Expanding roles of advanced clinical practitioners (ACP) to improve lumbar puncture (LP) practice and patient waiting times in acute medicine

Mary Erica Diaz-Santos, Dr Alaoye Foy- Yamah, Dr Nilu Bhadra

Introduction

Lumbar punctures (LP) are crucial in diagnosing and managing acute headaches in secondary care.1 An audit was undertaken of all patients admitted to the acute medical unit (AMU) with a presenting complaint of acute headache (n=417) in a three-month period, which revealed that 12% (n=50) had an LP. These patients waited an average of 64 hours after brain imaging to rule out contraindications, for an urgent LP. There was also significant variation of LP practice against guidelines, particularly with use of cutting spinal needles and failure to give patient information leaflets. Previous research has highlighted that not following guidelines can lead to poor patient outcomes.2 Anecdotal feedback from AMU staff has suggested that prolonged waiting times have been worse recently due to significant operational pressures on senior doctors, who have traditionally been relied on for performing LPs. Evidence suggests that extending roles of permanent members of the multidisciplinary team such as advanced clinical practitioners (ACP) to include procedures such as LP was linked to better patient access and outcomes. 3

Aim

The main aim of this quality improvement project is to improve standards of LP practice

Discussion

Extending LP training to ACPs, ensured availability of staff to support senior doctors, leading to a reduction in waiting times. 3 Furthermore, expanding roles of ACPs to include LP was linked to better outcomes, thus providing basis for this change idea. By establishing expectations in LP practice through training, standards of care and patient safety improved. 4 However, the benefits of training depended on opportunities for clinical supervision, which required early engagement and availability of supervising senior doctors. By the 3rd PDSA Cycle, we noted an increase in LP waiting time because

I-chart to show average waiting time for lumbar puncture from Nov 2021- Oct 2022, between 1-37 occurrences in the AMU by reducing waiting time for LPs and reducing variation in LP practice.

Method

The main change idea that was tested was the introduction of an LP training programme for ACPs and junior doctors. Three Plan-Do-Study-Act (PDSA) cycles were performed to develop and improve the programme and to monitor QI measures. Guidelines in LP practice were reviewed and addressed in the training programme and reinforced by the introduction of an LP trolley in the unit. 2 Outcome, process and balance measures were identified to monitor improvement. This was done through retrospective review of records of a random sample of patients who had LP during a specified time frame.

The main outcome measure identified was waiting time for LP, which was measured by the number of hours between a patient’s computerised tomography (CT) head scan being reported and the time cerebrospinal fluid(CSF) sample was received by the laboratory as indicated in their ‘CyberRad’ and ‘CyberLab’ records, respectively. CyberLab/Rad is the Trust’s electronic system used to order and view Pathology and Radiology investigations for all inpatients. Process measures used included: the percentage of patients who had LP who were given information leaflets, number of LP attempts, percentage of LPs performed with atraumatic needles and grade of staff performing the LP. Written feedback from patients and trainees were monitored as balancing measures.

Results

Data was gathered four-monthly, to allow ample time for trainees to gain competence with the procedure. This showed consistent improvement in aspects of LP practice. An initial decrease in percentage of successful 1st attempts was noted and associated with trainees gaining skill with LPs as seen in Figure 2 below. By the 3rd PDSA Cycle successful 1st attempts increased to over 90%. LP waiting time also showed marked decrease from baseline (M=64) by the 2nd PDSA cycle (M=19) as illustrated by the run chart (Figure 1). Overall reduction in LP waiting time (M= 38) was noted by 8 months.

of operational demands on senior doctors which impacted on their time to provide supervision. Buy-in and commitment from senior stakeholders to the benefits of training is key in this transition. As ACPs and junior doctors become competent in LPs, supervision roles can be assumed so that benefits of training are sustained.

References

1 BASH, National headache management system for adults, 2019.

2 Engelbohrs, et al., ‘Consensus guidelines for lumbar puncture in patients with neurological diseases’, Alzheimers & Dementia, vol. 8, 2017, pp. 111-126.

3 Ernst, et al., Expanding RN scope of practice to include lumbar puncture, AJN, vol. 118, no.3, 2018, pp. 54-60.

4 Lavery & Whitaker, Training advanced practitioners to perform lumbar puncture, Nursing Times, vol. 114, no.11, 2018, pp. 33-35.

Acknowledgements

Many thanks to all the technical help and guidance extended by the BTH QI Hub, with special mention to Parya Rostami and Sean Cross, as well as the unfailing support of the BTH Acute Medical Consultants and ACP/NP Team.