CORRESPONDENCE: OUR EXPERIENCE
148 Correspondence
Can nurse practitioners provide a safe and effective ENT emergency service? Our Experience Vijendren, A., Huggins, M. & Yung, M. ENT Department, Ipswich Hospital Trust, Ipswich, UK Accepted for publication 27 October 2014
In 2004, the European Working Time Directive (EWTD), which had only been applicable to career grade doctors and consultants, was extended to include all junior doctors.1 As a result, there was a gradual tapering of junior doctors working hours, from 56 h a week to 48, by August 2009. This presented many hospitals in the UK with the challenge of balancing a compliant junior workforce rota, whilst maintaining the highest standards of patient care. One solution adopted by many trusts was the introduction of a Hospital-at-Night system.2 Using a multiprofessional and multispecialty approach to providing patient care outof-hours, junior doctors would be expected to cover multiple specialties at unsociable times where workload and medical activities were deemed to be of ‘low volume’. Although this satisfied the compliance of most departmental rotas, there were issues raised with regard to the doctors’ perceived lack of knowledge, clinical skills and supervision in the unrelated specialties, as well as the effects it could have on patient safety. Recognising these potential problems, the ENT department in Ipswich Hospital Trust (IHT) recruited nurse practitioners (NP) in 2004 to cover the ENT on-call commitments, alongside junior doctors. They were all experienced nurses with more than 5 years nursing experience within the field of ENT (Table 1). The scheme was aimed at achieving a more sustained provision of service and patient care, in comparison with junior doctors who rotate through ENT, often for a short period. Ten (10) years following the introduction of the NPs, we conducted a service evaluation to identify their daily activities, the skills required for them to perform their job and the frequency of which problems were escalated to the 2nd on-call doctors (ENT specialty doctor/registrar). We subsequently compared this data with previous service evaluations carried out in 2008 and 2009.
Method Ethical consideration
The study was registered with Ipswich Hospital Trust audit department. NREC ethical approval was not necessary as the study participants were NHS employees. The daily activities of the ENT 1st on-call in IHT were recorded between 23 January 2014 and 23 February (1 month). This included the combined activities of four (4) NPs, one (1) Foundation Year 2 doctor (FY2) who rotated every 4 months and one (1) GP Specialty Trainee (GPST) who rotated every 3 months. At the time of data collection, the NPs had between 5 and 10 years of ENT emergency on-call experience (Table 1). Data were collected on the times the ENT 1st on-call were contacted, the source and purpose of the emergency call, skills required by the 1st on-call to deal with the nature of emergencies, outcome and whether the problems needed escalation to the ENT 2nd on-call. The above information was recorded on a Microsoft Excel spreadsheet by the ENT 1st on-call, who was holding the ENT on-call bleep. These were subsequently cross-referenced, tabulated and analysed by the authors. All statistical calculations were performed using chi-squared tests. Results
During our study period, there were 175 recorded calls to the ENT 1st on-call. Ten (10) calls were excluded as they were dealt with by the ENT 2nd on-call directly due to gaps in the 1st on-call rota as a result of sickness absence. Of the remaining 165 calls, 134 were attended by NPs and 31 by junior doctors (1 FY2 and 1 GPST). Time of call
Correspondence: Ananth Vijendren, ENT Department, Ipswich Hospital Trust, Heath Road, IP4 5PD Ipswich, UK. Tel.: +4401473 712233; e-mail: [email protected]
NPs had answered most calls between the hours of 9 pm to 8 am (95 of 134 calls), whereas junior doctors were contacted mostly during the day between 8 am and 5 pm (23 of 31 calls). The majority of calls (64.8%) took place out-of-hours between 5 pm and 8 am (Table 2). © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
Correspondence
149
Table 1. Demographics of ENT 1st on-call during data collection period (23 January 2014 and 23 February) Grade
Gender
Prior background
Postgraduate ENT 1st on-call experience
Nurse practitioner Nurse practitioner Nurse practitioner Nurse practitioner Foundation Year 2 doctor GP trainee doctor
Male Female Female Female Male Male
ENT theatre scrub nurse and day care unit ENT ward sister ENT ward nurse ENT senior ward nurse Foundation year 1 training Foundation programme, GP training year 1
9 7 6 5 2 3
Table 2. Breakdown of bleeps recorded by ENT 1st on-call Total recorded calls = 175*
8 am–5 pm 5–9 pm 9 pm–8 am
Nurse practitioners (n = 134)
Junior doctors (n = 31)
35 4 95
23 2 6
*10 calls excluded as attended by 2nd on-call. Source of call
A greater number of calls were from the accident and emergency department (51%), ward staff (27%) and general practitioners (16%). Other recorded calls originated from patients, other hospitals as well as staff from outpatient clinics and theatres (Fig. 1).
years years years years months months
otitis media, vertigo and sudden onset hearing loss, as well as acute sore throats (12%). The 1st on-calls were also contacted for matters regarding existing ENT inpatients on the ward (19%). These were for instances when patients wanted to speak to a member of the ENT team, increasing staff concerns regarding a patient’s deteriorating clinical condition, or if other healthcare professionals were unsure about the long-term management plan of ENT patients. Alongside the aforementioned, other recorded calls were for patients with foreign bodies (12%), swallowing concerns (3%), sinus-related infections (e.g. acute sinusitis, periorbital cellulitis) (3%), neck lumps (3%) and fractured noses (2%), prescription of medication such as analgesia or antibiotics (9%) and venesection and cannulation (12%). Only 1% of the 165 calls were for patients with airway concerns (Fig. 2). Skills to manage the problems
Reason for call
The nature of calls varied, with a large proportion of them pertaining to patients with epistaxis (20%), otological presentations (14%) such as acute otitis externa, acute
NPs were able to perform more advanced ENT-related procedures and interventions in comparison with junior doctors (Table 3). This included the removal of foreign bodies from children’s ears and adults’ throats, closure of facial wounds (including aural and nasal laceration) by Steri-
Source of calls (n = 165) Reason for calls in % (n = 165) 1
1 1 Accident and emergency
7 2
3
Wards
2 3 2
Review of inpatient
20
3
26
Epistaxis
Otological presentation Sore throat
GP
9
Foreign bodies Medication prescription
Other hospitals 84
Swallowing concerns
Patients
12
19
Sinus-related infection Neck lump
44
Outpatient clinic
Fractured nose
12
Theatres
Fig. 1. Source of 1st on-call bleeps. © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
14
Venesection + cannulation Airway concern
Fig. 2. Reason for 1st on-call bleeps.
150 Correspondence
Table 3. Comparison of recorded skills performed successfully during 1st on-call Nurse practitioners
Junior doctors
Basic ear, nose and throat examination Ear microsuction Drainage of quinsy Venesection + cannulation Prescribing Nasal cautery Flexible nasoendoscopy Foreign body removal from ear and throat Closure of facial wounds Anterior and posterior nasal packing
Basic ear, nose and throat examination Ear microsuction Drainage of quinsy Venesection + cannulation Prescribing Nasal cautery Flexible nasoendoscopy
2nd on-call involvement
2ndon-call involvement 140 125 120 Nurse practitioners Junior doctors
80 60 40 18 9
13
0 2nd on call contacted
Comparison with previous service evaluations
Patient complaints
There was one recorded complaint against the nurse practitioners within the last 5 years. This was in relation to the removal of cannula dressing from a patient, who found the procedure painful and discomforting. Discussion
Junior doctors were more likely to escalate the problems to the second ENT on-call in comparison with NPs when oncall (18 of 31 occasions for junior doctors versus nine of 134 occasions for NPs, P = 0, x2 = 48.5). Overall, the NPs were able to manage the problem independently as 1st on-call for ENT 93.3% of the time (Fig. 3).
20
The reasons for contacting 2nd on-call varied between NPs and junior doctors (Table 4). It was noted that most of the NPs’ contacts with the 2nd on-call were pertaining to clinical advice whereas the junior doctors required more hands on assistance. The subjective perception of all senior members of the ENT team was that both NPs and junior doctors dealt with their on-call commitments safely.
We compared our data to our previous studies carried out in 2008 and 2009. NPs did not require the assistance of the 2nd on-call in 90.2% of the time in 2008, 93.1% of the time in 2009 and 93.3% of the time in 2014 (P = 0.51, x2 = 1.36) (Table 5).
StripsTM (3M Health Care, St Paul, MN, USA), skin glue or basic suturing, as well as anterior and posterior nasal packing. They were also able to perform venesection, cannulation and prescribing, after having attended courses and assessments for competencies.
100
Reason for contacting 2nd on-call
2nd on call not contacted
Fig. 3. 2nd on-call involvement from 1st on-call contact (P = 0, x2 = 46.1368).
The concept of advanced nursing practice has existed in the United States since the 1960s and in the United Kingdom since the early 1980s.3 This aspect of continual professional development provides the nursing community with an opportunity to further enhance their clinical skills and make a larger contribution towards the overall patient care.3 In today’s healthcare systems, NPs are an integral aspect of many specialties and departments. Their roles vary from a pure nurse-led service within primary care communities, dealing with dressings and intravenous medications, to working alongside other secondary and tertiary healthcare professionals as part of a bowel, breast or head and neck cancer service.3 In addition, NPs have become a vital aspect of a hospital’s paediatric and adult accident and emergency establishment, with favourable responses from doctors, other healthcare workers, patients and parents.4,5 As a result of the continual evolvement of their responsibilities, many trusts have incorporated NPs into their Hospital-at-Night systems.6 Although this has been met with scepticism by some parties, the authors of a 2012 paper argued that many of the pitfalls predicted, such as the perceived incapacity in assessing acutely ill patient out-ofhours, can be rectified with regular education and training as well as adequate supervision.6 The extensive roles played by NPs in delivering emergency care within other specialties © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
Correspondence
151
Table 4. Nature of contact with 2nd on-call by nurse practitioners and junior doctors Nurse Practitioners
Junior doctors Contact Reason/outcome of frequency contact with 2nd on-call
Scenario
Contact Reason/outcome of frequency contact with 2nd on-call
Change of treatment plan post-discussion with tertiary teaching hospital Epiglotitis
2
To inform 2nd on-call
Epistaxis
3
Cauterised by 2nd on-call
1
Neck lumps
4
Bleeding neck lump
1
Reviewed, nasoendoscopy, management plan decided Reviewed, management plan decided Reviewed, returned to theatre for surgical arrest Advice from 2nd on-call
Paediatric foreign bodies in nose Ear infections
1
Sore throats
3 2
Reviewed, management plan decided Foreign bodies removed by 2nd on-call Reviewed, management plan decided Reviewed, nasoendoscopy, management plan decided Foreign bodies removed by 2nd on-call
Scenario
Post-tonsillectomy 1 bleed Patients with dysphagia 2 Epistaxis patient requiring posterior packing Embedded ear stud in child
2
1
Advice from 2nd on-call
Adult foreign bodies in throat
1
Advice from 2nd on-call
Neck space infections 1 Assessment for tracheostomy in an ITU patient Periorbital cellulitis
Table 5. Comparison of 2nd on-call not contacted by nurse practitioners between 2008, 2009 and 2014 (P = 0.51, x2 = 1.36) Frequency of 2nd on-call not contacted by nurse practitioners (in %) 2008
2009
2014
90.2
93.1
93.3
prompted our department to utilise their expertise in providing a cost efficient and sustainable service for ENT emergencies. Our setting is an 800-bedded large district general hospital, with a range of services for the population of East Suffolk, England. The ENT department consists of four consultants, seeing approximately 25 000–30 000 patients a year. It offers a variety of general ENT and tertiary otology services, with malignant head and neck operations being carried out in a nearby teaching hospital 50 miles away. In 2004, Band seven nurses,7 as noted in Table 1, were recruited to assist junior doctors in maintaining the existing ENT emergency service, as a result of the EWTD restrictions on junior doctors’ working hours. After starting in November © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
1
1
Reviewed, management plan decided Reviewed and surgical tracheostomy performed Reviewed, management plan decided
2004, the NPs underwent regular teaching sessions and vigorous hands-on training with the departmental consultants on how to deal with basic ENT emergencies. They also attained competencies in venesection, cannulation and prescribing, to allow the instillation and limited prescription of analgesia, antibiotics and intravenous fluids. Initially (early 2005), they were paired up alongside junior doctors as 1st on-call, with the ENT middle grade/registrar (2nd oncall) and ENT consultant (3rd on-call) off-site. From 2006 onwards (12–15 months later), following a series of risk assessments and audits, the NPs were deemed safe to cover the 1st on-call out-of-hours duties independently. This was not only EWTD compliant but also allowed junior doctors to be more available for daytime work, enhancing their educational opportunities, when it is postulated to be busier. A thorough literature search on PubMedâ revealed no other existing papers or studies pertaining to NPs’ role in covering ENT 1st on-call activities, night shifts or emergencies within the UK. We are, however, aware of St Georges Healthcare NHS Trust having incorporated a similar service despite being a head and neck unit. As the vast majority of the NPs’ work is out-of-hours, hence 99 of their 134 calls were between 5 pm and 8 am the following morning (Table 2). In fact, most bleep calls
152 Correspondence
taken by the ENT 1st on-call (105 of 165) were during these hours. It is thus important that the 1st on-call personnel is adequately trained with ENT specific skills and knowledge to deal with such volume of work after the hours of 5 pm, where senior support may not be readily available. From our study, we found that the NPs’ were able to perform a wider range of interventional procedures in comparison with the FY2 and GPST (Table 3). This is most likely the result of their long experience as opposed to junior doctors who rotate through ENT for a relative short period. In general, ENT is poorly taught in most medical schools with some having removed the subject from their undergraduate syllabus,8 culminating in a lack of basic concepts and knowledge amongst many clinicians. It therefore comes as no surprise that the junior doctors were more likely to contact the 2nd on-call for advice and assistance (Fig. 3). We postulate that the lack of statistical difference when comparing both groups and previous service evaluations carried out (Fig. 3; Table 5) was due to our small sample size, especially as a power calculation was not performed. We were, however, able to infer that NPs were certainly no inferior to junior doctors in providing a consistently safe and effective ENT emergency service (Table 4). Alongside their clinical expertise, NPs may also be a more cost-efficient way forward, especially in today’s NHS economical climate. Reviewing the pay scales, we found that the annual salary of a Band seven nurse starts from £30 764 per annum, increasing to a maximum of £40 558 depending on years of service.9 Comparatively, the most junior doctor covering the ENT 1st on-call in our department is a FY2 doctor who earns £39 306 a year (inclusive of a 40% supplement due to out-of-hours’ work), while the majority of first year core surgical trainees and GPSTs’ who have progressed through training sequentially since graduation would have a minimum annual salary of £42 002 (inclusive of a 40% banding).10 The potential savings per annum could be channelled into staff education and training or into improving other aspects of patient care. Conclusion
From our experience, we strongly feel that the NPs’ are a safe, effective and cost-efficient way of providing an ENT emergency service. There is certainly a more sustained development of their clinical skills as well as greater continuity of patient care in comparison with junior doctors who rotate frequently. This would suggest that their service is more prudent out-of-hours where senior support may not be readily available, allowing junior doctors to be free for daytime work and educational activities within the specialty.
This service may be applicable to other ENT units and specialties within the NHS. Keypoints
• • •
•
•
The extension of the European Working Time Directive to junior doctors has resulted in many hospitals adopting alternative means of providing their out-ofhours service In Ipswich, nurse practitioners (NP) were recruited in 2004 to cover the majority of ENT on-call and out-ofhours’ commitments 10 years later, we conducted a prospective service evaluation of ENT 1st on-call activities between 23 January 2014 and 23 February 2014. This included one Foundation Year 2 (FY2) doctor, one GP Specialist Trainee (GPST) and four NPs Of 175 recorded emergency calls, 10 were excluded as they were dealt by the ENT 2nd on-call directly. 134 calls were taken by NPs and 31 by junior doctors at varying times throughout the day. The majority of calls were during the hours of 9 pm to 8 am (61.2%) and were mostly covered by NPs. These usually originated from the emergency department (50.9%), wards (26.7%) and general practitioners (15.8%). Common reasons for being contacted were patients with epistaxis (20%), review of ENT conditions on existing inpatients (19%), otological problems (14%) and acute sore throats (12%). NPs were able to perform more advanced ENT outpatient interventions in comparison with junior doctors. They were also less likely to contact the 2nd on-call for assistance or advice (6.7% NP versus 58.1% junior doctors P = 0, x2 = 46.1368). This finding was similar to studies carried out in 2009 and 2008, suggesting a consistent level of service provision (2nd on-call not contacted = 92.6% in 2014 versus 93.06% in 2009 versus 90.21% in 2008, P = 0.5879, x2 = 1.062). We feel that the properly trained NPs are a safe, effective and cost-efficient way of providing an alternative first-line ENT emergency service.
Conflict of interest
None to declare. References 1 BMA. European Working Time Directive http://bma.org.uk/practical-support-at-work/ewtd [accessed on 9 July 2014]
© 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
Correspondence
7 NHS Careers. Pay for nurses. http://www.nhscareers.nhs.uk/exploreby-career/nursing/pay-for-nurses/ [accessed on 12 July 2014] 8 Khan M.M. & Saeed S.R. (2012) Provision of undergraduate otorhinolaryngology teaching within general medical council approved UK medical schools: what is current practice? J. Laryngol. Otol. 126, 340–344 9 Royal College of Nursing. Pay rates 2014-15 http://www.rcn.org.uk/ support/pay_and_conditions/pay_rates_2014-15 [accessed on 12 July 2014] 10 BMA. Pay scales for doctors in training in England 2014 http://bma. org.uk/practical-support-at-work/pay-fees-allowances/pay-scales/ juniors-england [accessed on 7 October 2014]
Virtual reality simulation training in temporal bone surgery Arora, A.,* Hall, A.,† Kotecha, J.,* Burgess, C.,‡ Khemani, S.,§ Darzi, A.,¶ Singh, A.† & Tolley, N.* *Department of Otolaryngology Head and Neck Surgery, St. Mary’s Hospital, Imperial College Healthcare NHS Trust, †Department of Otolaryngology, Northwick Park Hospital, London, ‡Department of Otolaryngology, John Radcliffe Hospital, Oxford, §Department of ENT, Surrey and Sussex NHS Trust, Redhill, ¶Department of Biosurgery and Surgical Technology, St. Mary’s Hospital, Imperial College, London,UK Accepted for publication 10 November 2014
Virtual reality (VR) surgical simulation training expedites the acquisition of anatomical knowledge and psychomotor skills.1 Although several VR temporal bone simulators have been reported a proficiency-based curriculum for postgraduate simulation training has not been described. Studies of face, content, construct validation and the effect of iteration using the Voxelman temporal bone simulator suggest that it has a potential role in postgraduate training.2–5 A standardised proficiency-based curriculum incorporating virtual reality simulation may help to resolve training variability and expedite the acquisition of temporal bone surgical skills in novice ENT surgeons. An important educational concept of skill acquisition is using a stepwise approach and deconstructing a complex surgical procedure into its key stages to attain progress through deliberate practice. Appropriate selection of VR tasks and the identification of robust performance measures are necessary to guide skills development. Minimum acceptable performance criteria must be established. Our aim was to address these issues in order to develop and pilot the first proficiency-based training curriculum for VR temporal bone dissection.
Correspondence: Mr A. Arora, ENT Department, St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed St, London W2 1NY, UK. Tel.: 07976 897 446; Fax: 207 886 1847; e-mail: [email protected] © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
Method Ethical considerations
Ethical approval was not required under NHS research governance arrangements. The study was exempt from review by Imperial College Healthcare Joint Research Office. VR platform
The simulator displays volumetric high-resolution images viewed using shutter glasses to provide a three-dimensional representation of temporal bone. A hand-piece provides haptic feedback and is used to simulate a drill. VR component tasks
The procedure ‘extended cortical mastoidectomy’ was defined and deconstructed into component tasks on the simulator. Tasks were selected by the regional training programme director and faculty using validated assessment tools for temporal bone dissection.6,7 The skills curriculum began with two familiarisation tasks (FTs) followed by four procedural tasks (PTs). FT1: Wide drilling FT2: Narrow drilling PT1: Skeletonisation of the sinu-dural angle PT2: Identification of lateral semicircular canal and short process of incus PT3: Delineation of the facial nerve and chorda tympani
CORRESPONDENCE: OUR EXPERIENCE
2 NHS. Hospital at night http://www.nrls.npsa.nhs.uk/resources/? EntryId45=59820 [accessed on 9 July 2014] 3 Callaghan L. (2008) Advanced nursing practice: an idea whose time has come. J. Clin. Nurs. 17, 205–213 4 Griffin M. & Melby V. (2006) Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors. J. Adv. Nurs. 56, 292–301 5 Forgeron P. & Martin-Misener R. (2005) Parents’ intentions to use paediatric nurse practitioner services in an emergency department. J. Adv. Nurs. 52, 231–238 6 Clark S. & Paul F. (2012) The role of the nurse practitioner within the hospital at night service. Br. J. Nurs. 21, 1132–1137
153
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148 Correspondence
Can nurse practitioners provide a safe and effective ENT emergency service? Our Experience Vijendren, A., Huggins, M. & Yung, M. ENT Department, Ipswich Hospital Trust, Ipswich, UK Accepted for publication 27 October 2014
In 2004, the European Working Time Directive (EWTD), which had only been applicable to career grade doctors and consultants, was extended to include all junior doctors.1 As a result, there was a gradual tapering of junior doctors working hours, from 56 h a week to 48, by August 2009. This presented many hospitals in the UK with the challenge of balancing a compliant junior workforce rota, whilst maintaining the highest standards of patient care. One solution adopted by many trusts was the introduction of a Hospital-at-Night system.2 Using a multiprofessional and multispecialty approach to providing patient care outof-hours, junior doctors would be expected to cover multiple specialties at unsociable times where workload and medical activities were deemed to be of ‘low volume’. Although this satisfied the compliance of most departmental rotas, there were issues raised with regard to the doctors’ perceived lack of knowledge, clinical skills and supervision in the unrelated specialties, as well as the effects it could have on patient safety. Recognising these potential problems, the ENT department in Ipswich Hospital Trust (IHT) recruited nurse practitioners (NP) in 2004 to cover the ENT on-call commitments, alongside junior doctors. They were all experienced nurses with more than 5 years nursing experience within the field of ENT (Table 1). The scheme was aimed at achieving a more sustained provision of service and patient care, in comparison with junior doctors who rotate through ENT, often for a short period. Ten (10) years following the introduction of the NPs, we conducted a service evaluation to identify their daily activities, the skills required for them to perform their job and the frequency of which problems were escalated to the 2nd on-call doctors (ENT specialty doctor/registrar). We subsequently compared this data with previous service evaluations carried out in 2008 and 2009.
Method Ethical consideration
The study was registered with Ipswich Hospital Trust audit department. NREC ethical approval was not necessary as the study participants were NHS employees. The daily activities of the ENT 1st on-call in IHT were recorded between 23 January 2014 and 23 February (1 month). This included the combined activities of four (4) NPs, one (1) Foundation Year 2 doctor (FY2) who rotated every 4 months and one (1) GP Specialty Trainee (GPST) who rotated every 3 months. At the time of data collection, the NPs had between 5 and 10 years of ENT emergency on-call experience (Table 1). Data were collected on the times the ENT 1st on-call were contacted, the source and purpose of the emergency call, skills required by the 1st on-call to deal with the nature of emergencies, outcome and whether the problems needed escalation to the ENT 2nd on-call. The above information was recorded on a Microsoft Excel spreadsheet by the ENT 1st on-call, who was holding the ENT on-call bleep. These were subsequently cross-referenced, tabulated and analysed by the authors. All statistical calculations were performed using chi-squared tests. Results
During our study period, there were 175 recorded calls to the ENT 1st on-call. Ten (10) calls were excluded as they were dealt with by the ENT 2nd on-call directly due to gaps in the 1st on-call rota as a result of sickness absence. Of the remaining 165 calls, 134 were attended by NPs and 31 by junior doctors (1 FY2 and 1 GPST). Time of call
Correspondence: Ananth Vijendren, ENT Department, Ipswich Hospital Trust, Heath Road, IP4 5PD Ipswich, UK. Tel.: +4401473 712233; e-mail: [email protected]
NPs had answered most calls between the hours of 9 pm to 8 am (95 of 134 calls), whereas junior doctors were contacted mostly during the day between 8 am and 5 pm (23 of 31 calls). The majority of calls (64.8%) took place out-of-hours between 5 pm and 8 am (Table 2). © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
Correspondence
149
Table 1. Demographics of ENT 1st on-call during data collection period (23 January 2014 and 23 February) Grade
Gender
Prior background
Postgraduate ENT 1st on-call experience
Nurse practitioner Nurse practitioner Nurse practitioner Nurse practitioner Foundation Year 2 doctor GP trainee doctor
Male Female Female Female Male Male
ENT theatre scrub nurse and day care unit ENT ward sister ENT ward nurse ENT senior ward nurse Foundation year 1 training Foundation programme, GP training year 1
9 7 6 5 2 3
Table 2. Breakdown of bleeps recorded by ENT 1st on-call Total recorded calls = 175*
8 am–5 pm 5–9 pm 9 pm–8 am
Nurse practitioners (n = 134)
Junior doctors (n = 31)
35 4 95
23 2 6
*10 calls excluded as attended by 2nd on-call. Source of call
A greater number of calls were from the accident and emergency department (51%), ward staff (27%) and general practitioners (16%). Other recorded calls originated from patients, other hospitals as well as staff from outpatient clinics and theatres (Fig. 1).
years years years years months months
otitis media, vertigo and sudden onset hearing loss, as well as acute sore throats (12%). The 1st on-calls were also contacted for matters regarding existing ENT inpatients on the ward (19%). These were for instances when patients wanted to speak to a member of the ENT team, increasing staff concerns regarding a patient’s deteriorating clinical condition, or if other healthcare professionals were unsure about the long-term management plan of ENT patients. Alongside the aforementioned, other recorded calls were for patients with foreign bodies (12%), swallowing concerns (3%), sinus-related infections (e.g. acute sinusitis, periorbital cellulitis) (3%), neck lumps (3%) and fractured noses (2%), prescription of medication such as analgesia or antibiotics (9%) and venesection and cannulation (12%). Only 1% of the 165 calls were for patients with airway concerns (Fig. 2). Skills to manage the problems
Reason for call
The nature of calls varied, with a large proportion of them pertaining to patients with epistaxis (20%), otological presentations (14%) such as acute otitis externa, acute
NPs were able to perform more advanced ENT-related procedures and interventions in comparison with junior doctors (Table 3). This included the removal of foreign bodies from children’s ears and adults’ throats, closure of facial wounds (including aural and nasal laceration) by Steri-
Source of calls (n = 165) Reason for calls in % (n = 165) 1
1 1 Accident and emergency
7 2
3
Wards
2 3 2
Review of inpatient
20
3
26
Epistaxis
Otological presentation Sore throat
GP
9
Foreign bodies Medication prescription
Other hospitals 84
Swallowing concerns
Patients
12
19
Sinus-related infection Neck lump
44
Outpatient clinic
Fractured nose
12
Theatres
Fig. 1. Source of 1st on-call bleeps. © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
14
Venesection + cannulation Airway concern
Fig. 2. Reason for 1st on-call bleeps.
150 Correspondence
Table 3. Comparison of recorded skills performed successfully during 1st on-call Nurse practitioners
Junior doctors
Basic ear, nose and throat examination Ear microsuction Drainage of quinsy Venesection + cannulation Prescribing Nasal cautery Flexible nasoendoscopy Foreign body removal from ear and throat Closure of facial wounds Anterior and posterior nasal packing
Basic ear, nose and throat examination Ear microsuction Drainage of quinsy Venesection + cannulation Prescribing Nasal cautery Flexible nasoendoscopy
2nd on-call involvement
2ndon-call involvement 140 125 120 Nurse practitioners Junior doctors
80 60 40 18 9
13
0 2nd on call contacted
Comparison with previous service evaluations
Patient complaints
There was one recorded complaint against the nurse practitioners within the last 5 years. This was in relation to the removal of cannula dressing from a patient, who found the procedure painful and discomforting. Discussion
Junior doctors were more likely to escalate the problems to the second ENT on-call in comparison with NPs when oncall (18 of 31 occasions for junior doctors versus nine of 134 occasions for NPs, P = 0, x2 = 48.5). Overall, the NPs were able to manage the problem independently as 1st on-call for ENT 93.3% of the time (Fig. 3).
20
The reasons for contacting 2nd on-call varied between NPs and junior doctors (Table 4). It was noted that most of the NPs’ contacts with the 2nd on-call were pertaining to clinical advice whereas the junior doctors required more hands on assistance. The subjective perception of all senior members of the ENT team was that both NPs and junior doctors dealt with their on-call commitments safely.
We compared our data to our previous studies carried out in 2008 and 2009. NPs did not require the assistance of the 2nd on-call in 90.2% of the time in 2008, 93.1% of the time in 2009 and 93.3% of the time in 2014 (P = 0.51, x2 = 1.36) (Table 5).
StripsTM (3M Health Care, St Paul, MN, USA), skin glue or basic suturing, as well as anterior and posterior nasal packing. They were also able to perform venesection, cannulation and prescribing, after having attended courses and assessments for competencies.
100
Reason for contacting 2nd on-call
2nd on call not contacted
Fig. 3. 2nd on-call involvement from 1st on-call contact (P = 0, x2 = 46.1368).
The concept of advanced nursing practice has existed in the United States since the 1960s and in the United Kingdom since the early 1980s.3 This aspect of continual professional development provides the nursing community with an opportunity to further enhance their clinical skills and make a larger contribution towards the overall patient care.3 In today’s healthcare systems, NPs are an integral aspect of many specialties and departments. Their roles vary from a pure nurse-led service within primary care communities, dealing with dressings and intravenous medications, to working alongside other secondary and tertiary healthcare professionals as part of a bowel, breast or head and neck cancer service.3 In addition, NPs have become a vital aspect of a hospital’s paediatric and adult accident and emergency establishment, with favourable responses from doctors, other healthcare workers, patients and parents.4,5 As a result of the continual evolvement of their responsibilities, many trusts have incorporated NPs into their Hospital-at-Night systems.6 Although this has been met with scepticism by some parties, the authors of a 2012 paper argued that many of the pitfalls predicted, such as the perceived incapacity in assessing acutely ill patient out-ofhours, can be rectified with regular education and training as well as adequate supervision.6 The extensive roles played by NPs in delivering emergency care within other specialties © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
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Table 4. Nature of contact with 2nd on-call by nurse practitioners and junior doctors Nurse Practitioners
Junior doctors Contact Reason/outcome of frequency contact with 2nd on-call
Scenario
Contact Reason/outcome of frequency contact with 2nd on-call
Change of treatment plan post-discussion with tertiary teaching hospital Epiglotitis
2
To inform 2nd on-call
Epistaxis
3
Cauterised by 2nd on-call
1
Neck lumps
4
Bleeding neck lump
1
Reviewed, nasoendoscopy, management plan decided Reviewed, management plan decided Reviewed, returned to theatre for surgical arrest Advice from 2nd on-call
Paediatric foreign bodies in nose Ear infections
1
Sore throats
3 2
Reviewed, management plan decided Foreign bodies removed by 2nd on-call Reviewed, management plan decided Reviewed, nasoendoscopy, management plan decided Foreign bodies removed by 2nd on-call
Scenario
Post-tonsillectomy 1 bleed Patients with dysphagia 2 Epistaxis patient requiring posterior packing Embedded ear stud in child
2
1
Advice from 2nd on-call
Adult foreign bodies in throat
1
Advice from 2nd on-call
Neck space infections 1 Assessment for tracheostomy in an ITU patient Periorbital cellulitis
Table 5. Comparison of 2nd on-call not contacted by nurse practitioners between 2008, 2009 and 2014 (P = 0.51, x2 = 1.36) Frequency of 2nd on-call not contacted by nurse practitioners (in %) 2008
2009
2014
90.2
93.1
93.3
prompted our department to utilise their expertise in providing a cost efficient and sustainable service for ENT emergencies. Our setting is an 800-bedded large district general hospital, with a range of services for the population of East Suffolk, England. The ENT department consists of four consultants, seeing approximately 25 000–30 000 patients a year. It offers a variety of general ENT and tertiary otology services, with malignant head and neck operations being carried out in a nearby teaching hospital 50 miles away. In 2004, Band seven nurses,7 as noted in Table 1, were recruited to assist junior doctors in maintaining the existing ENT emergency service, as a result of the EWTD restrictions on junior doctors’ working hours. After starting in November © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
1
1
Reviewed, management plan decided Reviewed and surgical tracheostomy performed Reviewed, management plan decided
2004, the NPs underwent regular teaching sessions and vigorous hands-on training with the departmental consultants on how to deal with basic ENT emergencies. They also attained competencies in venesection, cannulation and prescribing, to allow the instillation and limited prescription of analgesia, antibiotics and intravenous fluids. Initially (early 2005), they were paired up alongside junior doctors as 1st on-call, with the ENT middle grade/registrar (2nd oncall) and ENT consultant (3rd on-call) off-site. From 2006 onwards (12–15 months later), following a series of risk assessments and audits, the NPs were deemed safe to cover the 1st on-call out-of-hours duties independently. This was not only EWTD compliant but also allowed junior doctors to be more available for daytime work, enhancing their educational opportunities, when it is postulated to be busier. A thorough literature search on PubMedâ revealed no other existing papers or studies pertaining to NPs’ role in covering ENT 1st on-call activities, night shifts or emergencies within the UK. We are, however, aware of St Georges Healthcare NHS Trust having incorporated a similar service despite being a head and neck unit. As the vast majority of the NPs’ work is out-of-hours, hence 99 of their 134 calls were between 5 pm and 8 am the following morning (Table 2). In fact, most bleep calls
152 Correspondence
taken by the ENT 1st on-call (105 of 165) were during these hours. It is thus important that the 1st on-call personnel is adequately trained with ENT specific skills and knowledge to deal with such volume of work after the hours of 5 pm, where senior support may not be readily available. From our study, we found that the NPs’ were able to perform a wider range of interventional procedures in comparison with the FY2 and GPST (Table 3). This is most likely the result of their long experience as opposed to junior doctors who rotate through ENT for a relative short period. In general, ENT is poorly taught in most medical schools with some having removed the subject from their undergraduate syllabus,8 culminating in a lack of basic concepts and knowledge amongst many clinicians. It therefore comes as no surprise that the junior doctors were more likely to contact the 2nd on-call for advice and assistance (Fig. 3). We postulate that the lack of statistical difference when comparing both groups and previous service evaluations carried out (Fig. 3; Table 5) was due to our small sample size, especially as a power calculation was not performed. We were, however, able to infer that NPs were certainly no inferior to junior doctors in providing a consistently safe and effective ENT emergency service (Table 4). Alongside their clinical expertise, NPs may also be a more cost-efficient way forward, especially in today’s NHS economical climate. Reviewing the pay scales, we found that the annual salary of a Band seven nurse starts from £30 764 per annum, increasing to a maximum of £40 558 depending on years of service.9 Comparatively, the most junior doctor covering the ENT 1st on-call in our department is a FY2 doctor who earns £39 306 a year (inclusive of a 40% supplement due to out-of-hours’ work), while the majority of first year core surgical trainees and GPSTs’ who have progressed through training sequentially since graduation would have a minimum annual salary of £42 002 (inclusive of a 40% banding).10 The potential savings per annum could be channelled into staff education and training or into improving other aspects of patient care. Conclusion
From our experience, we strongly feel that the NPs’ are a safe, effective and cost-efficient way of providing an ENT emergency service. There is certainly a more sustained development of their clinical skills as well as greater continuity of patient care in comparison with junior doctors who rotate frequently. This would suggest that their service is more prudent out-of-hours where senior support may not be readily available, allowing junior doctors to be free for daytime work and educational activities within the specialty.
This service may be applicable to other ENT units and specialties within the NHS. Keypoints
• • •
•
•
The extension of the European Working Time Directive to junior doctors has resulted in many hospitals adopting alternative means of providing their out-ofhours service In Ipswich, nurse practitioners (NP) were recruited in 2004 to cover the majority of ENT on-call and out-ofhours’ commitments 10 years later, we conducted a prospective service evaluation of ENT 1st on-call activities between 23 January 2014 and 23 February 2014. This included one Foundation Year 2 (FY2) doctor, one GP Specialist Trainee (GPST) and four NPs Of 175 recorded emergency calls, 10 were excluded as they were dealt by the ENT 2nd on-call directly. 134 calls were taken by NPs and 31 by junior doctors at varying times throughout the day. The majority of calls were during the hours of 9 pm to 8 am (61.2%) and were mostly covered by NPs. These usually originated from the emergency department (50.9%), wards (26.7%) and general practitioners (15.8%). Common reasons for being contacted were patients with epistaxis (20%), review of ENT conditions on existing inpatients (19%), otological problems (14%) and acute sore throats (12%). NPs were able to perform more advanced ENT outpatient interventions in comparison with junior doctors. They were also less likely to contact the 2nd on-call for assistance or advice (6.7% NP versus 58.1% junior doctors P = 0, x2 = 46.1368). This finding was similar to studies carried out in 2009 and 2008, suggesting a consistent level of service provision (2nd on-call not contacted = 92.6% in 2014 versus 93.06% in 2009 versus 90.21% in 2008, P = 0.5879, x2 = 1.062). We feel that the properly trained NPs are a safe, effective and cost-efficient way of providing an alternative first-line ENT emergency service.
Conflict of interest
None to declare. References 1 BMA. European Working Time Directive http://bma.org.uk/practical-support-at-work/ewtd [accessed on 9 July 2014]
© 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
Correspondence
7 NHS Careers. Pay for nurses. http://www.nhscareers.nhs.uk/exploreby-career/nursing/pay-for-nurses/ [accessed on 12 July 2014] 8 Khan M.M. & Saeed S.R. (2012) Provision of undergraduate otorhinolaryngology teaching within general medical council approved UK medical schools: what is current practice? J. Laryngol. Otol. 126, 340–344 9 Royal College of Nursing. Pay rates 2014-15 http://www.rcn.org.uk/ support/pay_and_conditions/pay_rates_2014-15 [accessed on 12 July 2014] 10 BMA. Pay scales for doctors in training in England 2014 http://bma. org.uk/practical-support-at-work/pay-fees-allowances/pay-scales/ juniors-england [accessed on 7 October 2014]
Virtual reality simulation training in temporal bone surgery Arora, A.,* Hall, A.,† Kotecha, J.,* Burgess, C.,‡ Khemani, S.,§ Darzi, A.,¶ Singh, A.† & Tolley, N.* *Department of Otolaryngology Head and Neck Surgery, St. Mary’s Hospital, Imperial College Healthcare NHS Trust, †Department of Otolaryngology, Northwick Park Hospital, London, ‡Department of Otolaryngology, John Radcliffe Hospital, Oxford, §Department of ENT, Surrey and Sussex NHS Trust, Redhill, ¶Department of Biosurgery and Surgical Technology, St. Mary’s Hospital, Imperial College, London,UK Accepted for publication 10 November 2014
Virtual reality (VR) surgical simulation training expedites the acquisition of anatomical knowledge and psychomotor skills.1 Although several VR temporal bone simulators have been reported a proficiency-based curriculum for postgraduate simulation training has not been described. Studies of face, content, construct validation and the effect of iteration using the Voxelman temporal bone simulator suggest that it has a potential role in postgraduate training.2–5 A standardised proficiency-based curriculum incorporating virtual reality simulation may help to resolve training variability and expedite the acquisition of temporal bone surgical skills in novice ENT surgeons. An important educational concept of skill acquisition is using a stepwise approach and deconstructing a complex surgical procedure into its key stages to attain progress through deliberate practice. Appropriate selection of VR tasks and the identification of robust performance measures are necessary to guide skills development. Minimum acceptable performance criteria must be established. Our aim was to address these issues in order to develop and pilot the first proficiency-based training curriculum for VR temporal bone dissection.
Correspondence: Mr A. Arora, ENT Department, St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed St, London W2 1NY, UK. Tel.: 07976 897 446; Fax: 207 886 1847; e-mail: [email protected] © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 40, 140–166
Method Ethical considerations
Ethical approval was not required under NHS research governance arrangements. The study was exempt from review by Imperial College Healthcare Joint Research Office. VR platform
The simulator displays volumetric high-resolution images viewed using shutter glasses to provide a three-dimensional representation of temporal bone. A hand-piece provides haptic feedback and is used to simulate a drill. VR component tasks
The procedure ‘extended cortical mastoidectomy’ was defined and deconstructed into component tasks on the simulator. Tasks were selected by the regional training programme director and faculty using validated assessment tools for temporal bone dissection.6,7 The skills curriculum began with two familiarisation tasks (FTs) followed by four procedural tasks (PTs). FT1: Wide drilling FT2: Narrow drilling PT1: Skeletonisation of the sinu-dural angle PT2: Identification of lateral semicircular canal and short process of incus PT3: Delineation of the facial nerve and chorda tympani
CORRESPONDENCE: OUR EXPERIENCE
2 NHS. Hospital at night http://www.nrls.npsa.nhs.uk/resources/? EntryId45=59820 [accessed on 9 July 2014] 3 Callaghan L. (2008) Advanced nursing practice: an idea whose time has come. J. Clin. Nurs. 17, 205–213 4 Griffin M. & Melby V. (2006) Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors. J. Adv. Nurs. 56, 292–301 5 Forgeron P. & Martin-Misener R. (2005) Parents’ intentions to use paediatric nurse practitioner services in an emergency department. J. Adv. Nurs. 52, 231–238 6 Clark S. & Paul F. (2012) The role of the nurse practitioner within the hospital at night service. Br. J. Nurs. 21, 1132–1137
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