Supported by the AGPC report on the Australian health care workforce

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2 NPs 1960, USA to provide primary health care in under resourced/disadvantaged communities. Loretta Ford and Henry silver (Walsh, Crumbie and Revely 2003) Western Australia 1997, investigation (Judge Antoinette Kennedy) into the role of remote area nurses recognised many were working outside their scope of practice. Implementing the NP role could legitimise those activities Change in political climate= desire to expand the role

3 Supported by the AGPC report on the Australian health care workforce Australian Government Productivity Commission (2005) Australia s Health Workforce Position Paper Canberra: Productivity Commission Despite the support many challenges Medical resistance Pharmacology and prescribing resistance and law changes Accredited courses Designation

4 A Nurse Practitioner is a registered nurse educated to function in an advanced clinical role. The scope of practice of the Nurse Practitioner will be determined by the context in which the Nurse Practitioner is authorised to practice and will include legislative authority not current within the scope of nursing practice National Nursing Organisation 2000

5 Dynamic practice that incorporates application of high-level knowledge and skills in extended practice across stable, unpredictable and complex situations. Advanced comprehensive health assessments High level of clinical proficiency in procedures, treatments and interventions Extended practice competencies

6 Professional efficiency whereby practice is structured in a nursing model and enhanced by autonomy & accountability. Established therapeutic links Applies extended practice competencies

7 Clinical leadership that influences & progresses clinical care, policy & collaboration through levels of health service Engages in, and leads clinical collaboration that optimises outcomes for patients /clients and communities

8 Nurses Act 1992, Nurses Amendment Act 2003 Medical Act 1984 Misuse of Drug Act 1981 Pharmacy Act 1964 Poisons Act 1964 Radiation Safety Act 1975 Road Traffic Act 1974

9 Registration (AHPRA)- Endorsed Nurse Practitioner Code of Practice Designation of Practice Area (Director General or Department of Health) Clinical Protocols Drug formulary Monitoring and evaluation

10 Enrolled Nurse Registered Nurse Clinical Nurse School Teacher Clinical Nurse Specialist Nurse Practitioner

11 Bachelor of Nursing Post Graduate Studies Orthopaedic Certificate Graduate Diploma Education Graduate Diploma in Clinical Nursing Master of Nursing (Nurse Practitioner) Flinders South Australia/ECU

12 Identifying the need-clinical expertise Increasing complexity of the patients Increasing presentations, admissions, support of orthopaedic patients in outlying areas (ICU, NOSA, General wards, ED) increasing needs of the community-early discharge A business case

13 Role Coordinates the clinical management of all minimal trauma fractures Mx. complex acute medical conditions/co-morbidities timely manners Peri-operative management optimising pt. condition Maintaining consistent and comprehensive approach Encouraging compliance/education #hip pathway Facilitates discharge planning Enhance rehabilitation outcomes Cost effective- Reducing length of stay

14 Peri-operative Mx Pre and post op x-rays/bloods/ecg/fluid Mx/Transfusions/Benzodiazepine withdrawal nicotine, insulin infusion, prophylactic AB s Pain Mx VTE prophylaxis UTI Constipation Nausea and vomiting Osteoporosis

15 Nurse Practitioner Scope All medically stable orthopaedic patients requiring surgery. All medically stable minimal trauma patients being conservatively managed. Outcomes Identify patients suitable for Ortho NP CPG MEDICAL PRACTITIONER +/- Nurse Practitioner Exclusion Criteria Complex orthopaedic patients (e.g. multi-trauma patients) Medically unstable orthopaedic patients Palliative Intent Identify patients not suitable for Ortho NP CPG exit CPG refer orthopaedic +/- Orthogeriatric team ASSESSMENT & INTERVENTION Primary Survey Airway Breathing Circulation Identify patients not suitable for Ortho NP CPG exit CPG refer orthopaedic +/- Orthogeriatric team

16 History Scope Presenting injury/condition Planned orthopaedic surgical interventions Risk factors 1 As per Risk Ax Tools (VTE/Falls/Pressure areas, withdrawal drug/alcohol) Relevant past medical history medication use (including anticoagulants/anti-platelets) Renal function Weight Allergies Outcomes Identify patients not suitable for Ortho NP CPG exit CPG refer orthopaedic +/- Orthogeriatric team Focused clinical assessment Haemodynamically stable Trauma injuries- open wounds Fracture type Potential compartment syndrome Muscular skeletal examination General examination Vital signs Differential diagnosis exit CPG refer to Orthopaedic +/- Orthogeriatric Team.

17 Scope Outcomes Working diagnosis and Investigations Imaging X-ray suspected fracture Pelvic X-ray (suspected hip #) Chest X-ray Post-op X-ray Abdominal X-ray (Constipation protocol) Bone densitometry (DXA) (OP protocol) Differential diagnosis exit CPG refer to Orthopaedic +/- Orthogeriatric Team. Routine pre and Post-op x-rays Facilitate early diagnosis and rehab goals (post op)

18 Pathology Scope Laboratory Test Clinical biochemistry tests Blood glucose Serum urea and electrolytes Serum calcium Cardiac markers Thyroid function test LFTs: alanine transferase (ALT), gamma glutamyl transpeptidase (GGT), alkaline phosphate (AP), bilirubin and albumin Therapeutic drug monitoring -digoxin Haematology test Full blood count Coagulation profile Erythrocyte sedimentation rate and C-reactive protein Blood transfusion testing Blood group, antibody screen and crossmatch (as per routine pre-op and post-op guidelines Microbiology Urine microscopy, culture and sensitivity Blood Cultures Osteoporosis Bloods Ca, Vitamin D, LFT, Creatinine/eGFR, PTH, TFT Outcomes Identification of abnormalities and initiate treatment refer to Orthopaedic +/- Orthogeriatric Team. Implement VTE Risk assessment and Mx Therapeutic Mx as per anticoagulation chart Transfusion protocol Ab s as per UTI protocol OP medications as per OP protocol

19 Scope Outcomes Other ECG Routine pre-op Early identification in Dx cardiac event (e.g. AF ACS) Working diagnosis and Investigations Imaging Confirmation of fracture Confirmation of good alignment post-op Identification of chest abnormalities (consolidation/po) Early identification of abnormalities refer to Orthopaedic +/- Orthopaedic Team facilitate early mobilisation Interpretation of results (diagnostic features) and management decisions Pathology and clinical features Identify abnormalities and notify Orthopaedic +/-Orthogeriatric Team Implement treatment modalities Differential diagnosis exit CPG refer to Orthopaedic +/- Orthopaedic Team Implement VTE Risk assessment and Mx Therapeutic Mx as per anticoagulation chart Transfusion protocol Ab s as per UTI protocol OP medications as per OP protocol Correct dose charted

20 Associated Care Acute Referral Referrals Scope Patient education/family education Pre and Post op care Discharge planning Rehabilitation goals and referral to rehab facilities OP education and referral Referral to Orthopaedic +/- Orthogeriatric Team Duty Anaesthetist APS Interpreter Allied Health As appropriate to allied health team members Referrals may be made for specific patient problems or as required to -HITH - Interpreter -Pharmacist -- Physiotherapist - Occupational therapist -Social work - Aboriginal liaison officer -Drug and alcohol counsellor Outcomes Identify patients not suitable for Ortho NP CPG exit CPG refer orthopaedic +/- Orthogeriatric team Prompt referral Improved pain management Early identification of D/C Requirements for rehab

21 Medications Analgesia As per NP Pain management protocol Assist in effective pain relief Antibiotics Antacid Anti-emetics Aperients Antifungal As per UTI protocol As per orthopaedic surgical prophylaxis (IV cephazolin/ mupirocin) Mylanta As per nausea and vomiting protocol As per constipation protocol Fluconazole (oral) Nystatin (Nilstat) Oral Clotrimazole (Canestin Cream) (topical) Prompt treatment of infections identified Improve compliance with prophylactic protocol Relief of indigestion Assist in effective nausea and pain management Prevent and treat constipation Treatment of simple Candida infections (throat and vagina)

22 Benzodiazepine Drugs for eye infections Intravenous Fluids Nicotine Medications Diazepam (As per drug/alcohol withdrawal chart, Benzodiazepine withdrawal chart, Amphetamine withdrawal Chart, Cannabis Withdrawal chart) Chloramphenicol 1% ointment Chloramphenicol 0.5% eye drops Normal Saline Red blood cells As per SCGH Withdrawal guidelines and nicotine Dependency Assessment Assist in management of reducing withdrawal symptoms Treatment of conjunctivitis and simple eye infections common to the elderly patient Assist in maintaining hydration Assist in treating hypovolaemia as per orthopaedic transfusion protocol Encourage cessation of smoking whilst undergoing surgery. Reduce the incidence of aggression related to withdrawal

23 Medications Osteoporosis As per OP protocol Assist in improving initiation of OP treatment and prevention VTE prophylaxis protocol As per Risk Assessment Tool for Venous Thromboembolism (VTE) and Department of Orthopaedics VTE Prophylaxis (Jan 2011) Reduce incidence of VTE Improve compliance of risk assessment and prophylactic administration References A guide for assessing older people in hospitals(2004) Developed by the Centre for Applied Gerontology, Bundoora Extended Care Centre, Northern Health. Commissioned on behalf of the Australian Health Ministers Advisory Council (AHMAC) by the AHMAC Care of Older Australian Working Group. Australian Medicine Handbook Pty. Ltd. July 2011 Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings: Update 2007 Best practice approaches to minimise functional decline in the older person across the acute, sub-acute and residential aged care settings (2004) British Orthopaedic Association (2007) The Care of Patients with Fragility Fracture Brown, A.F.T and Cadogan, M.D Emergency Medicine emergency and Acute Medicine: Diagnosis and Management (5 th. Ed), Hodder Arnold, London. Dandy, D., Edwards. D. Essential Orthopaedics and Trauma 3 rd. Ed (1998) etg Complete Therapeutic Guidelines 2011 ( Management of hip fracture in older people. A national clinical guideline (2009) Scottish Intercollegiate Guideline Network. MIMS Online 2011 SCGH Withdrawal Guidelines and Nicotine Dependency Assessment SCGH Alcohol Withdrawal Chart SCGH Amphetamine Withdrawal Chart SCGH Benzodiazepine Withdrawal Chart SCGH Cannabis Withdrawal Chart

24 AUTHOR(S) ENDORSEMENT This CPG was written by: Sharon Pickles Nurse Practitioner Orthopaedics Sir Charles Gairdner Hospital Dr Denise Glennon Geriatrician Rehabilitation and Aged Care Department Sir Charles Gairdner Hospital Reviewed & Authorised by: Dr Gerard Hardisty Head of Orthopaedic Department Sir Charles Gairdner Hospital Dr Denise Glennon Geriatrician Rehabilitation and Aged Care Department Sir Charles Gairdner Hospital Jennifer Benzie Chief Pharmacist Sir Charles Gairdner Hospital Michael Bynevelt Head of Radiological Department Sir Charles Gairdner Hospital Dr Ee Mun Lim Head of Department Clinical Biochemistry PathWest QEII Consultant Endocrinologist Sir Charles Gairdner Hospital Date written: December 2011 Review date: December 2013

25 Analgesics Aspirin Tablet Buprenorphine Transdermal Patch (Norspan) (5mcg, 10mcg) Buprenorphine sublingual immediate release (200mcg-400mcg) (As per APS) Hydromorphone HCL prolonged- release tablet (Jurnista PR) 4mg Hydromorphone immediate release tablet (0.5mg-4mg) Oxycodone hydrochloride controlled release tablet (Oxycontin- 5mg, 10mg) Oxycodone hydrochloride immediate release tablet/capsule (Endone IR/Oxynorm mg) Oxycodone hydrochloride liquid (1mg-10mg) Oxycodone hydrochloride & Naloxone hydrochloride dihydrate controlled release tablet (Targin CR) (5/2.5, 10/5mg) Paracetamol PO/PR/IV Paracetamol Osteo (665mg) Paracetamol /Codeine Tablet (500mg/8mg) (Panadeine) Paracetamol/Codeine (500mg/30mg) (Panadeine Forte Tablet) Tramadol PO/IV (50mg-100mg) Antacids Mylanta Aperients Bisocodyl tablets/suppository Benefibre Coloxyl and Senna Epson salts Fleet enema Glycerine suppository Microlax enema Movicol Picoprep Sorbitol

26 Antibacterials Amoxycillin Amoxycillin with clavulanic acid Flucloxacillin Phenoxymethylpenicillin (penicillin V) Cephalexin Cephazolin Doxycycline Roxithromycin Metronidazole Trimethoprim Mupirocin ointment/cream (*As part of Hip pathway and all orthopaedic metal work implantation) Antiemetic Metoclopromide hydrochloride Ondansetron Prochlorperazine Antifungal Fluconazole (oral) Nilstat (oral) Canestin Cream (Topical) Benzodiazepines Diazepam (as per withdrawal protocols) Drugs for eye infections Chloramphenicol ointment Chloramphenicol eye drops IV Fluids Normal Saline 5% Dextrose Red Blood Cells (Transfusion as per Orthopaedic Transfusion Protocol)

27 Insulin Actrapid (as per fasting protocol) Patient s usual insulin dose NSAIDS Diclofenac Ibuprofen Indomethacin Naproxen Osteoporosis Medications Vitamin D Cholecalciferol 25mcg Vit D 2, D 3 Calcitriol Calcium Supplements Calcium Carbonate 600mg Calcium Citrate 500mg Bisphosphonates Alendronate (patient s usual meds) Fosamax (patient s usual meds) Strontium(patient s usual meds) Actonel Combi D (patient s usual meds)

28 Pre admission clinics Anaemia management Outpatient clinics Fragile bone clinic- Management of OP Falls Clinic Private consultant rooms

29 Funded until 2014 Annual report Justify cost saving benefits Justify clinical needs Patient outcomes

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