Emergency Nurse Practitioners Research Articles

Case sharing by an Emergency Nurse Practitioner student—A patient presenting with a swollen and red leg

Case sharing by an Emergency Nurse Practitioner student—A patient presenting with a swollen and red leg

A 12-month evaluation of the impact of Transitional Emergency Nurse Practitioners in one metropolitan Emergency Department

Summary Objective To meet increasing work demand, the NSW government funded Transitional Emergency Nurse Practitioner (TENP) roles which would work within a Nurse Practitioner (NP) framework. The role provided opportunity for experienced nurses to, develop advanced practice skills, manage a range of patient conditions and injuries. Therefore, the aims of this study were to: (i) describe patient demographics and conditions managed within the TENP model; (ii) examine the efficiency and safety of TENP management; and (iii) evaluate the impact of the TENP role on the delivery of emergency services. Design A 12-month prospective observational study was conducted to evaluate the implementation of a TENP model. Setting A 550 bed University Referral Hospital St George Hospital providing around 50,000 admissions and 770,000 outpatient treatments annually to a catchment population of 250,000. Subjects Patients presenting with minor injuries and illnesses to one metropolitan emergency department (ED). The majority of patients seen were in triage categories 3, 4 and 5. Results Ten percent ( n =5249) of ED patients were managed by TENPs. For the TENP patients the mean time to be seen was 38min. Within the model for the See & Treat patient group the mean time to be seen was 53min (median 38min). For the collaborative group the mean time was 47min (median 24min). Length of stay (LOS) for individual diagnostic groups identified TENP patients had a shorter or equal LOS to medical staff patients. Conclusion The study demonstrated that TENPs provide timely, efficient and appropriate patient management. The role has led to increased recognition of nursing expertise along with acceptance by colleagues and peers for the contribution TENPs make to ED services.

Scope of emergency nurse practitioner practice: where to beyond clinical practice guidelines?

Aim: The aim of this paper is to discuss some of the issues around continuing development of the Emergency Nurse Practitioner (ENP) role in a Victorian metropolitan Emergency Department (ED) setting. More specifically the discussion will consider the evolving clinical practice of the ENP in relation to clinical practice guidelines (CPG) and optimal utilisation of ENP skills and expertise. Background: Internationally the mainstay of ENP practice is predominantly minor injury/minor illness models of care. This trend reflects traditional areas of need, or service gap. It is recognised however, that for a service to be sustainable and effective, it must be flexible, dynamic and prepared for future challenges.The development of CPGs to inform ‘scope of practice’, has become contentious. The restrictive nature of ENP specific guidelines has become evident over time, and together with the labour intensive nature of their development, continuing use is questionable. The trend towards the use of multidisciplinary clinical practice guidelines that utilise existing clinical protocols has gained support for future nurse practitioner (NP) role development. These guidelines are generally of a robust, evidence based nature, with regular review and update and don’t apply to any specific clinician group. Method: An exploration of the progression of the ENP role and service model at a large metropolitan hospital ED was undertaken. An examination of the ongoing changes in demand for ENP service within this organisation was carried out together with the strategies in place, or required, for ENP role expansion and flexibility. Setting: The setting for this discussion is a large metropolitan Emergency and Trauma centre in Melbourne, Victoria, Australia. The ENP team consists of endorsed ENP and those in training, generally referred to as Emergency Nurse Practitioner Candidates (ENPC). This ENP/C team is employed and cover sixteen hours per day, seven days per week, primarily in the ‘fast-track’ area of the department. ‘Fast-track’ is an area within the ED specifically treating patients presenting with minor injury and minor illness deemed likely to be seen, treated and discharged within a four hour time frame. Conclusion: The ENP model of care at this organisation confirms ongoing evolvement and expansion of the role in terms of increasing numbers of ENP/C. Questions continue as to the most efficient utilisation of the role to best benefit the ED as a whole and more specifically, patient outcomes. The need for a continued, cooperative and collaborative approach by stakeholders to inform role progression and continuing clinical practice expansion is paramount for continuing department improvements and better patient outcomes.

Nurse Practitioners in Emergency Care

Nurse Practitioners in Emergency Care

Maintaining the Moral High Ground

Maintaining the Moral High Ground

Stakeholders' Conceptualizations of the Nurse Practitioner Role in the Pediatric Emergency Department

In Quebec, as in the rest of Canada, the increasing service demands placed on emergency departments (EDs), and the dwindling resources of physicians, nurses and trainees, have obliged those managing EDs to question whether new roles need to be introduced. Increasing acuity and complexity of care, coupled with rising numbers of pediatric patients seeking care for non-urgent health issues, have created a need to address long waiting times for non-urgent patients, as well as more standardized care (using approved and evidence-based protocols) for acutely ill patients during their ED stay. Presently, the nurse practitioner (NP) role may be operationalized in Quebec EDs, as recent legislation has cleared the path for its introduction. Some theorists view the development of a new role such as the NP's as a dynamic process of shared conceptualizations (i.e., expectations and conceptions) that help maintain stable interaction. To succeed in introducing the NP role, and to minimize conflict in the post-implementation phase, it is important to understand the conceptualizations of those most closely involved: the stakeholders. Given the lack of Canadian literature on this subject, a qualitative descriptive design was effected to identify stakeholders' conceptualizations of the paediatric emergency nurse practitioner (ENP) role in the early stages of development. Stakeholders described it as a largely clinical role with other responsibilities, including teaching and mentoring, and minimal research responsibilities to ensure a clinical focus. The stakeholders agreed that they must be involved in the role development process, i.e., implementation must not be a top-down initiative. The results of this study support the view that stakeholders have conceptualizations of the role itself and of the role development process, and that these conceptions guide expectations of both the role and the process. It is imperative for those developing new roles to be well informed about stakeholders' conceptualizations during the early planning phase.

A comparative analysis of ENP’s and SHO’s in the application of the Ottawa ankle rules

This study investigates the comparative effectiveness of Senior House Officers (SHOs) and Emergency Nurse Practitioners (ENPs) in the application of the Ottawa ankle rules, in a large inner city Emergency Department in the United Kingdom (UK). Sixty patients with ankle injuries were randomly included in this study which took place in the minor injuries unit of the ED over a 12month period. Data were obtained retrospectively from the patients records relating to six individual aspects of the Ottawa ankle rules. Sixty patients were selected and divided equally between the ENPs and SHOs. The results show a variation between the ENPs and SHOs in application of individual criteria of the Ottawa ankle rules. ENPs more commonly documented bony tenderness to lateral and/or medial malleoli than the SHOs. However, the SHOs documentation of their diagnostic testing was superior with the ENPs failing to document what X-rays 17 patients received. The study demonstrates a statistically significant difference between the two groups of health practitioners. In all but one of the five subquestions of the Ottawa ankle rules there was a statistical significance of 0.053 or less. This clearly shows a difference in the documentation of the Ottawa ankle rules by the health practitioners questioning whether appropriate care is given. Both groups were poor at documenting negative findings and neither consistently documented their application of the Ottawa ankle rules either in part or its entirety.

Diagnostic Accuracy of Emergency Nurse Practitioners Versus Physicians Related to Minor Illnesses and Injuries

Our objectives were to determine the incidence of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses and to evaluate diagnostic accuracy of the emergency nurse practitioners (ENPs) compared with junior doctors/senior house officers (SHOs). In a descriptive cohort study, 741 patients treated by ENPs were compared with a random sample of 741 patients treated by junior doctors/SHOs. Groups were compared regarding incidence and severity of missed injuries and inappropriately managed cases, waiting times, and length of stay. Within the total group, 29 of the 1,482 patients (1.9%) had a missed injury or were inappropriately managed. No statistically significant difference was found between the ENP and physician groups in terms of missed injuries or inappropriate management, with 9 errors (1.2%) by junior doctors/SHOs and 20 errors (2.7%) by ENPs. The most common reason for missed injuries was misinterpretation of radiographs (13 of 17 missed injuries). There was no significant difference in waiting time for treatment by junior doctors/SHOs versus ENPs (20 minutes vs 19 minutes). The mean length of stay was significantly longer for junior doctors/SHOs (65 minutes for ENPs and 85 minutes for junior doctors/SHOs; P < .001; 95% confidence interval, 72.32-77.41). ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected.

Addressing scope of practice issues from an organisational perspective

Aim: This paper aims to explore the transition and role expansion of Emergency Nurse Practitioner (ENP) role in Emergency Departments (EDs). Given the infancy of this model of care in Victoria, the progression from project to sustainable and effective main stream care delivery in a metropolitan Emergency & Trauma Centre is of interest.

Clinical and cost effectiveness of different emergency department healthcare professionals in the management of musculoskeletal soft tissue injuries

This study compared the minor injuries care provided by extended scope physiotherapists (ESPs) and emergency nurse practitioners (ENPs) with routine treatment by doctors (of all grades) in emergency departments. It...

A survey of patient satisfaction in a metropolitan Emergency Department: Comparing nurse practitioners and emergency physicians

The Emergency Nurse Practitioner role was introduced to an Emergency Department, Melbourne in 2004 as an alternative health-care model to provide accessible and efficient patient care. The aim of the study was to explore patient satisfaction using a questionnaire from their emergency department experience comparing Emergency Nurse Practitioners and emergency department doctors. Patients who received care from either Emergency Nurse Practitioners or emergency department doctors were given a self-administered questionnaire to complete. Descriptive statistics and non-parametric tests were used for data analysis. A total of 202 patients completed the survey with 103 seen by the Emergency Nurse Practitioners and 99 seen by emergency department doctors. Significant differences were reported in 12 of the 16 questions comparing patient satisfaction with either Emergency Nurse Practitioners or emergency department doctors with greater patient satisfaction demonstrated with the Emergency Nurse Practitioners. The Emergency Nurse Practitioner model demonstrates consistent levels of patient satisfaction with patients reporting more favourable satisfaction with the Emergency Nurse Practitioners compared with emergency department doctors.

Emergency nurse practitioners and doctors consulting with patients in an emergency department: a comparison of communication skills and satisfaction

Background:Emergency nurse practitioners (ENPs) play an increasingly important role in UK emergency departments (EDs), but there is limited evidence about how this affects patient care and outcome. A study was...

Medial tibial stress syndrome – A case report

The role of the Emergency Nurse Practitioner (ENP) is an ongoing educational one for the nurse. The practitioner will at some point encounter situations and cases that they have had little or no experience of before in their career. This case report is an example of just such a presentation for the author who examined a patient with Medial Tibial Stress Syndrome (MTSS) who came to an ENP led minor injury unit (MIU) in Bristol. MTSS is a term which is used to describe the three main causes of MTSS. These are: stress fractures, periostitis and deep posterior compartment syndrome (DPCS) ( Detmer, 1986). It is noted that while still popular, the term ‘shin splints’ will not be discussed due to many authors considering it to be an ill defined lay term used to describe overuse injuries in the lower leg (Beck and Osternig, 1994; Ugalde and Batt, 2001; Story andCymet, 2006; Bouche and Johnson, 2007)) and should therefore be disregarded as a final diagnosis.

The Transitional Emergency Nurse Practitioner role: Implementation study and preliminary evaluation

Summary Background An implementation study was undertaken to develop and employ Transitional Emergency Nurse Practitioners (TENPs) to address increased service demands. The TENP role was to be a new advanced practice role, which was based on a Nurse Practitioner (NP) framework. The implementation study provided a roadmap for the introduction of the new nursing role. The implementation study aimed to i) develop an integrated and supported Transitional Emergency Nurse Practitioner role; ii) provide a framework for practice and knowledge development; and, iii) undertake a six month preliminary evaluation of TENP work performance. Methods The study describes the communication strategy, the consultative process for role definition, education, ongoing support structures and assessment and feedback mechanisms embedded in the implementation process. In addition, a six month mixed method preliminary evaluation was undertaken as part of the implementation plan. The preliminary evaluation included review of TENP managed patient groups; peer audit of TENP documentation; a senior emergency physician survey of TENP work performance; and, review of TENP investigations and referrals. Results TENPs managed the care of, or were involved with, 2730 patients (10%) of which 68% ( n =1987) were in the ‘See and Treat' group and 32% ( n =721) were in the ‘Collaborative' (742) and ‘Consultative' (22) groups. TENPs managed an average of 20 patients per 15 hour work day. Work performance evaluation identified the role was safe and efficient and that staff supported the new role. Conclusions The implementation study provided an effective framework for the introduction of a transitional nursing role based on a NP framework. The advanced role had made a significant contribution towards meeting local service needs.

Literature review of studies on the effectiveness of nurses ability to order and interpret X-rays

Summary Background The role of radiography within the context of the emergency department (ED) is to aid the physician in the accurate clinical diagnosis of trauma or illness and traditionally, the responsibility for interpreting radiographic images has been with medical physicians. X-rays should be used in tandem with other clinical information to confirm or deny a diagnosis and the role of ordering and interpreting X-rays is now within the scope of the emergency nurse practitioners (NPs). Methods The purpose of this review was to examine the available evidence defining the ability of emergency NPs to appropriately order and interpret radiographs. A literature search was performed to identify papers on emergency NP X-ray accuracy and appropriateness compared to medical physicians. Results A total of 58 publications were identified, and of these 50 papers had no direct relevance to emergency NPs. The eight studies concluded that advanced specially trained nurses are able to order and interpret X-rays to a level comparable to that of their medical colleagues. However, there was a lack of homogeneity in the level of experience of practitioners examined. The physician level of experience reported was from junior doctors to registrar and consultant level and nurses were not always NPs but categorized by years of experience in ED. Methods described included rating scales, benchmarking against radiologists, specificity and sensitivity and auditing techniques. The numbers of X-rays used in each studied also varied greatly from 30 to 2000 radiographs and the majority of studies were performed in the United Kingdom. Overall with the nurses' interpretations, the rate of false negatives and false positives was low. Conclusions From the studies examined, it is difficult to extrapolate an acceptable level or standard for nurse practitioners from this research and clearly further research needs to be performed, especially in the local context.

Too Much Information

Too Much Information

Emergency nurse practitioner management of tetanus status and tetanus-prone wounds

The aim of this paper is to address the management of tetanus-prone wounds and the use of tetanus prophylaxis within the remit of the emergency nurse practitioner (ENP) to ensure safe and effective management of patients who present to the Emergency Department (ED) with tetanus-prone wounds. The paper will also provide the reader with an overview of the epidemiology of tetanus along with the signs and symptoms of tetanus. Practicalities of tetanus vaccine storage and injection will also be discussed. The paper will also discuss Protetanus which is a single step immunoassay for the determination of anti-tetanus immune status; this product has the potential to reduce over immunisation with tetanus and can provide the clinician with a tetanus antibody status in patients who are unaware of their own immunisation status.

Transition into an Emergency Nurse Practitioner: A Sharing of Self‐Reflection

The role of the Emergency Nurse Practitioner (ENP) has been established in other countries for a few decades, such as the United Kingdom (UK) and the United States where it has developed rapidly in these countries. The concept of the nurse practitioner is to empower those nurses who have a sound clinical base and specialty skills to enable them to make autonomous judgements and decisions regarding patient care. Evidence shows that the expanded role enables greater continuity and consistency in the delivery of “holistic care”. Moreover, the ENP service also helps the accident &amp; emergency department to be more effective in its use of available nursing and medical resources. In view of the situation in Hong Kong, because of the unsatisfactory primary health care system, health care providers in emergency care have to deal with huge numbers of patients with minor illnesses and injuries. Patients in this category have to wait for long periods to see a doctor. So the development of the role of ENP for the management of minor injury would be a good option to better utilise departmental manpower to meet patient needs. The author has finished training for minor injury in UK which prepared emergency nurses to take up the ENP role in accident &amp; emergency departments. In this article, the author will share her ENP training experience in the whole process of learning.

Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia

The aim of this study was to evaluate the impact of the introduction of Emergency Nurse Practitioner Candidates (ENPC) on waiting times and length of stay of patients presenting to a major urban Emergency Department (ED) in Melbourne, Australia. As part of a Victorian state funded initiative to improve patient outcomes, the role of the Emergency Nurse Practitioner has been developed. The integration and implementation of this role, is not only new to the Alfred Emergency and Trauma Centre but to EDs in Melbourne, Australia, with aims of providing holistic and comprehensive care for patients. A retrospective case series of all patients with common ED diagnostic subgroups were included. The ENPC group (n = 572) included all patients managed by the ENPC and the Traditional Model (TM) group (n = 2584) included all patients managed by the traditional medical ED model of care. Outcome measures included waiting times and length of stay. Statistically significant differences were evident between the two groups in waiting times and length of stay in the ED. The overall median waiting time for emergency patients to be seen by the ENPC was less than for the TM group [median (IQR): ENPC 12 (5.5-28) minutes; TM 31 (11.5-76) minutes (Wilcoxon p < 0.001)]. Length of stay in the ED was also significantly reduced in the ENPC group [median (IQR): ENPC 94 (53.5-163.5) minutes; TM 170 (100-274) minutes (Wilcoxon p < 0.001)]. The comparison of overall waiting times for ENPC shifts vs. non-ENPC shifts revealed significant differences [median (IQR): ENPC rostered 24 (9-52) minutes; ENPC not rostered 33 (13-80.5) minutes (Wilcoxon p < 0.001)]. This study has demonstrated that ENPCs implementation in Melbourne, Australia were associated with significantly reduced waiting times and length of stay for emergency patients. Emergency Nurse Practitioners should be considered as a potential long term strategy to manage increased service demands on EDs. Relevance to clinical practice. This study is the first in Australia with a significant sample size to vigorously compare ENPC waiting times and length of stay outcomes with the TM model of care in the ED. The study suggests that ENPCs can have a favourable impact on patient outcomes with regard to waiting times and length of stay.

The delivery of a minor injuries telemedicine service by Emergency Nurse Practitioners

We conducted a retrospective review to assess the potential for Emergency Nurse Practitioners (ENPs) to deliver telemedicine advice for minor injuries. Over a one-year study period, 835 patients from 15 minor injury units in community hospitals presented to the minor injuries telemedicine service and were seen via videoconferencing by a doctor at the Aberdeen emergency department. A case review showed that overall, ENPs were considered capable of treating 470 of 788 new presentations (60%). If children under 14 years of age and shoulder injuries were excluded, this figure rose to 84%. Assessment of all minor injuries via a telemedicine network by medical staff is unnecessary. An ENP-led service offers a realistic and attractive alternative.