Independence and interdependence of non-medical practitioners in the emergency care skill-mix (SKILLMix-ED): a multi-method study to develop a measurement tool.

BackgroundPatient demand, internationally, on emergency departments and urgent care treatment centres has grown. Shortages of staff, particularly of emergency medicine doctors, have compounded problems. Some countries are pursuing solutions of including non-medical practitioners e.g., nurse practitioners and physician associates/assistants in their emergency department workforces. This study investigated at the macro and meso level of the health system in England: what the rationale was and the factors influencing the current and future employment, or otherwise, of non-medical practitioners in emergency departments and urgent treatment centres.MethodsMixed qualitative methods in the interpretative tradition were employed. We undertook, in 2021–2022, a documentary analysis of national, regional and subregional policy (2017–2021), followed by semi-structured interviews of a purposive sample (n = 18) of stakeholders from national, regional and subregional levels. The data were thematically analysed and then synthesised.ResultsThere was general national policy support for increasing the presence of non-medical practitioners as part of the solution to shortages of emergency medicine doctors. However, evidence of policy support dissipated at regional and subregional levels. There were no published numbers for non-medical practitioners in emergency departments, but stakeholders suggested they were relatively small in number, unevenly distributed and faced uncertain growth. While the experience of the COVID-19 pandemic and its aftermath were said to have made senior decision makers more receptive to workforce innovation, many factors contributed to the uncertain growth. These factors included: limited evidence on the relative advantage of including non-medical practitioners; variation in the models of service being pursued to address patient demand on emergency departments and the place of non-medical practitioners within them; the lack of a national workforce plan with clear directives; and the variation in training for non-medical practitioner roles, combined with the lack of regulation of that level of practice.ConclusionsWe identified many features of a system ready to introduce non-medical practitioners in emergency departments and urgent treatment centres but there were uncertainties and the potential for conflict with other professional groups. One area of uncertainty was evidence of relative advantage in including non-medical practitioners in staffing. This requires urgent attention to inform decision making for short- and long-term workforce planning. Further investigation is required to consider whether these findings are generalisable to other specialties, and to similar health systems in other countries.

Emergency department (ED) utilisation continues to increase, particularly for primary care presentations that do not require high level ED services. The reasons for this are complex, and research has focused on patient perspectives in choosing where to seek care rather than those of ED and general practitioner (GP) providers. This study aimed to address this gap by exploring the views of ED and GP providers regarding ED utilisation for primary care type health conditions in a small, remote Australian city with perhaps unique population demographics and service configuration. Service providers from the ED and general practice clinics were invited to participate in focus groups and semi-structured interviews exploring their views on ED utilisation for primary-care-type health presentations. The data were analysed using thematic content analysis. In total, 24 healthcare providers (five GPs, seven ED practitioners, seven community nurse navigators, four Aboriginal and Torres Strait Islander Health Workers and one Indigenous Liaison Officer) participated in focus groups discussion and interviews. The analysis identified three themes: access and logistic barriers, rational decision-making and self-perceived urgency. While there was some overlap in the healthcare providers' perceptions, there were also strong differences between ED and GP groups. In particular, the ED group believed that GP services are less accessible for urgent appointments, whereas GPs believed that such arrangements were in place. Both groups agreed on the need for clear communication between the ED and general practice. ED and GP providers demonstrate similarities and differences in understanding patients' reasons for choosing which service to access. The differences may stem from ED providers' focus on offering a rapid resolution of acute presentations and GP providers' focus on offering comprehensive and continuing care. Effective communication between general practice and the ED services and clearer referral pathways may help in reducing ED utilisation for less urgent primary-care-type problems.

Emergency Departments internationally have struggled to meet increased patient demand in the context of staffing shortages, particularly doctors. Some countries have employed non-medical practitioners (NMPs), such as advanced nurse practitioners and physician assistants, who undertake some of the clinical work of the doctors across the range of patients attending, not just those with minor injuries. This study investigated the perceived impact of skill mixed staffing, which included established NMPs in emergency departments, in the period post pandemic when patient attendances were particularly high. Semi-structured interviews were conducted and thematically analysed in six emergency departments with 35 patients and 37 staff members between September 2023- June 2024. Patient participants offered views of positive impact of teams with NMPs in the context of long waiting times but were concerned that all were appropriately trained, supervised and that they were informed of their role. Staff participants also perceived a mix of positive and challenging impacts on aspects of service efficiency, safety, effectiveness and acceptability. Those participants who reported the most positive impacts on patient experience could also identify some challenging issues, for example on the workload of the senior clinical decision makers in supervising both NMPs and resident doctors. Conversely those who reported the most negative impacts, such as potential loss of training opportunities and jobs for doctors, also identified some positive impacts on the service efficiency and staff experience. The deployment of NMPs in ED/UTCs requires careful planning so the perceived efficiency benefits can be maximised without jeopardising quality of care, safety, and staff experience. Consideration of underlying explanatory mechanisms led to theorisation of the concept of balance as important to the optimal skill-mix within emergency department staffing. The findings suggest that the elements that require attention from clinicians and managers within the complex system of skill-mix staffing in ED/UTCs include balance between patient volume and staffing, between numbers and capacity of senior clinical decision makers and junior clinical decision makers; and between provision of service and provision of training.

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.

Factors influencing streaming to General Practitioners in emergency departments: A qualitative study

Exploring Entrustment: Housestaff Autonomy and Patient Readmission

Organizational factors associated with practitioners’ support for treatment of opioid use disorder in the emergency department

What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis?

Both the practice of medicine and the expectations of patients regarding their care are changing. A point of confluence is in the need for medicine to be more patient centered, and in the need for patients to be more involved in their care.(1,2) This confluence is particularly pertinent when more than one reasonable approach is available to manage the patient's situation, and when those approaches differ in ways that matter to patients.(3) In shared decision-making (SDM), clinicians and patients work together to understand the patient's situation and to determine how best to address it. Emergency medicine is not exempt from these trends. In this paper we seek to define SDM and its role in contemporary healthcare. Our goal is to set the stage for the active exploration of SDM in the care of patients in the emergency department. This article is protected by copyright. All rights reserved

BackgroundAsthma is a difficult-to-manage chronic disease marked with associated outcome disparities including an increase rate of emergency department (ED) visits for uncontrolled asthma among patients who are most at-risk. Shared decision making (SDM) is a process by which the patient and provider jointly make a healthcare choice. SDM improves patient outcomes; however, implementation barriers of time constraints and staff availability are limitations. The use of health IT solutions may increase the adoption of SDM, but best practices for implementation are not well understood. The Consolidated Framework for Implementation Research (CFIR) is a flexible comprehensive model used to identify barriers and facilitators influencing implementation. The goal of this study is to implement an innovative web-based pediatric SDM tool in the real-world setting of two large healthcare system EDs through the following aims: (1) convene a patient, research, and ED stakeholder advisory board to oversee review of protocol and study materials prior to implementation, (2) implement the SDM intervention where providers and staff will be trained to incorporate use of this SDM intervention, (3) conduct on-going evaluation of barriers, facilitators, and implementation outcomes to tailor implementation in the EDs, (4) evaluate patient-centered outcomes of primary care utilization and changes in ED visits and hospitalizations before and after the SDM intervention, and (5) understand and document best practices for ED implementation.MethodsThe CFIR model will guide the implementation evaluation. Researchers will administer surveys to the clinical team and patients at baseline, 3, 6, and 12 months to inform implementation design, determine barriers and facilitators, and resource-needs to allow for real-time process adjustments within the EDs. Focus group or key-informant interviews and analysis will provide additional feedback to the stakeholder team to iterate the implementation process. Researchers will track patient-centered outcomes including increased primary care, ED, and inpatient utilization over the duration of the study.DiscussionTo advance asthma care and the field of implementation science, further research is needed to assess best practices for incorporating SDM into high-need healthcare settings such as the ED. This knowledge will facilitate improved outcomes and appropriate policy changes towards further use of SDM interventions in local and national acute care settings.

Ambulance clinicians use pre-alert calls to emergency departments to enable them to prepare for the arrival of a patient. This can lead to improved time-critical treatment. However, pre-alerts should be used judiciously, as over-alerting may add pressures on busy emergency departments, while under-alerting may lead to delays in time-critical patient care. We undertook a mixed-methods study to explore how pre-alerts are used and their impact on patients, ambulance and emergency department staff. The mixed-methods study integrated data from: (1) linked routine data set of 12 months' (2020-1) electronic patient records (3 ambulance services), clinician information and routine hospital statistics, (2) semistructured interviews with 34 ambulance clinicians and 40 emergency department staff and 162 hours non-participant observation of pre-alerts across 6 emergency departments, (3) national online survey of ambulance clinicians (1298 responses). Multivariate logistic regression was undertaken in R™ (The R Foundation for Statistical Computing, Vienna, Austria) to identify factors associated with pre-alert rates in terms of patient (National Early Warning Score 2, working diagnosis, age, sex), ambulance clinician (experience, role, sex, time to end of shift) and hospital factors (journey time, percentage of ambulances waiting > 30 minutes). Qualitative data were analysed using thematic analysis in NVivo™ (QSR International, Warrington, UK). Findings were integrated using a triangulation protocol. Pre-alerts are key to enabling emergency department staff to prepare physically and psychologically for critically ill patients, particularly when resources are constrained. We identified significant variation in pre-alert practice and pre-alert rates at both individual and organisational level that was not explained by patient case mix. Pre-alert decisions were based on clinician risk perception, clinical experience (pattern recognition), protocols and anticipated response by emergency department staff, including consideration of different emergency department expectations regarding pre-alerts. Pre-alert calls included advice calls, 'courtesy' or 'heads up' calls where clinicians had no immediate clinical concern, but called due to protocol requirements or concern about the potential for subsequent deterioration during a handover delay. Frustrations arose from different individual expectations of a pre-alert. Inconsistent guidance between ambulance services and emergency departments, and limited clinician knowledge and awareness of guidance, led to uncertainty and misunderstanding regarding who required pre-alerting. Understanding how to pre-alert was based primarily on learning 'on the job' and informal feedback mechanisms rather than formal training and feedback, including emergency department response to previous pre-alerts. Pre-alert calls created interruptions but were valued by emergency department staff. Emergency department response to pre-alert calls was highly variable and dependent principally upon resource availability (staffing, crowding, acuity of other patients) at the time of pre-alert. Variation in individual emergency department's clinician practice and in emergency departments processes for managing pre-alerted patients (particularly for patients not brought into resuscitation bay) contributed to different responses for similar types of pre-alert calls. Different protocols and documentation used by emergency department and ambulance staff to deliver and document the pre-alert created interruptions and frustration during the pre-alert call. Provision of a headline clinical concern to frame the pre-alert was perceived as useful, particularly when observations and clinical concern did not align. Despite flexible recruitment procedures, no patients were interviewed. Pre-alert decision-making and communication may be improved by increased consistency of emergency department and ambulance service pre-alert guidance and training. Improved ambulance service and emergency department communication and co-produced shared documentation may help improve pre-alert clarity and usefulness while reducing tensions. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR131293.

Objective: The purpose of this study was to determine whether formal training in point-of-care ultrasonography (POCUS) significantly influenced innovation adoption, and competency by a cohort of emergency department (ED) practitioners, in the southwestern United States. Materials and Methods: There main variables were identified to gather data on formal training, innovation adoption, and competency therefore corresponding assessment tools were needed: Training Survey for Kirkpatrick Model, Survey of Technology Use, and the Ultrasound Competency Assessment Tool. The study gathered data to address two research questions: To what extent does formal training significantly predict POCUS innovation adoption for ED practitioners? To what extent does formal training significantly predict POCUS competency for ED practitioners? Data were collected anonymously via an online survey from 132 participants. Results: The results from this cohort were produced with simple linear regression analysis. It found that formal training was a statistically significant strong predictor of innovation adoption, R 2 = .559, adj. R 2 = .556, F (1, 130) = 164.794, p < . 001; B = .745, β = .748, t = 12.80, p < .001. Competency assessment had and a significant lack of prediction, R 2 = .085, adj. R 2 = .078, F (1, 130) = 12.142, p < .001; B =.147, β = .292, t = 4.48, p < .001. Conclusion: These findings may be directly relevant to clinical practice. They support the efficacy of formal training of POCUS for ED practitioners and justify systematic delivery of such training.

ABSTRACTWorkforce reform has led to Nurse Practitioners (NP) and Physiotherapy Practitioners (PP) employed in Emergency Departments (ED) to see patients alongside doctors. This qualitative study gathered consumer opinions and preferences regarding NPs, PPs, and doctors, and the attributes desired of them. Twenty-two members of the organization’s Consumer Representative Program participated in one of three focus groups which were audio-recorded and transcribed verbatim. Data were subsequently collected using an emergent-systematic design that enabled ideas to be explored and refined in sequential focus groups. Data analysis, utilizing the principles of thematic analysis, identified four themes. First, consumers understand and accept that reform is necessary to improve care, better utilize available resources and create sustainable services. Second, although consumers accept the rationale for employing NPs and PPs, preferences vary regarding who they want as their primary clinician. Some consumers do not mind who provides care as long as they receive the care they need; others believe doctors provide superior care and preferred a doctor; a third group indicated that not everyone who presents to an ED needs to see a doctor and specialized care would be provided by NPs and PPs for certain conditions. Some consumers expressed incomplete or inaccurate understanding of ED staff roles, responsibilities, and skillsets, which influenced their care preferences. Third, consumers identified a core set of desirable staff attributes that apply to everyone irrespective of professional demarcation; all staff should embody these attributes, though the expression of the attributes will vary according to circumstances and the staff member’s scope of practice. Fourth, consumers expect effective governance over ED services so that all staff, irrespective of their profession provides safe and effective care. In conclusion, these results can be used by health-care administrators and clinicians to inform workforce reform in EDs, helping to ensure that consumers’ opinions and preferences are acknowledged and appropriately addressed.

The incidence of imported disease within the emergency department (ED) is not known, but a significant number of patients present to medical services after return from traveling. Unless practitioners in ED are aware of the potential for nonendemic disease in the population of patients they attend, there is a possibility that imported diseases will not be diagnosed in the acute setting. A questionnaire was sent to all medical practitioners involved in assessing patients presenting to the EDs of hospitals. This questionnaire consisted of five clinical scenarios describing acute presentations of imported diseases but without a travel history included. Responses were requested to ascertain whether practitioners would elucidate the travel history and consequently establish the correct diagnosis. A response rate of 96% was achieved. When presented with a clinical scenario suggesting imported disease, travel history is only elicited in 16% of cases by the acute care practitioners. A correct diagnosis was given in 22% of responses. Interestingly, there was generally no significant correlation between eliciting a travel history and establishing the correct diagnosis. When presented with a clinical scenario that describes an imported disease, medical practitioners in EDs do not routinely establish a travel history or consider the diagnosis of imported disease. There may be a high potential for imported disease to be missed in the ED.

Background/aims Little is known regarding the impact that physiotherapists can have on patients in the emergency department. A study was carried out to explore attitudes of physicians, physician assistants and nurse practitioners in emergency departments about physiotherapists being staffed full-time to assist with patient care. It also aimed to investigate whether physiotherapists should be staffed in emergency departments, what they are capable of doing in an emergency department and identify areas where physiotherapists are most useful in emergency departments in the USA. Methods This sequential mixed method study examined the perceptions and recommendations of emergency medicine practitioners regarding physiotherapists' services in the emergency department. Phase one analysed geographical data. Phase two analysed qualitative components of the survey. Frequencies were analysed and either Fisher's exact or Chi-square tests used to analyse the findings. Participants included physician assistants, nurse practitioners and physicians in emergency departments in the USA. Results A statistically significant association was shown between the geographic region and whether or not physiotherapists were staffed within the emergency departments in states outside the western region. Additionally, 97% of qualified participants reported positive experiences working with physiotherapists regularly. Conclusions Physiotherapists should be used for the specialisation and knowledge they have. More education is needed in emergency departments around the USA to understand what a physiotherapist can offer and how this reduces unnecessary hospital admission. Physiotherapists working in the emergency department can ultimately reduce costs for hospitals.