Stroke Nurse Practitioner Model Development Report The Alfred Department of Human Services Victorian Nurse Practitioner Project Phase 4 Round 4.2 6 February 2009 ENDORSED BY Ms Julie Cairns Co-Director (Nursing), Medical Specialties The Alfred Associate Professor Sharon Donovan Director of Ambulatory & Mental Health Services Director of Nursing The Alfred Chief Nursing Officer Alfred Health Ms Jennifer Williams Chief Executive Officer Alfred Health Dr Judy Frayne Head of Stroke Service The Alfred Associate Professor Richard Gerraty Head of Stroke Research & Education The Alfred February, 2009 CONTACT Ms Julie Cairns Nursing Co-Director Medical Specialties The Alfred Phone: 03 9076 2891 e-mail: [email protected] The Alfred Stroke Nurse Practitioner Model Development Report i TABLE OF CONTENT Page Abbreviations v Acknowledgement vi Executive Summary 1 Section 1: Introduction 3 Section 2: Background 2.1 History of nurse practitioner role within Alfred Health 5 2.2 Priming the organisation for the stroke nurse practitioner 6 2.3 Incidence and prevalence of stroke 6 2.4 Increase in local demands on stroke service 7 2.5 Victorian Stroke Care Strategy – management of acute stroke/TIA 8 Section 3: Current model of stroke care 3.1 The Alfred stroke service 9 3.2 The stroke service team 10 3.3 Current management of acute stroke 10 3.4 Stroke prevention 11 3.5 Gaps in current service model 11 Section 4: Shaping the service model 4.1 Stroke nurse practitioner models from overseas 11 4.2 The Alfred proposed SNP model 12 4.2.1 Target population 12 4.2.2 SNP emergency management of stroke 13 4.2.3 SNP acute stroke care 13 4.2.4 Discharge from ED 14 4.3 SNP protocols and guidelines 14 4.3.1 Clinical practice guidelines 14 4.3.2 Drug formulary 15 4.3.3 Pathology 15 4.3.4 Radiology 15 4.3.5 Referrals 15 Section 5: Potential issues or barriers 15 5.1 Delay in patient suffering stroke/TIA presenting to ED 16 5.2 Failure to notify the SNP of a potential stroke or TIA arrival in ED 16 5.3 Failure to recognise stroke as a medical emergency 16 5.4 Expansion of professional boundaries 17 5.5 Failure to capture all patients presenting with stroke or TIA symptoms 17 The Alfred Stroke Nurse Practitioner Model Development Report ii Section 6: Evaluation of the SNP model 17 Section 7: Preparing the stroke nurse practitioner candidate 18 7.1 Clinical vs non-clinical hours 19 7.2 Academic preparation 19 7.3 Clinical mentorship 19 7.3.1 Who can be a clinical mentor 19 7.3.2 Responsibilities of the clinical mentor 20 7.3.3 Responsibilities of the SNPC within the clinical mentorship model 21 7.4 Professional mentorship 21 7.4.1 Who can be a professional mentor? 21 7.4.2 Responsibilities of the professional mentor 21 7.4.3 Responsibilities of the SNPC within the professional mentorship model 22 Section 8: Governance of the SNP model 22 Section 8: Milestones for the next twelve months 22 References 23 The Alfred Stroke Nurse Practitioner Model Development Report iii APPENDICES Appendix 1: Stroke Nurse Practitioner Steering Committee: Terms of Reference Appendix 2: Stroke Nurse Practitioner Project Overview Appendix 3: Clinical Practice Guideline Ischaemic Stroke Appendix 4: Clinical Practice Guideline TIA Appendix 5: Proposed SNP Drug Formulary Appendix 6: Proposed SNP/C Extensions to Scope of Practice Appendix 7: Stroke Nurse Practitioner Evaluation Plan Appendix 8: Position Description Stroke Nurse Practitioner candidate Appendix 9: Position Description Stroke Nurse Practitioner Appendix 10: Proposed Stroke Nurse Practitioner weekly timetable Appendix 11: Endorsed Master’s Courses and Pathways to Endorsement Appendix 12: Project budget expenditure The Alfred Stroke Nurse Practitioner Model Development Report iv ABBREVIATIONS ASUN Australian Stroke Unit Network ANPA Australian Nurse Practitioner Association ANMC Australian Nursing and Midwifery Council ANPA Australian Nurse Practitioners Association ATS Australasian Triage Scale CPG Clinical practice guidelines CTA Computed Tomography Angiogram CT Computed Tomography DVT Deep vein thrombosis ED Emergency Department ESC European Stroke Council GP General Practitioner MRA magnetic resonance angiography MRI magnetic resonance imaging mRS modified Rankin Score NIHSS National Institutes of Health Stroke Scale NBV Nurses Board of Victoria NP Nurse Practitioner NPB Nurse Policy Branch NPC Nurse Practitioner Candidate NSF National Stroke Foundation SCSV Stroke Care Strategy for Victoria SITS Safe Implementation of Thrombolysis in Stroke SNP Stroke Nurse Practitioner SNPC Stroke Nurse Practitioner candidate SPC Stroke Prevention Clinic TIA Transient ischaemic attack tPA tissue plasminogen activator PBS Pharmaceutical Benefits Scheme VAED Victorian Admitted Episodes Dataset VNPP Victorian Nurse Practitioner Project VSNPC Victorian Stroke Nurse Practitioner Collaborative VSCN Victorian Stroke Clinical Network The Alfred Stroke Nurse Practitioner Model Development Report v ACKNOWLEDGEMENTS The Alfred Health Stroke Nurse Practitioner Project was funded by the Department of Human Services as part of the Victorian Nurse Practitioner Project (VNPP) Phase 4 Round 4.2. Acknowledgement is made of the time and considerable effort that the Alfred Health Stroke Nurse Practitioner Steering Committee members have contributed to this project and their names are listed below. Ms Chris Batey Nurse Manager Emergency and Trauma Centre Ms Julie Cairns Co-director (Nursing) Medical Specialties Ms Shin Choo Pharmacy, Alfred Hospital Ms Michelle Farquhar Occupational Therapist, Stroke Service Dr Judy Frayne Head of Stroke Service A/Prof Richard Gerraty Head of Stroke Research and Education Dr Anthony Kam Head of MRI, Alfred Radiology Mr Tony Ryan Nurse Manager Ward 7 West Dr De Villiers Smit Acting Director of Emergency and Trauma Centre Ms Erica Tong Pharmacy, Alfred Hospital Ms Anne-Marie Watson Stroke Nurse Practitioner Project Officer 7 West nursing staff, the multidisciplinary stroke team, Dr Luke Chen and Dr Paul Tomlinson Nursing and medical staff of the Emergency and Trauma Centre, especially Rosie Bushnell and Emergency nurse practitioners Natasha Jennings and Kylie Chou. Ms Danielle Bolster Alfred Health Nurse Practitioner Service Plan Development Project Officer of 2006. Ms Katy Fielding Manager Workforce, Policy and Programs Branch, Department of Human Services Ms Michelle Thomas Nurse Policy Officer, Policy, Research and Practice Standards, Nurses Board of Victoria Ms Robyn Wright Clinical Governance Unit. Victorian Stroke Nurse Practitioner Collaborative in particular the other project officers Ms Jill Dunn, St Vincents Health; Ms Louise James, Austin Health; Ms Elizabeth Mackey, Melbourne Health and Ms Deanna O’Donnell, Eastern Health. Prepared by Anne-Marie Watson Robyn Wright The Alfred Stroke Nurse Practitioner Model Development Report vi EXECUTIVE SUMMARY Stroke, along with heart and vascular diseases, are Australia’s largest health problem. Stroke is the second leading cause of death in females and the third leading cause of death in males. The number of strokes will increase each year due to the ageing population and in the next ten years, more than half a million people will suffer stroke. The forecasts for stroke service demands across the State of Victoria are estimated to increase by 2.7 per cent per annum. Each year there are between 600-700 people presenting to The Alfred with stroke and transient ischaemic attacks (TIAs) symptoms. Consistent with this, local projections forecast a 25% increase in acute admissions for stroke at The Alfred over the next 10 years. There is strong evidence that patient outcomes following stroke/TIA are significantly improved when signs and systems of stroke/TIA are recognised early and prompt treatment is provided. Over 80% of all stroke presentations are for thrombotic or embolic stroke and the therapeutic time window is limited to 4.5 hours from the onset of symptoms to treatment with thrombolytic agents. For patients presenting with TIA symptoms, early risk factor management and follow up is essential due to the increased risk of stroke of up to 10% within one week. In 2007, the National Stroke Audit revealed that although 42% of patients in category A (or Level 4) hospitals arrived within 3 hours of onset of stroke symptoms, only 6% received thrombolysis therapy. This data suggests that barriers to this treatment are not just those associated with delay in presentation, but also factors associated with prompt assessment and intervention once the patient has arrived in the Emergency Department. National guidelines and the Victorian Stroke Care Strategy emphasises the time-critical nature of management of acute stroke and recommends: (cid:131) promoting early recognition of stroke/TIA symptoms by the general public (the FAST Campaign) (cid:131) early transfer via ambulance to a health care facility able to provide acute stroke care (cid:131) treating acute stroke as a medical emergency – rapid assessment, investigation and diagnosis (cid:131) early intervention for ischaemic stroke with thrombolytic therapy, anticoagulation therapy or interventional radiology in experienced health facilities (cid:131) the initiation of investigations for TIA in the emergency department and instigation of pharmacological agents to treat known risk factors for stroke, and (cid:131) early follow up of TIA patients in a Stroke Prevention Clinic within 14 days. While The Alfred is able to provide a comprehensive Level 4 Stroke Service, there are clear gaps in the acute management of stroke/TIAs that relate to the organisations capacity to rapidly triage, The Alfred Stroke Nurse Practitioner Model Development Report 1 assess and instigate time critical therapies for patients experiencing acute stroke, or follow up patients at high risk of potential stroke within one or two weeks of discharge from ED. The Nurse Practitioner model offers an opportunity to introduce an advanced nursing role into the Stroke Service at The Alfred, with extensions to nursing practice that would increase the capacity of the Stroke Service to rapidly respond to acute stroke and TIA patients. The primary objectives of the Stroke Nurse Practitioner model are to optimise the management of acute stroke in the ED, decrease transit times through the ED (from ED to ward or ED to home) and ensure timely follow up of high risk TIA patients in a Stroke Prevention Clinic When fully implemented the proposed SNP model will primarily focus on: (cid:131) early assessment and management of acute/TIA stroke patients in the ED including the initiation of relevant investigations, consultation with the stroke registrar and consultant, and discussion with the patient/family regarding the management plan (cid:131) facilitating the admission of the patient to the Stroke Unit (cid:131) initiation of further investigations or referrals to other clinics or services (cid:131) liaison with general practitioners for patients being discharged from the ED; (cid:131) follow up of low risk TIAs and minor stroke in the Stroke Prevention clinic (cid:131) education and policy development relating to acute management of stroke in ED Preparation for a SNP candidate (SNPC) role would include academic preparation and workplace training, supervision and mentoring (both clinical and professional) in accordance with the requirements of the NBV and Alfred Health. Academic preparation for a candidate to become an endorsed SNP includes successful completion of an approved Master of Nursing program. Clinical practice for the SNPC would be guided by Clinical Practice Guidelines for ischaemic stroke and TIA and the implementation of the role and assessment of clinical competence would be overseen by a multidisciplinary the SNP Steering Committee. The assessment, investigations and management of patients with acute stroke and TIA are protocol driven and can readily be performed by an experienced stroke nurse. The SNP model offers a means to increase the capacity of the Stroke Service to meet project future workload demands and enable skilled and experienced stroke nurses to exercise their clinical potential. Further development activities for the SNP model are contingent on funding for the SNPC position. Milestone for the next six months include: completion and submission of a business case to support the implementation of the SNP model and enrolment of potential SNPCs in a suitable Masters of Nursing (Nurse Practitioner). The Alfred Stroke Nurse Practitioner Model Development Report 2 Section 1 Introduction In 2008 The Alfred was one of eight Victorian Health Services successful in obtaining funding from the Victorian Nurse Practitioner Project (VNPP) (Department of Humans Services, 2008) to examine the opportunities for strategic, sustainable and integrated nurse practitioner service in the provision of stroke care. The purpose of this report is to: (cid:131) describe the proposed Stroke Nurse Practitioner (SNP) model and discuss how it will operate in the clinical setting at The Alfred; (cid:131) demonstrate how the SNP model will assist in meeting the strategic goals of Alfred Health as well as the recommendations for acute health services as outlined in the Stroke Care Strategy for Victoria (SCSV) (Department of Human Services, 2007a); and (cid:131) outline the implementation processes, tools and resources required to implement a SNP model at The Alfred. Alfred Health (formerly known as Bayside Health) is the main provider of health services to people living in the inner south east suburbs of Melbourne. Alfred Health includes the following health care institutions: The Alfred, a 544 bed major metropolitan tertiary referral health service; Caulfield Hospital, a 348 bed major provider of aged care, rehabilitation, aged psychiatry and residential care; and Sandringham Hospital, a 101 bed community hospital which provides both elective and emergency surgery and general medicine as well as women’s health and maternity services. Overall Alfred Health serves a local catchment population of approximately 400,000 and provides services across the continuum of care from ambulatory, to inpatient, home and community based services (Alfred Health, 2008). The Alfred provides a comprehensive range of specialist acute health and mental health services and is a designated State-wide provider of Heart and Lung replacement and transplantation (including mechanical heart program and Paediatric lung transplantation), Adult Cystic fibrosis, Adult Major Trauma, Adult Burns, HIV/AIDS, Haemophilia, Sexual Health, Hyperbaric Medicine, Psychiatric Intensive Care and Statewide Elective Surgical Services. These services are provided in a range of inpatient and ambulatory settings and in partnership with other community service providers. Between 2006 and 2011 the resident population of Alfred Health’s primary catchment area of inner Melbourne is expected to experience a growth rate of 1.9%. The greatest population change will be in the proportion of people over the age of 60 years (Bayside Health, 2006a). Because older people have an increased burden of disease and use health services at a higher rate than younger people, the ageing population is expected to contribute to an increased demand for health services. Stroke, along with heart and vascular diseases, are Australia’s largest health problem. Stroke is the second leading cause of death in females (10.8% of all female deaths) and it is the third The Alfred Stroke Nurse Practitioner Model Development Report 3