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Day in the Life of Ambulatory Orthopedic Care NP Shereen Grubb

Practice Area: Ambulatory Care

Number of Years in Practice: 16

Describe your entire practice area.

I have 2 areas of practice at the Strathcona Community Hospital within Ambulatory Care.  I have an independent NP led minor fracture follow up clinic that runs 1.5 days per week. I also the rest of my clinical time doing an Emergency Department Transition/follow-up clinic.

NP Shereen Grubb reviewing x-rays

How did you become interested in orthopedics?

I spent 9 years working in urgent care in Sherwood Park that saw a significant number of MSK/fracture type injuries. I had a young family and so I worked Thursday to Sunday evenings. Urgent care ran a 4-hour low risk fracture follow up clinic every Thursday, and as such I was often the provider assigned to cover those patients which was helpful for continuity of care.  Our site did have access to complete radiology exams on shift, however, radiology did not report on the weekend.  This left a gap between seeing patients on Friday, needing to make a decision based on clinical exam and radiographic review while the radiology report would be pending

How are patients referred to you?

Most of the patients are referred to the fracture follow up clinic through the emergency department at the Strathcona Community Hospital.  We do receive a very small number referrals from community physicians.  Triage guidelines were established in conjunction with local orthopedic providers and site leadership that provides specific direction on fractures will be followed in the clinic.

How does your role differ from physician roles in orthopedic office-based care?

Similarities would be the low-risk fracture management.  Higher risk fractures would be seen by one of our orthopedic consultants.  Our triage guidelines have listed patients that are appropriate for me to manage independently, and those that would be done in consultation with one of our orthopedic providers.  If there is a presentation that requires more urgent or surgical follow up then a referral through RAAPID would be completed

Describe the challenges you face in your position.

There is always an opportunity to advocate for the NP role within AHS and with the public

What is something that all NPs can learn from the work you are doing in your current environment?

It is possible to have an independent clinic, managing your own patients while working with other consultants in an ambulatory setting. If there is something that interests you – and an opportunity comes up – jump at it.  You never know where it may lead.

What do you feel is unique about your practice role?

There are not many NPs that I know of that have a portion of their practice that is focused on independent fracture management and follow up.  Often, in the community, orthopedics may be seen as part of primary care, urgent care or in the emergency department.  It is really nice to get to follow the patients through the trajectory of their healing.

What do you feel is the biggest impact of the role of the NP in your practice setting?

Triage review is exclusively done by NPs for our orthopedic follow up.  Having an NP review the referral, the x-rays, the immobilization and the care plan and make a triage decision has helped from a patient safety standpoint (ability to review x-rays and immobilization – modifying at triage if appropriate).  During triage if it is deemed that the patient would be more appropriate for an urgent/surgical consult compared to non-operative management, then a referral to a more appropriate department will be made (Orthopedic Consult Line, specialized MSK follow up).  Triage and schedule review also ensures that timely follow up is achieved and no patient is lost to follow up.

How did you become competent and maintain competence in such a unique practice are for NPs?

I have attended specialty courses through the Edmonton zone department of orthopedics as well as a National Orthopedic course for fracture management in primary and urgent care.  I have partnered and shadowed with orthopedic surgeon, MSK specialist, radiologist and physiotherapy.  I have had much self-directed/on the ground education.

Do you have any advice for NPs looking to work in a specialty area such as orthopedics? 

Do some background work.  Do some self-directed learning.  Shadow other providers.  Do a needs assessment for your own site; could there be a role for a fracture follow up clinic in your area?  Are there other sites/areas that are looking to expand their current programs? Seek out support of site leadership. Go into it knowing that it will be a process and it will evolve J.