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Extended nursing roles in intermediate care: a cost-benefit evaluation

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VOL: 98, ISSUE: 21, PAGE NO: 37

Joanne Bernhaut, BSc, is clinical governance facilitator, Barnet Primary Care Trust;Kate Mackay, MD, FFPHM, is consultant in public health medicine, Enfield Primary Care Trust

The development of intermediate care is an important element in the modernisation of the NHS (Department of Health, 2000a). Intermediate care was initially seen as one way to unblock acute beds and manage the reduced availability of long-stay beds. More recently the focus has been on patients' needs.

The development of intermediate care is an important element in the modernisation of the NHS (Department of Health, 2000a). Intermediate care was initially seen as one way to unblock acute beds and manage the reduced availability of long-stay beds. More recently the focus has been on patients' needs.

The King's Fund defined intermediate care as covering a range of therapeutic and recuperative services designed to avoid unnecessary admissions to acute settings (Vaughan and Lathlean, 1999), while the Department of Health (2001a) states that services must be targeted at those who otherwise face unnecessary stays in hospitals and institutions.

The Department of Health (2000a; 2000b) plans to expand intermediate care services, with the emphasis on new models of care and a whole-systems approach. One way to do this is by extending the role of nurses.

Nurse-led units have existed in the UK for more than 10 years (Pearson et al, 1988). To date, most have been post-acute, step-down beds for medically stable patients (Vaughan and Lathlean, 1999; Steiner et al, 2001). Rehabilitation services, such as stroke units, have been evaluated but there is a lack of information on nurse-led units that are designed to prevent unnecessary admission to acute hospital wards (Parker et al, 2000). For this reason researchers evaluated a nurse-led GP-admissions unit where nurses were involved in clinical decision-making.

A district general hospital in a north-London health authority was closed in 1996 as part of the borough's acute care strategy. The HA developed a community hospital on the site, including a 17-bed GP-admissions unit providing 24-hour care for patients who could not be managed at home but did not require hospital admission. Patient care was to be supervised by GPs in a nurse-led environment.

At the time of the study, the unit had an H-grade senior nurse, three G-grade, six E-grade and five A-grade nurses. It also had an occupational therapist and a physiotherapist, with a social worker available once a week. To admit a patient, the GP and a senior nurse discuss whether the unit is appropriate. When patients are admitted, their GP visits them within 48 hours of admission and at least once a week after that. Medical cover is provided by the GPs and an out-of-hours medical cooperative. A doctor at the neighbouring urgent-treatment centre is available in emergencies.

Team members in the unit share their skills and knowledge across professional boundaries. The emphasis is on holistic assessment, nursing intervention and rehabilitation to restore independence.

A combination of qualitative and quantitative methods were used to assess unit activity, and the views of the provider and users, and to understand individualised outcomes and unit processes (Patten, 1987).

Semi-structured interviews were conducted with all nurses in the unit, as well as 25% of the GPs who had admitted patients and 8% of those who had not. Six per cent of patients admitted to the unit during the study period were also interviewed, a sample that reflected the range of conditions managed in the unit.

Nurses were asked whether they had acquired any new skills while working in the unit, how decisions on care were made and what the term 'nurse-led' meant to them. The topics for GP interviews depended on the characteristics of the GPs' admission patterns. Patients were asked how they felt about the care they received.

Questionnaires were posted to all 80 GPs in the catchment area (44 users of the unit and 36 non-users). They asked the GPs to give their reasons for using or not using the unit. The questions also covered the distance from the unit, the time taken when using it and the perceived effectiveness of its staff.

After being discharged, all patients were sent a postal questionnaire asking about their condition, communication on the ward, their involvement in the decision-making process and their confidence in the staff.

All questionnaires were first piloted among the research team and patients in the unit. The data was analysed for statistical relevance, and interviews were taped, transcribed and analysed for themes.

Unit activity

The unit opened in March 1998, and by September 30 the following year there had been a total of 319 admissions. This represented 248 patients, of whom 191 (77%) had been admitted once, 48 (19%) twice and nine (4%) more than twice. Mean bed occupancy was 20% in the first four months, increasing to 74% after that.

The average stay was 14 days, which compared well with the unit's preferred maximum of 21 days. Eighty-three per cent of patients spent 21 days or less in the unit (Table 1). Table 2 lists the most common conditions, which account for 141 patients, six of whom were admitted twice.

Nurse interviews

The nurses described the care provided as holistic, focusing on individual needs and including patients' dietary and cultural needs, social circumstances and clinical problems. If patients need support after discharge, for example from social services, this is arranged before they leave the unit.

The nurses described their extended roles as carrying out tasks that they would not do traditionally, such as listening to the patient's chest and heart. G-grade nurses order chest X-rays and the nurses are able to initiate blood tests. Their extended skills include venepuncture and cannulation, enabling them to initiate and maintain patients on intravenous drugs such as antibiotics. They also interpret blood test results, and have begun to interpret X-rays and electrocardiograms so that they can alert GPs to anything that might require urgent attention.

Nurses prescribe drugs from the Nurse Prescribers' Formulary, while a protocol allows others to take telephone instructions from a GP, if necessary. The protocol dictates that two nurses have to take the verbal message independently. The GP then signs the drug sheet on his or her next visit.

Although nurses liaise with GPs on most matters, they highlighted some areas, such as wound management, in which they practice autonomously. The GPs also have confidence in the nurses' ability to manage aspects of patient care: 'We have to negotiate when a patient is going to be discharged, discuss wound dressings etc ... but often the GPs leave it up to the staff.'

The nurses also decide whether they need to contact the GP if a patient's condition deteriorates and, when necessary, suggest referral to the acute sector. This autonomy is perceived to reduce delays in treatment.

GP experience

One GP summed up the reasons for admitting patients to the unit as follows: 'I'm not sure there is a typical patient. Generally, however, they are elderly and need investigation as an inpatient or have a known illness which will respond to inpatient treatment, but can't be kept at home.' GPs who use the unit are confident of the nurses' ability to assess patients accurately and contact them when appropriate. They said they were not likely to be contacted outside surgery hours or to visit the unit without good reason.

The GP interviews show that they would have to admit patients to acute care if the unit did not exist: 'Approximately one-third of my patients admitted to the unit would otherwise have been admitted to acute care.'

A total of 44 GPs had registered for admission rights at the time of the study and there were wide variations in its use by individual practices and doctors. The reasons given by those who did not use the unit included that they feared an emergency at the unit might disrupt their work in the community and that their patients did not require the unit's facilities.

Thirty-five questionnaires were returned by the 44 GPs who admitted patients to the unit (80% response rate). Of these, 34 (97%) said they had not experienced difficulties in having patients admitted and 30 (87%) were satisfied with the admission categories. Twenty-eight (80%) GPs were satisfied with the quality of nursing care and 33 (94%) trusted the nurses to inform them of changes in patients' conditions.

Open-ended questions highlighted the types of patients GPs considered suitable for admission, which were divided into the following main categories:

- Acute medical conditions, such as severe chest infections requiring intravenous antibiotics, asthma and leg ulcers;

- Acute medical conditions that impair self-care abilities, for example an older person with a urinary-tract infection who has become confused/dehydrated but is usually self-caring;

- Chronic disease management and terminal care;

- Investigation, treatment and rehabilitation, for example stabilisation of diabetes, investigation of abdominal pain.

GPs indicated that they would not admit patients with severe or unexplained chest pain or acute stroke, or those likely to require immediate surgery or resuscitation.

Twenty-seven of the 36 GPs not using the unit returned their questionnaires (a response rate of 75%). The geographical position of the unit was not a problem and 20 (74%) agreed that it was a legitimate extension of primary care. The two main issues for these GPs were that an emergency at the unit would disrupt their work (14; 52%) and the lack of an in-house medical officer (15; 56%).

Patient experience

Interviews with 14 patients and responses to a postal questionnaire indicated a generally high level of satisfaction with the unit. Twenty-nine out of 46 (63%) questionnaires were returned. Twenty-three (80%) of the respondents rated their privacy as sufficient and 28 (97%) felt confident in the abilities of the staff to manage their condition. Twenty (69%) said the time they had spent with the doctor had been adequate.

Clinical effectiveness
It is unit policy that patients receive a full assessment within 48 hours of admission. In an audit of 141 casenotes, 135 (96%) patients received a comprehensive assessment within that time. Clear interventions for identified problems were documented for 130 (92%) of these. Insufficient discharge processes were identified in 32 (24%) cases in which no discharge summary was present in the notes. An audit of leg ulcer management using RCN standards (Cullum and Roe, 1995; RCN, 1996) showed that the assessment of patients with leg ulcers was initially unsystematic but that it improved considerably after the introduction of detailed assessment forms.

Cost comparisons
The unit needed to maintain a bed occupancy rate of at least 65% to be more cost-effective than acute hospital care. At 65% occupancy, the cost per occupied bed day was £130.76, compared with £135.76 on a medical ward in the neighbouring hospital. It is likely that the cost will have reduced over time as the unit was responsible for high capital charges at the time of the evaluation.

This evaluation aimed to determine whether the unit was providing the effective and efficient service required by the local population. Both nurses and GPs agreed that admissions were appropriate, while patients felt that they received a useful service. The audit confirmed that admissions were in line with the protocol and that treatment and discharge-planning were efficient.

GPs and nurses identified a need for time-limited inpatient care that is not provided by the acute sector. Typically, this category of patients is older and frailer, and GPs were concerned that acute hospitals could not cater for their needs. The unit was seen as providing a service that is more appropriate to individual needs.

The study showed high levels of patient satisfaction. In particular, patients appreciate the holistic approach to their care. Those who used the unit more than once highlighted the continuity of care offered as a result of low staff turnover and the minimal use of agency or bank nurses.

Nurses in the unit felt that their roles were distinctly different from previous work settings. Teamworking is important and staff share knowledge, skills and experience, and encourage junior staff to develop new skills. Nurses are willing to extend their roles and develop new modes of practice, for example by creating protocols to enable senior staff to order chest X-rays and blood tests, and to take verbal orders from GPs for prescribing certain drugs.

The nurses were enthusiastic about their work and believed that they were improving and innovating in practice. Another important factor is the unit's patient-centred focus. Patients are encouraged to be involved in their own recovery and are asked whether they need help with daily activities, rather than the nurses assuming that they do.

The GPs reported that they were happy with the care provided and were confident that the senior nurses could assess patients accurately, and that they knew when to involve GPs and when to make clinical decisions themselves.

Limitations of the study
A full cost-effectiveness analysis was not carried out because the unit was too small to demonstrably affect admission patterns in the neighbouring acute hospital. It also had high capital charges because the surrounding premises on the hospital site were vacant during the transition from a district general hospital to a community hospital.

Costs would have decreased as the unit established itself in the developing hospital and it is likely that the cost per occupied bed day would have been significantly lower than in the acute sector. Although the small size of the unit made formal comparison with larger acute units difficult, 81% of GPs using the unit believed that it had reduced the number of referrals to acute care.

The evaluation took place while the unit was still developing. This affected the assessment of its clinical effectiveness in that all evidence-based protocols had not been in force from day one.

This evaluation assessed the effectiveness of extended nursing roles in an intermediate care facility. It shows that the unit is effective and efficient and is providing an appropriate service for the local population. There is strong support from local GPs and the nurses running the unit are confident that they are extending their roles and improving their professional profiles. This model of nurse-led care should be considered in response to the National Service Framework for Older People's call to expand intermediate care services in the NHS (Department of Health, 2001b).

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