drug & alcohol nurse practitoner proposal - · pdf fileand/or other drugs ... the nurses...

Melbourne Health

Drug & Alcohol Nurse Practitioner

Model

2009

Model Development Project Victorian Nurse Practitioner Project

Phase 4 Round 4.6 (Alcohol and Drug Services)

Authors

Elizabeth Mackey – Nurse Practitioner Project Nurse Patricia Green – Drug and Alcohol Clinical Nurse Consultant, Addiction Medicine Service November 2009

Contact

[email protected]

Drug & Alcohol Nurse Practitioner Model Development Project – December 2009 1

Contents Definitions / Abbreviations............................................................................3

EXECUTIVE SUMMARY .................................................................................4 INTRODUCTION .............................................................................................5

Nurse Practitioners.......................................................................................5 Nurse Practitioners at Melbourne Health......................................................6

SECTION 1: THE ADDICTION MEDICINE SERVICE.....................................7

Addiction Medicine Patients – service background ......................................7 Overview of current service model ...............................................................7 Current Drug and Alcohol Clinical Nurse Consultant Role ...........................9 The Drug and Alcohol Nurse Practitioner in Australia ................................10

SECTION 2: GAP ANALYSIS........................................................................12

Addiction Medicine Service gaps / needs...................................................12 SECTION 3a: DRUG & ALCOHOL NP MODEL ............................................13

Introduction to the model............................................................................13 Definitions ...............................................................................................15 Service need...........................................................................................15 Where and who.......................................................................................15 Inclusion Criteria .....................................................................................15

SECTION 3b: D&A NP MODEL FLOWCHARTS...........................................18 SECTION 4: D&A NP MODEL IMPLEMENTATION ......................................20

Alignment with Melbourne Health plans .....................................................20 Support for the D&A NP role from key stakeholders ..................................20 Budget........................................................................................................20 Candidate education program and other resources ...................................20 Further infrastructure supports ...................................................................21 Succession planning and role sustainability plans for this role...................21

REFERENCES ..............................................................................................22 APPENDICES................................................................................................23

Appendix 1 – Guidelines for Addiction Medicine practice...........................23 Appendix 2 – Health Minister (Vic) Approved Drug and Alcohol NP Formulary ...................................................................................................24 Appendix 3 – Addiction Medicine Service - Gap Discussion and Recommendations .....................................................................................25


Definitions / Abbreviations AOD Alcohol and/or other drugs CNC Clinical Nurse Consultant D&A Drug and Alcohol NBV Nurse Board of Victoria NP Nurse Practitioner NPC Nurse Practitioner Candidate VAADA Victorian Alcohol & Drug Association


EXECUTIVE SUMMARY The Nurse Practitioner (NP) role is regulated by the Nurses Board of Victoria. The NP is required to be endorsed by the NBV for an extended scope of practice, following extensive clinical and academic preparation. Melbourne Health Addiction Medicine Service manages patients with issues with alcohol and/or other drugs (AOD), as primary care providers or following referral from units treating patients with secondary AOD issues. An Addiction Medicine Service gap analysis and stakeholder engagement as part of the Drug and Alcohol (D&A) NP model development elicited four main areas in which the Addiction Medicine Service’s D&A NP may help fill gaps in current service provision. These include:

1. D&A NP led primary and secondary consultation service for inpatients with drug and alcohol issues

2. Consultation for Emergency Department patients with primary drug and alcohol issues

3. Outpatient clinic management of patients with alcohol issues in collaboration with the Addiction Medicine Medical Consultant and referring services e.g. Pain Services (Acute and Chronic), Liver Clinic

4. Tertiary consultant / Staff education on addiction issues. The key gaps in the Addiction Medicine Service are related to only 18 hours medical coverage (medical consultant and HMO) each week – with the Addiction Medicine Consultant a 0.3 EFT position – and thus limited access to the service for patients with AOD issues. An important aspect of the D&A NP role will be around using a “no wrong door” approach to facilitate timely and accessible service for primary and secondary patient consultations. Characteristics of the D&A NP should include: flexibility with service provision; ability to engage in client, health professional and community education; advanced assessment skills; advanced counselling skills; ability to appropriately order and interpret diagnostics and prescribe medications; facilitate withdrawal and AOD management; provide certification of leave of absence; and facilitate linkages for AOD services on discharge. Extensions of scope of practice for the D&A NP include making and receiving referrals to other health practitioners, ordering investigations and prescribing from the D&A NP formulary. Patient inclusion will be those that fit within the D&A NP’s scope of practice. Patients excluded from D&A NP-led care will be those deemed inappropriate by the treating D&A NP, the Addiction medicine Consultant, and/or the referring team due to increased complexity or complications.


INTRODUCTION Nurse Practitioners The Nurses Board of Victoria has accepted the following Australian Nursing and Midwifery Council (ANMC) definition:

A nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession’s values, knowledge, theories and practise and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practise (ANMC, 2006).

The standard of practice required for endorsement as a NP is guided by the ANMC “National Competency Standards for the Nurse Practitioner” (2006). These build on the core competency standards for registered nurses and midwives. These competency standards provide the NP with the framework for assessing competence, and are used by the Nurses’ Board of Victoria to assess a Nurse Practitioner Candidate’s eligibility for endorsement as a NP (NBV, 2008). The following assumptions underpin the use of the competency framework:

1. The nurse practitioner is a registered nurse whose practice must first meet the following regulatory and professional requirements of Victroia • National Competency Standards for the Registered Nurse (ANMC, 2006) • Code of Ethics for Nurses (ANMC, 2008) • Code of Professional Conduct for Nurses (ANMC, 2008)

2. The NP standards are core standards that are common to all models of NP practice and ensure safe NP practice that relates to a specific field of health care. They can accommodate specialty competencies that are designed to meet the unique health care needs of specific client / patient populations.

3. The NP standards will be used by NP education providers to develop the content and process requirements for a nurse practitioner education program.

4. The NP standards will be used by regulatory authorities to determine the eligibility of NPs seeking authorisation as NP in Australia.

Nurse Practitioners must demonstrate competence across three standards. They are (ANMC, 2006):

1. Dynamic practice that incorporates application of high-level knowledge and skills in extended practice across stable, unpredictable and complex situations;

2. Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy and accountability;

3. Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health care.

Nurse Practitioners are regulated by the NBV, and Registered Nurses must apply to the NBV for endorsement as a Nurse Practitioner, following academic (at Masters level) and substantial clinical experience. The title of Nurse Practitioner is protected in Victoria through


legislation. The position integrates clinical practice, research, education, management and leadership. The Nurse Practitioner role aims to meet the gaps and add value to patient service delivery from an advanced nursing practice perspective, promoting a seamless and quality service to a specified group of patients. Nurse Practitioners at Melbourne Health The Melbourne Health Nurse Practitioner Strategic Framework 2009 (Melbourne Health, 2009) outlines the process for Melbourne Health to provide considered support for the Nurse Practitioner role, and the process for development of Nurse Practitioner roles. The role of the Nurse Practitioner should align itself with Melbourne Health’s goals and values. This gives clarity to the purpose of the role and the scope of practice of each NP, and ensures that the culture of care delivery supports patients’ needs. The Advanced Nursing Practice Steering Committee oversees role and model development. The role of the steering committee is to provide governance and oversight of the design, implementation and evaluation of APN roles within Melbourne Health.


SECTION 1: THE ADDICTION MEDICINE SERVICE Addiction Medicine Patients – service background Addiction Medicine Services provide cost-benefits to hospitals through reduced length of patient stay and reduced re-presentation to hospital. Clinical staff learn through consultation-based interactions with the Addiction Medicine Service and patients benefit through appropriate clinical management and referral on discharge. The Addiction Medicine Service’s philosophy is to provide a service that links with the referring unit’s plans for patient management, whilst counselling patients on ways to solve their alcohol and / or other drug (AOD) problems. The Addiction Medicine Service collaboratively facilitates development of a clear and consistent plan of management, to which everyone subscribes (Gijsbers, 2006). The majority of patients referred to the Addiction Medicine Service have drug and / or alcohol abuse issues as concomitant problems to their reason for admission. Referrals to the Addiction Medicine Service arise when (Gijsbers & Green, 2005):

• A patient has a known history of AOD use. • A patient is exhibiting signs and symptoms that may or not be related to AOD

withdrawal or intoxication. • A family member may be concerned. • A patient may request assistance with their ongoing problem (relapse prevention).

Withdrawal signs and symptoms from alcohol and other drugs can be present on admission or the patient may go into withdrawal several hours to a few days after the last drug was consumed (Mayo-Smith et al, 2004; McKeown & West, 2009). Outcomes are improved if withdrawals are prevented as the effects of alcohol withdrawal delirium can increase patient stays by up 10 days (Stanley et al, 2003). Patients referred to the Addiction Medicine Service undergo thorough physical, mental health and psychosocial assessment. Clinical practice guidelines used at Melbourne Health for patients with alcohol and other drug issues are listed in Appendix 1, and provide recommendations for treatment. Overview of current service model Definitions

• Primary consultation: health professional has direct clinical contact with the patient, assesses the patient and provides and implements a plan for management

• Secondary consultation: health professional provides telephone / distance advice or advice on ward-round to the treating unit (referrers) for patient management, following collaborative assessment of the patient

• Tertiary consultation: health professional provides education to treating unit (referrers) to improve the referrer’s ability to manage patients

The Melbourne Health (MH) Addiction Medicine Service aims to improve the identification, and management of patients attending RMH who have AOD problems which may cause complications during treatment and recovery. The service aims to reduce complications and improve outcomes for patients through better management of AOD issues that are impacting on their admission. This may result in a reduced length of stay. The main strategy is to better equip staff to prevent or manage patient behaviours associated with patients’ AOD use. The Addiction Medicine Service has two main models for patient management. Firstly, the Addiction Medicine medical and nursing staff perform direct patient assessments and care planning, linking in with referring teams, in the form of primary consultations. Secondly, the Addiction Medicine team provide consultation and education about addiction medicine issues, through secondary and tertiary consultations, enabling referrers to look after the patient’s


AOD problems by educating staff about AODs. Assessment and advice is available for the following:

• Identifying patients at high risk of AOD problems in the wards. • Management of AOD withdrawal in hospital, including alcohol, opioids,

psychostimulants, cannabis, benzodiazepines and other mind altering drugs, either singly or in combination.

• Assessment and advice for managing pain in patients who are opioid tolerant or resistant because of illicit drug use of opioid substitution pharmacotherapy.

• Assessment and advice on post-discharge management of patients with AOD problems.

(Melbourne Health, http://info1.mh.org.au/DrugAlcohol/default.htm, April 2009). The Addiction Medicine Service has the following staff and EFT:

• Medical staff (18 hours per week) o Addiction Medicine Medical Consultant (0.3 EFT) o Addiction Medicine HMO position (0.5 EFT, rotating position every 3 months)

• Drug and Alcohol Clinical Nurse Consultant (1 EFT) The Addiction Medicine Service, managed under the Division of Medicine, began 2004. The number of referrals has been steadily increasing (see Table 1). The types of drugs used by patients referred to the service are mainly alcohol and opiates (see Table 2). Table 1: Addiction Medicine referrals by year

Year No of Patient’s referred to the service

2004 2005 2006 2007 2008

2009 (Nov)

189 349 379 440 445 442

Table 2: Types of Drugs referred to Addiction Medicine Service 2004 – 2008

51%

23%

10%

7%9%

Alcohol

Opiates

Cannabis

Benzo

Amphet/Meth/MDA/GHB

Each referred patient is seen an average of 2.5 times. The main referral units include Trauma, General Medicine, Psychiatry and the Emergency Department. (DHS, 2009, p.42) notes:

In 2005–06, more than 20,000 bed days in Victoria’s public hospital system were utilised by people in a state of withdrawal while being treated for other medical and mental health conditions. Withdrawal adds to the complexity of treatment with an average bed day per separation of 7.6 days. There is an opportunity to strengthen prevention initiatives through the hospital system.


Public hospitals in 2005-2006 had over 3,000 separations where patients were withdrawing from AODs: the average stay per patient was 3.7 bed days (DHS, 2009, p.42). In the past year at Melbourne Health the number of patients referred to the service was 435 (see Table 3): of these 34 patients (7.8%) were commenced on substitution pharmacotherapy (methadone or buprenorphine for withdrawal) indicating the need for registered prescribers of substitution pharmacotherapy. Currently the only registered substitution pharmacotherapy prescribers at the Royal Melbourne Hospital are A/Prof Alan Gijsbers, the Addiction Medicine Medical Consultant, and Dr Malcolm Hogg, the Pain Service Consultant. Dr Hogg assists for substitution pharmacotherapy patients when A/Prof Gijsbers is on leave. Table 3: Breakdown of patient groups referred to Melbourne Health’s Addiction Medicine Service (Nov ’08-Oct ’09)

Total Episodes: Separations

Average Length of stay

Inlier Episodes: Separations

Average Length of stay

V60A ALCOHOL INTOXICATN&WITHDRWL+CC 31 4 29 1V60B ALCOHOL INTOXICATN&WITHDRWL-CC 239 1 237 1V60Z Alcohol Intoxication and Withdrawal 83 1 82 1V61Z Drug Intoxication and Withdrawal 39 4 28 1V62A Alcohol Use Disorder and Dependence 17 5 16 3V62B ALCOHOL USE DSRD & DEPENDNC+SD 2 1 2 1V63A OPIOID USE DSRD & DEPENDENCE 5 2 4 1V64Z OTHER DRUG USE DISORD & DEPEND 19 1 18 1

Total 435 416 Current Drug and Alcohol Clinical Nurse Consultant Role The Drug and Alcohol Clinical Nurse Consultant (D&A CNC) provides primary, secondary and tertiary consultations and advice on complex withdrawal issues and longer-term management for patients at the Royal Melbourne Hospital and secondary consultations to the Royal Park Campus. Currently the D&A CNC works with the Addiction Medicine Medical Consultant and / or Hospital Medical Officer (HMO) for 18 hours per week. The Addiction Medicine Medical Consultant has seven-hours of ward rounds and is available “on-call” at other times. However the on-call availability is not a paid service and may not be available on demand. The D&A CNC currently provides education and mentorship for the Addiction Medicine HMO staff in the absence of the Medical Consultant. The current role is summarised in Table 4. Table 4: Drug and Alcohol Clinical Nurse Consultant Role Summary: Role requirements

• Nurse with training and experience in Drug and Alcohol Services • This role works closely with the Addiction Medicine Consultant

Patient Screening

• The CNC works with staff to improve screening and identification of patients with potential drug and alcohol risk factors, which will then be incorporated into their pre-admission work up and care plans. This would pre-empt complications, e.g. anaesthetic risk, withdrawal during their


inpatient stay. Patient Coordination

• The Co-ordinator is the first point of access for the service and takes referrals from ED, Outpatients and Pre-Admission Clinic, as well as inpatient units.

• Works closely with the Addiction Medicine Consultant, providing a consultation service to MH on management of patients with Drug and Alcohol problems through ward rounds, individual consultation and referral.

• The Co-ordinator works with the Addiction Medicine Consultant to provide education and support for staff in targeted areas (those where impact of patients’ Drug and Alcohol problems may be greatest). This will cover screening, medical management and behavioural management and links to available support services. It will also entail development of clinical guidelines for management of this patient group.

Staff Support and Links

• To assist and support staff in the development and implementation of Drug and Alcohol nursing care plans.

• To evaluate current process of documentation and participate in the development and implementation of best practice documentation.

• To foster liaison with other Drug and Alcohol stakeholders. Research and Quality

• To actively participate in any research or evaluation processes related to the target group. • To actively participate in related working parties such as aggression management, restraint and

code grey calls. • To ensure that the objectives, policies, rules and regulations established by the Addiction

Medicine Service, MH, & / or higher authorities are implemented. The Drug and Alcohol Nurse Practitioner in Australia In Victoria, there is one D&A NP, working at Uniting Care Moreland Hall – a 12 bed Community residential drug withdrawal unit. The D&A NP also works on occasion in Homebased, Outpatient and Youth Withdrawal. The Nurse Practitioner works where possible in Shared Care with General Practitioners whose patients enter treatment for residential withdrawal. There may be occasion to provide treatment for patients who have no General Practitioner. Treatment is provided only during their admission into the residential withdrawal service (Uniting Care Moreland Hall, 2009). There are two registered Drug and Alcohol Nurse Practitioners in New South Wales (NSW), one at the John Hunter Hospital and the other at the Royal North Shore Hospital and Herbert Street Clinic. For both D&A NPs their patients must be over 16 years of age. The RNSH and Herbert Street Clinic clients may be inpatients or outpatients of the Hospital or the Clinic. The diagnoses and presenting symptomatology / complaints of patients for the NSW D&A NPs include (NSCCAHS, 2007; HNEAHS, 2007):

• Alcohol related disorders – intoxication, withdrawal, and dependence. • Nicotine related disorders – dependence, cessation and withdrawal. • Licit & illicit substance-use disorders – intoxication, withdrawal, and

dependence. NB: this includes management of patients receiving pharmacotherapies for opioid dependence.

This D&A NP case manages and provides consultative input to the care of individuals and responds to the needs of their families, and interacts with other health care providers to the benefit of the patient. The D&A NP provides specialist referral where necessary and recognises the limits of this scope of practice in relation to patients’ co morbidities (NSCCAHS, 2007). There is a Drug and Alcohol NP drug formulary approved by the Victorian Minister for Health, July 2009 (See Appendix 2).


The Turning Point Alcohol and Drug Centre (2004) review of drug treatment services in Victoria recommended that the Nurse Practitioner role be expanded to the AOD sector – to enhance and expand existing drug treatments.

The model involves the integration of advanced nursing and health knowledge, skills and clinical expertise into daily practice. This specialist role assists in the promotion of care between health providers and in partnership with clients and communities (Turning Point, 2004, p.78).

An important aspect of the D&A NP role is to ensure timely and accessible service. A new blueprint for alcohol and other drug treatment services 2009-2013 (DHS, 2008, p.41) states:

The ‘no wrong door’ approach recognises that timely access to the right treatment is critical regardless of whether a person presents for alcohol and other drug treatment; at a needle and syringe program; or at a mental health, primary health, hospital, family or housing services facility.

Using the recommendations of Turning Point Alcohol and Drug Centre (2004), the Victorian Alcohol and Drug Association (VAADA, 2005 p.15-16) consulted on the key characteristics of the nurse practitioner role in the alcohol and other drugs sector. Table 5 provides a list of characteristics that are relevant to a D&A NP in Addiction Medicine services within a hospital context: Table 5: Characteristics of a D&A NP (VAADA, 2005, p.15-16)

Characteristic Further explanation

Flexibility Access to D&A services for clients when it is required rather than when they are able to get a GP appointment

Personal Education Identification and understanding of local cultures, as well as increased educational needs

Client and community education

Concerning harm reduction around alcohol and other drug use, and other broader information (eg. blood borne viruses, vein care, wound care, dental care, sexual health and overdose prevention)

Assessment A holistic approach relating to general, mental and emotional health, as well as alcohol and drug history, followed by appropriate referral, liaison or co-case management with other general health/mental health services

Counselling Alcohol and other drug counselling, as well as generalist counselling (eg. Pre and post counselling for Hepatitis C and HIV)

Diagnostics Pathology testing of blood including full blood examination, electrolytes, liver function and for viruses and sexually transmissible infections

Withdrawal Provision of inpatient and outpatient withdrawal services

Prescribing As per approved D&A NP Drug formulary to treat signs and symptoms of withdrawal and for maintenance pharmacotherapy

Certification Ability to approve absence from employment / Centrelink requirements during withdrawal period

Linkages The ability to interact with other services other than alcohol and drug (eg. mental health, domestic violence, family support, employment and housing, education and training programs, parenting support)

Funding If introduced, additional funding for nurse practitioners is integral to the effective development of any model


SECTION 2: GAP ANALYSIS Addiction Medicine Service gaps / needs

The Addiction Medicine service is within the Division of Medicine at Melbourne Health. Departments from many Melbourne Health Divisions in Melbourne Health use the Addiction Medicine service, including the Divisions of Medicine and Emergency, Surgery and Perioperative (including notably Gastroenterology), Neurosciences, Cardiac, Mental Health and Ambulatory and Continuing Care, and Intensive Care. A gap analysis was completed November 2009 using feedback provided by relevant stakeholders from the above Divisions of Melbourne Health. Interviews were undertaken with medical staff, nurses, allied health staff, and service directors. Four key areas of opportunity were identified for model development and extension of the role of the D&A CNC. These were used to facilitate discussion about gaps in the Melbourne Health Addiction Medicine Service:

5. D&A NP led primary and secondary consultation service for inpatients with drug and alcohol issues

6. Consultation for Emergency Department patients with primary drug and alcohol issues

7. Outpatient clinic management of patients with alcohol issues in collaboration with the Addiction Medicine Medical Consultant and referring services e.g. Pain Services (Acute and Chronic), Liver Clinic

8. Tertiary consultant / Staff education on addiction issues. Primarily, the D&A NP role will ensure responsive timely access to the Addiction Medicine Service Appendix 3 provides a summary of feedback from stakeholders in relation to the current Addiction Medicine Service and how the NP may potentially fill appropriate gaps in the service, based on scope of practice.


SECTION 3a: DRUG & ALCOHOL NP MODEL Introduction to the model The recommendations from Turning Point Alcohol and Drug Centre (2004), VAADA (2005), the Australian D&A NP models, and the service gap analysis have been used to develop the Melbourne Health’s D&A NP model. The D&A NP in the Addiction Medicine Service would primarily perform functions of clinical care delivery for patients who have substance-use disorders. The D&A NP role extends the current CNC scope of practice to include advanced assessment, autonomous and collaborative decision making and management (See Table 6). This entails the management of patients with drug and / or alcohol dependency experiencing acute withdrawal issues, including ordering and interpreting diagnostic tests and prescribing medication. The D&A NP would be a registered methadone / buprenorphine prescriber and would be qualified to commence an inpatient on substitution pharmacotherapy. The aim of the model is to enhance the timeliness and responsiveness of the Addiction Medicine Service, and to decrease the length of stay for patients with withdrawal issues or suspected withdrawal issues. The current limited hours of medical consultation is a barrier to inpatient and outpatient service accessibility. The new model will allow greater access for patients with AOD issues to Addiction Medicine Services, through the advanced scope of practice of the NP, and thus will allow enhanced service capacity. The extended scope of practice links in with ANMC (2004) competency standards for Nurse Practitioners (Table 6). Table 6: D&A Nurse Practitioner Role Summary

Drug and Alcohol Nurse Practitioner Conducts advanced, comprehensive and holistic health assessment of drug and alcohol patients

• Assess the biological, psychological and social aspects of each individual patient’s drug and / or alcohol issue

Demonstrates a high level of confidence and clinical proficiency in carrying out a range of procedures, treatments and interventions that are evidence based and informed by specialist knowledge

• Autonomously (within scope of nursing practice) and collaboratively (with referring unit) manage patients with drug and alcohol issues, providing linkage to support the patient’s return home / to their community

• Manage and provide consultation for inpatients referred with drug and alcohol issues • Lead regular outpatient clinics for patients with primary drug and alcohol issues, and for patients

with concomitant drug and / or alcohol issues • Provide counselling for patients that may be either motivated or ambivalent to modify their

lifestyle to change their drug and / or alcohol use • Provide counselling about the physiological aspects of drug and alcohol usebased on individual

patient blood results and physical symptoms Has the capacity to use the knowledge and skills of extended practice competencies in complex and unfamiliar environments

• Develop skills in leading regular outpatient clinics for patients with primary drug and alcohol issues, and for patients with concomitant drug and / or alcohol issues

• May be asked for advice on community issues and in complex environments such as ICU Demonstrates skills in accessing established and evolving knowledge in clinical and social sciences, and the application of this knowledge to addiction medicine patient care and the education of others

• Actively promote evidenced based practice, and educate medical, nursing and allied health staff in drug and alcohol management, medication and associated illness prevention management

Applies extended practice competencies within the Drug and Alcohol nursing model Establishes therapeutic links with the patient / carers / community that recognise and respect cultural identity and lifestyle choices


Is proactive in conducting clinical service that is enhanced and extended by autonomous and accountable practice Engages in and leads clinical collaboration that optimise outcomes for drug and alcohol patients and carers

• Coordinate and facilitate higher level nursing decision making for patients with drug and / or alcohol issues

• Take on a higher collaborative leadership role within the unit – including during the Addiction Medicine round and meetings, in family meeting discussions, and in Addiction Medicine Service activities including projects and research

• Take on a higher collaborative leadership role with external professional, clinical and community bodies

Engages in and leads informed critique and influence at the systems level of health care Develop leadership skills in decision-making, team coordination, and communication


The Melbourne Health D&A NP Definitions

• Primary consultation: health professional has direct clinical contact with the patient, assesses the patient and provides and implements a plan for management

• Secondary consultation: health professional provides telephone / distance advice or advice on ward-round to the treating unit (referrers) for patient management, following collaborative assessment of the patient

• Tertiary consultation: health professional provides education to treating unit (referrers) to improve the referrer’s ability to manage patients

Service need The Addiction Medicine Service has limited medical consultant cover (18 hours per week), which creates a gap in the service for inpatients and outpatients with AOD issues. The D&A NP role will bridge this gap, and facilitate timeliness and responsiveness for primary consultation referrals for patients with AOD issues. The D&A NP will also enhance the consultation advice in secondary and tertiary consultations. Where and who The D&A NP, as part of the Addiction Medicine Service, will provide care for patients in the following areas of Melbourne Health:

1. Inpatients: D&A NP led primary and secondary consultation service for inpatients with AOD issues, including:

a. Pre-Admission Clinic patients identified at risk by GP or Melbourne Health staff prior to admission for elective procedures

b. Acute medical wards, surgical wards, and specialty units (e.g. Day Procedure Unit, Intensive Care Unit)

c. Acute psychiatric inpatient unit in collaboration with the dual-diagnosis (drug / alcohol and mental health) service based on protocol

2. Emergency Department (ED): Primary consultation for ED patients with primary AOD

issues 3. Primary and secondary consultation service for outpatients, including at:

a. Addiction medicine Clinic b. Acute Pain Clinic c. Chronic Pain Clinic d. Liver Clinic e. Hepatitis C Clinic f. Methadone Clinic (5-year plan)

4. Tertiary consultations on addiction issues and management of patients with substance abuse disorders.

Inclusion Criteria The Addiction Medicine Service is designed to improve the referrer’s ability to look after the patients’ AOD problems. All patients referred to the Addiction Medicine Service will be eligible for primary management / secondary consultation management by the D&A NP, using the “no wrong door” approach. This cohort of patients has complex needs in their psycho-social-biological domains. Due to the complex nature of this group of patients the majority of the consultations will be secondary consultations with the treating (referring) unit. Exclusion Criteria The D&A NP’s scope of practice is bounded by the knowledge and skills of the NP and the agreed Clinical Guidelines and Formulary that will underpin this position. In the context of this scope of practice there will be ample opportunities for the D&A NP to consult specialist


clinicians including D&A (and other-specialty) Staff Specialists, Registrars, Nurses, Psychologists and General Practitioners. The D&A NP will consult or make a referral to a medical officer or specialist medical officer in the following situations:

Where signs or symptoms persist beyond the expected time of their resolution despite treatment

Where symptomatic or laboratory evidence exists of previously unidentified decreased or decreasing function of any vital organ or system

Where a patient presents co morbidities falling outside the D&A NP’s expertise eg. Infection, pregnancy, asthma, diabetes.

In the event of an atypical presentation of a common illness or an unusual response to treatment

Where a patient’s chronic condition destabilises, especially an unexpected deterioration in the condition being managed or any existing co morbidity

When a patient requires admission or other-specialty review Any other conditions/clinical presentations that the D&A NP and the medical officers

have agreed to Any other conditions that the D&A NP believes are outside this scope of practice

Access to D&A NP The D&A NP will work across Melbourne Health campuses (City and Royal Park) with inpatients and outpatients in the acute and subacute settings during business hours (Monday – Friday). Referral to the service will be via electronic referral and a page or telephone call. Consultation by the D&A NP may be primary where by the patient is reviewed and the plan communicated directly to the staff, and secondary consultation to staff where advice would be offered on management of addiction issues. The scope of practice would be defined by assessment of the addiction issue and management of bio-psycho-social and spiritual issues surrounding drug withdrawal, opioid tolerance and pain management and ongoing treatment options. Clinical review of patients will involve the use of advanced patient management skills. These include advanced assessment including history taking, physical assessment, and care planning in collaboration with patient’s treating unit. The D&A NP will order (or make recommendations to the treating unit for orders in secondary consultations) and interpret diagnostic investigations (see below), and will use this information to help formulate a plan of care for the patient. The D&A NP will also prescribe substitution pharmacotherapy and other medications from the D&A NP drug formulary (Appendix 2). Communication of plans will be in the patient medical record and communicated orally to the patient, treating medical unit, nursing staff, pharmacist and allied health staff. The D&A NP will also liaise with the patient’s GP and other services, to communicate care plans. Diagnostic Investigations Diagnostic investigations may include:

• Blood alcohol, • Toxicology, • Haematology and Biochemistry (FBE, U&Es, Magnesium, liver function tests,

coagulation profile (INR), CRP) • Immunological status (HIV / Hepatitis B / Hepatitis C)

Discharge from the D&A NP service Patients may be referred back to or linked in to primary / community care providers, such as GP, support group or pharmacotherapy provider for ongoing community support. All patients referred to the D&A NP fall under the Addiction Medicine Service. If the management recommendations have been achieved, and following consultation with the treating unit (referrer), the patient, and case review with the Addiction Medicine Service, the patient will be discharged from the Addiction Medicine Service.


Drug Formulary The D&A NP will prescribe within his / her scope of practice. The formulary of this NP is supported by the Melbourne Health policy and sits within the approved NP prescribing drug and alcohol category (Appendix 2). This formulary provides for the poisons and restricted substances that may be possessed, used, supplied or prescribed by nurse practitioners under section 14A of the Drugs Poisons and Controlled Substances Act 1981 and forms part of approved nurse practitioner guidelines. It is the Nurse Practitioner’s responsibility to use this formulary in conjunction with the most recent product information available. Any alteration must be submitted to the Melbourne Health Advanced Nursing Practice Steering Committee and the Melbourne Health Drugs and Therapeutics Committee. Accountability The D&A NP is accountable for health outcomes. The D&A NP accepts responsibility for all aspects of clinical decision-making. The D&A NP will seek expert advice and make referrals where necessary to ensure quality patient care. The D&A NP will participate in the continuing evaluation of the service in the following quality parameters: safety, patient/clinician access, and efficacy. The D&A NP will ensure that there is evidence of continuing professional development and maintenance of clinical skills in line with NBV Continuing Professional Development. The Addiction Medicine Service regularly goes on ward round together to review clinical decision made by the members of the team. Decisions are discussed, and advice sought using each member’s knowledge and skills. The clinical decision process is represented in the flow chart (Figure 1) below, and involves:

1. Medical Consultant provides clinical supervision to NP (Medical care) and HMO (Addiction Medicine speciality) and general Medical care

2. NP provides specialist addiction knowledge to HMO and service co-ordination. Accountable for own decisions.

3. HMO provides general medical knowledge/skills working in collaboration with Medical Consultant and NP.

Figure 1: Clinical Decision Process

Addiction Medicine Service

1. Medical Consultant (0.3 EFT) Head of Service

Divisional Director Division of Medicine

Executive Director of Medical Services

General Medicine Department Head

Chief Executive OfficerMelbourne Health

3. Hospital Medical Officer (2nd/3rd Yr HMO 0.5 EFT) 3 Mth Training Position

2. D &A Nurse Practitioner (NP) (1.0 EFT)

Co‐Divisional Director Nursing

Division of Medicine

Executive Dir of Nursing


SECTION 3b: D&A NP MODEL FLOWCHARTS

Referral to D&A NP by Pre-Admission Clinic / GP prior to elective admission, Acute medical wards, surgical wards, and specialty units, Acute psychiatric

inpatient unit

Outside Scope of Practice: Secondary consultation with Addiction Medicine Consultant and/or Referring Team

Emergency department presentation

Patient management by Addiction Medicine

Team

Assessment of patient (in patient’s ward / unit or Pre-Admission Clinic) of physical health, mental health, psychosocial issues, goals of treatment plan, other supports

Development of treatment plan.

Communication of treatment plan with patient, referring unit. Documentation in medical record.

Treatment in collaboration with referring team, including regular ward round review. Discharge planning in response to post withdrawal and/or ongoing community

management of D&A problem

Acute medical condition

Review with Referring Team

Completion of treatment episode. Letter to General Practitioner. +/- Referral to mental health services, Melbourne Health D&A Outpatient Clinic, other alcohol and drug

support agency, residential rehabilitation, counselling, psychiatric services.

INPATIENTS: D&A NP-led Primary Inpatient Consultations

Discharged from Addiction Medicine Service


Referral to D&A NP from Addiction Medicine Service, Acute Pain Service, Chronic Pain Service, Liver Unit, Gastroenterology (Hepatitis C) Service

Outside Scope of Practice: Secondary consultation with Addiction Medicine

Consultant and/or referring team

Ad hoc referrals from other Outpatient Clinics

Patient management by Addiction Medicine

Team

Assessment of patient (in Outpatient Clinic) of physical health, mental health, psychosocial issues, goals of treatment plan, other supports

Development of treatment plan.

Communication of treatment plan with patient, referring unit. Documentation in medical record.

Treatment in collaboration with referring team, including regular Outpatient Clinic follow-up. Discharge planning to link patient into community care providers, including

GP.

Acute medical condition

Refer back to Referring Team

Completion of treatment episode. Letter to General Practitioner. +/- Referral to mental health services, other Outpatient Clinics, other alcohol and drug support agency,

residential rehabilitation, counselling, psychiatric services.

OUTPATIENTS: D&A NP-led Primary Outpatient Consultations

Discharged from Addiction Medicine Service


SECTION 4: D&A NP MODEL IMPLEMENTATION Alignment with Melbourne Health plans The D&A NP Model aligns with the Melbourne Health Strategic Plan (2010-2015) in the following areas:

Strategic priorities Deliverables / outcomes Develop our workforce • Develop a flexible and skilled workforce

• Enhance management and leadership capability Improve the quality and safety of our services

• Deliver high quality and safe care • Develop a culture of person centred care • Ensure transparent practices and systems • Improve patient flow

Foster a culture of research and innovation

• Develop flexible models of care and innovative business practices based on evidence and evaluation

Build a sustainable organisation

• Improve access to our services • Plan future services based on the needs of our

communities Support for the D&A NP role from key stakeholders

• Assoc Prof Alan Gijsbers: Service Head Addiction Medicine Service • Assoc Prof David Russell: Director of Department of General Medicine • Dr Tony Snell: Medial Director: Medicine, Emergency and Hospital in the Home • Paula Stephenson: Co-Divisional Director Nursing and Operations: Medicine,

Emergency and Hospital In The Home • Assoc Prof Denise Heinjus, Executive Director of Nursing, and Chair Melbourne

Health Advanced Nursing Practice Steering Committee Budget Extension of the existing CNC role to a NP role would incur the following costs:

Position Classification Salary Budget required

Clinical Nurse Consultant C G5 Year 2 (201-400 beds)

ZA8 $ 87,678.29

$ 0.00

Nurse Practitioner Grade 6 Year 1 (first year)

NO1 $ 91,016.74

$ 3,338.45

Nurse Practitioner Grade 6 Year 2 (second and subsequent years)

NO2 $ 94,360.86

$ 6,682.57

All salaries include 0.09% superannuation Candidate education program and other resources The Melbourne Health Nurse Practitioner Strategic Framework 2009 addresses the education requirements and candidacy program for Nurse Practitioner Candidates (NPC). Addiction Medicine services has identified Dr Gijsbers as the clinical mentor for the D&A NPC, and the D&A NPC at Moreland Hall as a secondary clinical mentor. Melbourne Health will identify a professional mentor when the candidacy period commences.


Further infrastructure supports

1. Melbourne Health Nurse Practitioner Strategic Framework 2009 2. The Melbourne Health Advanced Nursing Practice Steering Committee 3. Nurse Practitioner Project Nurse, with support through the Nursing Workforce Unit 4. Executive support through the nursing Divisional Co-Directors and Executive Director of

Nursing Succession planning and role sustainability plans for this role The D&A NP is a single practitioner model. There is limited scope for other nurses to become D&A NPs, although Melbourne Health has addressed role sustainability plans in the Melbourne Health Nurse Practitioner Strategic Framework 2009. The D&A NP position will be backfilled for leave by the medical staff. It is anticipated that the Addiction Medicine Service will evolve over the next five years, and due to the nature of patient presentations requiring access to the Addiction Medicine Service, the NP role may work out of business hours, including on weekends. This will facilitate responsiveness to a “no wrong door” policy. As this role evolves to an out-of-hours service, there is scope for additional nursing support by a D&A CNC.


REFERENCES

The Australian Nursing and Midwifery Council (ANMC), 2004, “National Competency Standards for the Nurse Practitioner”. http://www.anmc.org.au/ Accessed 23 February 2009

DHS (Department of Human Services). 2006. “Policy for maintenance pharmacotherapy for opioid dependence”. http://www.health.vic.gov.au/dpu/downloads/poilicy-opioid.pdf Accessed 30 November 2009

DHS (Department of Human Services). 2008. “A new blueprint for alcohol and other drug treatment services 2009-2013 Client-centred, service-focused.” Victorian Government. http://www.health.vic.gov.au/drugservices/pubs/blueprint09-13.htm

DHS website http://www.health.vic.gov.au/nursing/furthering/practitioner

Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. 2008. “What Percentage of Chronic Nonmalignant Pain Patients Exposed to Chronic Opioid Analgesic Therapy Develop Abuse/Addiction and/or Aberrant Drug-Related Behaviors? A Structured Evidence-Based Review”. Pain Medicine, 9(4): 444-459

Gijsbers A. 2006. “Knowledge Skills and Attitudes Medical Students should acquire in Drug and Alcohol Studies”. Melbourne Health (intranet). http://info1.mh.org.au/DrugAlcohol/Resources/Resources.htm Accessed 26 November 2009

Gijsbers A, Green P. 2005. “D&A for Interns.ppt”. Melbourne Health (intranet). http://info1.mh.org.au/DrugAlcohol/Talks/Talks.htm Accessed 26 November, 2009

HNEAHS (Hunter/New England Area Health Service). 2007. “Nurse Practitioner Clinical Practice Guidelines and Scope of Practice for the Assessment and Management of Alcohol and Other Drug Presentations”. http://www.health.nsw.gov.au/resources/nursing/practitioner/cpg_drugpres_hneahs_pdf.asp Accessed 30 November 2009

Knott JC, Bennett D, Rawet J, Taylor DM. 2005. Epidemiology of unarmed threats in the emergency department. Emerg Med Australas. 17(4):351-358.

Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL, Hill A, Jara G, Kasser C, Melbourne J. 2004. “Management of alcohol withdrawal delirium. An evidence-based practice guideline”. Arch Intern Med. 164(13):1405-12

McKeown NJ, West PL. 2009. “Withdrawal Syndromes” http://emedicine.medscape.com/article/819502-overview Accessed 16 Nov 2009

Melbourne Health. 2009. “Melbourne Health Nurse Practitioner Strategic Framework 2009”. Melbourne Health.

NSCCAHS (Northern Sydney Central Coast Area Health Service). 2007. “Scope of Practice Drug & Alcohol Nurse Practitioner”. Royal North Shore Hospital.

Stanley KM, Amabile CM, Simpson KN, Couillard D, Norcross ED, Worrall CL, 2003. “Impact of an Alcohol Withdrawal Syndrome Practice Guideline on Surgical Patient Outcomes”. Pharmacotherapy. 23(7): 3

Turning Point Alcohol and Drug Centre. (2004). “Rural Pathways: A Review of the Victorian drug treatment service system in Regional and Rural Victoria. Final Report”. http://www.health.vic.gov.au/drugservices/downloads/rural_pathways.pdf Accessed 30 November 2009

Uniting Care Moreland Hall. 2009. “Community Alcohol and Other Drug Nurse Practitioner: Model and Scope of Practice, Drug Formulary”. Moreland Hall.

VAADA (Victorian Alcohol and Drug Association). 2005. VAADA’s consultation on the RRSSR ‘Nurse Practitioner Model’. http://www.vaada.org.au/resources/items/2005/08/11888-upload-00001.doc Accessed 30 November 2009


http://www.anmc.org.au/

http://www.health.vic.gov.au/dpu/downloads/poilicy-opioid.pdf

http://www.health.vic.gov.au/drugservices/pubs/blueprint09-13.htm

http://www.health.vic.gov.au/nursing/furthering/practitioner

http://www.ingentaconnect.com/content/bsc/pme;jsessionid=1oa7rz4ly11sx.alice

http://info1.mh.org.au/DrugAlcohol/Resources/Resources.htm Accessed 26 November 2009

http://info1.mh.org.au/DrugAlcohol/Resources/Resources.htm Accessed 26 November 2009

http://info1.mh.org.au/DrugAlcohol/Talks/Talks.htm

http://www.health.nsw.gov.au/resources/nursing/practitioner/cpg_drugpres_hneahs_pdf.asp

http://www.health.nsw.gov.au/resources/nursing/practitioner/cpg_drugpres_hneahs_pdf.asp

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Knott%20JC%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Bennett%20D%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rawet%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Taylor%20DM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://emedicine.medscape.com/article/819502-overview

http://www.health.vic.gov.au/drugservices/downloads/rural_pathways.pdf

http://www.vaada.org.au/resources/items/2005/08/11888-upload-00001.doc

http://www.vaada.org.au/resources/items/2005/08/11888-upload-00001.doc

APPENDICES Appendix 1 – Guidelines for Addiction Medicine practice Australian Medicines Handbook Alcohol and other drug withdrawal: Practice Guidelines. Turning Point Alcohol and Drug Centre Inc 2009 Frank & Pead, (1995) New Concepts in Drug Withdrawal: A resource handbook. Services for Alcohol and Drug Withdrawal Monograph series, No. 4, The University of Melbourne, Department of Public Health and Community Medicine: Melbourne National clinical guidelines and procedures for the use of Buprenorphine in the treatment of heroin dependence. Australian Government Department of Health and Aging. Policy for maintenance pharmacotherapy for opioid dependence, Department of Human Services, 2006 http://www.health.vic.gov.au/dpu/downloads/poilicy-opioid.pdf Accessed 30 November 2009 Therapeutic Guidelines Psychotropic. Version 5. (2003). http://etg.hcn.net.au/

Therapeutic Guidelines Gastrointestinal. Version 4, 2006 http://etg.hcn.net.au/ National methadone guidelines Naltrexone Guidelines


http://www.health.vic.gov.au/dpu/downloads/poilicy-opioid.pdf

Appendix 2 – Health Minister (Vic) Approved Drug and Alcohol NP Formulary Reference: Victoria Government Gazette, By Authority of Victorian Government Printer, GENERAL No. G 28 Thursday 9 July 2009, www.gazette.vic.gov.au, 1824-1826

Drugs, Poisons and Controlled Substances Act 1981 APPROVAL UNDER SECTION 14A(1)

Pursuant to section 14A(1) of the Drugs, Poisons and Controlled Substances Act 1981 (‘the Act’), I, Daniel Andrews, Minister for Health, hereby approve for the purposes of authorisation under section 13(1)(ba) of the Act the Schedule 2, 3, 4 and 8 poisons or classes of Schedule 2, 3, 4 and 8 poisons listed in the tables below, with illustrative examples from each class, in relation to the category of Nurse Practitioner – Drug and Alcohol.

This approval takes effect from the date of publication in the Victoria Government Gazette. NURSE PRACTITIONER – DRUG AND ALCOHOL

SCHEDULE 2 POISONS BY CLASS Class of poison Example of poisonSalicylate analgesics aspirinNarcotic analgesics codeine Nonsteroidal anti-inflammatory agents ibuprofen

naproxenAntispasmodic agents hyoscine Antidiarrhoeal agents loperamideLocal anaesthetic agents lignocaine

prilocaineH2-receptor antagonists ranitidineAgents used to assist in smoking cessation nicotine

OTHER SCHEDULE 2 POISONS Poison Paracetamol

SCHEDULE 3 POISONS BY CLASSClass of poison Example of poisonNarcotic analgesics codeineNonsteroidal anti-inflammatory agents ibuprofenAntidiarrhoeal agents diphenoxylateAntiemetic agents prochlorperazineSympathomimetics adrenaline

SCHEDULE 4 POISONS BY CLASSClass of poison Example of poisonNarcotic analgesics codeineNonsteroidal anti-inflammatory agents ibuprofenNarcotic analgesic agents tramadolNarcotic antagonist agents naloxoneLocal anaesthetic agents lignocaineAntiemetic agents metoclopramide

prochlorperazinedomperidonedolasetron

Antihistamines pheniraminepromethazinetrimeprazine

Anticholinergic agents benztropineAntispasmodic agents hyoscine butylbromideAntidiarrhoeal agents diphenoxylate


http://www.gazette.vic.gov.au/


Sympathomimetics adrenalineAnaesthetic agents clonidineAnxiolytic agents diazepam

midazolamClass of poison Example of poisonAntipsychotic agents haloperidolHypnotics and sedatives temazepamAntiepileptic agents clonazepamAgents used in the treatment of drug dependence naltrexone

acamprosatebupropion

Agents used to assist in smoking cessation vareniclineVaccines hepatitis B vaccine

OTHER SCHEDULE 4 POISONSPoisonAtropineParacetamol

SCHEDULE 8 POISONS BY CLASSClass of poison Example of poisonNarcotic analgesic agents methadone

buprenorphine

HON DANIEL ANDREWS MP Minister for Health

Appendix 3 – Addiction Medicine Service - Gap Discussion and Recommendations Current service Area of Opportunity Service Gap Discussion and Recommendations

Consultation service

D&A NP led primary and secondary consultation service for inpatients with drug and alcohol issues

Limited Addiction Medicine medical cover (18 hours per week plus unpaid on call by Consultant) CNC Role Currently the Clinical Nurse Consultant “suggests” medication for parent units to prescribe, or telephones the Addiction Medicine Medical Consultant, discusses the case and takes advice from Dr Gijsbers over the telephone and then communications this to the parent unit. The parent unit may not be available immediately to write up the medication: as such there is the risk of not having the medication written up all. Trauma Patients The Trauma unit is one of the highest referrers to the Addiction Medicine Service. The Trauma service reports that the Addiction Medicine Service meets their patient’s needs very effectively. As patient turnover is high, patients with drug and alcohol issues may not be seen by the Addiction Medicine Medical Consultant. The Trauma Service notes that following her review of the patient, the current D&A CNC is able to suggest medications for the Trauma team to prescribe to for patient’s drug and alcohol disorders: a D&A NP role would be able to review patients and prescribe. Pain Services Acute Pain Services: For patients with acute pain and concomitant D&A issues including patients prescribed methadone, the services of the D&A NP would be very helpful for those patients that have had a procedure, may be receiving Patient Controlled Analgesia, and need management of the their D&A issues. Chronic Pain Services: The knowledge of the D&A CNC is reported as being very useful for providing access and links to community D&A services. There is a gap for an older cohort of patients with D&A issues need linkage to D&A service, for long term regular (e.g. yearly) follow-up e.g. bloods and counselling. Another gap is becoming evident for a small number of patients with drug and alcohol issues that are put on opioids for chronic pain management. Fishbain et al (2008) note that this group will demonstrate aberrant drug related behaviours. Timely intervention by a D&A NP may alleviate this issue.

Current service Area of Opportunity Service Gap Discussion and Recommendations

Emergency Department Consultation

Consultation for Emergency Department patients with primary

Background: In a prospective observational study conducted over 12 months (1 May 2002 to 1 May 2003) in the Emergency Department (ED) at the Royal Melbourne Hospital, Knott, Bennett, Rawet and Taylor (2005) found that drug and alcohol use is one of main predictors of aggression. Reviewing 105 patients involved in Code Grey (unarmed threat) incidents, 35% had a


http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Rawet%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Taylor%20DM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract

drug and alcohol issue history of illicit drug abuse and 25% had a history of alcohol abuse. Of the 151 code grey calls 30% of patients were intoxicated from alcohol at the time and 17% had used illicit drugs (Knott et al. 2005). In a retrospective audit of behavioural emergencies in a NSW ED leading to a Code Black in 2006, Downes, Healy, Page, Bryant and Isbister (2009) found that of the 122 patient (143 Code Black incidents) the primary problems for a third of the patients was alcohol and illicit drug intoxication (33%) and for just under a third it was psychiatric, organic illness and drug withdrawal (29%). One hundred and eight (89%) patients had a past history of alcohol / illicit drug abuse or psychiatric illness (Healy et al, 2009). It is recognised that if the effects of intoxication and withdrawal can be immediately addressed, then the incidence of patient aggression can be reduced. This improves patient outcomes and addresses occupational health and safety issues for staff and other patients. Immediate prescribing of a nicotine patch would be also beneficial for reducing patient aggression in nicotine dependent persons. Currently the Emergency Department is the fourth largest referrer to the RMH Addiction Medicine service, with many patients presenting with AOD issues out of business hours. The Addiction Medicine Service is currently available during business hours and is based hospital wide, and as such is often unable to attend the Emergency Department immediately. Referrals to Addiction Medicine from the ED are reported to be ad hoc. During a two-week trial (March 2007) the Addiction Medicine service attended the ED morning medical handover, and as a result the referral rate increased by 100%, but referrals dropped off after the Addiction Medicine presence was removed. It is a goal of the Addiction Medicine service to increase its presence in the Emergency Department, and the Emergency Department is keen to utilise the Addiction Medicine service more often. The extended scope of practice of the D&A NP would decrease waiting times for patients in the ED with primary drug and alcohol medical conditions by the ordering of medication and blood tests such as liver function and blood alcohol tests. Future: The ED electronic notes system (Symphony) will be an important tool in referring ED patients with drug and alcohol issues in a timely manner from triage to the D&A NP. Symphony would also be available for the D&A NP to externally (to ED) review a list of current patients to assess whether the NP’s services are required.


Outpatient clinic management

Outpatient clinic management of patients with alcohol issues in collaboration with the Addiction Medicine Medical Consultant and Pain Services (Acute and Chronic)

Addiction Medicine The outpatient clinic is currently only attended by the Addiction Medicine Medical Consultant. The D&A NP would be able to attend the clinic when Dr Gijsbers is on leave or have a room in the clinic also see Patients. The D&A NP could also attend the clinic on alternate day to increase outpatient accessibility for patients of the service. Current Service: The Addiction Medicine Consultant has one morning session per week in clinic in which patients with primary and secondary AOD disease are assessed and managed. A strong emphasis of the clinic management is on understanding the biological, psychological and social aspects of the patient’s AOD disorder, often using blood results to aid discussion.


Management is based on counselling the patient to change their lifestyle to give-up drugs and or alcohol, and possibly prescribing or adjusting withdrawal medications. Future service: The extended scope of practice of the D&A NP would enable autonomous management of patients with primary drug and alcohol disorders. This would facilitate timely follow-up of patients following discharge from hospital / ED Pain Services Clinics, Liver Clinic, Hepatitis C Clinic Current Service: There is a gap in the outpatient pain management service for patients with concomitant drug / alcohol issues, for up to four patients per service a fortnight. Pain Services, the Liver Clinic and Hep C Clinic could use the knowledge and skills of a D&A NP for these patients in clinic every second week. Future Service: Concurrent D&A NP-led clinics at the same times as Pain, Liver and Hepatitis C Clinics.


Staff development Tertiary consultant / Staff education on addiction issues.

The Drug and Alcohol Nurse Practitioner would provide formal multidisciplinary education to medical, nursing and allied health staff and students to support improved care for patients requiring addiction medicine services. A key difference between the D&A NP and Addiction Medicine medical staff is that the NP is able to look beyond the medical aspects of patient care and appreciate the holistic needs of these patients and families. D&A NP Education: • Linking into local Divisions of General Practice through Melbourne Health’s Community Partnerships Unit. Pre-admission

clinic could contact D&A NP and flag patient management issues with after advice from the GP. • Education linking into anaesthetists via Pain Services


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