Site nurse practitioner service Making Decisions that Matter 24:7

The Hospital at Night (HaN) project has led to patients being seen by the right person with the right skills at the right time - care is responsive and timely. It has also led to a decrease in reportable clinical incidents.

National evaluation of the project also highlights improved communication, better team working out of hours, and improvements in support and training for junior doctors.

Alison Hendron, head of nursing inpatient services, Guy’s and St Thomas’ NHS Foundation Trust, discusses the role of the site nurse practitioner (SNP) and the role it plays within the hospital.

At Guy’s and St Thomas’ NHS Foundation Trust, the HaN model was successfully introduced in August 2004. The role of the SNP service is critical to the hospital functioning out of hours, and WTD 2009 compliance.

The trust SNP service provides an operational and clinical service for patients, staff and the trust 24/7. The SNP role is banded at 8A, there are two to three practitioners on duty depending on the time of day or night, and one on the Guy’s site 24 hours a day.

Historically, the role of the practitioner has been advanced clinical response and delegated duty site management, incorporating the bed management function of hospitals.

Practice for 2009 onwards also needs to reflect the safety and performance agendas, and equip practitioners to deliver services so that trusts can meet them, and the WTD requirement. In particular practice needs to be congruent with the NICE Acutely Unwell Adult Guidelines, 2007, and the Health Act, 2007.

Key delivery areas and performance objectives for the team are defined as:

Clinical - acutely ill adult

• Response to all first line calls for acutely and critically unwell adults (outside of critical care areas) out of hours, based on hospital response scoring systems
• Patients are assessed and treated, or referred under the priority for review system
• Advanced practice supported by acute clinical management pathways, and a service based competency framework.

Leadership and coordination of care

• Leading the HaN team
• Coordinating the response to care to ensure patients are seen according to priority and in a timely manner
• Chairing the HaN clinical handover.

Site management

• Duty management function out of hours, reporting directly to the executive director on call
• Trust wide 24:7 patient access and placement
• Management of capacity and occupancy levels cross site
• Trust wide clinical and non-clinical emergency response team lead, which includes adverse incident management.

Safety

• Delivering the trust’s safety, quality, and infection control agendas out of hours
• Through routine ward rounds, ‘walking the board’, and a hospital ‘safety’ big four.

SNP acute triage and treatment (SATTs)

All ward calls to medical staff at night are filtered by the SNP, this is to ensure that patients are seen according to clinical priority, and that patients are not disturbed unnecessarily for routine or planned tasks that can wait until the morning aiming to protect the patients sleep. SNPs provide first line inpatient triage and treatment according to our service based model for acutely or critically unwell adults at night. Patients are then managed by the SNP, or referred to the most appropriate member of the medical team using a time lined priority for review system.

Priority for review

Priority 0 - urgent or immediate
Priority 1 - within one hour
Priority 2 - within two hours
Priority 4 - within four hours
Priority 5 - review the following day.

The team practises at an advanced skill level which includes skills in advanced clinical assessment, arterial blood gas sampling and interpretation, ordering tests and investigations, and x-ray ordering and interpretation.

The service has developed clinical management pathways for presenting acute and emergency clinical situations, and practice is supported by a training and competency framework, both are continually being developed.

Clinical handover

Handover is chaired by a duty SNP and takes place in a formal meeting room. It initially took place in a less formal setting and was, as a result, a more difficult process to manage. Clinical nurses and junior doctors initially needed support in both chairing and attending these meetings.

Operational handover

An operational handover also takes place out of hours, this was introduced during 2007 and has been extremely successful to date. The SNP service perceives that the non clinical team members are critical to the clinical response out of hours, and also to the management of access, and safety. The SNPs chair a meeting with supervisors of the following services; security, housekeeping, portering, and estates mobilising teams according to priorities.

Independent prescribing

The service is currently rotating SNPs through the independent prescribing course, and we hope to have the majority of the team through the course by 2009. Changes in legislation since 2006 will lead to the greatest service developments and changes to practice for the nursing team.

Taking care 24:7

The trust is a Skills for Health - Workforce Projects Team WTD 2009 pilot site comprising of a trust wide multiprofessional project. Critical to the pilot is the introduction of new ways of working for healthcare workers, and key service developments include:

• The separation of the management of emergency/acute care from planned care
• The introduction of extended and new roles to support the delivery
• The extension of the clinical role of the SNP to cover the full 24 hour period on both sites, in order to lead and provide an acute response role for unwell patients.

The extension of the clinical role of the SNP 24:7 commenced on the Guy’s hospital site in November 2007. The model replicates the SNP acute triage and treatment model, and allows for case management of acutely unwell patients, and/or support for ward based teams on a 24 hour basis.

Guy’s hospital has 249 acute inpatient beds, it is characterised by the fact that the majority of care is planned, it is a tertiary referral centre for oncology/haematology, renal and urology, max-fax and ENT, orthopaedic and plastic elective surgery.

During the day there is a critical care outreach service, and the team refer to this team as well as therapists and SpRs. Out of hours the duty SNPs undertake this role.

Initial results show that the SNP day time role has been successful; staff report feeling better supported and welcome the additional clinical support. There have been direct referrals by speciality medical staff and, on a couple of occasions, SNP day time clinical involvement has prevented inappropriate cross site transfers.

The results of three months data shows that the duty clinical SNP is case managing between four to eight patients during the day. The average time spent with each patient was 26 minutes. The most commonly recorded intervention by SNP was assessment, advice, and/or review. The majority of patients required further review after three or four hours - they were categorised as Priority 3 or Priority 4.

The majority of referrals occurred during routine ward rounds. However, the number of direct referral by phone has increased from 1 percent to 29 percent from November to January. This reflects that ward staff have become more aware of the service as the pilot has progressed.

During November and January the most frequent referrals by the SNPs were to the duty FY2, followed by SpRs and the outreach team. During December the opposite referral pattern was noted, with the majority of referrals being to the SpRs and outreach. This reflects a rise in activity during this time.

Future developments

Services to support HaN have been developed across the country and are remunerated according to levels of autonomy and responsibility. Key to future service developments is ensuring that there are clear career pathways.

It is essential that practice is supported and validated by academic programmes that recognise the role and expertise of nurses in these specialised clinical roles. Guy’s is working with its academic partners to look at providing this. A recognised qualification will provide career advancement for the professional, and succession planning for the organisation in which they are employed.

The service is also looking at developing band 7 trainee acute care practitioner posts to support development to an SNP role.

For further information contact Alison Hendron, head of nursing inpatient services at Guy’s and St Thomas’ NHS Foundation Trust, alison.hendron@gstt.nhs.uk

To view more information about the Guys and St Thomas’ pilot project please visit
www.healthcareworkforce.nhs.uk/guysstthomaspilot