler technique, was commenced on a new medicine and was referred to the ANP lead respiratory clinic for follow up Pulmonary Function Testing. This is a good example of how the service can efficiently provide an appropriate management plan to meet the long-term health needs for patients. This patient’s journey would most definitely have involved a lengthy wait behind the more acuity unwell if presenting at the Emergency Department. “Patients with lower acuity needs after triage can often face long waits in the ED because they would often be at the back of the queue while more serious cases are seen first,” said Karen.

Karen has 20 years’ nursing experience in a variety of nursing roles and grades, spending the last 9 years working in the Acute Medical Assessment Unit, Our Lady of Lourdes Hospital.

“I had a line manager who had the vision for the implementation of this role within our AMAU and she encouraged me to go down an education pathway towards advanced practice. I completed the Masters in Advanced Practice in 2017 and I have a diploma in prescribing of medications and radiation and there is a lot of continuous professional development attached to this role; I am delighted to be operating in this new type of role,” she said.

A further two ANP candidates in Acute Medicine are currently undertaking the training process. The implementation of these posts will further enhance service delivery with the expansion of the RANP Acute Medicine services in the Drogheda AMAU.

Access to the AMAU is through a referral from your GP or a referral from the ED. We also see patients referred from outpatients who require urgent medical assessment and management. The AMAU Team could see up to 50 patients on a busy day, averaging between 20 to 40 assessments daily in the 12-bed unit.

 “When a patient presents, they are triaged within minutes by the AMAU nursing team who identify if they are to be seen by the ANP or a higher risk patient to be seen by the medical service. In the rapid assessment room, a plan is put in place early by our skilled and highly competent nursing team to expedite the journey for the patient,” explained Karen.

“We have access to same-day diagnostics such as ultrasounds and CTs, as well as some cardiology investigative procedures. Within four to six hours, the patient would usually have all their tests done and reported on. Phlebotomy is also done here by our nursing team so the patient doesn’t have to leave the department to get their bloods taken and we have an interdisciplinary approach to care. These are all quality initiatives to enhance the patient’s journey. I believe the AMAU services can help eliminate the revolving ED door scenario for a cohort of medical patients living with chronic long term illness and this is generally the frail elderly population. We want to get these patients on the right path immediately, and empower people to manage their own health and put a long-term plan in place to keep them healthy and out of hospital.”

As well as managing acute patient presentations to the AMAU, the ANP Acute Medicine service is also managing the DVT (deep vein thrombosis) VTE (venous thromboembolism) ambulatory care pathway and providing virtual clinic follow-up services.

“These strategies are providing improved efficiency, avoidance attendance to outpatient clinics, enhancing patient safety through virtual clinic reviews and telephone communication and preventing hospital admissions. These services are enhancing quality for patients and are still in the early stages of development,” said Karen. 

“The DVT VTE service would have approximately 600 presentations a year. They are generally a lower acuity patient group and ideal for being seen by an ANP. These patients are followed-up by us in our virtual clinic. It is a hospital admission avoidance strategy and it is working very well.”

Lorraine Gray, CNM2, AMAU, highlighted the value of the service.

“This service provides a holistic rapid access service for patients presenting with suspected DVT and frees up doctor time to see the more acutely unwell patients,” she said.

Dr Mustafa Salem, the lead consultant physician in the AMAU, praised Karen and her team for “an incredible contribution to the service.”

One service user was moved to write a letter to Karen and her team, praising them as “a great example of professionalism, excellence, kindness and an empathy with the patient that could not be surpassed”.

“I count myself privileged to have been treated by a team of such wonderful, caring, kind and efficient people,” she wrote.