Scenarios using Extended Primary Care

Case 1

A 70 year-old male patient arrived to his rural practice with chest pain earlier that day, currently pain free; patient was initially assessed by GP, stabilised and monitored with initial troponin which was below acute referral level, so was kept under observation in the practice under supervision of nursing and administrator team, ultimately requiring transfer to the Emergency Department following second trop rise in 2 hours; time spent approximately as follows

 

1. GP/NP time

• Initial assessment (15 mins): history, examination, EDACS score

• Reassessment (a number of occasions) during time spent in practice (including discussions with nursing team, patient, assessing results/obs/ECG, response to medication etc) but also seeing other patients between episodes of care (30-45)

• Notes and referral completed + verbal hand over to ED, ambulance crew following troponin rise (15 mins)

2. Nurse time

• Initial and subsequent assessment, obs, monitoring

• ECG

• Initiation of medication: aspirin, GTN, morphine as appropriate

• IV access

• POC troponin taken x 2

• Monitoring patient periodically while awaiting troponin results; outside of this nurse spent time with other patient’s or duties

3. Administrative time

• Checking patient in, completing paper work and referrals, billing, coordinating cares (15 mins)

• Potentially providing ‘in eye sight’ monitoring of patient sitting in waiting room, while waiting for second troponin (15 mins over a 2 hour period: other work was being done during this time

 

Total GP/NP time:          60-75 mins

Total Nursing time:        60-75 mins

Admin time:                      30 mins

 

 

Case 2

18 year-old female arrives with parents with an acute asthma episode on background of generally well controlled asthma and concurrent viral infection; deemed to be ‘moderate’ severity at presentation.

• Initial assessment and initiation of treatment plan with hand over to nursing team by GP (15 mins)

• Moved to treatment bay and managed by practice nurse with initial inhalers and obs per NZ Guidelines (15 mins)

• Reassessed after 15 mins by GP to determine response to inhalers with plan to monitor over the next 45 mins until things are stable (5-7 mins)

• Monitoring for 45 mins in direct line of site by nursing team or admin team, with clinical review every 15 min by practice nurse including obs +/- peak flow +/- inhalers, brief corridor updates to GP over this time (15-30 mins nursing time, 5-7 mins GP time)

• Reassessed by GP at 60 mins, determined no features of severe asthma, no indications for admission or prolonged supervision and meeting pre-discharge conditions; agreed for discharge (15 mins + 15 mins cumulative documentation time over the duration of care)

• Nurse discharge with education, inhaler technique, updated action plan and planned phone call follow up by nurse in 4 hours to review progress (30 mins)

• Admin to review as above, complete arrival, discharge paperwork, scan and copy action plan, arrange follow up call and repeat GP review in 1 week for longer term plan (15 mins)

 

Total GP time:                  45-60 mins

Total nursing time:         60-75 mins

Total admin time:           15 mins

 

Case 3

55 year-old male presents to semi-rural practice with 3 days significant gastro (vomiting and diarrhoea) which has gone through the whole family; no co-morbidities or red flags noted 

• Initial assessment by NP (history, exam, obs) and clinically determined to be severely dehydrated but not requiring acute admission (15 mins)

• Handover to nursing team: oral anti-emetic, IV access and 1L IV fluids over 30 mins + ORT trial (30 mins time)

• Following this, supervised with ORT for 30 mins in treatment area by HCA with periodic nurse review or discussion including documentation (30 mins HCA time + 15 mins nursing)

• Nurse review at 60 mins, feeling better, tolerating orals and passing urine so discharged per NP determined criteria at initial consult handover

 

Total NP time:                                 30 mins (initial review, documentation, brief handovers during the hour from rest of team)

Total nursing time:                        60 mins

Total admin/HCA time:                30 mins