Emergency nurse practitioners: a three part study in clinical and cost effectiveness

Aims: To compare the clinical effectiveness and costs of minor injury services provided by nurse practitioners with minor injury care provided by an accident and emergency (A&E) department.     

Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors

AIM: This paper reports a study to determine the attitudes of nurses, doctors and general medical practitioners towards the development of an advanced nurse practitioner service within an emergency department. BACKGROUND: The role of advanced nurse practitioner in emergency care has emerged in a number of countries, and has brought with it confusion about titles, role boundaries, clinical accountability and educational requirements. Initially, the role resulted from a need for healthcare professionals to provide a service to the increased numbers of patients presenting to hospital with less urgent problems. Since then, the service has evolved to one where nurse practitioners provide high-quality and cost-effective care to persons who seek help for non-urgent, urgent or emergent conditions in a variety of emergency care settings. However, little research could be identified on the attitudes of relevant nursing and medical staff towards the development of this role. METHODS: A questionnaire survey was carried out, and a 29-item Likert rating scale was developed to measure attitudes. Along with some demographic variables, two open-ended questions were added to allow respondents to elaborate on what they perceived as benefits and difficulties associated with an advanced nurse practitioner service. All general practitioners, emergency nurses and emergency doctors in one health board in the Republic of Ireland were targeted, and 25 emergency nurses, 13 emergency doctors and 69 general practitioners were approached to take part. Data were collected in February 2004. FINDINGS: An overall response rate of 74.8% was achieved. All respondents were positive towards the development of an advanced nurse practitioner service, with general practitioners being less positive. The principal differences appeared between general practitioners and hospital emergency care staff. CONCLUSION: There is a need for a multidisciplinary approach to the planning of advanced nurse practitioner services. To achieve multiprofessional acceptance, an accredited and standardized education programme is required, and this must address existing role boundaries.     

Can accident and emergency nurse practitioners interpret radiographs? A multicentre study.

OBJECTIVE: To assess the ability of nurse practitioners in accident and emergency (A&E) to interpret distal limb radiographs, by comparison with senior house officers. DESIGN: Nurse practitioners and senior house officers in 13 A&E departments or minor injury units were shown 20 radiographs of distal limbs, with brief history and examination findings, and asked to record their interpretation. OUTCOME MEASURE: A total score for each subject was calculated by comparing answers against agreed correct responses. RESULTS: Nurse practitioners in general compared favourably with senior house officers. Those nurse practitioners who interpret radiographs as part of their role in minor injury units performed as well as the experienced senior house officer group. CONCLUSIONS: Nurse practitioners in A&E are able to interpret radiographs to a standard equal to senior house officers with three to five months' experience. Those nurse practitioners actively interpreting radiographs as part of their role in minor injury units are able to interpret radiographs to the same standard as senior house officers with more than five months' experience.     

Inappropriate attendance in accident and emergency

Patients who attend Accident and Emergency (A & E) departments with problems that could be dealt with by their general practitioners (GPs) use time and resources of the department that could be otherwise used for patients with more appropriate needs. Definitions used for inappropriate attendance are drawn from the literature, and the usefulness of the term is discussed in the light of evidence that these patients have logical reasons for attending.Methods of improving the service offered to these patients are discussed, including emergency nurse practitioners, minor injuries units and GPs in the A & E department. The reluctance of GPs to treat minor injuries in their surgeries is noted.The implications of changing the service provided in A & E to accommodate or deter patients with primary care problems are discussed.     

The Sheffield experiment: the effects of centralising accident and emergency services in a large urban setting

Objectives—To assess the effects of centralisation of accident and emergency (A&E) services in a large urban setting. The end points were the quality of patient care judged by time to see a doctor or nurse practitioner, time to admission and the cost of the A&E service as a whole.

Methods—Sheffield is a large industrial city with a population of 471 000. In 1994 Sheffield health authority took a decision to centralise a number of services including the A&E services. This study presents data collected over a three year period before, during and after the centralisation of adult A&E services from two sites to one site and the centralisation of children's A&E services to a separate site. A minor injury unit was also established along with an emergency admissions unit. The study used information from the A&E departments' computer system and routinely available financial data.

Results—There has been a small decrease in the number of new patient attendances using the Sheffield A&E system. Most patients go to the correct department. The numbers of acute admissions through the adult A&E have doubled. Measures of process efficiency show some improvement in times to admission. There has been measurable deterioration in the time to be seen for minor injuries in the A&E departments. This is partly offset by the very good waiting time to be seen in the minor injuries unit. The costs of providing the service within Sheffield have increased.

Conclusion—Centralisation of A&E services in Sheffield has led to concentration of the most ill patients in a single adult department and separate paediatric A&E department. Despite a greatly increased number of admissions at the adult site this change has not resulted in increased waiting times for admission because of the transfer of adequate beds to support the changes. There has however been a deterioration in the time to see a clinician, especially in the A&E departments. The waiting times at the minor injury unit are very short.

     

The use of the accident and emergency department.

Many studies have shown that a high proportion of patients attending accident and emergency (A&E) departments have only trivial or non-urgent complaints. A&E staff treat these inappropriate attenders while recognizing that this detracts from the care given to more serious cases. Dwindling resources and higher attendances make it a matter of necessity that inappropriate attenders be treated by general practitioners or equivalent primary care services. In this study, the authors examined the feasibility of methods of reducing inappropriate attendance. The authors investigated patients' ability to accurately assess the urgency of their condition and, hence, their need for A&E services. The authors concluded that there is probably no practical way of reducing inappropriate attendance that does not involve risk to a proportion of patients. The possibility of extending the role of the A&E department to provide more general primary care is discussed.     

Nurse endoscopists in United Kingdom health care: a survey of prevalence, skills and attitudes

OBJECTIVES: To assess the prevalence and potential benefits of attitudes towards nurse endoscopy in the United Kingdom (UK). DESIGN: Postal questionnaire. SUBJECTS: All hospitals in the UK with accident and emergency, general medical and general surgical services in October 2000. MAIN OUTCOME MEASURES: Number of teaching or district general hospitals employing nurse endoscopists, range of diagnostic and therapeutic endoscopic skills and potential benefits to the endoscopy unit and patients. RESULTS: Seventy-six hospitals employed 102 nurse endoscopists. Forty-four nurse endoscopists performed both oesophago-gastroduodenoscopy (OGD) and flexible sigmoidoscopy with solitary OGD and flexible sigmoidoscopy performed by 17 and 31, respectively. Three performed full colonoscopy while seven could perform all three procedures. Nurse endoscopists were found to provide good patient care in the majority of endoscopy units with no compromise in safety. Lead clinicians were keen to restrict nurse endoscopy to diagnostic OGD and flexible sigmoidoscopy only in the majority of units. CONCLUSIONS: Nurse endoscopy is widely practised in the UK and is not limited to one procedure or solely for diagnostic purposes. Benefits include good patient acceptability, improved care and safety. Most clinicians predict an important but restricted role for nurse endoscopy in contributing to endoscopic services.     

Identification of the development needs for the emergency care nursing workforce

In 2000, the government launched their agenda to modernise the National Health Service to deliver high quality care. Within this agenda, Emergency Care provision was seen as a priority. Primarily national targets were set to reduce waiting times in Accident and Emergency (A&E) departments to no more than 4h from arrival to admission, transfer or discharge. National targets to improve access were further expanded into other facets of Emergency Care which together has resulted in major changes in the provision and delivery of emergency care. These changes have resulted in new ways of working across traditional professional and organisational boundaries resulting in the development of new professional roles; new services such as nurse led minor injury units, walk in centres, nurse practitioners and telephone triage in Out of Hours services. Locally, emergency care was a key priority in Shropshire and Staffordshire Strategic Health Authority. As a result the Workforce Development Directorate commissioned this project to scope the nursing workforce to identify nursing staff numbers; roles and titles; and educational preparation. Variations of new nursing roles and titles: educational preparation for all nursing staff; nursing staff establishments compared to national recommendations in particular Emergency Nurse Practitioners, Registered Children's Nurses and Healthcare Assistants and Out of Hours provision are key themes that have been presented together with recommendations.     

A urological urgent assessment unit service evaluation in a United Kingdom hospital

What are the experiences, evaluations and satisfaction levels of service users requiring ambulatory, urgent and emergency urological care who attended a newly implemented urology assessment unit (UAU) in a National Health Service (NHS) hospital in the United Kingdom (UK)? A UAU within an acute care setting was set up for ambulatory, emergency and urgent urological care. The objectives of the unit was to improve patient satisfaction, divert patients from the emergency department, provide an area for early specialist review, allow earlier discharge from hospital and prevent unnecessary admissions to hospital. The aim of this service evaluation (SE) was to evaluate the service user experience and satisfaction when attending this unit. Surgical assessment units are well-supported in terms of reducing admissions and diverting patients from emergency departments, however, there is little published research regarding units specifically for urology. Important sources involved in urological care delivery and services advocate their implementation but there remains very little published evidence to support this. Opinion pieces and short case studies have yielded positive results. No research was found that has looked into patient satisfaction, experience and feedback of these units in any detail. A SE was conducted involving sending a postal questionnaire to a random selection of 150 patients who attended the UAU. The questionnaire contained a set of 13 Likert-style questions with additional free text open-ended questions for provision of further clarification and service user expression. Questions around age, reason for admission and accessibility to the UAU were also included. The Likert-style and demographic questions were analysed by quantifying responses to percentages and the open-ended responses were analysed thematically. The questionnaire response rate of 51% was seen from 76 respondents and these were most commonly over 71 years old (47%). The most common reasons for attending were urinary retention, infection and post-operative urological problems. Of these, 22% did not need to see a doctor and were treated and discharged by the urology nurse practitioner. The care on the UAU was rated highly and generally found to be preferable over the care provided by emergency departments (ED) and general practitioners (GP) family doctors and patients were grateful to avoid being admitted to hospital. Patients appreciated easy access to specialist care and knowledge. Good levels of communication were highlighted as important. Open-ended response themes included; nursing, doctors, environment, access, communication, specialist access, preventing ED attendances and hospital admissions. Participants rated the care from the nurses and doctors highly; there was a focus on appreciating seeing a specialist directly and avoiding admission to hospital. They were satisfied with being able to avoid attending their GP or ED, and generally preferred the unit over these routes of care. There are multiple areas within emergency and urgent urological care that require further research.     

Are today's junior doctors confident in managing patients with minor injury?

Objectives

To assess the confidence of junior doctors in managing minor injuries, compared with other common acute conditions.

Method

A questionnaire designed to elicit areas of confidence and subjective competence was distributed to junior doctors working in the emergency department in December 2004.

Results

Junior doctors felt most competent and confident working with medical trolley patients and least competent working with patients with minor injury. A lack of teaching and experience in handling minor injuries (which are seen by nurse practitioners in a separate unit during the day) was highlighted.

Conclusions

Nurse‐led minor injury units may have an effect on junior doctors'' experience and confidence in minor injury care. Further effort needs to be made to increase the training of junior doctors in minor injury care.Increasing numbers of patients with minor injuries are being assessed and treated by nurse practitioners in separate units. Previous studies have shown that nurse‐led minor injury services can provide worthwhile and effective service.^1,2 However, little attention has been focused on the effect of minor injury units on the training and experience of junior doctors.³The study was carried out in the emergency department of the Northern General Hospital, Sheffield, an adult‐only department, seeing approximately 90 000 patients per year. There is a minor injuries unit within the department, open from 08:00 to 22:00 h, which is staffed exclusively by nurse practitioners.This study aimed to assess the confidence and subjective competence of current junior doctors in managing minor injuries, compared with other common conditions presenting to the emergency department.     

Emergency care of children and adults with head injury

Head injury is common and accounts for a significant proportion of patient attendances at emergency departments and minor injury units. While most injuries will not be serious in nature, some will be severe. Therefore assessment, investigation and early management of head injury are essential to reduce the potential risk of disability or even death. This article focuses on emergency care of children and adults with head injuries. Advice about the signs and symptoms of severe head injury, the importance of computed tomography and after care following head injury are outlined.     

An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department

This study aimed to investigate the effectiveness of nurse practitioner services for minor injuries in an adult emergency department and to ascertain consumers' satisfaction with the care received. Nurse practitioner roles in Australia have been progressively developing since a pilot project in 1990 examined their feasibility. Currently, nurse practitioners in Australia practise in a variety of specialist areas including coronary care cardiology, adult and paediatric palliative care, emergency, diabetics, aged care and perinatal care. The reported study used a retrospective design that conducted case-note audits and explored patient satisfaction with after-care questionnaires. One hundred case notes of patients treated by the nurse practitioner were audited and 57 patients completed questionnaires exploring their satisfaction and perception of the care received. Analysis of the case-note data indicated that the majority of presenting complaints were minor injuries. Of these injuries, 96.3% of presentations triaged level 4 and 94.4% of those triaged level 5 were seen within the time frame recommended by the Australasian Triage Scale. Forty-six per cent of patients required X-rays and 2% required pathology tests during their emergency department stay. The majority of patients were satisfied with the treatment received from the nurse practitioner. Patients are satisfied with management of small injury presentations by nurse practitioners in the emergency department. Incidentally, it was noted that the flow of patients through the department was improved, resulting in medical resources concentrated to higher priority presentations.     

Primary care problems in patients attending a semi-rural accident and emergency unit: a prospective study.

OBJECTIVE: To analyse the characteristics of patients attending a coastal resort accident and emergency (A&E) unit and compare use by summer visitors with use by the indigenous winter population by previously validated assessment criteria. SETTING: Accident and emergency unit of a semi-rural coastal town district general hospital. SUBJECTS: 3643 first attenders in the summer cohort and 2876 in the winter cohort. METHODS: All patients attending the A&E unit over two 28 day periods in summer and winter 1995 were assessed prospectively in four categories by trained, experienced nurse assessors. Category 4 identified patients who fulfilled the King''s College Hospital criteria as being suitable for care from primary care practitioners. RESULTS: 43.8% of the summer patients could have been seen in the primary care setting, as could 38.7% of the winter visitors. CONCLUSIONS: The proportion of patients with primary care problems who attend semi-rural A&E units appears to be much higher than previously thought. These findings cast doubt on the validity of the King''s College Hospital criteria for classifying patients to either primary care or A&E categories.     

Home care service employees’ contribution to patient safety in clients with dementia who use dietary supplements: a Norwegian survey

ObjectiveTo explore home care services (HCS) employees'' professional experiences with the use of dietary supplements (DSs) in their clients with dementia. We also investigated their attributed professional responsibility concerning this use and their attitudes toward DSs in general. Differences between nurses and nurse assistants were investigated.DesignA cross-sectional survey with self-administered questionnaires.SettingHome care services in six Norwegian municipalities in the period August-December 2016.SubjectsA total of 231 (64% response rate) HCS employees; 78 nurses and 153 nurse assistants (auxiliary nurses and employees without formal education).Main outcome measures: Health care employees’ experiences with patient safety in clients with dementia who use DSs.ResultsFifty per cent were concerned that clients with dementia might harm their health due to DS use. Thirty-one per cent reported having intervened in order to reduce the risk. Seventy-one per cent preferred to administer DSs to clients with dementia rather than leaving this responsibility to the clients. The respondents placed the responsibility for patient safety in clients with dementia using DSs mainly with the general practitioners, while they ascribed themselves and pharmacies a medium level of responsibility. There were only minor difference between nurses and nurse assistants, and no difference in attitudes towards DSs.ConclusionEmployees in HCS were concerned about the DS use in clients with dementia. Moreover, almost one-third had intervened to improve clients'' patient safety. The majority indicated that HCS should administer DSs rather than the clients with dementia themselves.

KEY POINTS

• To our knowledge, this is the first study investigating the role of home care services with regard to patient safety in clients with dementia who use dietary supplements (DSs).
• •Home care service employees worried about patient safety related to DS use in clients with dementia.
• •Home care service employees attributed to themselves medium responsibility to ensure the safe use of DSs in these clients.
• •Lack of knowledge was the most important reason why home care service employees did not recommend DSs to clients.

     

Accident and emergency services for children within Trent region

Objectives—To investigate the provision of accident and emergency (A&E) services for children within Trent region, and to compare these with published recommendations.

Methods—A postal questionnaire was sent to all A&E and minor injury units within Trent region providing services for children. Findings were compared with published recommendations including those of the Multidisciplinary Working Party into Accident and Emergency Services for Children.

Results—Thirty six units provided A&E services for children within Trent: 17 mixed units, 17 minor injury units and two children's units. Within mixed A&E units complete audio-visual separation from adult patients was provided by six units (35%), inpatient paediatric facilities were available at 11 units (65%) and a minimum of one registered children's nurse was always on duty in three units (18%).

Conclusions—Few A&E units within Trent region currently meet the recommendations of the Multidisciplinary Working Party. The most common shortfall identified was in the provision of registered children's nurses.

     

An evaluation of the safety and effectiveness of telephone triage as a method of patient prioritization in an ophthalmic accident and emergency service

Service changes in the accident and emergency service at Manchester Royal Eye Hospital in England resulted in a telephone triage-based referral service for health care professionals. It became clear that this service needed evaluation in order to assure both providers and users of the service that this referral strategy, based on experienced nurse practitioners making decisions about patient priority, was safe and effective. The evaluation was extended to encompass the other area of the service where telephone referrals tend to be directly from patients. A mixed method was used. Information gained within the telephone triage conversation was compared with a final diagnosis through retrospective analysis of secondary data; the documentation of those patients who were not given access to the service initially was followed-up to ensure that this decision was safe and a number of nurses were questioned about telephone information gathering, using partially structured interviews. The study showed that nurse practitioners within the accident and emergency service were able to elicit accurate information from the telephone triage conversation on which to base a decision about patient access in most cases (76% over the whole service). This resulted in the appropriate prioritization of patients. No patient who needed urgent access to the service was denied it. The decisions made to deny urgent appointments to a number of patients were safe in all cases. It appears that one of the problem areas in the gathering of information for prioritization purposes is in the nurses' telephone triage discussions with some, but by no means all, doctors. Some general practitioners seemed unwilling to discuss the patient and give accurate information to a nurse and this is an area which appears to need some further work.     

Management of alcohol misuse in Scotland: the role of A&E nurses.

Despite national targets to reduce excessive drinking in Scotland, rates have increased dramatically since the mid-eighties. The role of Accident and Emergency (A&E) departments in the management of alcohol misuse is much debated. This postal survey was conducted with senior medical and nursing staff in A&E departments and minor injury units throughout Scotland to examine the prevalence of alcohol-related attendances and staff's attitudes towards identifying and responding to alcohol-related attendances. A 57% response rate was achieved, representing 87% of all A&E institutions in Scotland (n = 84). The results reveal an estimated 1 in 7 attendances in A&E in Scotland are alcohol-related, and 1 in 5 of these result in admission. However, over two-fifths of departments do not routinely screen for, or keep records of, patients who attend with alcohol problems. Intervention is normally limited to a brief dialogue and referral to the patient's GP. Despite considerable barriers, A&E nursing staff express a willingness to assume a preventive role, but acknowledge lack of appropriate training and sources of support. It is concluded that there is scope for developing identification and brief intervention services within A&E. However, such developments are dependent upon alcohol issues assuming a higher priority among senior A&E staff.     

An action research investigation into the feasibility of experienced registered sick children's nurses (RSCNs) becoming children's emergency nurse practitioners (ENPs)

• ? Emergency nurse practitioners (ENPs) formally developed in accident and emergency (A & E) departments as a direct response to waiting times for the walking wounded, the need to reduce junior doctors hours and changes in nursing practice.
• ? ENPs existed informally for many years in minor injuries units and specialist ophthalmic departments.
• ? This study aimed to examine whether or not the role of ENP could be applied to the specialist service of a paediatric casualty department.
• ? The results showed that 3% of patients could be seen and treated to conclusion by a children's ENP, and some patients could have their care accelerated by a children's ENP.
• ? The introduction of children's ENPs would have an impact on waiting times, junior doctors work-load and the quality of patient care.

     

UK accident and emergency departments and emergency contraception: what do they think and do?

OBJECTIVES: A postal questionnaire survey was conducted to assess what staff in UK accident and emergency (A&E) departments thought of providing an emergency contraception service, the degree of enthusiasm in and level of provision of the service, and staff attitudes to the introduction or continuation of provision of the service. METHODS: A questionnaire was sent to all 560 departments providing A&E services in the UK. RESULTS: Of the 560 units sent questionnaires, 355 (63.4%) replied. Half the units were located in small county towns, and a quarter in large towns. Requests for emergency contraception were received by 96% of responding units, but only 57% provided treatment. Requests for emergency contraception in 84 of these units ranged between one and 50 per month. The A&E senior house officer (SHO) and the gynaecology SHO and registrar prescribed most of the pills. Nurses were more involved in nurse led or general practitioner (GP) led units. Initial treatment only was given by 77% of providing units while the remainder also discussed subsequent contraception. Follow up was arranged with GPs by 92 units, and with family planning clinics by 66 units. Information packs were available in only 37 providing units. A total of 155 of providing units felt it was worthwhile and 56% of respondents thought emergency contraception should be provided by A&E departments. However, 91 units could identify one or more groups within the hospital who were antagonistic to provision by A&E departments, of which non-A&E medical staff formed the largest group. Over the counter availability of emergency contraception was not supported by 62% of respondents. CONCLUSION: The results show that while the female population appears to see a need for emergency contraception services to be provided in A&E departments, there is some reluctance by UK A&E departments to provide the service. Given the current interest in approaches to reducing unplanned pregnancies, especially in teenagers, provision of emergency contraception by A&E departments requires a pragmatic approach to ensure their cooperation in providing the service when alternative sources of provision are not available.