Nurse-run Clinic Research Articles

A Nurse-Run Public Health Clinic for Individuals Utilizing a Community Outreach Center

ABSTRACT This article describes a nurse-run clinic for low-income individuals or individuals experiencing homelessness. We conducted a quality improvement project using data from 111 individuals over 194 visits. Thirty-seven percent of patients had difficulty managing their health and 22% reported being in an active health crisis. The visits resulted in patients leaving with their visit goal being met (86%), and 96% of nonemergent cases being diverted from the emergency room. The nurse-run clinic provided access to care and served as a safety net for a vulnerable population, providing support for this clinic model with this population.

Assessment for sexually transmitted infections in men who have sex with men attending a nurse-run HIV preexposure prophylaxis clinic.

Male-to-male sexual contact remains the primary mode of transmission for HIV and other sexually transmitted infections (STIs) in the United States. Reported STI rates in men who have sex with men (MSM) taking HIV preexposure prophylaxis (PrEP) are higher than expected, possibly due to decreased condom use while on PrEP or more frequent STI screening with routine PrEP care. Hamilton County, located in southwestern Ohio, consistently has the highest rates of gonorrhea and syphilis and second highest rate of chlamydia in the state. The purpose of this project was to incorporate Centers for Disease Control and Prevention (CDC)-recommended comprehensive STI evaluations for MSM attending a nurse-run PrEP clinic in southwestern Ohio. Seventy-five MSM seen for PrEP between January 1, 2017, and May 15, 2019, were included in the STI testing program. Of these, 59 were included in outcome evaluation. Sexually transmitted infection testing was performed every three months, including HIV and syphilis, with chlamydia/gonorrhea testing performed at all potentially exposed sites. During the evaluation period, 43 STIs occurred in 18 patients (30.5%). Affected sites for gonorrhea included 10 oropharynx, eight anorectal, and two genitourinary; for chlamydia, it included one oropharynx, 12 anorectal, and one genitourinary. All extragenital infections were asymptomatic. Sexually transmitted infection results in this population are consistent with those reported in other PrEP centers and reinforce importance of three-point chlamydia/gonorrhea testing as part of comprehensive STI evaluation. Implementing CDC screening recommendations in PrEP programs has been effective in identifying and treating STIs. Incorporating sexual history and comprehensive testing may help providers in other settings identify patients who need more frequent HIV/STI screening and prevention services.

Nurse-run clinic for functional bowel disorders at a district general hospital

Background: Functional bowel disorders (FBDs) include constipation, diarrhoea, bloating and unspecified FBD. FBDs have serious symptoms that impact quality of life and require effective resource management to reduce their impact on clinical services. Aim: The experience of a nurse-led FBD service in a UK district general hospital is presented. The service is protocol driven and led by a colorectal clinical nurse specialist (CNS), with appropriate consultant supervision. Referrals are from primary care and consultant clinicians. Method: Demographics, investigations, treatments and outcomes were analysed using a prospectively run database of the clinic's patients from 2005 to 2016. Results: There were records of 980 patients (median age 56 years; 115M:865F); 60.1% had diarrhoea alone, 36.5% had constipation alone and 3.4% had both. Investigations included barium enema, endoanal ultrasound and transit study. Treatments included rectal irrigation (59.7%), laxative (53.2%), enema (12.3%), anti-diarrhoeal (6%), bowel training (2.4%) or another drug (1.8%). Conservative management was successful in most patients, and only 83 (8.4%) patients were referred for surgery. Conclusion: The nurse-led service is safe, effective and has good outcomes, with a low surgery conversion and high patient satisfaction.

Effects of Service-Learning on Graduate Nursing Students: Care and Advocacy for the Impoverished.

Service-learning is a widely used teaching method that appears to be a good fit for graduate nurses, with essential outcomes of advocacy and culturally responsive health care in special populations. However, quantitative evidence to support its effectiveness is minimal. This study evaluated the impact of service-learning on graduate nursing students' cultural competence, civic engagement, and knowledge and understanding of the effects of poverty on health care. Students are required to serve 16 to 20 hours in a nurse-run free clinic as part of their clinical experience. Students (N = 152) completed pre- and postservice surveys. Statistically significant increases were noted in graduate students' civic engagement (p = .0001 to .0495), knowledge and understanding of health care issues (p < .0001), and in three of six statements related to cultural competence (p = .0001 to 9.662). Patient-reported outcomes and community impact is also positive. Service-learning appears to be an effective tool with graduate nurses.

A nurse-run clinic for patients with incidentally discovered small abdominal aortic aneurysms is feasible and cost-effective.

Patients with incidentally discovered small abdominal aortic aneurysms (AAA) require assessment by a vascular surgery department for possible enrollment in a surveillance programme. Our unit implemented a vascular nurse-run AAA clinic in October 2010. The aim of this study was to assess the feasibility of a specialist nurse-run small AAA clinic. Demographic and clinical data were collected prospectively for all patients seen in the new vascular nurse clinic between October 2010 and November 2012. A validated AAA operative mortality score was used to aid decision making by the vascular nurse. Some 250 patients were seen in the clinic. 198 (79.2%) patients were enrolled in surveillance, 40 (16%) declined enrollment and 12 (4.8%) were referred to a consultant clinic for further assessment. The majority of patients were male and the mean age was 73.7 years. Co-morbidities included hypertension, a history of cardiovascular disease, and hyperlipidaemia. The majority of referrals were considered to be low operative risk. No aneurysms ruptured whilst under surveillance. A nurse-run clinic that assesses patients with incidentally discovered small AAAs for inclusion in AAA surveillance is a feasible alternative to assessment of these patients in a consultant-run clinic.

Impact of a Nurse-Run Clinic on Prevalence of Urinary Incontinence and Everyday Life in Men Undergoing Radical Prostatectomy

To determine the prevalence of urinary incontinence (UI) in patients undergoing prostatectomy and to evaluate the impact of UI on the everyday life in order to select the patients eligible to enter a pelvic floor rehabilitation program. The sample comprised 114 consecutive men undergoing laparoscopic or open radical prostatectomy between April 2007 and April 2008. Participants' mean age was 59 years (range, 46-67 years). The research setting was a hospital-based clinic in Barcelona, Spain. Patients who required an indwelling urinary catheter due to other factors were excluded from the trial. During admission, nursing staff explained the study and obtained informed consent from patients willing to participate in the trial. The impact of UI on daily living was evaluated via administration of the International Consultation on Incontinence Questionnaire-Short Form. Impact of UI was evaluated before surgery, and after 1 and 12 months following indwelling catheter removal. A total of 95.5% patients developed UI 1 month following bladder catheter removal. Slightly less than 1 in 4 patients (24.8%) indicated that UI had no effect on activities of daily living. In contrast, 27.5% indicated that UI had a moderate impact and 47.7% indicated a severe impact. Ninety-one patients reported performing pelvic floor muscle exercises to improve UI, but only 45% were found to be performing them correctly. When evaluated at 1 year following catheter removal, 52.64% of the patients continued to experience UI. The majority (79.8%) indicated that UI did not impact their daily lives, 8.8% indicated a moderate impact, and 20.4% reported that UI had a severe impact on daily life. Seventy patients (61.4%) continued to perform pelvic floor muscle exercises; after 1 year, 93% were deemed to be correctly identifying, contracting, and relaxing their pelvic floor muscles. Urinary incontinence remains prevalent as long as 12 months following catheter removal. Incontinence exerts a moderate to severe impact on daily life in 27.5% to 20.4% of respondents. In order to minimize the negative impact as much as possible, we advocate a pelvic floor muscle training program overseen by RNs.

Characteristics of Women with Continued Use of Vaginal Pessaries

Vaginal pessaries have been shown to be a safe, effective treatment for pelvic organ prolapse, and in some cases, female urinary incontinence. There are limited data that predict long-term pessary use; therefore, the aim of this retrospective, exploratory study was to describe selected characteristics of women using a pessary for 12 months or longer in a nurse-run clinic.

Removal of impacted cerumen in children using an aural irrigation system

ObjectivesImpacted cerumen in the ear canal is a common problem that can cause discomfort or prevent assessment. Cerumen removal can have deleterious side effects if performed improperly. We created an aural irrigation system which is currently not available on the market to provide a continuous flow of water at a regulated pressure and temperature. The purposes of this study were to (1) evaluate the safety and efficacy of this aural irrigation system in children and (2) determine the success rate of cerumen disimpaction when used by an allied health professional. MethodsThe following were evaluated in a nurse-run clinic: (1) referral patterns; (2) extent of canal occlusion; (3) cerumen consistency; (4) peak water pressure used; (5) patient discomfort; (6) efficacy of removal. Each ear was recorded as a separate event. Results302 procedures were performed on 244 children (mean age 7.6±4.1years (range 0.5–18.3years)). Patients were most commonly referred by an Otolaryngologist (63%), parent (17%), hearing aid provider (10%) or audiologist (9%). The most common reasons for referral were difficulty seeing the tympanic membrane (42%), fitting a hearing aid (20%) or performing an audiogram (11%). Prior to irrigation, 98% of canals were partially or fully occluded. After irrigation (mean peak pressure=488.21±18.61mmHg (range 390–590mmHg), 92% of canals were completely free of cerumen (99% clear enough for evaluation or treatment). There was mild or no discomfort in 99% of patients and there were no incidences of trauma. ConclusionsAn aural irrigation system can be effective at clearing impacted cerumen from pediatric ear canals with minimal discomfort and no trauma and can be successfully employed in a completely nurse-run clinic.

Response to Islam et al.: Opportunistic and continuing health care for injecting drug users from a nurse-run needle syringe program-based primary health-care clinic

Drug and Alcohol ReviewVolume 31, Issue 1 p. 116-117 Response to Islam et al.: Opportunistic and continuing health care for injecting drug users from a nurse-run needle syringe program-based primary health-care clinic INGRID VAN BEEK, INGRID VAN BEEK South Eastern Sydney Local Health District, Kirketon Road Centre, Sydney, NSW, Australia, E-mail: [email protected]Search for more papers by this author INGRID VAN BEEK, INGRID VAN BEEK South Eastern Sydney Local Health District, Kirketon Road Centre, Sydney, NSW, Australia, E-mail: [email protected]Search for more papers by this author First published: 06 December 2011 https://doi.org/10.1111/j.1465-3362.2011.00389.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume31, Issue1January 2012Pages 116-117 RelatedInformation

Elevated International Normalized Ratio Associated with Use of Dronedarone and Warfarin

To describe a case of elevated international normalized ratio (INR) after addition of dronedarone to warfarin therapy. A 72-year-old white female with a history of tinnitus, gastroesophageal reflux disease, and permanent pacemaker implantation was taking warfarin (target INR 2-3) and sotalol for chronic atrial fibrillation; atorvastatin for hyperlipidemia; and risedronate for osteopenia. Her warfarin therapy had been managed by a nurse-run anticoagulation clinic for several years. During the prior year, her INR had been stable with a weekly dose of warfarin 25 mg. After persistent episodes of atrial fibrillation, the antiarrhythmic agent was changed from sotalol to dronedarone 400 mg twice daily. Approximately 10 days after starting dronedarone, the INR was 4.8; she stated that there was no bleeding. The warfarin dose was decreased to 20 mg/wk, and the INR remained stable with that dosage for the next 11 months. Postmarketing surveillance has revealed cases of increased INR values with or without bleeding in patients taking warfarin who were started on dronedarone. In this case, the Horn Drug Interaction Probability Scale suggested a probable causality for an interaction between dronedarone and warfarin. Based on current knowledge, this interaction may involve an indirect gastrointestinal mechanism and/or a direct pharmacokinetic mechanism. Clinicians should monitor patients who are taking warfarin and dronedarone for INR changes and bleeding episodes about 1 week after initiation of dronedarone. If a significant interaction is noted, the warfarin dosage should be decreased and the patient should be monitored within 2 weeks to assess the need for further adjustments.

Current management of popliteal fossa incompetent superficial venous systems

Controversy exists regarding the management of varicose veins at the level of the popliteal fossa. This questionnaire reviews the current practice of vascular surgeons. A postal questionnaire was sent to 440 consultant surgeon members of the Vascular Society of Great Britain and Ireland. Recipients were asked to indicate their current practice of investigation and management of small saphenous (SSV), gastrocnemius and Giacomini varicosities. We have received 296 (67%) responses to the questionnaire. Duplex scanning is utilized by 275 (93%) for the initial assessment of patients. Preoperatively, 188 (64%) reuse duplex scanning to mark the saphenopopliteal junction (SPJ) site, 53 (18%) mark with hand-held Doppler only and 24 (8%) do not mark the SPJ. At operation, 198 (67%) flush ligate the SPJ and 87 (29%) tie the SSV 2-3 cm from the junction. A total of 101 (34%) usually strip the SSV to various levels. In symptomatic patients, 158 (53%) ligate the SPJ when an incompetent segment of SSV with a competent SPJ exists. One hundred and sixty-nine (57%) disconnect incompetent gastrocnemius veins during SPJ surgery and 172 (58%) regularly look for the Giacomini vein. Routine follow-up after surgery is practised by 172 (58%), most commonly at six weeks. This is mostly (88%) by clinical examination, with 14 (8.1%) using duplex scanning and six (4.7%) using a nurse-run clinic for the follow-up. This review suggests marked variation in the management of popliteal fossa venous incompetence. There is a clear need for further research to clarify the role of ablation in the management of symptoms and skin changes.

Poster 83: Healthy People 2010 Community Collaborative: Integration of Vision and Eye Health Education Into a National Diabetes Community Rural Health Education Program

Community partnerships are central to educating nurses and providing much-needed services to underserved children in Baltimore City. Johns Hopkins University School of Nursing (JHUSON) collaborates with Head Start programs and a local elementary school for faculty practice and child-health clinical Service Learning experiences. At local Head Start programs, undergraduate nursing students annually screen > 1000 children for height, weight, hearing, vision, and blood pressure. Results are sent to parents with referral information if indicated. In addition, graduate and baccalaureate nursing students implement skills and knowledge learned in the classroom in a nurse-run clinic in a local elementary school, a faculty practice site. The Service Learning community partnerships benefit nursing students because they can apply principles of growth and development while providing important health screening to children in underserved populations. All students gain from practicing in the community and applying their classroom instruction to the care of children.

Developing community partnerships in nursing education for children’s health

Community partnerships are central to educating nurses and providing much-needed services to underserved children in Baltimore City. Johns Hopkins University School of Nursing (JHUSON) collaborates with Head Start programs and a local elementary school for faculty practice and child-health clinical Service Learning experiences. At local Head Start programs, undergraduate nursing students annually screen > 1000 children for height, weight, hearing, vision, and blood pressure. Results are sent to parents with referral information if indicated. In addition, graduate and baccalaureate nursing students implement skills and knowledge learned in the classroom in a nurse-run clinic in a local elementary school, a faculty practice site. The Service Learning community partnerships benefit nursing students because they can apply principles of growth and development while providing important health screening to children in underserved populations. All students gain from practicing in the community and applying their classroom instruction to the care of children.

Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success

An aging population has resulted in higher prevalence of urinary incontinence (UI) and pelvic organ prolapse (POP). This study examines a nurse-run clinic and analyzes the factors contributing to successful pessary use. A retrospective chart review of 1,216 patients was completed. History, pelvic examination and pessary fitting was done. Data was analyzed utilizing a categorical model of maximum-likelihood estimation to investigate relationships. Median patient age was 63 years. Median number of pessaries tried was two. Eighty-five percent of post-menopausal women were on hormone replacement therapy (HRT) prior to fitting. Highest success rate of 78% was in the group on both systemic and local HRT. Success rates ranged from 58% for urge incontinence to 83% for uterine prolapse. Prior vaginal surgery was a factor impacting success. In our series highest success rates for fitting were obtained with ring pessaries, ring with support, and gellhorns. This model is a viable, option for the conservative management of UI and POP. Local HRT plays an important role in successful pessary fitting. Complications are rare.

Temporal improvement in heart failure survival related to the use of a nurse-directed clinic and recommended pharmacological treatment

Background The use of recommended drugs for chronic heart failure (CHF) has been discouragingly low in clinical practice. The aim of this study was to prospectively evaluate to which extent a nurse-directed heart failure clinic could accomplish drug titration with modern heart failure treatments, with focus on β-blockers. Methods Outcome of drug titration was evaluated for 418 patients referred to the nurse-run clinic from 1995 through 2001, using a prospective, open, non-randomised quality control protocol. Results Throughout the period, most of the patients were discharged on an ACE inhibitor (during 2001, 86%). The use of β-blockers increased during the observation (from 43% to 88%). Patients started on an ACE-inhibitor treatment continued in 89% and in 95% when started on a β-blocker. There was a significant decrease in mortality, relative risk per year 0.84 (95% CI, 0.75 to 0.94), P=0.002. Three-year mortality was reduced from 27% to 10%. In a multivariable analysis, survival was significantly associated with ejection fraction, renal function, the use of β-blockers and ACE inhibitors, and negatively with digitalis treatment. Conclusions The nurse-directed titration succeeded in introducing more patients on β-blockers than on ACE-inhibitors. Mortality was reduced during the study period, associated with more use of documented therapy, β-blockers in particular. These findings suggest that the observed signs of improvement in CHF prognosis are likely caused by more efficient medical treatment.

An investigation of the suitability of bra fit in women referred for reduction mammaplasty

Reduction mammaplasty is rationed in NHS plastic surgery provision, despite abundant evidence that most women who undergo this operation obtain significant improvement in their physical health and quality of life. We suspected that women seeking reduction mammaplasty often wear ill-fitting bras, which may exacerbate some of their symptoms. Therefore, we studied 103 women who attended a nurse-run pre-assessment clinic, asking them what size bra they currently wore and then measuring them to see whether their bra size was correct. We also questioned bra manufacturers, designers and shop bra fitters about bra manufacture, sizing and fitting techniques, and we reviewed these findings. Of the 102 women suitable for inclusion in the study, all wore the wrong size bra. Their mean ‘claimed’ back measurement was 36 inches (range: 30–42in.) and their mean cup size was F (range: C–J). We found that all but one underestimated their back measurement (by a mean of 4in.; range: −2–10in.) and overestimated their cup size (by a mean of three sizes; range: one size smaller to seven sizes larger) when compared with manufacturers' fitting guidelines. Multiple regression analysis used to assess the relationships of various factors to incorrect bra sizing showed a strong link (Pearson correlation=0.54; P<0.001) between obesity and inaccurate back measurement. The reasons why women with breast hypertrophy wear incorrectly fitting bras are discussed. We conclude that obesity, breast hypertrophy, fashion and bra-fitting practices combine to make those women who most need supportive bras the least likely to get accurately fitted bras, so exacerbating the symptoms for which they seek surgery.

A partnership management model for a nurse-run clinic in medically underserved rural areas: Health policy initiative

Providing primary care for the medically underserved, especially in rural areas, falls disproportionately to advanced practice nurses (APNs). Rural areas have high levels of unemployment and seasonal work and relatively low rates of health insurance coverage, as well as many unmet health care needs. Whereas there are urban settings with all of these characteristics, the realities of rural life make the poor in those areas difficult to serve, partly because the health care options available to the urban poor are significantly fewer than those available to the urban poor.

Evaluation of a Nurse-run asthma clinic in general practice.

Since 1985, nurse-run asthma clinics have been developing and are now widespread in the United Kingdom, having been greatly stimulated by the New Contract for General Practice (1990). To date, there have been few definitive studies evaluating such clinics. This study, in two adjacent general practices in semi-rural Somerset, evaluates the effect of nurse-run clinics on patients' symptoms, pulmonary function, and healthcare utilisation over a four-month period. One hundred and twenty-nine subjects, aged 2-79 years, were recruited from the two practices over a one-year period (1991-1992). All patients identified in either practice who had used preventive therapy in the preceding 12 months were eligible and were included if they had a positive exercise or reversibility (20%) test and had not previously received formal asthma education. A pre- and post-experimental study design was used. Subjects' symptoms, pulmonary function, and health care in the preceding eight weeks were assessed at intake and at 16 weeks; the nurse education being delivered at intake, one and four weeks. Both mean number of days off work/school and mean number of nights on which waking occurred fell (p < 0.001). Peak expiratory flow rates and forced expiratory volumes improved during the study period (p < 0.001 and p < 0.01 respectively). Use of antibiotics, oral steroids, and rescue bronchodilator use all improved significantly (p < 0.001). Physician attendances were also reduced. A nurse-run asthma clinic in general practice is an effective way to improve symptoms, pulmonary function, and health care utilisation for asthmatic patients.

Developing a synagis clinic for respiratory syncytial virus prophylaxis.

Respiratory Syncytial Virus (RSV) can be devastating to premature infants and children with chronic lung disease. Palivizumab (Synagis) is a monoclonal antibody that is administered monthly by injection to prevent RSV infection in infants at high risk. This article describes a nurse-run ambulatory clinic to provide RSV prophylaxis. Coordination with other agencies, including community neonatal intensive care units, was essential to the clinic's success. For each of its first 2 years of operation, 24 infants and their families attended the clinic once each month for 5 months throughout the RSV season. Outcomes for this patient population were compared to outcomes reported in the literature, and include reduced RSV-related hospitalizations and reduced days of hospitalization.

Evaluating innovation in general practice: a pragmatic framework using programme budgeting and marginal analysis.

Innovation in primary care in the UK, in terms of new service developments, is occurring at a fast pace. However, little information is available on the costs and benefits of these changes. We aimed to illustrate the use of programme budgeting and marginal analysis (PBMA) as a framework for evaluating innovation in primary care, using an example of practice-based diabetes care. The aim was to examine changes in the use of practice resources and the changes in benefits to patients, following the introduction of a diabetes clinic. PBMA is a form of pragmatic economic evaluation combining practice data for the 'before' period and data from the literature to model the 'after' period. In 1995/6, the total amount of resources devoted to diabetes care in the two practices was 145813 pound sterling (634 pound sterling per patient). Of this sum, 62% was allocated to out-patient visits, 28% to prescribing, 5% to hospital admissions, 2% to GP consultations and 2% to tests. The literature suggests that a nurse-run diabetes clinic would result in similar health outcomes and better access for patients. The introduction of such a clinic could potentially save each practice between 2000 pound sterling and 16000 pound sterling per year. This result takes into account a wide range of assumptions about changes in resource use, but does depend on the findings of previous studies. The results of this study show that PBMA is a useful framework for helping practices be accountable and make 'evidence-based' decisions about service innovations in primary care.