Elementary My Dear Watson, Ambulatory Care Is a Specialty

I almost shouted, “No Sh*#t Sherlock,” at Medscape when I saw the article Ambulatory Care Nursing: Yes, It’s a Specialty, by Laura A. Stokowski, RN, MS. Once I got past the title and read the article, however, I found Stokowski’s grasp of ambulatory care nursing accurate.

When I left Pediatric Intensive Care to work in a hospital based oncology/ infusion clinic, I had to acquire oncology skills and national certification (OCN). I also had to revise my approach to patient care.  Ambulatory care is different from inpatient nursing, but no less challenging. Each requires a large amount of knowledge, expert assessment skills coupled with critical thinking, and the ability to communicate clearly and accurately to a variety of educational levels. Unlike inpatient nursing, outpatient continuity of care necessitates coordination with home infusion, hospice, pharmacies, and other medical offices. Often these services occur outside of the hospital system of our clinic, and information exchange creates extra work. An understanding of insurance carriers, ICD codes, pre-authorization, and billing is helpful. I never worried about this part of healthcare when I worked in a hospital.

Our clinic is nurse run. We are not Nurse Practioners. Most days, my only contact with a physician occurs through his or her medical assistant over the telephone. Physicians send their patients with orders for treatments. We schedule the patients; they get their treatments, and go home, most of the time. Occasionally, patients confuse ambulatory care with emergency care, and they come in too sick for our services. We deliver them to the ER for triage instead. Part of my job is making sure they are in the right department for the care they need.

As a PICU nurse, I was used to taking report from an ER nurse, not giving report to one. Occasionally, I’d catch a nurse rolling his or her eyes at me, indicating doubt that the patient needed a hospital admission. After a time or two I’ve proven I know a sick patient when I see one.

We infuse blood products, and medications requiring close monitoring such as chemotherapies, Rituxan, Remicade, IVIG, and first-time doses of IV or IM antibiotics. Most reactions patients experience are controlled by slowing the infusion rate and additional pre medications, but it is not unusual to hear a shout from a nurse and find a patient in the beginning phase of anaphylaxis. I have acquired ninja-like skill with subcutaneous Epi-pens.

We have advanced IV and Central Venous Access Device (CVAD) skills, because we are responsible for the care of our patients’ PICC and midlines, ports, Broviacs, and with permission from their doctors, dialysis catheters. If any of these devices clot, they come to us for first-line treatment.

We do a LOT of teaching about cancer care, including stem cell transplant mobilization and tri-lumen catheter care. Encompassed in teaching oncology patients is compassionate presence, the ability to sit quietly listening to the patient and their caregivers. In my opinion, this is the most rewarding part of our work, and the juncture where science, humanity, and art converge.

Stokowski reveals the long-term relationships ambulatory care nurses develop with patients over years of care. Professional boundaries with patients seen multiple times a week over years poses a different set of challenges for the ambulatory care nurse versus an inpatient nurse. I imagine it’s even more challenging for hospice and home care nurses.

On weekends, patients often ask if I like my job. What they want to know is if I mind giving up my Saturday, Sunday, or holiday caring for them. Nursing sort of makes one day equal to another; weekends aren’t special to me. I explain that what I enjoy most about ambulatory nursing is that, at the end of the day, everyone gets to go home. When I worked inpatient, it felt like a continuing onslaught of never ending tasks; only the person in the bed changed. It felt like a relay race: the baton is passed from runner to runner, but somehow the finish line is never in sight. Ambulatory care is more like a 10K: You go as fast as you can, as hard as you can, but at the end of the day, you’ve finished the race. Everyone has a night to himself or herself. The sun rises again, and we come back and start over, anticipating the challenges of a new day.