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The Role of the Nurse Practioner at the Skull Base Institute
By M. Fe Mangila, RN, NP

Since accepting my position as nurse practitioner at the Cedars-Sinai Skull Base Institute, I have often been asked what my role is in the care of patients with skull base disorders. I feel that my role enables the Institute to individualize the care we provide to our patients and to ensure care coordination from the pre-operative phase through discharge and follow-up.

The best way to explain my clinical role is by utilizing the following patient scenario to demonstrate my participation in patient care: After an acoustic neuroma was detected on a recent MRI, P.S., a 63year-old male was referred by his physician to the Skull Base Institute for a surgical consultation. To facilitate a comprehensive evaluation of his problem, I ensured that pertinent data, such as radiological and laboratory test results, were obtained prior to the office visit.

On the day of consultation, P.S., accompanied by his spouse, was seen and thoroughly evaluated. After careful consideration and discussion, surgery was recommended to correct his problem. My role during the surgical consultation was mostly supportive.

The pre-operative phase began by arranging a surgery date and a pre-op visit for obtaining consent, pre-op teaching, blood and diagnostic tests and a complete history and physical examination. The pre-operative teaching included discussion regarding the disease process; the events before, during and after surgery; discharge planning; prevention of complications; resources available; and other areas of patient needs. These preparations were done in collaboration and consultation with his primary care and referring physicians. Furthermore, arrangements were made with the OR staff to ensure that all necessary instruments, equipment and supplies for the case were prepared. Insurance verification and pre-authorization were also obtained prior to admission.\par The operative day began early. I was available to assist the OR staff in preparing for the case such as positioning and microscope and camera equipment checks. During the surgical procedure, I was asked to scrub and assist with tasks such as retracting, suturing, dressing application and facial nerve monitoring. I also ensured that the spouse was periodically updated on the progress of the surgery.

Monitoring during the immediate post-operative period was maintained until he was stabilized and transferred out of the Surgical Intensive Care Unit to the surgical nursing floor. At rounds, discussions of the patient's plan of care were conducted with the nursing staff and documented in the medical record. Through participation in daily disharge planning rounds, it was noted that P.S. required a home health referral for physical therapy. Prior to discharge, he was given a follow-up visit schedule to his primary care physician and to the Skull Base Institute for a wound check and staple removal.

My role also involves acting as clinical resource and liaison to the nursing and ancillary staff, health agencies, and payers. In the office setting, I ensure that every patient's post-op follow-up schedule and periodic phone follow-up are completed. These activities include: monitoring post op meditations, radiologic or laboratory tests in collaboration with the patient's primary care physician.

The non-clinical role of the NP includes archiving every patient's operative slides, photographs, films, and videotapes. In addition, it is also my responsibility to keep accurate and adequate inventory of surgical instruments, supplies and equipment. A patient database is collaboratively maintained by the office staff and myself.