Friday, August 24, 2007

Practice nurse

Things are progressing for the Family Health Team. We've hired a dietician and several practice nurses. The nurses have been coming to family practices to shadow us.

I have started working with a nurse for the past few days. It is an interesting experience for both of us, since I've never had a nurse in my office, and she comes from an emergency room background.

I asked our FHT physician advisor if I could have a copy of the nursing scope of practice. The advisor is one of my family practice colleagues who has worked for the ministry; he is also a FHT member, and is knowledgeable about these issues. It looks like a nurse can do most things, but can't prescribe.

When our new nurse came in, I registered her in the EMR, and set her Permissions as "Nurse". By default, she is not allowed to prescribe or bill.

I gave her my resident's Tablet, and logged her in. I would come into the exam room, and introduce her. As she shadowed me, she would load a patient's record on the Tablet, so she could see what I was doing as I was doing it. After a couple of days, she had a good idea of the structure of the record, where things are kept, how to access the CPP, how to do an encounter and how to load templates. Patients seemed comfortable with having her in.

Yesterday, she started seeing patients before I came in. The EMR logs who does what, so it keeps her notes under her name. She does not sign off encounters, but instead sends them to me with the heading "Nurse saw patient". I can then modify and complete the record, and sign it off.

The Fall will be hectic for me. I have been doing a part time Masters of Science at the University of Toronto as I'm very interested in the effects of EMR on medical practice and wanted some extra education on policy and research topics. This is my third and final year; I will be taking a course in biostatistics, which will keep me away from my office on Mondays from September to December. I have been trying to figure out how to schedule things so I can still cover my practice, and will be adding extra hours on Tuesday afternoons and some Wednesday mornings. However, I think this will not be enough.

The nurse may be able to help here. I am getting some idea of what she does, and I think she can triage many problems over the phone or through an office visit. I think we will schedule her in on Monday afternoons and Tuesday mornings. She can see patients Monday, and shedule a follow up for those needing to see me urgently (which may not be a majority) on the following day. Having worked in Emerg, she is very comfortable triaging patients who require emergent treatment. She cannot prescribe; if she thinks a prescription is needed (example, positive quick strep), we can collect the pharmacy's phone number and I will authorize the script when I return from my course in the late afternoon. My practice partner is present in the office on Mondays, but I don't want to burden him with this, as he has not joined the FHT and therefore would not benefit from having a nurse; however, he is still there for emergencies.

There are hotspots at the university, and I will also log-on Mondays at lunchtime. While logistically challenging, I think this will work, and is a good opportunity to try interprofessional care in an EMR primary care environment, and to see what roles the practice nurse can take.

My Master's thesis is on the Effect of EMRs on Preventive Services with Pay for Performance Incentives. I recently received some funding for this; I will study two cohorts, one using EMRs and the other one on paper records, to see whether the introduction of EMRs had an additional effect beyond P4P.



Anonymous said...

As a senior doctor in the uk why didnt i think of this system it would save so much work! I would love more details of how you started it if it is at all possible.

Michelle Greiver said...

Thank you, but I'm no expert on the subject. What I am doing is mostly learning along with my nurse, so please take this as an early practice-based trial.

Basically, she first started by shadowing me. We'd talk after seeing patients to see what she could do. Also, I looked at the scope of practice and the medical directives papers.

She learned how to use the EMR. Now she sees patients first, then I come in later; a bit like teaching residents or medical students. She now gives injections; she gets the history and enters it into the record; she can interpret ECGs; she can take blood if needed.

My preventive health exams are very structured, because I use a template and handout. I showed her how to do it with several patients, then looked as she did several exams, and she can do most of it. We went over a breast exam together to make sure it was done thoroughly, and that's ok now. Now I let her do the exam and I come in at the end.

I have templates for sore throats (using the score), and it tells you what to do; she has used that. I also have templates for the Ottawa ankle rule and knee rule, so maybe I'll do directives on when to order XRs for that.

We've been reviewing my flow sheets for INRs blood pressure, and diabetes, so she knows how to use them, and when to put in alerts for me. She can use the emessaging system.

We also talked at lunch today with my staff about what she can do, so they know. She will come in Monday afternoons, and my staff will send her emessages so she can triage by phone. They can book things for her on Monday afternoons such as injections, ear syringe, or fit-in patients (URI, discuss results, UTI, some counseling etc). I will come in late afternoon after I finish class at the University to discuss things with her.

I would like her to also spend a half day with me Tuesday morning, because that will be busier than usual, and we can also continue to talk and fine tune things.

I hope that this gives you an idea of what I am trying to do. I think using templates is a good idea, because they can lead to consistent, evidence based care regardless of provider if used properly. Working with a nurse will also give you an idea of what they can (and can't) do. It seems to me that practice nurses are very under-used, considering what their skills are.

It has now been 3 weeks since she started, and I think things are going well.


Anonymous said...

Hi Michelle:

Interesting experience. We have been lookiing into hiring a practice nurse too. Is your nurse a regular RN or a RN (extended class) with nurse practitioner training in primary care?

Michelle Greiver said...

Hi TK. She is a regular RN. There is a lot that a RN can do if she works to full scope.