PROVIDER DEVELOPMENT BOARD PRESENTATION DISTRICT NURSING

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PROVIDER DEVELOPMENT BOARD PRESENTATIONDISTRICT
NURSING

• What is District Nursing?
• District Nursing is one of the range of adult
  nursing services offered to people within the
  community and home environment. The service in
  general provides both an assessment and care
  service for people that have urgent, long term,
  palliative or terminal care needs. In recent
  years the nature of District Nursing has changed
  due to new technology, new skills, an increase in
  the number of people living with long-term
  conditions and the discharge of more complex
  cases into the community.

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KEY CHARACTERISTICS

• Current model structured around housebound
  patients with very limited clinic based
  activities.
• Operates 24 hrs a day, 7 days a week 365 days a
  year.
• Open referral, reactive service, demand led.
• Operates no waiting list.
• Increasingly managing more complex patients.
• Twelve teams across the PCT with subdivisions.

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SWOT Analysis
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Responding to the Challenges

• Development of service specification for District
  Nursing
• Fit for purpose programme-Shaping The Future
• GP survey and DN skills and workload stock take
• Potential for increased skills and knowledge base
  of staff
• Rio-potential for improved reporting of activity
  to GP Practices
• Improving District Nursing for patients in
  Westminster Project

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Approach

• Whole systems, processes, resources
• Continuous incremental improvements
• Share achievement, build on success
• Learn from our mistakes and close the loop
• Communicate, Integrate, Evaluate and Implement

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Patient Pathway
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The daily diary of a District nurse

• A student nurse recently said to me do we have
  to go out visiting today, its pouring? I
  responded in disbelief I dont think patients
  would appreciate going without insulin or being
  left with a painfully blocked catheter because of
  the weather. In our unique central London area,
  within the congestion zone, driving and
  particularly parking are notoriously problematic
  we therefore walk, sometimes over 3 miles a day.
• The client group consists of a largely frail
  elderly one, some very elderly and isolated, but
  not forgetting a number of younger chronically
  ill adults, such as with M.S and Parkinsons
  disease. Many have no living relatives or no
  relatives or friends living close by. The home
  environment markedly contrasts to the hospital
  setting. On home territory some clients are
  resistant to nursing advice or treatments! The
  majority of clients are a pleasure to visit,
  entertaining and even eccentric.
• Back to the daily diary We start the day as a
  team examining the pre-prepared allocated work
  diary with regular visits listed. At 9am its
  looking quite acceptable, might even be able to
  squeeze some overdue paperwork or client
  documentation in. The helpful receptionist
  phones to say several faxes have just arrived for
  us. Two faxed are for non urgent blood requests
  one is a client who has taken a self discharge
  needing a visit today. At the same time a phone
  call comes in from a client whose catheter has
  been pulled out accidentally (caught in the
  hoist) - this particular patient requires two
  nurses to re-catheterise him. Another phone call
  is for an urgent INR blood test the client is
  feeling too unwell to attend the anti-coag clinic
  today. The new work is shared amongst the team.
  Equipment is assembled vene puncture box, spare
  dressings for the self discharge client and off
  we go!
• The first client has a gastric (PEG) feed and
  requires medication to be crushed and
  administered through the line. Unfortunately the
  machine was inexplicably bleeping last night and
  the patient has not received all of his feed
  persuade the client to have a little bolus feed
  to make up for it, set to work with the pestle
  and mortar and attempt to reset the machine (with
  difficulty).
• The second patient for bloods does not have a
  decent vein in sight and cheerfully declares that
  the hospital phlebotomist has difficulty give
  up after two attempts and call on the assistance
  of a more expert team member.
• After hopping a bus to the bottom of Park Lane, I
  visit two patients needing dosette box refills,
  who miraculously live in the same block of flats
  so I dont have to walk far between them. Both
  have very poor sight, as well as poor memories
  and have frequent medication adjustments. The
  daily carers do a fantastic job of medication
  prompting and compliance coaxing.
• The next patient has a chronic leg ulcer and is a
  twenty minute walk from the last two patients.
  As I literally exit her flat, the mobile phone
  goes and the practice nurse informs me that a
  wound swab has come back MRSA positive and it
  happens to be for that particular patients.
• The next client has a daily anticoagulant
  injection and it is a little difficult finding an
  injection site not already painfully covered in
  bruises. The following patient I cannot get
  access to, despite hammering on the door and
  phoning from the outside I suspect she has gone
  back to bed and removed her hearing aid- the team
  will have to discuss a new strategy and this
  becoming a frequent problem
• Glancing at the time I rush up the road to meet
  another nurse for a joint visit we need two of
  us to help reposition the client on their side in
  bed, recatheterise them and dress the sacrum.
  The two of us then head back to the office for
  lunch and handover (generally these occur at the
  same time due to time constraints).