Introducing a nurse practitioner into an urban Canadian emergency department.(ED Administration)(Report)

Publication: Canadian Journal of Emergency Medicine

Publication Date: 01-JUL-08

Bookmark this article Print this article Link to this article Email this article Digg It! Add to del.icio.us RSS

COPYRIGHT 2008 Canadian Medical Association

ABSTRACT

Objective: Our objective was to compare the emergency care provided by a nurse practitioner (NP) with that provided by emergency physicians (EPs), to identify emergency department (ED) patients appropriate for autonomous NP practice and to acquire data to facilitate the development of the clinical scope of practice recommendations for ED practice for NPs.

Methods: Using a comprehensive 3-part process, we selected and hired the best NP from 12 applicants. The NP was oriented to the operations of our free-standing community ED and incorporated in the care team, working in real time with EP preceptors during a 6-month, prospective clinical assessment comparing NP care with EP care. ED preceptors reviewed every case in real time with the NP and completed an explicit evaluation form to determine whether NP assessment, investigation, treatment and disposition were "all equivalent to emergency physician care" (AEEPC) or whether they differed. The proportion of AEEPC interactions was determined for 23 patient presentation categories. Our a priori assumption was that a patient presentation category might be suitable for autonomous NP practice if 50% of NP encounters in that category were rated as AEEPC. Descriptive data were presented for patient case mix, teaching domains and time criteria.

Results: Eighty-three NP shifts and 711 patient encounters were evaluated by 21 EP preceptors. The NP saw a median of 8 patients per shift. In 43% of encounters, NP care was AEEPC. Highest AEEPC rates were found in the patient follow-up categories general follow-up (55.4%), diagnostic imaging (91.7%) and microbiology laboratory results (87.6%). NP scores over 50% were also seen for lacerations (63.6%) and isolated sore throats (53%). With teaching, NP performance improved over time. Conclusion: With the exception of follow up-related complaints, simple lacerations and isolated sore throats, NP care differed substantially from EP care. Although NPs with extensive emergency experience and training might ultimately be able to function as autonomous ED care providers, Canadian EDs currently developing job descriptions for emergency NPs should focus on a model of collaborative practice with EPs.

Keywords: nurse practitioner, emergency care, quality assurance, emergency department, emergency physician

RESUME

Objectif : Cette etude visait a comparer les soins fournis par une infirmiere praticienne (IP) a ceux donnes par des medecins d'urgence afin de determiner quels patients se presentant a l'urgence pourraient etre traites par une IP en pratique autonome et de recueillir des donnees pour faciliter le developpement de recommandations concernant le champ d'exercice de la profession d'IP.

Methodes : A l'aide d'un processus exhaustif en trois parties, nous avons selectionne la meilleure IP parmi les 12 candidatures retenues et l'avons embauchee. Nous lui avons explique le fonctionnement de notre salle d'urgence communautaire independante et l'avons assignee a l'equipe de soins, travaillant en temps reel avec les medecins d'urgence-precepteurs (MUP). Il s'agissait d'une evaluation clinique prospective d'une duree de six mois ou l'on comparait les soins donnes par les IP aux soins prodigues par les medecins d'urgence. Les MUP ont passe en revue chaque cas en temps reel avec l'IP et rempli le formulaire explicite d'evaluation afin de determiner si l'evaluation et l'examen de l'IP ainsi que les mesures qu'elle prenait etaient > (TESMU) ou s'ils differaient de ceux d'un medecin d'urgence. Le pourcentage d'interactions TESMU etait determine en fonction de 23 categories de raisons de consultation des patients. A priori, nous supposions que les patients d'une categorie de raisons de consultation pouvaient etre traites par un IP en pratique autonome si 50 % des rencontres de l'IP dans cette categorie etaient considerees comme etant TESMU. Des donnees descriptives ont ete presentees pour les groupes de patients, les domaines d'enseignement et le critere temporel.

Resultats : Vingt et un MUP ont evalue 83 quarts de travail de l'IP et 711 rencontres avec des patients. En moyenne, l'IP a vu huit patients par periode de travail. Pour 43 % des rencontres, les soins de l'IP etaient TESMU. Les taux les plus eleves de TESMU se trouvaient dans les categories de suivi suivantes : suivi general (55,4 %), imagerie diagnostique (91,7 %) et resultats de laboratoires de microbiologie (87,6 %). L'IP a obtenu une note superieure a 50 % dans les cas de lacerations (63,6 %) et de maux de gorge isoles (53 %). Le rendement des IP s'est ameliore avec le temps grace a l'enseignement qu'elle a recu.

Conclusion : A l'exception des raisons de consultation liees a un suivi, les soins prodigues par l'IP pour de simples lacerations et des maux de gorge isoles differaient considerablement des soins donnes par un medecin d'urgence. Bien que les IP ayant beaucoup d'experience en salle d'urgence et une formation appropriee puissent un jour fournir des soins d'urgence en autonomie, les services d'urgence au Canada qui redigent actuellement des descriptions de postes pour les IP cuvrant dans les salles d'urgence devraient concentrer leurs efforts sur un modele de pratique en collaboration avec les medecins d'urgence.

Introduction

There is growing interest in the introduction of nurse practitioners (NPs) to emergency departments (EDs), and published research suggests that NPs can provide care that is comparable to resident physicians, who provide the bulk of emergency care in some systems. (1,2) The current standard of care is different in urban Canadian EDs, where emergency physicians (EPs) provide 24 x 7 care and where resident-level physicians are not allowed to function on an unsupervised basis. When considering how NPs might be incorporated into multidisciplinary ED teams, it is important to determine whether they should have an autonomous scope of practice or whether they should work with EPs in a more collaborative model.

In some US, UK and Australian EDs, NPs with or without emergency care training function as an adjunct to or in lieu of EPs; (1-13) although NP education and scope of practice vary widely. (14) In the United States, NP designation requires a 2-year master's level graduate degree in an area of specialization, (15) while in the United Kingdom, national guidelines for training and minimal education standards do not exist. (8,10,16) UK NPs autonomously diagnose and...

Read the full article for free courtesy of your local library.