Nurse practitioner-led spinal clinic produced impressive results and shorter waiting times

Seventy-four per cent were happy to see her rather than wait up to a year to see a surgeon, with less than a quarter of those who preferred to see a surgeon saying that the extra wait was acceptable.

The pilot study at Toronto Western Hospital in Ontario, Canada, was judged a resounding success after nurse practitioner Angela Sarro came up with exactly the same clinical diagnosis as orthopaedic spine surgeons Dr Yoga Raja Rampersaud and Dr Stephen Lewis in 100 per cent of the 177 patients she assessed. She also suggested the same management plan as the two surgeons in 95 per cent of cases.

"Waiting times for specialty consultations in public healthcare systems worldwide are lengthy and impose undue stress on patients waiting for further information and management of their condition" says Angela Sarro. "Back pain can be very unpleasant and debilitating and 85 per cent of us will experience it at some point in our lives.

"According to the College of Family Physicians of Canada, 57 per cent of people in Canada waited longer than four weeks for specialty care in 2006, compared with 60 per cent in the USA, 46 per cent in Australia, 40 per cent in the UK, 23 per cent in Germany and 22 per cent in New Zealand.

"The aim of our study was to see whether a clinic led by a nurse practitioner could speed up the diagnosis and management of patients with certain spinal conditions pre-selected by the surgeons' offices."

The 96 male and 81 female patients ranged from 23 to 85 years of age, with an average age of 52. All had been referred by their family doctor with suspected disc herniation, spinal stenosis or degenerative disc disease.

Key findings included:

• Overall satisfaction was very high (96 per cent), with the nurse practitioner consultation scoring 97 per cent and the thoroughness of the examination scoring 94 per cent. Just over nine out of ten patients (91 per cent) understood their condition better after seeing the nurse practitioner.
  
• Patients waited ten to 21 weeks to see the nurse practitioner, with an average wait of 12 weeks. This compared with ten to 52 weeks to be seen by the surgeons in a conventional clinic, with average waiting times ranging from three to four months for disc herniations to eight to twelve months for spinal stenosis.
  
• Just over a quarter of the patients (26 per cent) said that they would have preferred to have been seen by a surgeon in a conventional clinic, but 77 per cent of those patients would not have been prepared to wait an extra three to four months to do so.
  
• Just under ten per cent (18 patients) were correctly identified as surgical candidates by the nurse practitioner. In addition, 66 were referred for specific nerve root block, 14 for facet block and 26 for further radiological imaging.

"At the moment there are clinical, legal and funding barriers in the Canadian health system that prevent nurse practitioners from being fully independent when it comes to assessing and managing patients who require specialist care.

"However, we feel that there may be scope for government-funded triage clinics led by nurse practitioners to reduce waiting times for spine consultations.

"This initiative would expand the role of the nurse practitioners and provide faster consultation and improved health outcomes for patients, families and communities."

Co-author Dr Yoga Raja Rampersaud adds: "We believe that our study demonstrates that nurse practitioners can play an effective and efficient role in delivering timely healthcare to patients requiring specific disease management in a specialty setting.

"Although skill levels will vary from one nurse practitioner to another, physicians can work with them to help them to develop expertise in their specialty area. Ongoing evaluation is also important to ensure that quality of care is maintained and that patients are satisfied with the consultation."

More information: Nurse practitioner–led surgical spine consultation clinic. Sarro et al. Journal of Advanced Nursing. 66.12, pp2671-2676. (December 2010). DOI: 10.1111/j.1365-2648.2010.05446.x

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