Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
This project improved access to specialist respiratory care by implementing nurse-led clinics, reducing waitlists and increasing capacity without extra medical staff.
Dates: September 2024 - January 2026
Implementation sites: Darling Downs Hospital and Health Service, Toowoomba Hospital
This project was presented as a Poster at CEQ Showcase 2026 (PDF, 358KB).
Aim
To optimise the respiratory outpatient workforce through the implementation of nurse-led clinics that improve timely access to specialist respiratory care while maintaining safe, high-quality, multidisciplinary governance.
Outcomes
- Improved patient access to specialist respiratory outpatient care.
- Reduced waitlist burden for COPD and severe asthma cohorts.
- 131 new COPD patients removed from the consultant waitlist through CNC-led clinics (2025).
- 88 severe asthma biologic review patients managed through CN-led clinics (2025).
- Increased consultant capacity to focus on complex conditions (interstitial lung disease, nodules, oncology, severe asthma and general respiratory streams).
- Improved multidisciplinary collaboration through structured Airways MDT meetings.
- Reduced non-contact clinical workload for respiratory consultants (e.g., biologic script management via structured MDTM process).
- Enabled nursing staff to work to top of scope within a governed, consultant-supported model.
Background
The respiratory outpatient service was experiencing significant capacity-versus-demand mismatch, with service growth increasing seven-fold over the past nine years with minimal resource expansion. Like many Queensland Health services, we faced prolonged outpatient waitlists, with patients triaged into Category 1, 2 and 3 and booked based primarily on time waiting rather than condition-specific urgency or appointment readiness. The central problem was how to improve patient access and reduce waitlist burden within existing fiscal constraints. While advocacy for increased funding continues, the broader economic climate required us to explore alternative models of care using existing workforce capability. In collaboration with the Specialist Outpatient Referral Centre, we analysed our waitlist by condition, creating a real-time dashboard to monitor referral
trends over a 12-month period.
This data-driven approach revealed:
* Respiratory oncology as the highest referral category (managed through an existing urgent access clinic).
* COPD as the second highest referral reason and a top five diagnostic-related group (DRG) within our hospital.
* A significant cohort of severe asthma patients requiring ongoing biologic review, often breaching recommended review intervals due to consultant capacity limitations. The traditional time-based triage model did not adequately account
for condition-specific risk and treatment considerations. Patients were often booked when not appointment-ready, resulting in inefficiencies and potential safety risks. This context prompted a service redesign focused on condition-specific nurse-led models
supported by structured multidisciplinary governance.
Methods
Using the Plan–Do–Study–Act (PDSA) cycle, we implemented two nurse-led clinics within the respiratory outpatient service:
1. CNC-led COPD optimisation clinic
2. Clinical Nurse-led severe asthma biologic review clinic Plan
We reviewed referral data and identified COPD and severe asthma as high-volume cohorts suitable for structured nurse-led pathways. Clear governance processes were developed, including mandatory presentation at the Airways Multidisciplinary Team Meeting (MDTM), which includes respiratory consultants, CNC/CN, physiotherapy, and respiratory scientists when available.
Do CNC-Led COPD Clinic New COPD referrals for optimisation were streamed to a CNC-led clinic. The assessment model was refined over 12 months, evolving from a rigid four-page objective tool to a structured progress note allowing comprehensive subjective and objective
documentation.
Patients receive:
- Pre- and post-bronchodilator spirometry
- Arterial blood gases (if indicated)
- Six-minute walk test
- Comprehensive symptom and inhaler assessment All cases are presented at the Airways MDTM. Following MDT discussion, patients
are streamed into one of three pathways: - Discharge to GP or alternative specialty
- Pulmonary rehabilitation ± allied health with possible CNC review if required
- Escalation to consultant clinic (surgical review, transplant consideration, diagnostic uncertainty)
CN-Led Severe Asthma Biologic Clinic Patients with confirmed severe asthma commenced on biologic therapy attend an initial consultant review post-initiation. Subsequent six-monthly reviews are conducted in the CN-led clinic.
Assessments include:
- Clinic spirometry
- ACQ-5 questionnaire
- Symptom and exacerbation review
- Inhaler technique and biologic administration review Patients are presented at MDTM where consultants generate repeat PBS scripts via PRODA in real time. This formalised script management process reduced ad hoc chart reviews and linked activity to a documented occasion of service. Following the MDTM the respective nurse will dictate a letter to the patients respective GP and whichever consultant has led the airways MDTM / case discussion will also be added to co-sign the correspondence which further supports the nurses.
Study In 2025:
- 131 new COPD patients were managed via CNC clinic.
- 88 asthma review patients were managed via CN clinic.
These cohorts were removed from consultant-led waitlists. Act Following positive results, consultant clinics were restructured into streamlined medical specialty streams (severe asthma, nodules, ILD, oncology clinics, general respiratory and urgent follow-up), increasing service efficiency.
Discussion
Success required strong interdisciplinary alignment, executive support, and collaboration with business practice improvement teams. A shared vision and consultant buy-in were critical to ensure governance and sustainability.
Key enablers included:
- Real-time referral dashboard data.
- Structured MDT governance.
- Condition-specific streaming rather than purely time-based triage.
- Temporary funding for 1.5 FTE Clinical Nurse positions via winter bed and specialist outpatient funding.
Limitations included:
- Periods of medical leave without backfill.
- Reliance on locums (excluded from nurse-led clinic governance to ensure consistency).
- Temporary funding model threatening sustainability. Transitioning from purely Category 1–3 time-based triage to incorporating condition-specific prioritisation was challenging. However, similar to emergency department or
surgical board processes, some conditions within the same triage category require prioritisation based on clinical risk and treatment timelines. This approach has enabled safer, more equitable care despite known system delays.
Strengths:
- Data-driven service redesign.
- Improved workforce optimisation.
- Reduced consultant non-contact workload.
- Enhanced multidisciplinary collaboration. Weaknesses:
- Funding insecurity. * Workforce vulnerability to leave.
- Change fatigue within system pressures.
Opportunities:
- Improvement activities for patients with Asthma and COPD in the ED and inpatient setting that can be nurse-led to improve patient outcomes
- Replication in other Queensland Health specialty outpatient services facing high-volume chronic disease burden (e.g.,
cardiology heart failure clinics, diabetes services). - Potential formal evaluation of patient outcomes and satisfaction. Next Steps:
- Secure recurrent nursing FTE funding.
- Formal outcome evaluation (wait time reduction, re-presentation rates).
- Improve emergency and inpatient management for COPD and Asthma patients.
- Embed condition-specific triage within district outpatient governance frameworks.
References
N/A
Key contact
Emily Phillips
Clinical Nurse Consultant
Toowoomba Hospital