Flying a nurse practitioner: a six month pilot study in regional outpatient cancer services

The past ten years have revealed a rapidly shifting climate within cancer care. The introduction of targeted therapies and immunotherapies has changed the way cancer services view metastatic disease and has opened up avenues for patients who may not have been suitable for any further systemic intervention. These treatments, however, are also associated with serious side effects that may occur concurrently with pre-existing co-morbidities, requiring increased medical and nursing intervention.

This has increased the number of patients accessing the Mid North Coast Cancer Institute (MNCCI) services for ongoing treatment and management. This incurs increased medical clinical reviews, more time spent at the MNCCI receiving treatment and supportive care and increases the likelihood of inpatient admission due to development and recognition of systemic treatment side effects. ¹

The Nurse Practitioner Six-Month Pilot

In response to the increasing demand and acuity of patients requiring outpatient treatment for their cancer, the Nurse Practitioner Six-Month Pilot (NP Pilot) was established. The NP Pilot provides a five-day service across MNCCI and Port Macquarie Base Hospital (PMBH) Emergency Department (ED) and offers an expert and autonomous advanced practice nursing service within the MNCCI. Patients have one point of contact for their cancer treatment symptom management, ensuring ED avoidance remains a priority if deemed safe for the individual’s symptoms. The NP role provides efficiencies within the ED department and provides support for fast-track reviews, admissions and facilitates early intervention discharge. The role targets four service gaps within the MNCCI, which include:

• a telephone triage program – introduced utilising the UKONS telephone triage tool to enhance ED avoidance
• symptom and urgent review clinic (SURC) – structured sustainable nurse led clinic for MNCCI PMBH
• nurse practitioner led treatment room reviews
• ED fast track service – collaboration with ED to facilitate instigation of treatment.

A collaborative inter-departmental approach

Prior to commencing, strict business rules, referral process, review criteria and key performance indicators (KPIs) were established to address the clinical needs identified in the initial gap analysis. Specific indicators collated included:

• patients who avoided the ED (by being treated at home or in the MNCCI)
• patients who received treatment in the ED and were discharged home
• patients who were treated and admitted through the emergency department and measuring their length of stay (LOS)
• early inpatient discharges with review in the MNCCI
• MNCCI treatment room clinical reviews
• patients reviewed within the SURC clinic in the MNCCI.

All key performance data was collated to ensure that the patient experience was central to the care provided. The NP Pilot was established and implemented through a collaborative inter-departmental approach across all medical, nursing and allied health staff members. Referral criteria were established prior to launch. Patients included in the pilot had to be receiving active systemic treatment for their cancer and be experiencing one of the following criteria:

• chemotherapy induced nausea and vomiting
• febrile neutropenia
• diarrhoea
• anti-neoplastic drug therapy side effect management
• immunotherapy/targeted therapy side effect management
• other treatment related side effects.

The NP Pilot established a model of care that maintains the patient as a sentinel focus whilst utilising all members of the multidisciplinary to ensure efficient utilisation of finite resources. Through the implementation of this pilot, patients can receive efficient, effective and timely management of their symptoms. The pilot incorporated teams from both MNCCI and PMBH ED to identify and treat patients in a timely manner and to prevent further deterioration which would require hospital admission and increased LOS.

Patients are able to avoid staying in hospital

Data collated from the six-month period allowed for the evaluation of the service, providing statistically significant evidence that the service has not only been utilised and evidence of significant hospital avoidance for patients who are currently receiving active systemic treatment. The data collected highlighted the gap initially identified within the outpatient service was being filled, along with increased patient, carer and colleague satisfaction.

A peer evaluation of the service was completed following the initial three months of the NP Pilot, with overall feedback positive with regards to patient outcomes, time-to-patient symptom management, uninterrupted patient care (particularly in clinic times) and time spent waiting in ED for initiation of treatment for symptoms related to cancer treatment.

Given the KPls and identified specific targets, this service model could be replicated in any outpatient oncology service. In addition, the pilot can be replicated and extended to smaller regional hospitals in order to address the treatment disparity experienced by many of our cancer patients living in regional areas. The model allows cancer services to increase their capacity to not only provide holistic patient care, but it also allows the medical officers to provide consultation to patients who are being investigated for their cancer and need complex investigations to provide a diagnosis uninterrupted.

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