Increasing Access through Top of License Practice

Initiated as part of Stanford’s CELT (Clinical Effectiveness Leadership Training) program, a team of Stanford nurses and physicians have been working to develop a policy that will allow RNs to identify and treat healthy women with an uncomplicated UTI by telephone, without prior physician or APP approval.


SHC’s primary care clinics are a relatively new addition to the SHC family, and the demand for their services are growing rapidly. Access to care can sometimes be challenging.  Express Care, which offers same-day appointments to patients at two different clinics, helps address these challenges, but there remains room for improvement.


Several studies have shown that young, health women with an uncomplicated UTI can be identified and safely treated by telephone, without testing or physical exam, by registered nurses, by utilizing a protocol.


As we’re located in the heart of Silicon Valley, our patients expect care that is safe, yet efficient. However, policy for accessing care for simple UTIs has been inconsistent across clinics, causing some confusion and frustration with our patients. This is especially evident to the nurses who work with Clinical Advice Services, who provide care and guidance to patients after clinic hours.


The CELT team’s goal was to develop a process by which women with an uncomplicated UTI could be treated quickly, and without a clinical visit. This summer, we initiated a trial of the protocol within the Express Care clinics, which offer same-day appointments to patients with acute health care needs. The pilot program required RNs to get sign-off on prescriptions from a prescriber prior to being sent to a pharmacy, but eliminated in-person exams or testing. Follow-up calls were done.health



Overall, the availability of telephone treatment was extremely well-received with patients. They appreciated the convenience.

Diverting women from an in-person clinical appointment opened up opportunities for more acutely-ill people to be seen by their primary care providers or within the Express Care clinics that same day. 

In many clinics, urinalysis with culture is the default standard of care for these patients, although there is much evidence that these expensive tests are not necessary.  Using this protocol eliminates this expense. By using a protocol, patients received antibiotics that meet best-practice guidelines set forth by Stanford and the IDSA.


We’re currently working on getting approvals for a policy that allows RNS to prescribe without provider pre-approval. This will improve efficiency of care, allow women who seek care after-hours to be treated in a more timely manner, and create a consistent pattern of care across our primary care clinics.

Since mid-July, we have treated 21 patients who would otherwise have been in seen in-person in Express Care



Using nurses to the top of their licensure and training can improve a patient’s access to safe, guideline-driven medical care.

The many, many different hoops a women has to jump through from the time she contacts SHC until the time she is treated for a simple UTI.

The Fishbone Diagram depicting many challenges in accessing consistent care


Clockwise, from Lower Left:

  • Yvette Santana, RN (ACM in Portola Valley)

  • Lori Guelman, FNP (Urology)

  • Mark Ramirez, MPH (Ambulatory Quality)

  • Elizabeth Malcolm, MD (Express Care)

  • Kelly Sanderson, FNP (Express Care)

  • Alex Iliescu, RN (CAS)

  • Adrienne Ramirez, RN (Triage RN)

  • (Middle) Marcie Levine, MD (Santa Clara)

--contributed by Kelly Sanderson, NP, RN

@Stanford Nursing 2018