Nurses provide key to improved clinic service: using specialist nurses' skills to the maximum at a Hutt Valley DHB clinic has seen waiting lists plummet and greater patient satisfaction.

HUTT VALLEY District Health Board's nurse-led respiratory clinics, that have seen waiting lists eliminated over the last two years, were highly commended at last month's New Zealand Health Innovation Awards. The service, which was entered in the organisation category, was one of 25 finalists selected from 126 entries. Initiated jointly by the Ministry of Health and ACC last year, the awards aim to promote and encourage health innovation and the sharing of services and ideas nationally.

The clinics were set up three and a half years ago, following the resignation of the hospital's respiratory physician, the failure to find a replacement and a backlog in referrals of up to two years. Desperately needing a solution, the service was restructured and a system of patient pre-assessment by a specialist nurse put in place. This enabled efficient use of limited doctor-led clinics and a greatly improved service.

Three years on, there are two part-time nurses--Kirsten Lassey and Tuppy Parker--providing assessment and education clinics in hospital wards and outpatient clinics.

During the initial pilot, the then clinic nurse Michelle Day pre-assessed and reviewed wait-listed patients for general physician Iwona Stolarek. Now the service has broadened, offering a range of nurse-led services, including a home oxygen assessment service, a Spiriva clinic (this assists and monitors people with chronic obstructive airways disease--COPD--who are using this medication) and the soon-to-be-launched breathlessness clinic, where patients with joint respiratory and cardiac problems will be screened and referred to the most appropriate service.

At the heart of the nurses' work is education, in the clinics, on the wards, in the emergency department and in the community. "Patients tell us they get a lot of different information about how to manage their respiratory disease from the various services and health professionals they come in contact with," said clinic nurse Kirsten Lassey. "We want to standardise the information they receive and ensure patients are getting consistent messages. We do a lot of bedside education on the wards and support nurses and doctors throughout the hospital. We run a two-day respiratory course three times a year, targeted at nurses working with patients with asthma and COPD throughout the lower North Island. We do some mentoring of nurses out in the community, who may be running or wanting to run asthma clinics, and we are available to answer questions from patients who have returned home from hospital with their self-management plans. Our long-term aim is to take our clinics out to the community and to run education sessions in local practices."

Reinforcing the nurses' work is the hospital's COPD pathway introduced four years ago. This standardises the care patients receive and has helped reduce hospital stays and re-admissions. Respiratory service team leader and nurse specialist Margaret Ankorn runs this pathway and sees people post-discharge.

Clinic nurse Tuppy Parker believes the secret to the service's success is its flexibility and the trust that has developed between the team members. "We can see people within one to four weeks of a GP referral and can get them started on treatment straight away or refer them to a more appropriate service if necessary. Four years ago, people often had to wait up to two years to get a clinic appointment. Last year we saw about 2000 patients compared to the 600 seen annually four years ago. There has been a 25 percent increase in the number of new patients seen. The nurses can also do a lot of the follow-up work. At the same time, we know our limitations and when we need to refer people to our consultant physician Iwona Stolarek.

"In our nurse clinics we provide patients with very intense education. We watch how they use their medication and recommend changes where appropriate. One of the lessons I was once taught was 'Keep it simple'. This is the approach that seems to work best for me and for our patients."

At present, a respiratory physician from Wellington Hospital visits the clinic once a week. The staff are looking forward to having their own physician soon, an overseas appointment expected later this year.

The service, Stolarek says, has waited four years for this appointment, following a national and international search. "New Zealand has several chest physician vacancies at present. Here at the Hutt, we had to look at other ways of working. Using our specialist nurses' skills to the maximum was the answer for us."

Both Lassey and Parker are interested in pursuing nurse practitioner (NP) status with prescribing rights at some point in their careers and both are undertaking master's studies towards this goal. They see great scope for NPs in the respiratory disease area.

Highly commended in the Health Innovation's individual award category was Gore Health's community wellness and education programme. This offers healthy lifestyle programmes for all ages and is based at Gore Hospital. The popular choice award went to Kura Whanau GP Clinic in the Wairarapa. This service featured in the April issue of Kai Tiaki Nursing New Zealand (Filling health gaps in the Wairarapa, p11-13). The Supreme Award went to Auckland District Health Board and ProCare for its improved primary health care management of dyspepsia.