Nurse practitioner management of acute in-hours home visit or assessment requests: a pilot study

INTRODUCTION

Whatever their out-of-hours arrangements may be, GPs in Britain are generally required to manage demands for immediate advice or treatment that occur within normal working hours. For patients presenting as acute ‘same-day’ or emergency cases to a GP surgery, nurse practitioners appear acceptable to them as a first or only point of contact.1^,2 Randomised controlled trials suggest that nurses who are solely responsible for the diagnosis and management of these patients achieve equivalent clinical outcomes to GPs,3^,4 with possibly higher levels of patient satisfaction, although their consultations are longer.5 To date, none of these studies has examined the feasibility of nurse practitioners extending their activity to home visits of patients who are acutely ill. Substituting a nurse practitioner to assess these requests, and to perform home visits if necessary, could potentially free up a substantial amount of GP time.

The suggestion that nurse practitioners could manage home-visit requests is not new; Jiwa et al, in an analysis of primary care out-of-hours visits, proposed that the nurse's role could realistically be extended from telephone triage to visiting and managing patients.5 Few providers have employed nurse practitioners in this way, although in one study emergency care practitioners (emergency medical technicians or paramedics who have undergone a further diploma course) appeared acceptable to patients as providers of out-of-hours emergency home assessment.6 Studies involving a wider role of nurses in managing acute illness at home in selected groups of patients, such as older people7 or patients recently discharged from hospital,8 also indicate that nurses are competent to adopt this role, and appear to value and enjoy it.8 However, nurse practitioner management of home-visit requests to GP practices within normal working hours (defined in the new general medical services [GMS] contract as 08:00–18:30) has not formed the subject of a study so far.

The new GMS contract provides for primary care trusts to relieve GPs of the responsibility for in-hours home visits when this is considered ‘feasible and desirable’.9 However, there is little reported experience of such transfer of responsibility, and little information regarding potential models of care or patients' views of such a change in working. This study examined the feasibility and acceptability of substituting nurse practitioners for GPs to manage in-hours acute same-day assessment requests, including home-visit requests, to inform service development and the design of a future randomised controlled trial.

METHOD

This study was conducted in one large group practice (14 600 patients) in south London. Data collection took place over 6 months from October 2006 to March 2007. The practice's usual procedure is to allocate one GP as a duty doctor for the day, who is solely responsible for responding to patient requests for in-hours urgent or same-day advice or assessment, as well as undertaking some routine administrative tasks. The duty doctor is not allocated any routine pre-booked patients. During the operation of the study, these responsibilities were effectively adopted by a single nurse practitioner who was responsible, on 2 working days each week for 6 months, for responding to in-hours patient requests for immediate assessment, including acute home-visit requests. On the remaining 3 days of the week, such requests were managed by a duty GP, according to the practice's usual procedure. Mondays were excluded from data collection as this day generates a higher workload than the remaining weekdays, and patients tend to have different presenting symptoms and demography.

Nurse practitioner management (on Tuesdays and Wednesdays) was compared with normal GP management (on Thursdays and Fridays). Patients who had previously been enrolled in the study remained eligible for recruitment again, provided that their new contact did not relate to the same clinical care episode. Contacts that related to a previous episode were coded as a follow-up for that episode.

Adult patients suffering acute minor illness, acute injury, chronic disease (excluding routine management), or an acute exacerbation of chronic disease were included in the study. Those who were excluded were patients under 18 years; those with a presenting complaint of mental illness involving psychosis, suicidal ideation, a risk of harm to self or others, or requiring assessment for detention under a section of the Mental Health Act 1983; those requesting confirmation of death; or those with illness or complications due to pregnancy. These patients were managed by the duty GP in the normal way. These exclusions were deemed, by the study nursing advisers and the nurse practitioner, to fall outside the usual expected competence of a nurse practitioner.

The nurse practitioner was a qualified independent prescriber with 12 years' experience of working in general practice. Upon initial contact (generally by telephone) with a patient who was eligible, the nurse practitioner's available options were to:

• offer telephone advice alone;

• request that the patient attend surgery for nurse or doctor assessment;

• visit the patient at home;

• seek advice from a GP regarding management; or

• deem the problem outside their area of clinical expertise and refer it to a GP.

The nature and outcome of each patient contact was recorded by the GP or nurse practitioner on a data-collection form and supplemented by researchers' scrutiny of the patient's computerised medical record. The nature of each contact (telephone, surgery, home) was recorded, together with the Read code classification of the presenting complaint, whether a physical examination was performed, and the clinical management of the episode.

Patients and/or their carers were asked to complete a questionnaire regarding their experience of the care they had received and were given a stamped addressed envelope for their reply. The questionnaire was either left with the patient by the GP or nurse practitioner at the time of consultation, to be completed later and posted back, or was posted to the patient within 7 days of the initial contact. It incorporated a validated instrument to assess satisfaction with the consultation experience (the Picker Institute's GP Questionnaire),10 together with measures of patient enablement, continuity, and practitioner empathy (using the Consultation Quality Index).11 Patients whose completed questionnaires had not been received within 2 weeks were sent a second questionnaire.

At the end of the study, practice staff (GPs, practice nurses, district nurses, and administrative staff) were asked to indicate how well they felt that the new arrangement had worked, by marking a linear scale from ‘didn't work at all’ to ‘worked perfectly’. They were also invited to describe their experiences of working with the nurse practitioner.

SPSS statistical analysis software (version 14.0) was used to compare the nature and outcome of GP and nurse practitioner consultations (χ²) and patient questionnaire scores (analysis of variance.) As a non-randomised pilot study with naturally occurring comparison groups, this investigation was not intended to demonstrate subtle differences between GP and nurse practitioner care, but rather to establish the feasibility and acceptability of the care model and methodology in order to inform a prospective, larger randomised controlled trial.

Patients were not asked to consent to nurse practitioner management. Lewisham ethics committee considered that such management fell within the normal range of services offered by the practice and that separate consent was unnecessary. Any patients who objected to nurse practitioner care would be offered normal care from a GP. Patients were asked to consent to scrutiny of their records by the researchers; they were told their records would be examined in-practice but that no patient-identifiable data would be extracted or retained.

RESULTS

A total of 568 contacts were analysed from 455 patients: 311 contacts were with a GP and 257 with the nurse practitioner. Twice as many contacts involved female patients as males; 22% of contacts were with patients >80 years of age.

There was no significant difference between nurse practitioner and GP consultations regarding patient age or sex. The nurse practitioner was significantly more likely than a GP to issue a prescription (56.9% versus 43.1%, P<0.001) and to assess patients in person (58.4% versus 42.4%, P<0.001); and the nurse practitioner was less likely to manage contacts by advice alone (42.9% versus 64.5%, P<0.001; Table 1). The nurse practitioner sought advice from a GP in 8.6% of cases and asked a GP to see her patient in 0.8% of cases. There was no significant difference between nurse practitioner and GP contacts regarding rates of home visiting, patient admission to hospital, referral to outpatients, or requests for further investigation (blood tests, urine tests, or X-ray).

Patient questionnaire data revealed no significant difference in any of the dimensions (empathy, patient enablement, communication, or prescribing management) between GP and nurse practitioner management. However, the proportion of questionnaires returned (21.5% overall, or 122 returned of 568 questionnaires issued) was too low to enable firm conclusions to be drawn. There was a significant difference in the response rate of patients, depending on whether they had consulted with a GP or nurse practitioner; 49 (15.75%) GP questionnaires were returned compared with 73 (28.4%) nurse practitioner questionnaires (P<0.001). Older participants were more likely to return their questionnaires: 25% of those aged >80 years and 27% of all those aged >50 years returned theirs, compared with 15% of those aged <50 years.

Twenty-nine questionnaires were distributed to practice staff, of which only 16 questionnaires were returned and indicated a score on the linear scale. Staff who did not score the scale reported they had experienced insufficient contact with the nurse practitioner to do so. Half of the responders (n = 8) indicated that the arrangement had worked well, of whom five indicated that it had worked perfectly. However, the remainder responded that the arrangement had worked less well, with common concerns including insufficient integration of the nurse practitioner at the beginning of the study, inadequate staff preparation for the initial learning curve as the practice adapted to a new way of working, and, from some GPs, residual anxiety that the nurse practitioner was insufficiently qualified to assess complex medical issues.

DISCUSSION