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(1)

Advanced

 

Practice

 

Nursing

 

in

 

Si

Cli i l O t

Singapore

 

– Clinical

 

Outcomes

Tan Siok Bee

Tan Siok Bee

Tan

 

Siok

 

Bee

RN, BHSc(N), CCNC, MN, APN, DipHT, CH

Tan

 

Siok

 

Bee

RN, BHSc(N), CCNC, MN, APN, DipHT, CH RN,RN,  BHSc(N),BHSc(N),  CCNC,CCNC,  MN,MN,  APN,APN,  DipHT,DipHT,  CHCH

(2)

What

 

is

 

an

 

Outcome?

Th t

hi h

t th

l f ll t

t

t

“t

k

That which represents the goal of all treatments: “to make

the patient better”.

(F i

1993)

(Fries 1993)

Outcomes in clinical practice provide the mechanism by

which the health care provider, the patient, the public, and

the payer are able to assess the end results of care and

the payer are able to assess the end results of care and

its effect upon the health of the patient and society.

(Anderson & Weinstein, 1994)

( & , )

(3)

Florence

 

Nightingale

Evaluating the quality of nursing practice began when

Fl

Ni hti

l id

tifi d

i

'

l i h

lth

g

g

Florence Nightingale identified nursing's role in health

care quality and began to measure patient outcomes

She used statistical methods to generate reports

correlating patient outcomes to environmental conditions

g p

(Dossey, 2005; Nightingale, 1859/1946)

(4)

Categories

 

of

 

Outcomes

Care-related – outcomes that result from health care

t

t

t

i t

ti

g

treatments or interventions

E.g. weight changes, clinical symptom changes such as

d i

dyspnoea or pain

Patient-related – outcomes which impact patient

perceptions, preferences or knowledge

Eg. Patient satisfaction, knowledge, quality of life

Performance related – outcomes which reflect the quality

of care provided by a health care provider

p

y

p

Eg. Technical quality, interpersonal skills

Jennings et al 1993 Jennings et. al, 1993

(5)

Patient

 

Care

 

Outcomes

Education and Training – Clinical, Evidenced Based 

Practice, Research

Outcome Assessment Clinical Effectiveness

GOALS Improve clinical

Measure patient 

outcomes 

Audits/Survey

Perform and support  research

Generate evidence for  Improve clinical  practice and  achieve best  possible outcomes  effectiveness of clinical  care

Review and appraise  Patient Safety

for patients existing evidencepp

Staffing Staffing

Skill mix and ratio

Quality Improvement

QIP 

CPIP 

Advanced Practice Nursing

5

C

JCI
(6)
(7)
(8)

Advanced Practice Roles

Certified Registered Nurse Anaesthaetist

Certified

 

Registered

 

Nurse

 

Anaesthaetist

Certified

 

nurse

midwives

Clinical

 

Nurse

 

Specialist

Nurse

 

Practitioners

Advance

 

Practice

 

Nurse

 

Case

 

Managers

I Si

APN i

bi

ti

f N

P

titi

d

In

 

Singapore,

 

APN

 

is

 

a

 

combination

 

of

 

Nurse

 

Practitioner

 

and

 

(9)

Benefits of APNs

I

d Q

lit I di t

Improved

 

Quality

 

Indicators

Greater

 

patient

 

independence,

 

promotion

 

of

 

health,

 

adjustment

 

to

 

illness,

 

stress

 

management,

 

functional

 

status,

 

compliance

 

with

 

treatment,

 

patient

 

satisfaction,

 

d

d

i it

d

h

it li ti

reduced

 

emergency

 

room

 

visits

 

and

 

re

hospitalisations

Positive

 

Patient

 

Outcomes

(10)

Benefits of APNs

Complement

 

medical

 

care

Establish a clear clinical track

Establish

 

a

 

clear

 

clinical

 

track

Increase

 

job

 

satisfaction

Boost

 

recruitment

 

and

 

retention

 

of

 

nurses

I

f

i

l i

f

i

(11)

Outcomes of APNs in SGH

Reduce Readmission rate within 72 hours

Orthopaedic

Reduce

 

Readmission

 

rate

 

within

 

72

 

hours

 

Orthopaedic

From 21% to less than 5%

From

 

21%

 

to

 

less

 

than

 

5%

• All patients discharged are advised to call the APN before visiting 

the DEM

• Patients are screened and assessed over the phone

• Patients are scheduled to visit APN the next working day for 

/

wound / pain related complains

• Patients who visits the GPs and are referred to the DEM are also 

advised to call the APN

• If assessed to be in need for urgent care, patient is admitted 

(12)

Outcomes of APNs in SGH

Spine

 

Coordinated

 

Clinical

 

Pathway

Coordinated

 

Clinical

 

Pathways

 

are

 

usually

 

driven

 

by

 

the

 

surgeons

New

 

pathway

 

driven

 

by

 

APN:

 

Cervical

 

Spine

 

launched

 

week

 

of

 

13

 

July

 

2009

Current

 

pathways

 

in

 

spine

 

reviewed

 

by

 

APN

 

Length of Stay reduced from 7 days to 5 Days for patients after lumbar 

fusion

 Nursing staff skill set enhanced

 All patients ambulated on the 1st POD. Nurses trained to assess and  ambulate patients over the week when there is no PT

ambulate patients over the week when there is no PT

 Cervical spine surgery – LOS from 5 to 2 days (APN follow‐up with 

(13)

Outcomes of APNs in SGH

Outcomes of APNs in SGH

Staff

 

Training

Clinical

 

teaching

 

rounds

Intermediate

 

Care

 

Area

 

Nursing

 

(ICA)

 

Course

 ‐

to

 

upgrade

 

all

 

High

 

Dependency

 

areas

 

into

 

ICA

 

status

Mass

 

Casualty

 

course

Patient

 

Simulation

 

&

 

Crisis

 

Handling

 

Workshop

Duke

NUS

 ‐

Practical

 

skills

 

teaching

g

 

Advanced

 

Health

 

Assessment

 

workshop

Problem Based Learning

Problem

 

Based

 

Learning

(14)

Outcomes of APNs in SGH

Outcomes of APNs in SGH

Conduct

 

research

 

and

 

systematic

 

reviews

 

and

 

facilitate

 

the

 

clinical

 

staff

 

in

 

research/systematic

 

reviews

Change

 

in

 

patient

 

care

 

practice

 

from

 

research

 

and

 

systematic

 

reviews

PreEmptive Analgesia 

• All patients undergoing elective orthopaedic surgery are 

administered preoperative analgesia two hours prior to 

induction including patients coming for Same Day induction including patients coming for Same Day 

Admission Surgery

• Significant decrease in VAS scores and use of post‐operative 

opioids consumption

(15)

Outcomes of APNs in SGH

Outcomes of APNs in SGH

Change

 

in

 

patient

 

care

 

practice

 

from

 

research

 

and

 

systematic

 

reviews

The Effect of Unrestricted Fluid Versus Standard Preoperative 

l d

Fasting on Gastric Volume and pH: A Systematic Review

• There was no evidence that patients given fluids two or three 

hours preoperatively were at increased risk of aspiration /

hours preoperatively were at increased risk of aspiration / 

regurgitation as measured by their gastric volume and pH. • The gastric volume was not significantly lower among 

patients that were administered fluids during the preoperative 

period,  than those who followed standard fast. 

• New Fasting guidelines were developed allowing fluids 2 3 • New Fasting guidelines were developed allowing fluids 2‐3 

(16)

Outcomes of APNs in SGH

Outcomes of APNs in SGH

Nurse

led

 

clinic

Pelvic Floor Disorder Service an outpatient clinic as tri party ofPelvic Floor Disorder Service an outpatient clinic as triparty  of 

Colorectal Surgery, O & G and Urology

• Collaborative clinic‐ Surgeons and APN follow‐up on patients 

together

• Nurse‐Led Clinic‐ APN sees patients

• At monthly Joint Clinic, case summaries and presentation of casesAt monthly Joint Clinic, case summaries and presentation of cases 

(17)

Outcomes of APNs in SGH

Outcomes of APNs in SGH

Nurse

led

 

clinic

Orthopaedic clinic (APN led on Tues and Fri)Orthopaedic clinic (APN led on Tues and Fri)  Postoperative orthopaedic clinic 

• (1 month visit see Surgeon, 3rd, 6th & 1 year see APN, 2nd

Year Surgeon)

• Reduce post‐operative SOC visits

P ti t ll t d f f ll t li i t

• Patients are generally requested for follow‐up at clinics at 

two weeks post spinal instrumentation clinic. Surgeon 

reviews the wound and managesg  painp  and its related 

complication

• To reduce patient’s visit at SOC, Initiated to work with the 

l ( ) d h l

General Practitioners (GP) to educate them on spinal surgery 

wound management and APN driven GP wound 

management clinic management clinic

(18)

Outcomes of APNs in SGH

Nurse led clinic

Nurse

led

 

clinic

 

PEG Tube Clinic ‐ Followup on difficult smallbore Nasogastric and  

PEG Tube; monitoring for home Parenteral Nutrition patients PEG Tube; monitoring for home Parenteral Nutrition patients   Rehabilitation and IBD Clinic – Physician collaboration

APN Preoperative Anaesthesia ‐ Assessing patients before 

surgery. Optimising patient's medical condition to minimise on 

table cancellation. table cancellation. 

Followup for neurological patients

Drug monitoring for Rheumatology patients

Drug monitoring for Rheumatology patientsHypnotherapy clinic

(19)

Outcomes of APNs in SGH

Nurse

led

 

homecare

 

services

 

3 months follow up of complex medical patients with regular

3 months follow up of complex medical patients with regular 

telephone surveillance and home visits 

Leads a team of 4 nurses, conducts training and teaching forLeads a team of 4 nurses, conducts training and teaching for 

Integrated Care Nurses 

Conducts daily multidiscipline discussion with Family Medicine & 

Continuing Care (FMCC) Consultant and Medical Social Worker to 

discuss patients plan of care 

Di t ti t ith l i f li ti t FMCC E l

Directs patients with early signs of complications to FMCC Early 

Review Clinic or FMCC‐GP network

Seeks to change patients/ caregivers health seeking behavior bySeeks to change patients/ caregivers health seeking behavior by 

empowering patients with knowledge and skills through education   Collaborate with community partners (e.g. Thye Hua Kuan Case 

(20)

Outcomes of APNs in SGH

In

patient

 

role

Continuity

 

of

 

care

(21)

“Without good and careful nursing many must suffer

greatly, and probably perish, that might have been

restored to health and comfort, and become useful to

themsel es their families and the p blic for man

themselves, their families, and the public, for many

years after.”

Benjamin Franklin (1751)

Benjamin Franklin (1751)

•< single image > •4.3cm x 5.5cm

Th

k

Thank you

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