Introducing a nurse practitioner into an urban Canadian emergency department

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. ORIGINAL RESEARCH • RECHERCHE ORIGINALE

Impact of a nurse practitioner on patient care in a Canadian emergency department

“…In our health region, NPs have a 37.5 hour workweek limit, in which 32 hours are devoted to clinical practice and 5.5 hours to research or administration. 4 Consequently, our NP's clinical work consisted of 3.5 eight-hour daytime shifts per week, starting at 7:30 or 10:00 am.…”

“…4 The NP's clinical collaborative scope of practice is similar to that of residents, with the EP retaining ultimate decision-making authority. Nurse practitioners also provide health promotion and counselling in primary care domains.…”

“…4 The authors also proposed a scope of practice for ED NPs and recommended a collaborative, rather than independent, practice role.…”

“…4 The assumptions underlying this grant were that the addition of an NP to the ED multidisciplinary team would create an emergency service delivery model that would optimize the use of EPs and provide an alternative to EP care for appropriate clinical presentations. 4 The goal of our prospective observational study was to determine the impact of the new NP on key ED operational outcomes.…”

“…4 The assumptions underlying this grant were that the addition of an NP to the ED multidisciplinary team would create an emergency service delivery model that would optimize the use of EPs and provide an alternative to EP care for appropriate clinical presentations. 4 The goal of our prospective observational study was to determine the impact of the new NP on key ED operational outcomes. 8 We hypothesized that for the shifts during which an NP was present, patient wait times (door-to-evaluation by physician or NP) and ED length of stay (LOS) would be shorter, and that fewer patients would leave without treatment, particularly patients triaged as categories 1-3 of the Canadian ED Triage and Acuity Scale (CTAS).…”