humber, coast and vale advanced clinical practice and
TRANSCRIPT
Humber, Coast and Vale Advanced Clinical Practice and Physician Associate Conference
WELCOME
Amanda Fisher
Programme Director, HCV
Advanced Practice
Professor Mark Radford
Deputy Chief Nursing Officer - Delivery
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Presentation title
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Presentation title
teamwork
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Presentation title
multiprofessional
Leadership is always an improvement
journey
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Radford,, P. Johnston, A. Williamson and A. Jewkes (2001)
Management of the minor surgical emergency workload by specialist
nurse pre-assessment and co-ordination
British Journal of Surgery, Volume 88, Issue s1, Page 27
M. Radford,, P. Johnston, A. Williamson, A. Jewkes (2001) Co-
ordination of the emergency surgical workload by specialist nurse pre-
assessment: the effect on emergency theatre operating patterns British
Journal of Surgery, Volume 88, Issue s1,
Williamson, A & Radford, M. (2002) The Role of the Clinical Nurse
Specialist in the pre-assessment and co-ordination of the care of the
Fractured Neck of Femur - Good Hope Experience
Anaesthesia (57), 11, pp 1148
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1999
10
Good Hope Hospital NHS Trust
Delays Associated with Emergency Surgery
May 1998 - May 1999
785.2 hours - 15.4% of Staffed Operating Time
0
50
100
150
200
250
Ho
urs
1999
Surgeon
Anaesthetist
Theatre staff
Patient
Admin
Ward
Other
Missed opportunity for 392 Fractured Neck of Femurs?
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‘The Ideal Nurse’ ‘No matter how gifted she may be, she will never become a reliable nurse until she can obey without question. The first and most helpful criticism I ever received from a doctor was when he told me I was supposed to be simply an intelligent machine for the purpose of carrying out his orders‟ – SD (1917)
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Contemporary model of Care
Modern Hospital
• Medical Lead, Senior Nursing support.
• Power delegated to Juniors
• Horizontal interdisciplinary power sharing
• The ‘have nots’ • HO and Junior Staff Nurse
• Students
Radford, 2012 . Power dynamics and professional expertise in the communication between specialist nurses and doctors in acute hospital settings., PhD
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Interprofessional working models
Typology and practice sphere ; Vertical , Horizontal and team
RN HCSW Snr RN
AHP
ACP/PA
Snr AHP Therapy Assistant
ACP/PA
FP Dr 1
2
3
4 Clinical environment
ACP
StR
Consultant
NA & Band 4
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State • Legislation
• Policy
Corporate
• Business model
• Productivity and Performance
• Finance
• Governance (Policy and Procedure)
Profession
• Licensing
• Regulation
• Educational requirements
• Knowledge and Expertise
Macro Division of
Labour
Division of labour in healthcare
Radford, 2012 PhD
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Skills/knowledge adaption
Adaptive medical
Redundant Medical
Clinical knowledge
Professional medical
Technical Medical
Nursing
Care
Examples include cannulation,
venepuncture and catheterisation
Examples include PIC, CVP,
arterial lines, ultrasound
scanning.
history taking, examination, diagnosis and ordering tests and investigations such as radiology tests
conducting assessments on junior doctors, conducting audit on the medical process or outcomes. Clinically, giving diagnosis, prognosis and referral
Radford, 2012 . PhD
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Band 2 Band 3
Band 5 - RN
Band 6
Band 8 ACP
Junior Doc
Unwarranted variation in scope and competence
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Technical
Knowledge
ECG (Electrocardiogram)
The ECG is a routine test for elective and emergency
patients.
The task can be broken down into several component features that are then routinely allocated to
members of the Healthcare team depending upon
training.
Traditionally many aspects of ECG work were the domain of
Medical staff .
The technical / knowledge boundaries of task allocations
Perform a 12 lead ECG
Interpret an ECG
Follow protocol to initiate an
ECG
Initiative treatment
based upon interpretation
Non-Protocol initiation of
and ECG
Medical or ACP
HCSW/Cardiac tecc Nursing
Nurses in spec area - ITU/ED
You are never ‘just a’ ……
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Vision – to enable a skilled and knowledgeable
Advanced Practice workforce to be used
effectively to enhance the capacity of the existing
health workforce to ensure a quality service for patients, now and in
the future Academic Framework
Curriculum diversity
Competence diversity
Academic and
Professional uncertainty
of ACP
Role Diversity
Deployment challenges
Regulation and
management
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ACP Program HEE(WM)
Aims
• Single model
• Common training
• Common curriculum
• Skill standardisation
• Deployment consistency
• Map to workforce shortages
• UHCW led program
• 15/16 - £500k
• 16/17 - £600k
• Future ongoing support as a key priority
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• Curriculum and training
• Consensus across all HEI’s
• Clear model and framework deployed
• Defined 80% core curriculum
• Covers Primary, Secondary , (Nurse, Midwife and AHP) MH and LD
• 20% local academic and speciality variation
• Agreed competence (Health assessment, prescribing, diagnostics)
• Single course title (ACP)
• Aligned to HEI expertise
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Profession No. Nurses 171 Paramedics 4 Occupational Therapists 8 Physiotherapist 13 Radiographer 1 Physiologist 2 Pharmacist 17 Psychiatrist 1 Orthoptist 1 Podiatrist 2 MH Practitioner 2 Total 222
HEE West Midlands ACP Program
NHS I & HEE national framework
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The UK context
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National ACP framework
• A new comprehensive national framework
• Alignment with devolved nations • Co-produced with system,
academics, patients, services users and policy leads
• Multiprofessional focus and support
• For the NHS • Impact on wider system of
practice
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Definition & pillars
• Clinical practice • Leadership and management • Education • Research
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We are the NHS
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#nursingnhsi
Rise and Rise Again How to remain resilient in a complex healthcare
environment
Key Elements of Resilience
• Realism
• Purpose
• Creativity
Realism
• Be present
• Be self-aware
• Be curious
• Acceptance
Being Present
• Practice mindfulness techniques (if you like)
• Make use of your senses rather than letting your intuition run riot
• Do something in your day that connects you with the present
Self Aware and Self Care
• Examine how you work best- introversion vs extroversion
• What is your default decision making style
• Evaluate your PERMA
• What do you do to take care of yourself?
PERMA
• Positive emotion
• Engagement
• Relationships
• Meaning
• Accomplishment
Curiosity • How much of what you believe to
be true is based on data?
• What assumptions are you making about your current situation?
• What part are you playing?
• Is your response reasonable and proportionate?
• Is there an alternative way to view this situation?
• Can you change the part you play?
The world is not set up for our convenience
• None of us are straightforward
• We all stuff things up
• Sometimes it feels like the world is against us
• Make room for the bad stuff in your life, don’t try to shut it out
Purpose
• Do you know what your core values are?
• Can you operationalise your values?
• Do you belong or are you trying to fit in?
• Do you trust yourself?
What Matters to You
• What do you value?
• What in your life is an immovable object?
• Can you identify 2 or 3 core values?
How do your values show up at work?
• Think of 3 occasions when you have worked within your values
• Think of 3 occasions when you not worked within your values
How to Belong
• Is everyone trying their best?
• Be civil, but don’t allow BS to go unanswered
• Hold hands with strangers
• Have a strong back, a soft front and a wild-heart
Civility and BS
“The desire to fit in and pick the right side, results in us bullshitting and often falling on the side of the oppressor, so therefore being uncivil.”
Brene Brown
Check on Self-Trust
• Boundaries
• Reliability
• Accountability
• Vault
• Integrity
• Non-Judgement
• Generosity
Creativity
• What resources do you possess?
• How can you possibly use those resources?
• Who can possibly help you?
• How can your sense of realism, and your purpose possibly help you be creative?
Hyponatraemia
Dr Kamrudeen Mohammed
Consultant Endocrinologist
Hull University Teaching Hospitals
Date of Preparation:April 2019 Prescribing Information at end of this presentation OPUK-1011-SAM-1442
Hyponatraemia
is a disorder of Body Water
1. Adrogue HJ, Madias NE. N Eng J Med. 2000;342(21):1581-1589.
The presence of hyponatraemia may be due to a number of underlying conditions
1. Fenske W, et al. Am J Med. 2010;123:652-657.
4%
20%
32%
35%
7% 2% Primary polydipsiaHypervolaemiaHypovolaemiaSIADHDiuretic-inducedAdrenal insufficiency
(n = 121)
Aetiology of hyponatraemia (serum [Na+] < 130mmol/L)
at the Medical University Hospital of Würzburg1
Case of hyponatraemia - tests
67 M - confusion
‘Off legs’
Self neglect
PMH
• Hypertension
• Osteoarthritis
DH
• Bendroflumethiazide
Smoker 40/day x 50yr
• Na 125
• K 4.5
• Creatinine 95
• Urea 2.4
Tests???
What is plasma osmolality?
Osmolality is the number of
particles contained in one
litre of water
Summary
Volume Regulation
effective circulating volume regulation.
The regulation of volume involves
the regulation of plasma volume
and blood pressure
Plasma volume is increased
through the resorption of sodium
and water
Renal resorption of sodium is the
first and best defence against
volume depletion
second-line defence - resorption of
water
Volume regulation occurs in three
steps
Osmoregulation is the maintenance of
a consistent plasma osmolality
Why is this important?
Because of the potentially devastating
consequences of abnormalities in plasma
osmolality, tight control is important.
The body changes water to control
plasma osmolality through thirst and
ADH
To increase plasma osmolality, water
excretion is enhanced by suppression of
thirst and ADH
To lower plasma osmolality, water is
added through thirst and the release
of ADH
Thirst is the body’s way of saying,
“Plasma osmolality is high. Give me
water
ADH ADds Hydration to the body by
forming a concentrated urine
Plasma osmolality is detected in the hypothalamus which controls thirst and ADH,
the two regulators of osmolality
The body regulates plasma osmolality by
controlling the amount of body water
Hyponatraemia!
Hyponatraemia is usually associated with
hypo-osmolality
Hyponatremia is important
because it can indicate a low plasma osmolality.
Hyponatraemia not associated with a low plasma
osmolality is not worrisome and is not treated
Hyponatraemia
Increased glucose and mannitol
cause pseudo-hyponatremia with
a high plasma osmolality.
True Hyponatraemia
True hyponatremia is due to a relative
excess of water and can occur with
hypovolemia, euvolemia and hypervolemia
Hypovolemic hyponatremia is due to
the loss of renal or extra-renal fluid.
Hypervolemic hyponatremia can
be caused by heart or liver failure
ADH release in the setting of
both normal osmolality and
euvolemia is inappropriate.
SIADH is defined by four
characteristics
Hypothyroidism can cause the
inappropriate release of ADH.
Addison's disease can also cause
the inappropriate release of ADH
Adaptation
Hyponatremia is either acute or
chronic depending on the
presence of cerebral adaptation
rapid correction of chronic, well-
compensated hyponatremia can
have devastating neurologic
consequences
The treatment of hyponatremia
should be approached with
caution.
four general strategies in the
treatment of hyponatremia.
Acute symptomatic hyponatraemia
Treatment
Patients with active seizures or respiratory failure
bolus of 100 ml of 3% saline over 10
minutes
to increase the plasma sodium abruptly by about
2–4 mmol/L
an infusion of 3% saline should be given at a rate of 1 ml/kg/hr
Less severe neurological manifestations
the bolus should
be omitted
Measure Na !!!
Thank You
Why I believe in PAs Jim Parle MBChB FRCGP MD, Emeritus Professor UoB,
Immediate past Chair of the PA Schools Council
Immediate past Director of the Birmingham PA programme
Current senior examiner for the PA national Exam
and More ‘PA years’ than any other Dr in UK
JP:
- Why me?
- Brief history of PAs
- PA education & standards
- What can PAs do for us?
- What’s so special about
PAs anyway?
• Why me?
Qualified 1978
GP from 1982
Senior partner from 1983
(retired December 2017)
Academic 1992
(retired December 2018)
Led GP-based medical
education at Birmingham
• Why me?
First involved with PAs
~2002
started VERY sceptical
GP & PA
West Mids struggling
Me refusenik!!
• Why me?
So
from SCEPTIC
to
Evangelist
OK: history of PAs
• Vietnam war – when was it?
– 1965-73
– (Joni Mitchell: California: „Sitting in a park in Paris France, Reading the news and it sure looks bad, They won‟t give peace a chance‟ That was just a dream some of us had‟)
• Body counts!
• ~1.5 million est .deaths
• 58,000 US deaths
• Max no. of US soldiers in Vietnam was ~1.5 million
‘Upside’ of the war
• Duke University
• Identified
opportunities for
‘medics’
• Dr shortages
(especially rural)
• 4 (!) initial recruits
US PA growth
• Lumpy!
• Now ~130,000 PAs
• Course numbers
growing
– (Dr shortages)
What about UK
history?
• 1st ‘PA’ course: UoW
• ‘Medical care practitioners’ etc etc
• 2003-6 DH committee (RCP and RCGP) led to 2006 Competence & Curriculum Framework
• ‘CCF-based’ PA courses: Jan 2008 Birmingham & Wolverhampton & September 2008 St George’s London
2014 onwards
• Slow start
• A few stumbles
• Now/soon: 36??
courses
• ~ 1,000 grads a year
• ~ 10,000 PAs in 10
years
PAs practice
medicine
• Therefore PAs must
be educated, like
doctors, to practice
medicine
139
Medical School
2yrs Basic Sciences
3 years Medical (Clinical) Education:
Breadth & Depth
Enter Foundation Years
Delivering medical education
140
PA Studies 3 year BSc Life Sciences, e.g. Biomedical Sciences
2 years Condensed Medical Education
Focus: Breadth: all systems
Depth: Common & Important Conditions
Enter Employment
What are the goals
of PA education?
• To develop safe and
competent PAs
• To always remember
the two key words…
• Patient safety
141
Developing education and training
programmes
• A National Curriculum
(c.f. medicine)
– Competence and Curriculum
Framework for the Physician Assistant
– 2006 / 2012 / UNDER REVIEW
• Competencies
• Procedural Skills
• Common Presentations
• Programme Specification
– 3200 Hours over 2 years
» 50% clinical; 50% theory
142
Developing education and training
programmes for Physician Associates
• The Matrix of Core Clinical Conditions
– Lists the common and important conditions
relevant to PAs at qualification, i.e., this is the
starting point at entry to the profession
– Significant role in Diagnosis
• 1A: with management
• 1B: without management
– Significant role in Management
• 2A: without diagnosis
• 2B: No significant role in Dx or Mx of condition
143
An Example:
Endocrine & Metabolic Matrix
144
Diseases of the Thyroid and
Parathyroid
Electrolyte and Acid-Base Disorders
Hypothyroidism 1A Hypo/ Hypernatraemia 1A
Hyperthyroidism: Graves’ disease 1B Hypo/ Hyperkalaemia 1A
Hyperthyroidism: Hashimoto’s thyroiditis 1B Hypo/ Hypercalcaemia 1A
Hyperthyroidism: Thyroid storm 1B Volume depletion 1A
Thyroiditis 1B Hypomagnesaemia 1B
Hyperparathyroidism 1B Metabolic alkalosis/ acidosis 1B
Hypoparathyroidism 1B Respiratory alkalosis/ acidosis 1B
Thyroid neoplastic disease 1B Volume excess 1B
Diabetes Mellitus Other Metabolic and Endocrine
Type 2 diabetes mellitus 1A Gynaecomastia 1B
Hypoglycaemia 1A Galactorrhoea 1B
Type 1 diabetes mellitus 1B Lactose intolerance 1B
Lipid Disorders Phaeochromocytoma 2B
Hypercholesterolaemia 1A Diseases of the Pituitary Gland
Hypertriglyceriadaemia 2A Acromegaly 2B
Diseases of the Adrenal glands Diabetes insipidus 2B
Corticoadrenal insufficiency 1B
Cushing’s syndrome 2A
Clinical Experience (Minimum 1600 hours)
NB recent changes
145
180
350
180 90
90
90
90
270
GP
General Med
Emergency Med
Mental Health
Obs & Gynae
Paediatrics
Gen Surgery
Electives
National
Assessment
• Must be rigorous
• Must assess broadly
– SBAs (single best answer)
– OSCEs
• MUST assess for safety and
competency
• The bottom line is patient safety
146
National Assessment
Institutional
Core
Scope for student
selection
High level of
Sickle Cell
Anaemia in
Population
Expertise in
communication
skills
National Centre for
Immunology
National Core
Looking forward to
regulation and
prescribing rights
• Regulation requires legislation
• UK Government Consultation on
Regulation of Medical Associate
Professionals (MAPs), including PAs
• 12th October DH announcement
regarding PA regulation
• GMC to be the regulator
• 18-24/12
148
So: what can PAs do?: how can PAs help?
• Flexibility – What do you need?
– What will you need in 10 years time?
• Bridge the primary and secondary care boundaries – More secondary care is moving into the primary care domain
• e.g. a frailty service
• Continuity of care – For patients
– For the MDT
• Patient satisfaction (Drennan et al, 2015)
• Reduce GP burnout; PAs can support, but not replace – Allowing time for training, leadership and complex cases
Why a PA?
• GPs are the true ‘generalists’ of medicine; PAs complement their role
• Trained to a medical model
• Clear scope of practice – Which can be developed in
time (as aligned with that of their supervising Dr)
– ‘You know what you are going to get’
• Revalidation
How to recruit?
• Recruit local
• Train local
• Work local (c.f. medicine0
• How many does the area need?
– Who knows?
– Daily Mail “16,000 PAs a year”
– Pro rata USA prob 20,000-25,000 total across UK
FAQs
• Hurdles
– Junior drs
– Nurses
– Patients
• Social media
• Newspapers
What’s the
evidence?
• Drennan et al
• ‘Pre-judging’
• Data gathered from Nurses, junior doctors, senior doctors, managers
• Overwhelmingly positive
• Key is to do the groundwork!
• Doh!!
Conclusion
• Courses well established
• Regulation coming
• RCGP position paper (2017): – „PAs can help to
broaden the capacity of the GP role and skill mix‟
• Churchill: – Not the beginning of the
end but the end of the beginning
2.9013 ‘Losada Line’
Positive to Negative Ratio
Positive Psychology • The science of happiness and
well-being • You can learn to live in the upper
reaches of your range of emotions
• The more you practice the easier it becomes!
lower level (negative)
upper level (positive)
2%
‘mood hoovers’
‘brilliant recap’
1. What do you appreciate but take for granted too often?
2. Remind yourself who ‘You are at your best’ 3. Recall 3 good things regularly (successes) 4. You get what you focus on