Improvement in Outpatient Wound Clinic Access Through Implementation of an Advanced Practice Provider and Registered Nurse Top of License Initiative

Introduction: Our academic medical center outpatient wound program is led by wound & ostomy certified APRNs with surgeon support as needed, with the clinic staffed by wound & ostomy certified RNs and technicians. Clinic space and FTEs for staffing the program are limited, resulting in access challenges for patients to enter the programs. In the existing workflow model with a medical assistant and APRN, new patient visits were averaging 60 minutes and established patient visits averaging 45 minutes.Methods:Efficiency studies were undertaken to look at this current workflow, and the lack of RN nursing support within the clinic visits was determined to be the cause of up-delegation of several nursing tasks to the providers. The by-product of this up-delegation resulted in the longer appointment times and fewer appointment slots for patient scheduling. Using the SQUIRE 2.0 framework for quality improvement, leadership, clinic staff and providers came together to develop a new workflow process that would reintroduce the wound/ostomy certified RN into the visits and allow both the RN and provider to work to top of license.Results:The new workflow proposed increased the number of daily appointments from 10 to 16. The role of the certified RN was utilized for assessments of advanced wounds, plan of care actualization by the patient, barriers to care, and formulation of recommended nursing interventions to discuss with the responsible APRN provider. With those tasks lifted from the APRN, the provider focus changed upon entry to the room to wound progress and medical decision making. A four-day trial was conducted to assess feasibility of the workflow model. Average times for the certified RN to see a new patient was 35 minutes, and 24 minutes for an established patient. APRN average time in a new visit was 21 minutes, and 14 minutes for established patients.Discussion: The trial demonstrated that utilizing the skills of the certified wound RNs and APRNs at the top of their training allowed for successful increase of daily templated patient slots. Templates have been adjusted within the clinic capacity limits, yielding an appointment slot increase of 30 percent.References:Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. November 2014;12(6):573-576. https://doi.org/10.1370/afm.1713 Kapu A, Rodgers J. Supporting advanced practice nurses to work at the top of their license: a partnership with nurse executives. J Nurs Adm. 2023;53(7/8):365-366. https://doi.org/10.1097/NNA.0000000000001300