Development of an RANP role, Acute Medicine. Emily Bury RANP, Acute Medicine
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1 Development of an RANP role, Acute Medicine Emily Bury RANP, Acute Medicine
2 Background 2010 National Acute Medicine Programme NAMP recommends established the in development of ANP Ireland. posts with emphasis on independent assessment and development of treatment plans 2017 June 2013 Acute Medical Unit/Acute Medical Assessment Unit SVUH opened business St. plan Vincent s which University stipulated Hospital, ANP role, Dublin, acute medicine Ireland. 17 ANP candidates March clinical nurse managers appointed. Nursing A need staff for re-deployed clinical nursing from role wards models (58% and less than development 5 years experience) of acute medical nursing as speciality 2015 Business plan for ANP post approved and ANP ED candidate Task force commenced - Development (Graduate of ANP model of Certificate care both Advanced in the ED Nursing and AMAU Practice) to assess
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4 The Acute Medicine philosophy of care how does ANP role fit? Reduce trolley waits Be seen by Senior Doctor within 1 hour RANP can assess and manage an agreed caseload Better communication Receive the right treatment, in the right place, without delays Multidisciplinary rapid response
5 Where next? Collaborative approach Local implementation group Agree scope of practice/caseload Agree appropriate referral pathways Clinical supervision arrangements
6 Common Presentations to AMU Local Need Audit of common presentations to the AMAU/AMU at SVUH Other CCF I/E COPD Seizure Migraine UTI Pneumonia Collape TIA Number of presentations
7 Caseload Winter month In Depth Analysis Cardiovascular (CV): Diagnosis Transient Ischaemic attack (TIA) Thrombophlebitis and thromboembolism Percentage of CV conditions 25% 17% Total 42%
8 Inclusion criteria Symptom based RESPIRATORY Acute SOB, Pleuritic chest pain, acute onset of cough CARDIO VASCULAR Acute onset of symptoms of focal limb weakness, speech disturbance, visual field defect, unsteady gait and/or dizziness COLLAPSE Syncope and falls
9 Exclusion criteria Generic and specific RESPIRATORY RR > 28 RPM, SaO2 < 92% RA, GCS < 14/15 CARDIO VASCULAR Patients commenced on the stroke pathway in ED and/or NIHSS score greater than 4 COLLAPSE Hemodynamically unstable
10 Integrated DVT/AMAU Pathway Confirmed DVT Provoked DVT - Known risk factor which will resolve Unprovoked DVT -No identified risk factor If no contraindications consider Rivaroxaban - 15mg BD for 21 days followed by - 20mg OD for remainder of 3 months + Compression stockings (grade 2) for 2 years If contraindications to Rivaroxaban - Warfarin therapy - Low molecular weight heparin until therapeutic on Warfarin (consider CIT referral) - Referral to Warfarin clinic + Compression stockings (grade 2) for 2 years If no contraindications consider Rivaroxaban - 15mg BD PO for 21 days followed by - 20mg OD PO ongoing Thorough history and examination for malignancy FBC, ESR, U&E, LFTs, Calcium, PSA (men>40), CXR. If abnormal refer for specific investigations If contraindications to Rivaroxaban commence Warfarin in LMWH - Warfarin therapy - Low molecular weight heparin until therapeutic on Warfarin (consider CIT referral) - Referral to Warfarin clinic Thorough history and examination for malignancy FBC, ESR, U&E, LFTs, Calcium, PSA (men>40), CXR. If abnormal refer for specific investigations Discussion about life-long anticoagulation at this visit or a future OPD visit Discussion about life-long anticoagulation at this visit or a future OPD visit + Compression stockings (grade 2) for 2 years + Compression stockings (grade 2) for 2 years
11 Syncope algorithm Stabilise ABC. Check capillary glucose and reverse hypolycaemia Evaluate Circumstance Prodrome During T-LOC Postdrome Comprehensive health history/old CART Risk factors (CAD, CCF, syncope, valvular disease, family history of SADS, epilepsy) Physical Examination, review of systems ECG, orthostatic BP measurements if tolerated Medication History Vital signs, Neurological observations Are there features to suggest a benign aetiology? YES Lightheadedness upon standing NO Physical Findings Vital signs: Low BP, sinus bradycaria CVS: HS normal Resp:Clear Neuro: no focal neurology YES Physical Findings signs: systolic (20mmHg) and/or diastolic BP (10mmHg)on standing, sinus tachycardia on standing CVS: HS normal Resp:Clear Neuro: no focal neurology Are there features to suggest a structural or arrythmic cardiac aetiology? YES Physical Findings Vital signs: rapid or slow HR, low or high BP CVS: Added heart sound S3, mumers, Aortic stenosis. JVP, ankle oedema Resp: Crackles Neuro: no focal neurology Is there evidence to suggest that the T-LOC was a seizure? YES Physical Findings Vital signs: GCS, normotensive, NSR CVS: HS normal Resp: Clear Neuro: focal neurological signs, diplopia, limb weakness Investigations Labs: FBC, u&e, Orthostatic BP and HR measurements CT Brain* 9 Investigations Labs: FBC, u&e, Orthostatic BP and HR measurements CT Brain* Medication review Investigations Labs: FBC, u&e,, TnT CXR 24 hour telemetry ECHO EST ** CT Brain* Investigations Labs: FBC, u&e, Ca, glucose VBG: lactate, ph EEG 9,12 CT Brain +/- MRI Brain 9 Neurally mediated syncope Orthostatic Hypotension Cardiac Syncope Seizure
12 Memorandums of Understanding
13 Virtual clinic nurse led AMU virtual clinic interpretation of agreed diagnostic tests and acting on results, supported by the AMU consultants. Benefits safe discharge, reduction in length of stay, re admission avoidance, reduction in outpatient clinic reviews and the improvement in communication with primary care.
14 Other benefits to ANP service in Acute Medicine? CLINICAL PRACTICE -Reduce PET times & trolleygar -Expedite diagnostics and initiation of tx plans - Initiate safe discharge planning LEADERSHIP - Implements change in health service delivery -Mentorship, teaching and perceptorship RESEARCH Non clinical time for research --Audit of clinical practice to shape local service
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16 Key Performance Indicators In alignment with NAMP targets Including patient satisfaction with RANP Service
17 COMPETENCY ATTAINMENT
18 Competency attainment Clinical attachments in relevant specialities Formative case based discussions Clinical and professional mentorship Academic education and conferences
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20 National Strategy RANPs, Acute Medicine Currently aiming to establish ANP services within AMAUs with 17 candidates commencing posts ANP forum - Establish support network for candidate ANPs and identify learning and service needs AMNIG work closely with ONMSD and DoH and demonstrator sites Vision to create further posts nationally
21 SVUH - the future 2 candidate ANPs commencing post (+ 1 candidate ANP with defined respiratory caseload) Extended working day Access (GP referral, pathways from ED ) nurse led clinics ( ie VTE clinic) protected non clinical days for research/audit/ quality initiatives and continuous review of service needs
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