Managing The Moderately Unstable Patient: The Challenge of Ambulatory Care Nursing

When a nurse educator makes the bold statement, “The moderately unstable patient is at the highest risk,” I’m interested in knowing why. I’ve thought about this statement ever since.

Wild Card by jparadisi

Wild Card by jparadisi

She explained that the task-oriented nature of ambulatory care units (ACU) is a contributing factor. While patients in the ACU are assessed by their physician or nurse practitioner for treatment readiness, and again assessed by the infusion RN during treatment, the primary goal of these appointments for patients and providers is to administer treatment, complete the appointment, and, for the providers, to move on to the next patient. The ACU patient then goes home to fend for his or herself until the next appointment.

If you spend only a small length of time at the triage nurse’s desk answering phones, the high risks faced by these moderately unstable patients are clear:

Chemotherapy-induced nausea and vomiting (CINV)
Blood clots
Febrile neutropenia
Herpes zoster shingles
This list is not comprehensive. Individual risk factors such as living alone or comorbidities also play a role in overall risk factors.

Some risk factors that might occur during the ACU appointment:

Patient falls
Adverse drug reactions
Patient and nurse are unaware that patient is unexpectedly unfit to drive after the appointment
The above factors often occur because the nurse caring for a particular patient is unfamiliar with that patient’s baseline functioning. This puts first-time patients, and nurses new to an established patient, at an increased risk for an unfortunate event.

So, how can ACU nurses protect patients and their nursing license in this fast paced, and rapidly expanding nursing specialty?

First, stop calling your place of work a clinic. The ACU is a specialty care area requiring its own unique set of nursing skills, and should be recognized as such.

Maintain a high level of suspicion. Asking the right question is more important than having all the answers. What you don’t know will harm your patient. One of the most common examples is explaining to a patient how to care for their back pain, only to later discover that the pain is shingles, which were missed because no one asked to see the patient’s back. Other important questions are: “When did you take your (fill in the blank) medication last?” If they haven’t recently, ask, “Why?” because the answer may surprise you. Asking the right questions is an essential part of a solid assessment.

Continuing education is critical to quality patient care. While ACU nursing may seem less demanding than inpatient nursing, it requires the same level of skill and vigilance.

Diplomacy, Apologies and Boneheads

Bone Head watercolor and charcoal 2012 by jparadisi

Diplomacy is as necessary to successful nursing as IV skills, medication administration accuracy, and critical thinking. In fact, diplomacy is a subheading of critical thinking. Further, apology is a subcategory of diplomacy. During a recent shift at the infusion clinic, I had plenty of opportunity to practice both.

Nurses are well familiar with these shifts: They start looking like a doable workload. Then nothing goes as planned and you and your coworkers spend the entire shift chasing after it like a pack of grey hounds trailing behind a rabbit on a track. Unexpectedly, the rabbit jumps the track: Medications are not delivered on time from pharmacy. The patient needing a nurse inserted PICC is vein-less, requiring radiology placement and transport to their department; this delays the patient’s antibiotic treatment. The home infusion company is late delivering the continuous chemotherapy infusion for another patient left twiddling his thumbs waiting. IV pump alarms ring longer than anyone can bear, and nothing is on time per the electronic medical record. Meanwhile, the phones never stop ringing! 

These factors cost patients lengthy waits. During such shifts, I say, “I’m sorry” to patients all day long. For the sake of diplomacy, I can’t explain the bonehead roadblocks I’ve endured while trying to move their day forward as efficiently as possible. Diplomacy also prevents me from telling the bonehead roadblock he or she is a bonehead roadblock. I remind myself everyone, including me, makes mistakes, and to show a little love to the bonehead on the other end of the phone, because my turn will come.

My last patient of this shift doesn’t understand my explanation of why her care is delayed. Her sister eyes me suspiciously from a chair. I know she thinks I’m the bonehead. I stay the course, however, and it all works out. The patient eventually received safe treatment.

At the end of these shifts, it’s the outcome that matters. No one really cares who’s the bonehead.

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.