Specialist nurses in a hospital improved the effectiveness and efficiency of care
In this article…
- How proactive case management helps avoid admissions and prevent unscheduled care
- How defining key performance indicators or auditing against national standards can help specialist nurses show the effectiveness of their role
- Benefits of adopting proactive case management and national guidance on nursing management in lung cancer
Jane Baxter is Macmillan clinical nurse specialist in lung cancer, Imperial College Healthcare Trust; Alison Leary is Macmillan lead cancer nurse, Royal Brompton and Harefield Foundation Trust and visiting lecturer, King’s College London.
Baxter J, Leary A (2011) Productivity gains by specialist nurses. Nursing Times; 107: 30/31, early online publication.
Workload analysis showed that the specialist nursing service in lung cancer in an acute hospital was being used primarily to support processes and administration rather than providing holistic cancer care. An analysis of the inpatient population showed that many people were being admitted for non-acute problems, such as symptom control in advanced disease.
As the key workers for patients with lung cancer, the clinical nurse specialists negotiated away the administrative burden and adopted standard, proactive case management in line with national standards. Their proactive and vigilant case management resulted in a drop in admissions for non-acute problems from four to a mean of 0.3 per month. This represents a significant saving in bed days.
Clinical nurse specialists who practise proactive case management and re-focus services in line with best practice represent a good return on investment.
Keywords: Specialist nurse role, Lung cancer, Proactive case management
- This article has been double-blind peer reviewed
5 key points
- Cancer nurse specialists play an important part in making services more cost-effective
- Their role includes improving care while ensuring safety
- Specialist cancer nurses should have an input into managing services, but should not have to bear the burden of administration
- Proactive case management is a patient-centred way to promote care being provided in the most appropriate setting
- Using national guidance and best practice means specialist practitioners can determine key performance indicators for their service and demonstrate their activity
Lung cancer accounts for over 3,000,000 deaths each year worldwide, 33,400 deaths in the UK from the 39,000 people diagnosed. The five-year overall survival rate is only 8-11% (Cancer Research UK, 2010). Specialist nursing practice in the condition has expanded since the Department of Health introduced cancer improvement initiatives in 2000 (DH, 2000).
Five-year survival from lung cancer has barely improved in the past 30 years, but there has been a decline in male deaths and an increase in female deaths (Spiro and Silvestri, 2005). One-year survival has improved to some degree. In England and Wales, for men with advanced non-small cell lung cancer it has risen from 15% in the 1970s to 25% in 2000-2001 (Coleman et al, 2004).
There are 284.26 full-time equivalent specialist nurses in lung cancer in England to provide specialist nursing support for patients (National Cancer Action Team, 2010a). One role of cancer clinical nurse specialists is to enhance patient experience and care quality, while ensuring safety (Macmillan Cancer Support, 2010). Patient advocacy organisations such as Macmillan Cancer Support say clinicians should ensure patients and carers are aware of the quality of care they can expect to receive from cancer services (Macmillan Cancer Support, 2010). The National Cancer Action Team also publishes guidance and measures on services (NCAT, 2008). The shape and functions of these services are well defined and are regularly examined by internal and external peer reviews as well as the national cancer patient experience survey (DH, 2011).
The role of the cancer nurse specialist is also to promote efficiency and productivity in line with government initiatives, particularly with increasing financial pressures on the NHS, as clinical nurse specialists often have insight into the entire patient pathway (DH, 2007). Some data is already showing the return on investment of cancer nurse specialists in lung cancer (National Lung Cancer Forum for Nurses, 2008). Our work looks at one area – how proactive case management helps avoid admissions or prevent unscheduled care.
To gain an idea of how the cancer nurse specialist’s role was performing against national standards in lung cancer and supportive care, we assessed the activity of the lung cancer nursing service at one hospital in a large London trust. We used workload analysis by modelling using methods described elsewhere (Leary et al, 2008), together with telephone enquiries, to establish a baseline of activity, examine patient need and propose possible interventions in line with current best practice.
The findings helped to support the redeployment of non-productive specialist nursing time spent on administration, identify possible key performance indicators (KPIs) for the service, and implement proactive case management as part of best clinical practice guidelines (NCAT, 2010b).
In specialist nursing, there is no equivalent of initiatives such as Productive Ward (tinyurl.com/productive-ward). We therefore designed a method to better evaluate the specialist nurse role using KPIs as a possible metric for performance of the service.
The workload analysis showed that lung cancer specialist nurses were spending a large amount of time (38%) on administration. This was primarily on work to support meeting the two-week wait target, as well as administrative and clinical support for the multidisciplinary team meeting, such as booking routine investigations and providing secretarial support to the cardiothoracic service. This was in direct contravention of best practice, which acknowledges specialist cancer nurses should have input into managing services but does not mean they should bear the burden of administration (NCAT, 2008). This was not a productive use of nursing time.
The team decided to make the service more patient focused. It was unclear how patients’ needs were being met or if care was not as good as expected, so we telephoned a selection of patients (n = 30). The basis for selection was no recent (>30 days) contact with any member of the multidisciplinary team, and being in the follow-up stage of the cancer journey, having completed a regimen of surgery, chemotherapy or radiotherapy.
This telephone survey revealed that each patient had a resolvable problem. Some had more than one problem. Issues included:
- Four patients being lost to follow-up from the chest or respiratory service, where lung cancer follow-up took place;
- Two patients being lost to follow-up after radiotherapy;
- Three patients had post-thoracic surgery pain that was not being managed, so they were given advice on lifestyle, rehabilitation and analgesia;
- Seventeen patients had symptom issues that were addressed, for example with a clinic appointment and referral to a psychologist.
Overall, 26 out of 30 patients had issues concerning pathway management or symptoms related to their disease, including its possible progression. We found many readmissions to the acute centre were for symptom control in advanced disease.
Change of approach
In view of these findings, we adopted a proactive case management approach, which is common practice in specialist nursing (Leary, 2011; NCAT, 2010b; Oliver and Leary, 2010). It uses vigilance to manage care in a proactive rather than reactive way within defined best practice, such as national guidance (NLCFC, 2009). It requires input and agreement on management from the multidisciplinary team, with the clinical nurse specialist as the key worker or key accessible professional. The Cancer Reform Strategy promotes care in the most appropriate setting, and proactive case management is a patient-centred method of doing this (DH, 2007).
From July 2009 until mid-March 2010, the lung cancer nursing service practised proactive case management with their outpatient caseloads. The high-level key performance measure for this study was rate of admission to acute beds for non-acute oncology issues (primarily symptom control).
A retrospective analysis of the reasons for admission showed many patients had been admitted for symptom control in the previous six months. Before these admissions, they had had little contact with the team.
From the workload analysis of the two whole-time equivalent clinical nurse specialists, it was clear the service had picked up much of the necessary administration. Various techniques were used to negotiate this work away. This involved managing the expectations of others to a great degree and finding a champion in management to support this.
Proactive case management was then used from July 2009 until mid-March 2010 in the population with advanced lung cancer where the agreed ceiling of care was active, supportive or palliative. It is important to determine the ceiling of care with the multidisciplinary team and the patient (that is, the point to which intervention will be escalated).
In line with the workload of most lung cancer nurse specialists, the majority of patients in this group were having active supportive care or symptom control only. Patients were contacted regularly as necessary, at least once a month. Colleagues in the community palliative care team as well as hospice and GP colleagues were able to respond to issues as a shared caseload. If a patient with advanced lung cancer had an issue with dyspnoea, this could be assessed and managed in the community or admission arranged for an acute cause.
Acute oncological emergencies that could not be managed in the community, such as pleural effusions, came back to the acute centre, as did patients needing any other acute intervention. This meant management was in line with best practice guidance in lung cancer and supportive care (NLCFN, 2009; DH, 2007; National Institute for Clinical Excellence, 2005).
The lung cancer nursing team collected data on the nature and frequency of readmission. The previous six months (January-June 2009) were used for comparison as part of an evaluation cycle (Fig 1). The team included KPIs, including rate of readmission and reason for readmission for non-acute oncology issues, such as poor symptom control. (Admission to the acute centre should only be for an acute problem or if the centre is a designated preferred place of care for end-of-life care.)
Patients were also given contact details of the specialist nursing team, so could trigger a call to the team if they came to the emergency department.
Audit results before and after proactive case management was introduced are shown in Table 1. The average length of stay per admission was six days, so admission avoidance relieved pressure
on acute beds and resources could be better spent.
The “before” group averaged four avoidable admissions per month. In the “after” group, there were three admissions in nine months, giving a mean of 0.3 per month. If the average rate of admission avoidance is then 3.7 per month, this represents a considerable saving.
Even in this small study, it was calculated that 33 admissions were avoided in nine months. At an average stay of six days, this represents 198 saved bed days over nine months, or 266 bed days per year as a result of outpatient proactive case management alone.
At a minimum cost of £250 per acute bed based on the 2009 tariff (NHS Institute for Innovation and Improvement, 2010) this represents a total saving of £66,500 per year for the admission avoidance aspect of the service. The breakdown of the reasons for admission are shown in Table 2.
Although this study was small, it highlighted the role intervention and auditing best practice can play in identifying areas for service improvement and to support changes in activity. Many specialist nursing groups struggle to show their contribution and return on investment. Defining KPIs or audit against national standards could be an effective way of showing this.
The refocus of the service endorsed the adoption of proactive case management and the implementation of national guidance on the nursing management of patients with lung cancer. This resulted in better patient outcomes, supported patients being in their preferred place of care at the end of life, and avoided unnecessary costly hospital admissions. The more productive use of nursing time allowed new initiatives like a patient self-management programme to take place in conjunction with the local psychology service.
Cancer nurse specialists play an important part in making services more cost- effective. Being responsive to patient needs and taking a proactive approach to case management appear to be effective ways of promoting their role. This approach was practised only in the outpatient setting and it would be interesting to see if inpatient proactive case management reduced length of stay.
This study could be expanded to examine other possible KPIs for specialist nursing practice drawn from national models.
Many specialist nurses spend 20-30% of their time performing administration for a service (Leary and Oliver, 2010; Leary et al 2008). As there have been no initiatives such as Productive Ward in specialist practice – which frees up specialist nurses’ time so they can manage care – a national programme may save the NHS money.
Using national guidance and best practice allows specialist practitioners to determine KPIs for their service, which they can then use to evaluate it and demonstrate their activity and possible cost benefits or return on investment. Combined with quality data such as questionnaires, this can be a useful method of evaluating nursing services.
We found that clinical nurse specialists who practise proactive case management and refocus services in line with best practice appear to represent a good return on investment. NT
The authors wish to thank Pacita Maranao, Di Howard, Sarah Elkin, Dani Power and Professor Christine Norton of Imperial College Healthcare Trust and Melissa Reddish from St John’s Hospice Community Palliative Care Team.
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