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Nurse practitioners in the emergency department: Establishing a successful service
Collegian 26 (2019) 457–462
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Collegian journal homepage: www.elsevier.com/locate/coll
Nurse practitioners in the emergency department: Establishing a successful service Sharyn J. Plath a,b,∗ , Jean A. Bratby a , Lee Poole a,c , Catherine E. Forristal a,d , Douglas G. Morel a,e a
Redcliffe Hospital Emergency Department, Anzac Ave, Redcliffe QLD 4020, Australia Queensland University of Technology, School of Nursing, Australia c University of Queensland, School of Nursing, Midwifery and Social Work, Australia d University of Queensland, School of Medicine, Australia e Queensland University of Technology, School of Public Health and Social Work, Faculty of Health, Australia b
a r t i c l e
i n f o
Article history: Received 10 August 2018 Received in revised form 20 November 2018 Accepted 30 November 2018 Keywords: Nurse practitioner Fast track Health services Emergency department
a b s t r a c t Background: A regional hospital emergency department was facing increasing patient presentations, medical workforce shortages and long delays for patients to be seen. Furthermore, a high percentage of low acuity ambulatory patients were not waiting to be seen. Aim: To introduce a sustainable / long-term nurse practitioner (NP) led model of care to address the identified emergency department service requirements for low acuity ambulatory patients. Methods: A descriptive exploratory design was used to establish and monitor a NP model. Organisational support and a steering committee was used to monitor clinical safety and patient satisfaction. Data was collected in relation to number of patients seen, conditions managed by nurse practitioners, time to treatment, length of stay and compliments and complaints received. Findings: NPs within this service now comprise 10% of the treating clinician workforce, see 15% of total presentations, contribute to a reduction in waiting time, length of stay within the targeted cohort and meeting National Emergency Access Targets 95% of the time. Discussion: Establishment of a NP model has been successful at addressing the needs of low acuity patients in the emergency department as evidenced by reduced waiting times, length of stay and customer satisfaction. We attribute this success to the following three key factors: targeting a patient population, commitment to the service and adaptability. Conclusion: Development of a dedicated NP model has enabled the emergency department to safely and sustainably provide care to low acuity ambulatory patients. © 2018 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Summary of relevance Problem/issue A regional hospital emergency department was experiencing increased activity together with long delays with for low acuity patients. What is already known Nurse practitioners provide safe care to patients in a wide variety of settings, the scope of which is defined by the setting in which they work.
What this paper adds A personal journey developing a successful, dedicated nurse practitioner service in an emergency department. This could be used to facilitate future role development and support in other health services.
1. Background
∗ Corresponding author at: Redcliffe Hospital Emergency Department, Anzac Ave, Redcliffe, QLD 4020, Australia. E-mail address: [email protected] (S.J. Plath). https://doi.org/10.1016/j.colegn.2018.11.005 1322-7696/© 2018 Australian College of Nursing Ltd. Published by Elsevier Ltd.
The nurse practitioner (NP) is an autonomous, advanced practice role first established in the USA and Canada to address the shortfall of medical doctors (Silver & Ford, 1967). NPs are provided with advanced training in relation to assessment, diagnosis and management of a wide range of conditions traditionally managed by doctors, with the aim being to improve access to health care
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(Jennings et al., 2015). The first Australian NPs were authorised in December 2000 (Turner & Keyzer, 2002). The NP role is regulated in Australia, the title protected by legislation, and educational requirements are standardised and set nationally. In Queensland the first nurse practitioners were authorised in 2007. By 2017 there were 1604 endorsed nurse practitioners in Australia, with 412 of these residing in Queensland (Nursing and Midwifery Board of Australia, 2018). Nurse practitioners working in emergency settings comprise the largest cohort of nurse practitioners in the Australian context (Dimeo & Postic, 2012). 2. Redcliffe hospital setting Established in 1965, the Redcliffe Hospital is currently a 250-bed mixed adult and paediatric regional hospital located 30 km north of the Brisbane CBD in Queensland, Australia. It provides a range of general surgical and medical services including an emergency department, orthopaedic, paediatric and maternity services. In 2005 Redcliffe Hospital emergency department (ED) presentation rate was 43,000 per annum (average 118 patients per day). At that time, the ED was experiencing 6–8% growth per annum in activity (Nurse Practitioner Steering Committee Redcliffe Caboolture Health Service District, 2006). It was identified that there was a service deficit predominantly affecting ambulatory subacute patients. The medical workforce was not adequately matched to the clinical workload at Redcliffe Hospital. Available medical staff prioritised the critically ill and higher acuity patients. The response to lower acuity patients was challenging and inconsistent. There was a high rate of lower acuity patients who did not wait to be seen. Understandably this contributed to consumer dissatisfaction, reflected in an increase in complaints and did not wait rates (Nurse Practitioner Steering Committee Redcliffe Caboolture Health Service District, 2006). Recognising the gap in service, Redcliffe Hospital explored an NP model over 24 months. The development of a dedicated clinical space for patients presenting with minor injuries and illness was in the planning ready for a new ED. Based on evidence that NPs provide a potential cost-effective solution to address increased demand and overcrowding in emergency departments (Jennings et al., 2015, 2013; Martin-Misener et al., 2015), and a successful 2 years of NP practice within the service, it was postulated that NPs would offer a consistent, stable workforce and quickly become experts within their scope. Furthermore, the development of a new ED provided an opportune time to develop a fast track
location with NPs in mind. The aim of a fast track is to provide an efficient way of providing timely assessment treatment and discharge of patients seeking care for less serious injuries and illnesses (Dinh et al., 2012). Fast track units are functionally distinct units within EDs that allow streaming of patients with lower complexity problems. Fast track units have previously been identified a successful model for nurse practitioners to operate within (Carter & Chochinov, 2007), as demonstrated by improving service indicators such as access and efficiency, and so impacting on quality of patient care (O’Connell and Gardner, 2012; Wilson et al., 2008). The aim of this paper is to draw on the experience of nursing and medical staff instrumental in the development, implementation and continued evolution of the Redcliffe Hospital ED NP service over the last 13 years. Service indicators and key findings are distilled and discussed so that others looking to initiate or refine an NP service may benefit from the authors’ experience. 3. Methods 3.1. Design A descriptive exploratory design (Patton, 2002) was utilised to establish and monitor the NP service over a period of 2005–2018. The study was conducted in a regional Emergency Department 30 km north of Brisbane, Australia. Queensland Health commissioned a demonstration of the NP role across 7 specialties in 2005. The ED validation of this demonstration was conducted at Redcliffe Hospital. Two experienced clinical nurses (CNs) were carefully chosen for the role, due to an absence of a formal training program. Both CNs subsequently went on to become NPs. 3.2. Development of a guideline To identify the target patient population at the point of triage, a guideline was developed collaboratively by the CNs and senior medical officers. This guideline defined the model and was utilised as a valuable tool to articulate the NP scope of practice to other health professionals within the Redcliffe Hospital ED and wider multi-disciplinary team. This document has continued to evolve with the NP model, see Table 1. 3.3. Support for the service Support for the ongoing success of the NP service was gained from key hospital stakeholders from an executive to operational
Table 1 Triage Guide: Nurse Practitioner Streaming Criteria (condensed version). “NO” column considers complicating or complex factors that may cause significant patient delays. HEENT
NO
YES
Face Minor Head Injury
-Contusion, laceration, etc. -Laceration, contusion
Dental Eyes Nose Throat
-Neurological deficit / palsy -Adult > 70 yrs with history of loss of consciousness -Spreading cellulitis -Neck swelling -Large facial swelling -Obvious injury to globe -Acute large Epistaxis -Severe pain with trismus
-Ear ache -FB, laceration -Dental pain, trauma -Corneal abrasion, etc. -Foreign bodies, trauma -Sore throat
MUSCULOSKELETAL & SKIN
NO
YES
Back or neck Pain Lacerations, etc. Extremity pain Burns Skin Bites / Stings Occupational Exposure
-Age < 17yrs and adults >50yrs -Threatened limb (CAT 1- 2) -Swollen joint no trauma -Circumferential burns - Cellulitis + co-morbidity - Snake bite antivenom - Exposure Non-QLD Health patients
-Twisting/lifting injury -Lacerations, etc. -Sprain/Strain/fractures -Superficial / partial - Localized cellulitis - Marine stings / punctures - Staff exposure
Earache
Earlobe
Legend: HEENT = Head, eyes, ear, nose, throat. FB = foreign body.
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level included nursing, allied health, medicine and administration staff. To this end a steering committee was established during the demonstration year in 2005. The committee consisted of nursing and medical executives, the Nurse Unit Manager and Medical Director of the ED, an academic researcher, two CNs selected for the demonstration, and representatives from the departments most likely to have frequent contact with the clinicians (radiology, orthopaedics, allied health, pharmacy). The steering committee recommended monitoring progress in clinical safety, staff and patient satisfaction, communication and role promotion, and data collection. 3.4. Monitoring of clinical safety Operationally each patient was discussed with the duty senior medical officer at the time of presentation. To monitor ongoing clinical safety and quality care a weekly case review process was established between the CNs and a senior medical officer. This became a forum to refine the inclusion / exclusion criteria for the NP service. It also provided education and peer review for the CNs and engaged medical officers who became champions for the new role. Triage streaming clinical criteria that were developed, see Table 1. The case review process has continued to evolve. As the NPs have been embedded into the department’s service model, reviews with senior medical officers no longer occur on a regular basis, only as required. However, a similar forum is now run by NPs for new NP candidates with the same aims of ensuring clinical safety, teaching, peer review and ongoing development of the role. The template used for case reviews has been published (Plath et al., 2017). 3.5. Staff and patient satisfaction Understanding the value of this role to staff and patients was essential in ensuring continued executive support. This was assessed through feedback from nursing and medical ED staff, radiology staff and patients utilising surveys six months after implementation. 3.6. Communication and role promotion Promotion and marketing of the NP role was vital to ensure the continuing success of the model. During the demonstration in 2005, the nurse practitioner role was not only new to the ED but also to the state. The CNs took every opportunity to promote their future role including: radio interviews; presentations to local small groups and conferences; General Practitioner network engagement; and promotional flyers to help patients understand the role. The breadth of promotional and education efforts raised the profile of the new role and the service offered by the ED. It also aided in understanding and acceptance of the role both within the hospital and the wider community. 4. Data collection Data collection was part of the role promotion to staff as it demonstrated the effectiveness and efficiency of the new service.
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Table 2 Case-mix Summary - Top presentations seen by CNs demonstrating the role; January 2005 – December 2005. Patient Presentation
Number
% of Total (n = 1656)
Distal Limb trauma Wounds-lacerations, bite-cat, dog, animal Pain limb-no trauma Plaster checks / splints Cellulitis
709 399 98 107 76
42.8% 24.0% 5.9% 6.4% 4.5%
Data were collected across a variety of measures such as the role breakdown, number of patients seen, type of conditions managed, time to treatment, length of stay and compliments / complaints. This data was regularly communicated to the various stakeholders. The data collected has evolved over the years but continues to be a necessary support in demonstrating the value of the NP service.
5. Findings Prior to endorsement of the NP model in 2007, Queensland Health led a trial using a Fast Track model, that then became the NP model. During this trial the CNs (referred to here as NP candidates (NPc)) targeted the low acuity cohort of patients by providing a service from 8:00am to 6:30pm seven days per week, with one clinician working 10 h per day. This allowed one day of the fortnight where both clinicians were rostered together, which was essential to enable communication, case review, peer support, education, data collection and report writing. This indirect clinical time equated to approximately 30% of the role. The most common patient presentations managed by NPc service in 2005 were distal limb trauma and wounds / lacerations, see Table 2 for further breakdown. Other less common presentations included patients with asthma, bites & stings, marine envenomation, earache, sore throat, and skin lesions or rash. Within six months of demonstrating the service, and with the NPcs working 70% of their time clinically, they were seeing 9% of total presentations to the ED and contributed to an average 50% reduction in waiting times and length of stay for the targeted cohort of low acuity ambulatory patients (Nurse Practitioner Steering Committee Redcliffe Caboolture Health Service District, 2006). Average wait times of patients to be seen by an NPc were between 28 and 38 min. less than the average ED patient in the same category (Australian Triage Scale categories 3–5 (ACEM, 2000), while length of stay (LOS) for these same patients was between 40 min. and 2 hs shorter, see Table 3a. Consumer surveys demonstrated that patients were quick to recognise, accept and appreciate the new role and that medical, nursing and medical imaging staff within the ED were supportive of the role, see Table 3b for sample comments. The feedback also reflected that some suspicions or fears held by staff about the role had been allayed. Importantly, no negative feedback was received.
Table 3a Waiting Times (Time of Arrival to Time Seen) and Length of stay (time of triage to time of discharge). July to December 2005.
Wait Times for ED Wait times CNs Difference Average LOS forED patients Average LOS for CNs Difference
Cat 3
Cat 4
Cat 5
41 min. 13 min. 28 min. 4 hr 40 min 2 hr 36 min 2 hrs
73 min 35 mins 38 min. 3 hr 52 min 2 hr 16 min 1hr 35 min
60 min 28 min. 32 min. 2 hr 43 min 2 hr 4 min 40 min
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Table 3b Quotes from the survey carried out 6 months after initial introduction of the NP role in 2006. Medical
Nursing Clerk Radiographer Patients
‘earlier directed review and care’ ‘definitely streamlines the process’ ‘Of service to the department they (NPs) are able to see and work through patients. They are another set of eyes; another worker; diversity.’ Patients gets early assessment and intervention. It provides them with a single person contact while in ED; personalises the service, streamlines care.’ ‘More patient satisfaction. Less waiting times. Good public relations for the hospital.’ ‘Less abuse from parents, and we get more thanks’ ‘Saves patients time. Clinical details on the form are accurate and very detailed allowing the radiographer to tailor the examination.’ ‘Excellent idea. Great professional service.’ ‘Very speedy, efficient and professional. Felt like I was listened to and all options discussed’ ‘Recognition of individuality of care – maintained respect & dignity. Caring & recognition of my social circumstance. Avoided wasting Doctors time with nursing expert’.
Table 4a Waiting time to be seen April 2017 to March 2018.
Wait Time for all ED Wait time NP service Difference
5.2. Nurse practitioner training program
Cat 3
Cat 4
Cat 5
28 min. 27 min. 1 min
35 min 34mins 1 min
27 min 26 min. 1 min
Table 4b Top 10 patient presentations seen by NPs April 2017 to March 2018. Patient presentation
Number
% of Total (n = 9833)
Ankle sprain/strain Plaster cast aftercare Fracture Radius lower end Lacerated finger Fracture fibula Contusion upper limb Fracture Tarsal or metatarsal bones Fracture finger Fracture Metacarpal bones Wrist Sprain / Strain
542 454 434 401 277 273 251 239 236 143
5.5% 4.6% 4.4% 4.1% 2.8% 2.8% 2.6% 2.4% 2.4% 1.5%
5.1. Achieving NEAT targets (The australian national emergency access target) In 2011, The Australian National Emergency Access Target (NEAT) was introduced in response to concerns about quality and timeliness of care provided in EDs (Council of Australian Governments, 2011). The service provided by nurse practitioners (n=4) at Redcliffe Hospital consistently achieved NEAT target, i.e. patients discharged within 4 h of arrival. Based on this success additional funding was secured allowing a trial of an additional NP during the busy evening period. This resulted in an increase in NP staffing which supported the sustainability of the service and thereby aided the whole department’s NEAT performance. Data collected between April 2017 and March 2018, the NP workforce represented 10% of the treating clinicians and saw 9833 patients (15% of total presentations to the ED, n = 64,821 patient). This represented an average of 820 patients per month seen, treated and discharged by the NP team. With this increase in patient numbers wait times for patients to be seen by an NP were now comparable to that of the overall ED, see Table 4a instead of previously being significantly lower. This reflects the greater complexity of patients seen by NPs and advanced procedures performed under procedural sedation. Ninety-five percent of patients seen by NPs in this time period were admitted or discharged within four hours compared to the ED average of 57.5%. (Emergency Department Information System, 2018). Furthermore, the LOS for patients seen by NPs was on average 1 h 40 min. compared to the ED average of 3 h 20 min. The top 10 patients seen during this time is outlined in Table 4b. NPs continue to receive compliments from patients; ‘Fantastic care, thank you’ – Paediatric patient carer, March 2018.
Role sustainability and succession planning was imperative for the ongoing success on the NP service. In 2016, the NP service secured funding for a NP candidate (NPc) training position. It has been identified that specific training in specialist fields, such as emergency, is highly desirable to support the more generalised training offered in the master of nurse practitioner programs (O’Connell and Gardner, 2012; Plath et al., 2017). As such, the NP team developed an emergency specific local training program to support the candidate position. The training focused on the skills, knowledge and procedures specific to the ED, with education sessions delivered by NPs and invited speakers, which are in addition to university program requirements (Plath et al., 2017). Redcliffe Hospital ED has contributed directly to the training of 13 NP candidates since 2006; all of whom have gained NP endorsement with APHRA and employment as NPs. 5.3. Secondary consultations At the time of writing, 13 years post-implementation, the NP team have become a reliable and stable workforce within the department, with minimal turnover. They are expert clinicians within their scope, sound decision makers, autonomous yet collaborative, and integrated as part of the stable ED workforce alongside senior medical officers, senior nurses and managers. Secondary consultations and collaborative practices relate to the NPs’ area of expertise, providing support to nursing and medical colleagues; from interns to specialists, in areas of trauma, wound care, radiography interpretation and complex procedural skills. The extent of this largely unseen or ‘hidden’ work of NPs has been demonstrated in the literature with up to one quarter of NP consultations in ED involving provision of expertise to other clinicians (Lutze et al., 2018). The consistently high feedback from both staff and patients over the years and the volume of patients seen demonstrates not only acceptance but now reliance on the service provided. The NP service is no longer assessed as an independent service, but rather, is embedded into the ongoing review and quality processes of the ED. The current characteristics and scope of practice of the service at Redcliffe Hospital is condensed in Table 5. 6. Discussion The purpose of this paper was to profile the journey of the NP service start-up and establishment in the ED over 13 years. The NP model has been a tremendous success as demonstrated by a significant contribution to the numbers of patients managed (10% of clinicians seeing 15% of the patient, equating to 820 patients per month; 9833 patients over 12 months), in turn contributing to overall flow through the department and number of patients seen and discharged within four hours (95% NEAT target). They contribute to the ongoing orientation and education of nurses, medical officers
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Table 5 Checklist of characteristics of an established nurse practitioner role at Redcliffe Hospital emergency department in 2018. CHARACTERISTIC
EXAMPLE
Characteristics of the NPs Characteristics of the patients seen by the NPs Characteristics of the setting
NPs are experienced RNs that have completed a Masters of Nursing (NP) and are employed to work in the ED. Patients aged 2yrs to 80+yrs / subacute patients. Fast track is a designated location with 6 trolley bays, 2 procedures rooms, one eye room, operating 0700-2300. Staffing includes 6 NPs one registrar, a junior doctor and 2 RNs per shift. NPs provide care autonomously from arrival to discharge or referral for patients with minor injury or illness. Patients are streamed based on triage criteria. They provide secondary consultations to nursing, medical & allied staff. One NP rostered 0700-1730 and two at 1200-2230. Ad hoc offline time is taken at the changeover. NPs aim for education monthly for 3 hrs and a 5 hr planning session yearly. NPs share the teaching of new NP candidates. NPs are involved in research projects. NPs function autonomously as intended in relation to their case mix, SMOs are available for collaboration. NPs prescribe, refer to other departments, and write Work Cover certificates. NPs are not legislated to write Centrelink medical certificates. NPs require SMO signature on their referrals to private specialists as hospital based NPs do not qualify for provider numbers. The NPs are negotiating a more formal approach to off line time.
Mode of delivery
Intensity and duration
Fidelity
SCOPE OF PRACTICE
CONTENT
Capacity to admit and discharge Diagnostic investigations Prescription of medications Therapeutic interventions
NPs facilitate admissions / transfers to inpatient teams or other hospitals and discharge patients to the care of their GP. NPs request plain film imaging and consult for USS / CT scan. They initiate pathology testing. NPs prescribe medications from the QLD LAM, and that are in line with their scope of practice. NPs undertake multiple procedures; some complex such as dislocation and fracture reductions; removal of foreign bodies; complex wound closures, regional blocks. NPs refer to GPs, private specialists (collaboratively), inpatients teams, fracture clinic, allied health, dental clinic, and sub specialties in other hospitals such as burns, ENT, ophthalmology, maxillary facial.
Referrals
Key: ED = Emergency Department; GP = General Practitioner; NP = Nurse Practitioner; SMO = Senior Medical Officer; LAM = List of Approved Medications; ENT = Ear Nose & Throat.
and allied health staff within the department. They are a reliable source of expertise within the ED and throughout the hospital. The success of the NP model of practice is grounded on the foundation of being viewed as a service providing consistent cover 16 h per day / seven days per week. The NPs have developed professionally to deliver a consistently high standard of clinical care. Key stakeholder involvement, evaluation measures, service needs assessment and defining scope of practice have been identified as important supporting factors in other models (Dimeo & Postic, 2012). Reflecting on the experience of developing, implementing and refining the NP service at Redcliffe Hospital ED, the authors have been able to identify key elements in its success: defining the target patient population, the commitment to the service and its adaptability. While developed and illustrated in the emergency setting, these elements are applicable across all areas of NP practice.
and inform them of the performance and achievements of the NP service. Lack of understanding of the role and its value can lead to frustration and restriction. To stay ahead of any such issue, NPs at this site meet monthly with senior level nursing management. Ongoing promotional activities and meeting with new ED team members are key to maintaining integrated nursing, medical and departmental support. The NP candidate training position and subsequent formalised ED specific training program has been an important evolutionary step in maintaining and enhancing the quality, evidence based care provided by NPs. The training program has supported the development of experienced and qualified NPs who are job ready, and it is anticipated that this will aid the stability and depth of the NP workforce and support succession planning; especially within the fast track model of care. 6.3. Adaptability of the service
6.1. Target patient population The targeted area of need requires clear articulation for purposes of communication to other health care professionals. The need will change over time as population, disease prevalence rates, new care providers and other variables change. Therefore, it becomes crucial to revisit the target population yearly or as the need arises. It may not be possible to replicate another successful model from an existing service without analysis of the local clinical need. The success of the service is attributed partly to the NPs expertise in a targeted cohort of patients whom had suffered prolonged waiting times to be seen and extended length of stay in the department, rather than a broad patient group across every area of the ED.
As health service needs are constantly changing, the ability to adapt and to take advantage of strategic opportunities and changes in political direction becomes paramount. The NP service continues to evolve with an increasing focus on creating value through non-clinical activities. This has come in the form of increased engagement in broader leadership activity within the ED, hospital and at a state and national level. The scope of practice and performance of the NP service are reviewed periodically to ensure that the service continues to meet the changing needs of the hospital and the community it serves. Monitoring monthly service indicators such as number and types of patient presentations, wait times to be seen and length of stay within 4 h is critical so that the service can adapt to changing trends.
6.2. Commitment to the service 7. Conclusion The level of support to the service requires continued monitoring. Managers, executives and individuals change over time and their understanding and support needs to be periodically reviewed. This may be as simple as meeting with new executive to present
Creating an NP service has been highly successful at Redcliffe hospital as demonstrated by its team contribution to overall statistics, department flow, provision of an experienced stable
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workforce, and managing a defined patient population in a fast track environment. The foundation to this success has been attributed to the ongoing commitment to the model as ‘service delivery’ embracing the three elements of targeting a patient population, embracing widespread support and providing a service that can adapt to changing trends. Commencing and growing a new NP service in an ED has been a journey, but not an end-point, as the service must continue to adapt to the challenges presented to it. This paper is grounded in practical experience over 13 years, and is applicable to nurse practitioner services across all areas of practice at any stage of development. Author statement SP, JB and DM conceived, designed and established the NP service. SP also drafted the original manuscript. LP contributed to the conception and critical review of the manuscript. CF provided expertise and intellectual input on the content and revision of the manuscript. JB and DM provided critical review of the manuscript. Conflict of interest None. Ethical statement This manuscript describes a personal experience establishing a service and is a quality improvement study therefore ethics approval was not required. Acknowledgements We acknowledge the following persons involved in this journey: Ms Caroline Weaver (Chair of the initial steering committee); Dr Charley McNabb and Dr Rob Cardwell (Consultant medical staff in the formative years). We would also like to thank the Redcliffe Hospital executive, all the ED NPs and staff (past and present) for their continued support. Finally, we would like to thank Dr Julia Hocking, Emergency Medicine Foundation for final review of the manuscript. This manuscript was developed using in kind support from the authors and Metro North Hospital and Health Service. References ACEM. (2000). https://acem.org.au/Content-Sources/Advancing-EmergencyMedicine/Better-Outcomes-for-Patients/Triage.aspx.
Carter, A. J., & Chochinov, A. H. (2007). A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. CJEM, 9(4), 286–295. Retrieved from. http://www. ncbi.nlm.nih.gov/pubmed/17626694 Council of Australian Governments. (2011). Expert panel review of elective surgery and emergency access targets under the national partnership agreement on improving public hospital services. https://www.myhospitals.gov.au/getmedia/ 35038e09-4fc0-48e6-b7e2-3f3e8506a37a/hp timeinemergencydepartments 2011 12 rpt.aspx Dimeo, M., & Postic, M. (2012). Lessons learned in developing and implementing the nurse practitioner role in an urban Canadian emergency department. Journal of Emergency Nursing: JEN : Official Publication of the Emergency Department Nurses Association, 38(5), 484–487. http://dx.doi.org/10.1016/j.jen. 2011.08.015 Dinh, M., Walker, A., Parameswaran, A., & Enright, N. (2012). Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors. Australasian Emergency Nursing Journal : AENJ, 15(4), 188–194. http://dx.doi.org/10.1016/j.aenj.2012.09.001 Emergency Department Information System. (2018). Jennings, N., Clifford, S., Fox, A. R., O’Connell, J., & Gardner, G. (2015). The impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department: A systematic review. International Journal of Nursing Studies, 52(1), 421–435. http://dx.doi.org/10.1016/j.ijnurstu.2014. 07.006 Jennings, N., McKeown, E., O’Reilly, G., & Gardner, G. (2013). Evaluating patient presentations for care delivered by emergency nurse practitioners: A retrospective analysis of 12 months. Australasian Emergency Nursing Journal : AENJ, 16(3), 89–95. http://dx.doi.org/10.1016/j.aenj.2013.05.005 Lutze, M., Fry, M., Mullen, G., O’Connell, J., & Coates, D. (2018). Highlighting the invisible work of emergency nurse practitioners. The Journal for Nurse Practitioners, 14(1), 26–32. http://dx.doi.org/10.1016/j.nurpra.2017.09.023, e21 Martin-Misener, R., Harbman, P., Donald, F., Reid, K., Kilpatrick, K., Carter, N., & DiCenso, A. (2015). Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: Systematic review. BMJ Open, 5(6), e007167 http://dx.doi.org/10.1136/bmjopen-2014-007167 Nurse Practitioner Steering Committee Redcliffe Caboolture Health Service District. (2006). Demonstration nurse practitioner role emergency department: 2005-12 month report. Nursing and Midwifery Board of Australia. (2018). Nursing and Midwifery Board of Australia Registrant data: Reporting period: 1 October 2017–31 December 2017 Retrieved from. http://www.nursingmidwiferyboard.gov.au/About/Statistics. aspx O’Connell, J., & Gardner, G. (2012). Development of clinical competencies for emergency nurse practitioners: A pilot study. Australasian Emergency Nursing Journal, 15(4), 195–201. http://dx.doi.org/10.1016/j.aenj.2012.10.004 Patton, M. Q. (2002). Qualitative research & evaluation methods. Plath, S. J., Wright, M., & Hocking, J. (2017). Evaluating an australian emergency nurse practitioner candidate training program. Australasian Emergency Nursing Journal : AENJ, 20(4), 161–168. http://dx.doi.org/10.1016/j.aenj.2017.07.001 Silver, H., & Ford, L. (1967). The pediatric nurse practitioner at Colorado. The American Journal of Nursing, 67(7), 1443–1444. http://dx.doi.org/10.2307/ 3420623 Turner, C., & Keyzer, D. (2002). Nurse Practitioners: A contract for change and excellence in nursing. Collegian, 9(4), 18–23. http://dx.doi.org/10.1016/S13227696(08)60429-1 Wilson, K., Cameron, P., & Jennings, N. (2008). Emergency nurse practitioners: An underestimated addition to the emergency care team. Emergency Medicine Australasia : EMA, 20(6), 453–455. http://dx.doi.org/10.1111/j.1742-6723.2008. 01128.x
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Nurse practitioners in the emergency department: Establishing a successful service Sharyn J. Plath a,b,∗ , Jean A. Bratby a , Lee Poole a,c , Catherine E. Forristal a,d , Douglas G. Morel a,e a
Redcliffe Hospital Emergency Department, Anzac Ave, Redcliffe QLD 4020, Australia Queensland University of Technology, School of Nursing, Australia c University of Queensland, School of Nursing, Midwifery and Social Work, Australia d University of Queensland, School of Medicine, Australia e Queensland University of Technology, School of Public Health and Social Work, Faculty of Health, Australia b
a r t i c l e
i n f o
Article history: Received 10 August 2018 Received in revised form 20 November 2018 Accepted 30 November 2018 Keywords: Nurse practitioner Fast track Health services Emergency department
a b s t r a c t Background: A regional hospital emergency department was facing increasing patient presentations, medical workforce shortages and long delays for patients to be seen. Furthermore, a high percentage of low acuity ambulatory patients were not waiting to be seen. Aim: To introduce a sustainable / long-term nurse practitioner (NP) led model of care to address the identified emergency department service requirements for low acuity ambulatory patients. Methods: A descriptive exploratory design was used to establish and monitor a NP model. Organisational support and a steering committee was used to monitor clinical safety and patient satisfaction. Data was collected in relation to number of patients seen, conditions managed by nurse practitioners, time to treatment, length of stay and compliments and complaints received. Findings: NPs within this service now comprise 10% of the treating clinician workforce, see 15% of total presentations, contribute to a reduction in waiting time, length of stay within the targeted cohort and meeting National Emergency Access Targets 95% of the time. Discussion: Establishment of a NP model has been successful at addressing the needs of low acuity patients in the emergency department as evidenced by reduced waiting times, length of stay and customer satisfaction. We attribute this success to the following three key factors: targeting a patient population, commitment to the service and adaptability. Conclusion: Development of a dedicated NP model has enabled the emergency department to safely and sustainably provide care to low acuity ambulatory patients. © 2018 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Summary of relevance Problem/issue A regional hospital emergency department was experiencing increased activity together with long delays with for low acuity patients. What is already known Nurse practitioners provide safe care to patients in a wide variety of settings, the scope of which is defined by the setting in which they work.
What this paper adds A personal journey developing a successful, dedicated nurse practitioner service in an emergency department. This could be used to facilitate future role development and support in other health services.
1. Background
∗ Corresponding author at: Redcliffe Hospital Emergency Department, Anzac Ave, Redcliffe, QLD 4020, Australia. E-mail address: [email protected] (S.J. Plath). https://doi.org/10.1016/j.colegn.2018.11.005 1322-7696/© 2018 Australian College of Nursing Ltd. Published by Elsevier Ltd.
The nurse practitioner (NP) is an autonomous, advanced practice role first established in the USA and Canada to address the shortfall of medical doctors (Silver & Ford, 1967). NPs are provided with advanced training in relation to assessment, diagnosis and management of a wide range of conditions traditionally managed by doctors, with the aim being to improve access to health care
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(Jennings et al., 2015). The first Australian NPs were authorised in December 2000 (Turner & Keyzer, 2002). The NP role is regulated in Australia, the title protected by legislation, and educational requirements are standardised and set nationally. In Queensland the first nurse practitioners were authorised in 2007. By 2017 there were 1604 endorsed nurse practitioners in Australia, with 412 of these residing in Queensland (Nursing and Midwifery Board of Australia, 2018). Nurse practitioners working in emergency settings comprise the largest cohort of nurse practitioners in the Australian context (Dimeo & Postic, 2012). 2. Redcliffe hospital setting Established in 1965, the Redcliffe Hospital is currently a 250-bed mixed adult and paediatric regional hospital located 30 km north of the Brisbane CBD in Queensland, Australia. It provides a range of general surgical and medical services including an emergency department, orthopaedic, paediatric and maternity services. In 2005 Redcliffe Hospital emergency department (ED) presentation rate was 43,000 per annum (average 118 patients per day). At that time, the ED was experiencing 6–8% growth per annum in activity (Nurse Practitioner Steering Committee Redcliffe Caboolture Health Service District, 2006). It was identified that there was a service deficit predominantly affecting ambulatory subacute patients. The medical workforce was not adequately matched to the clinical workload at Redcliffe Hospital. Available medical staff prioritised the critically ill and higher acuity patients. The response to lower acuity patients was challenging and inconsistent. There was a high rate of lower acuity patients who did not wait to be seen. Understandably this contributed to consumer dissatisfaction, reflected in an increase in complaints and did not wait rates (Nurse Practitioner Steering Committee Redcliffe Caboolture Health Service District, 2006). Recognising the gap in service, Redcliffe Hospital explored an NP model over 24 months. The development of a dedicated clinical space for patients presenting with minor injuries and illness was in the planning ready for a new ED. Based on evidence that NPs provide a potential cost-effective solution to address increased demand and overcrowding in emergency departments (Jennings et al., 2015, 2013; Martin-Misener et al., 2015), and a successful 2 years of NP practice within the service, it was postulated that NPs would offer a consistent, stable workforce and quickly become experts within their scope. Furthermore, the development of a new ED provided an opportune time to develop a fast track
location with NPs in mind. The aim of a fast track is to provide an efficient way of providing timely assessment treatment and discharge of patients seeking care for less serious injuries and illnesses (Dinh et al., 2012). Fast track units are functionally distinct units within EDs that allow streaming of patients with lower complexity problems. Fast track units have previously been identified a successful model for nurse practitioners to operate within (Carter & Chochinov, 2007), as demonstrated by improving service indicators such as access and efficiency, and so impacting on quality of patient care (O’Connell and Gardner, 2012; Wilson et al., 2008). The aim of this paper is to draw on the experience of nursing and medical staff instrumental in the development, implementation and continued evolution of the Redcliffe Hospital ED NP service over the last 13 years. Service indicators and key findings are distilled and discussed so that others looking to initiate or refine an NP service may benefit from the authors’ experience. 3. Methods 3.1. Design A descriptive exploratory design (Patton, 2002) was utilised to establish and monitor the NP service over a period of 2005–2018. The study was conducted in a regional Emergency Department 30 km north of Brisbane, Australia. Queensland Health commissioned a demonstration of the NP role across 7 specialties in 2005. The ED validation of this demonstration was conducted at Redcliffe Hospital. Two experienced clinical nurses (CNs) were carefully chosen for the role, due to an absence of a formal training program. Both CNs subsequently went on to become NPs. 3.2. Development of a guideline To identify the target patient population at the point of triage, a guideline was developed collaboratively by the CNs and senior medical officers. This guideline defined the model and was utilised as a valuable tool to articulate the NP scope of practice to other health professionals within the Redcliffe Hospital ED and wider multi-disciplinary team. This document has continued to evolve with the NP model, see Table 1. 3.3. Support for the service Support for the ongoing success of the NP service was gained from key hospital stakeholders from an executive to operational
Table 1 Triage Guide: Nurse Practitioner Streaming Criteria (condensed version). “NO” column considers complicating or complex factors that may cause significant patient delays. HEENT
NO
YES
Face Minor Head Injury
-Contusion, laceration, etc. -Laceration, contusion
Dental Eyes Nose Throat
-Neurological deficit / palsy -Adult > 70 yrs with history of loss of consciousness -Spreading cellulitis -Neck swelling -Large facial swelling -Obvious injury to globe -Acute large Epistaxis -Severe pain with trismus
-Ear ache -FB, laceration -Dental pain, trauma -Corneal abrasion, etc. -Foreign bodies, trauma -Sore throat
MUSCULOSKELETAL & SKIN
NO
YES
Back or neck Pain Lacerations, etc. Extremity pain Burns Skin Bites / Stings Occupational Exposure
-Age < 17yrs and adults >50yrs -Threatened limb (CAT 1- 2) -Swollen joint no trauma -Circumferential burns - Cellulitis + co-morbidity - Snake bite antivenom - Exposure Non-QLD Health patients
-Twisting/lifting injury -Lacerations, etc. -Sprain/Strain/fractures -Superficial / partial - Localized cellulitis - Marine stings / punctures - Staff exposure
Earache
Earlobe
Legend: HEENT = Head, eyes, ear, nose, throat. FB = foreign body.
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level included nursing, allied health, medicine and administration staff. To this end a steering committee was established during the demonstration year in 2005. The committee consisted of nursing and medical executives, the Nurse Unit Manager and Medical Director of the ED, an academic researcher, two CNs selected for the demonstration, and representatives from the departments most likely to have frequent contact with the clinicians (radiology, orthopaedics, allied health, pharmacy). The steering committee recommended monitoring progress in clinical safety, staff and patient satisfaction, communication and role promotion, and data collection. 3.4. Monitoring of clinical safety Operationally each patient was discussed with the duty senior medical officer at the time of presentation. To monitor ongoing clinical safety and quality care a weekly case review process was established between the CNs and a senior medical officer. This became a forum to refine the inclusion / exclusion criteria for the NP service. It also provided education and peer review for the CNs and engaged medical officers who became champions for the new role. Triage streaming clinical criteria that were developed, see Table 1. The case review process has continued to evolve. As the NPs have been embedded into the department’s service model, reviews with senior medical officers no longer occur on a regular basis, only as required. However, a similar forum is now run by NPs for new NP candidates with the same aims of ensuring clinical safety, teaching, peer review and ongoing development of the role. The template used for case reviews has been published (Plath et al., 2017). 3.5. Staff and patient satisfaction Understanding the value of this role to staff and patients was essential in ensuring continued executive support. This was assessed through feedback from nursing and medical ED staff, radiology staff and patients utilising surveys six months after implementation. 3.6. Communication and role promotion Promotion and marketing of the NP role was vital to ensure the continuing success of the model. During the demonstration in 2005, the nurse practitioner role was not only new to the ED but also to the state. The CNs took every opportunity to promote their future role including: radio interviews; presentations to local small groups and conferences; General Practitioner network engagement; and promotional flyers to help patients understand the role. The breadth of promotional and education efforts raised the profile of the new role and the service offered by the ED. It also aided in understanding and acceptance of the role both within the hospital and the wider community. 4. Data collection Data collection was part of the role promotion to staff as it demonstrated the effectiveness and efficiency of the new service.
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Table 2 Case-mix Summary - Top presentations seen by CNs demonstrating the role; January 2005 – December 2005. Patient Presentation
Number
% of Total (n = 1656)
Distal Limb trauma Wounds-lacerations, bite-cat, dog, animal Pain limb-no trauma Plaster checks / splints Cellulitis
709 399 98 107 76
42.8% 24.0% 5.9% 6.4% 4.5%
Data were collected across a variety of measures such as the role breakdown, number of patients seen, type of conditions managed, time to treatment, length of stay and compliments / complaints. This data was regularly communicated to the various stakeholders. The data collected has evolved over the years but continues to be a necessary support in demonstrating the value of the NP service.
5. Findings Prior to endorsement of the NP model in 2007, Queensland Health led a trial using a Fast Track model, that then became the NP model. During this trial the CNs (referred to here as NP candidates (NPc)) targeted the low acuity cohort of patients by providing a service from 8:00am to 6:30pm seven days per week, with one clinician working 10 h per day. This allowed one day of the fortnight where both clinicians were rostered together, which was essential to enable communication, case review, peer support, education, data collection and report writing. This indirect clinical time equated to approximately 30% of the role. The most common patient presentations managed by NPc service in 2005 were distal limb trauma and wounds / lacerations, see Table 2 for further breakdown. Other less common presentations included patients with asthma, bites & stings, marine envenomation, earache, sore throat, and skin lesions or rash. Within six months of demonstrating the service, and with the NPcs working 70% of their time clinically, they were seeing 9% of total presentations to the ED and contributed to an average 50% reduction in waiting times and length of stay for the targeted cohort of low acuity ambulatory patients (Nurse Practitioner Steering Committee Redcliffe Caboolture Health Service District, 2006). Average wait times of patients to be seen by an NPc were between 28 and 38 min. less than the average ED patient in the same category (Australian Triage Scale categories 3–5 (ACEM, 2000), while length of stay (LOS) for these same patients was between 40 min. and 2 hs shorter, see Table 3a. Consumer surveys demonstrated that patients were quick to recognise, accept and appreciate the new role and that medical, nursing and medical imaging staff within the ED were supportive of the role, see Table 3b for sample comments. The feedback also reflected that some suspicions or fears held by staff about the role had been allayed. Importantly, no negative feedback was received.
Table 3a Waiting Times (Time of Arrival to Time Seen) and Length of stay (time of triage to time of discharge). July to December 2005.
Wait Times for ED Wait times CNs Difference Average LOS forED patients Average LOS for CNs Difference
Cat 3
Cat 4
Cat 5
41 min. 13 min. 28 min. 4 hr 40 min 2 hr 36 min 2 hrs
73 min 35 mins 38 min. 3 hr 52 min 2 hr 16 min 1hr 35 min
60 min 28 min. 32 min. 2 hr 43 min 2 hr 4 min 40 min
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Table 3b Quotes from the survey carried out 6 months after initial introduction of the NP role in 2006. Medical
Nursing Clerk Radiographer Patients
‘earlier directed review and care’ ‘definitely streamlines the process’ ‘Of service to the department they (NPs) are able to see and work through patients. They are another set of eyes; another worker; diversity.’ Patients gets early assessment and intervention. It provides them with a single person contact while in ED; personalises the service, streamlines care.’ ‘More patient satisfaction. Less waiting times. Good public relations for the hospital.’ ‘Less abuse from parents, and we get more thanks’ ‘Saves patients time. Clinical details on the form are accurate and very detailed allowing the radiographer to tailor the examination.’ ‘Excellent idea. Great professional service.’ ‘Very speedy, efficient and professional. Felt like I was listened to and all options discussed’ ‘Recognition of individuality of care – maintained respect & dignity. Caring & recognition of my social circumstance. Avoided wasting Doctors time with nursing expert’.
Table 4a Waiting time to be seen April 2017 to March 2018.
Wait Time for all ED Wait time NP service Difference
5.2. Nurse practitioner training program
Cat 3
Cat 4
Cat 5
28 min. 27 min. 1 min
35 min 34mins 1 min
27 min 26 min. 1 min
Table 4b Top 10 patient presentations seen by NPs April 2017 to March 2018. Patient presentation
Number
% of Total (n = 9833)
Ankle sprain/strain Plaster cast aftercare Fracture Radius lower end Lacerated finger Fracture fibula Contusion upper limb Fracture Tarsal or metatarsal bones Fracture finger Fracture Metacarpal bones Wrist Sprain / Strain
542 454 434 401 277 273 251 239 236 143
5.5% 4.6% 4.4% 4.1% 2.8% 2.8% 2.6% 2.4% 2.4% 1.5%
5.1. Achieving NEAT targets (The australian national emergency access target) In 2011, The Australian National Emergency Access Target (NEAT) was introduced in response to concerns about quality and timeliness of care provided in EDs (Council of Australian Governments, 2011). The service provided by nurse practitioners (n=4) at Redcliffe Hospital consistently achieved NEAT target, i.e. patients discharged within 4 h of arrival. Based on this success additional funding was secured allowing a trial of an additional NP during the busy evening period. This resulted in an increase in NP staffing which supported the sustainability of the service and thereby aided the whole department’s NEAT performance. Data collected between April 2017 and March 2018, the NP workforce represented 10% of the treating clinicians and saw 9833 patients (15% of total presentations to the ED, n = 64,821 patient). This represented an average of 820 patients per month seen, treated and discharged by the NP team. With this increase in patient numbers wait times for patients to be seen by an NP were now comparable to that of the overall ED, see Table 4a instead of previously being significantly lower. This reflects the greater complexity of patients seen by NPs and advanced procedures performed under procedural sedation. Ninety-five percent of patients seen by NPs in this time period were admitted or discharged within four hours compared to the ED average of 57.5%. (Emergency Department Information System, 2018). Furthermore, the LOS for patients seen by NPs was on average 1 h 40 min. compared to the ED average of 3 h 20 min. The top 10 patients seen during this time is outlined in Table 4b. NPs continue to receive compliments from patients; ‘Fantastic care, thank you’ – Paediatric patient carer, March 2018.
Role sustainability and succession planning was imperative for the ongoing success on the NP service. In 2016, the NP service secured funding for a NP candidate (NPc) training position. It has been identified that specific training in specialist fields, such as emergency, is highly desirable to support the more generalised training offered in the master of nurse practitioner programs (O’Connell and Gardner, 2012; Plath et al., 2017). As such, the NP team developed an emergency specific local training program to support the candidate position. The training focused on the skills, knowledge and procedures specific to the ED, with education sessions delivered by NPs and invited speakers, which are in addition to university program requirements (Plath et al., 2017). Redcliffe Hospital ED has contributed directly to the training of 13 NP candidates since 2006; all of whom have gained NP endorsement with APHRA and employment as NPs. 5.3. Secondary consultations At the time of writing, 13 years post-implementation, the NP team have become a reliable and stable workforce within the department, with minimal turnover. They are expert clinicians within their scope, sound decision makers, autonomous yet collaborative, and integrated as part of the stable ED workforce alongside senior medical officers, senior nurses and managers. Secondary consultations and collaborative practices relate to the NPs’ area of expertise, providing support to nursing and medical colleagues; from interns to specialists, in areas of trauma, wound care, radiography interpretation and complex procedural skills. The extent of this largely unseen or ‘hidden’ work of NPs has been demonstrated in the literature with up to one quarter of NP consultations in ED involving provision of expertise to other clinicians (Lutze et al., 2018). The consistently high feedback from both staff and patients over the years and the volume of patients seen demonstrates not only acceptance but now reliance on the service provided. The NP service is no longer assessed as an independent service, but rather, is embedded into the ongoing review and quality processes of the ED. The current characteristics and scope of practice of the service at Redcliffe Hospital is condensed in Table 5. 6. Discussion The purpose of this paper was to profile the journey of the NP service start-up and establishment in the ED over 13 years. The NP model has been a tremendous success as demonstrated by a significant contribution to the numbers of patients managed (10% of clinicians seeing 15% of the patient, equating to 820 patients per month; 9833 patients over 12 months), in turn contributing to overall flow through the department and number of patients seen and discharged within four hours (95% NEAT target). They contribute to the ongoing orientation and education of nurses, medical officers
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Table 5 Checklist of characteristics of an established nurse practitioner role at Redcliffe Hospital emergency department in 2018. CHARACTERISTIC
EXAMPLE
Characteristics of the NPs Characteristics of the patients seen by the NPs Characteristics of the setting
NPs are experienced RNs that have completed a Masters of Nursing (NP) and are employed to work in the ED. Patients aged 2yrs to 80+yrs / subacute patients. Fast track is a designated location with 6 trolley bays, 2 procedures rooms, one eye room, operating 0700-2300. Staffing includes 6 NPs one registrar, a junior doctor and 2 RNs per shift. NPs provide care autonomously from arrival to discharge or referral for patients with minor injury or illness. Patients are streamed based on triage criteria. They provide secondary consultations to nursing, medical & allied staff. One NP rostered 0700-1730 and two at 1200-2230. Ad hoc offline time is taken at the changeover. NPs aim for education monthly for 3 hrs and a 5 hr planning session yearly. NPs share the teaching of new NP candidates. NPs are involved in research projects. NPs function autonomously as intended in relation to their case mix, SMOs are available for collaboration. NPs prescribe, refer to other departments, and write Work Cover certificates. NPs are not legislated to write Centrelink medical certificates. NPs require SMO signature on their referrals to private specialists as hospital based NPs do not qualify for provider numbers. The NPs are negotiating a more formal approach to off line time.
Mode of delivery
Intensity and duration
Fidelity
SCOPE OF PRACTICE
CONTENT
Capacity to admit and discharge Diagnostic investigations Prescription of medications Therapeutic interventions
NPs facilitate admissions / transfers to inpatient teams or other hospitals and discharge patients to the care of their GP. NPs request plain film imaging and consult for USS / CT scan. They initiate pathology testing. NPs prescribe medications from the QLD LAM, and that are in line with their scope of practice. NPs undertake multiple procedures; some complex such as dislocation and fracture reductions; removal of foreign bodies; complex wound closures, regional blocks. NPs refer to GPs, private specialists (collaboratively), inpatients teams, fracture clinic, allied health, dental clinic, and sub specialties in other hospitals such as burns, ENT, ophthalmology, maxillary facial.
Referrals
Key: ED = Emergency Department; GP = General Practitioner; NP = Nurse Practitioner; SMO = Senior Medical Officer; LAM = List of Approved Medications; ENT = Ear Nose & Throat.
and allied health staff within the department. They are a reliable source of expertise within the ED and throughout the hospital. The success of the NP model of practice is grounded on the foundation of being viewed as a service providing consistent cover 16 h per day / seven days per week. The NPs have developed professionally to deliver a consistently high standard of clinical care. Key stakeholder involvement, evaluation measures, service needs assessment and defining scope of practice have been identified as important supporting factors in other models (Dimeo & Postic, 2012). Reflecting on the experience of developing, implementing and refining the NP service at Redcliffe Hospital ED, the authors have been able to identify key elements in its success: defining the target patient population, the commitment to the service and its adaptability. While developed and illustrated in the emergency setting, these elements are applicable across all areas of NP practice.
and inform them of the performance and achievements of the NP service. Lack of understanding of the role and its value can lead to frustration and restriction. To stay ahead of any such issue, NPs at this site meet monthly with senior level nursing management. Ongoing promotional activities and meeting with new ED team members are key to maintaining integrated nursing, medical and departmental support. The NP candidate training position and subsequent formalised ED specific training program has been an important evolutionary step in maintaining and enhancing the quality, evidence based care provided by NPs. The training program has supported the development of experienced and qualified NPs who are job ready, and it is anticipated that this will aid the stability and depth of the NP workforce and support succession planning; especially within the fast track model of care. 6.3. Adaptability of the service
6.1. Target patient population The targeted area of need requires clear articulation for purposes of communication to other health care professionals. The need will change over time as population, disease prevalence rates, new care providers and other variables change. Therefore, it becomes crucial to revisit the target population yearly or as the need arises. It may not be possible to replicate another successful model from an existing service without analysis of the local clinical need. The success of the service is attributed partly to the NPs expertise in a targeted cohort of patients whom had suffered prolonged waiting times to be seen and extended length of stay in the department, rather than a broad patient group across every area of the ED.
As health service needs are constantly changing, the ability to adapt and to take advantage of strategic opportunities and changes in political direction becomes paramount. The NP service continues to evolve with an increasing focus on creating value through non-clinical activities. This has come in the form of increased engagement in broader leadership activity within the ED, hospital and at a state and national level. The scope of practice and performance of the NP service are reviewed periodically to ensure that the service continues to meet the changing needs of the hospital and the community it serves. Monitoring monthly service indicators such as number and types of patient presentations, wait times to be seen and length of stay within 4 h is critical so that the service can adapt to changing trends.
6.2. Commitment to the service 7. Conclusion The level of support to the service requires continued monitoring. Managers, executives and individuals change over time and their understanding and support needs to be periodically reviewed. This may be as simple as meeting with new executive to present
Creating an NP service has been highly successful at Redcliffe hospital as demonstrated by its team contribution to overall statistics, department flow, provision of an experienced stable
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workforce, and managing a defined patient population in a fast track environment. The foundation to this success has been attributed to the ongoing commitment to the model as ‘service delivery’ embracing the three elements of targeting a patient population, embracing widespread support and providing a service that can adapt to changing trends. Commencing and growing a new NP service in an ED has been a journey, but not an end-point, as the service must continue to adapt to the challenges presented to it. This paper is grounded in practical experience over 13 years, and is applicable to nurse practitioner services across all areas of practice at any stage of development. Author statement SP, JB and DM conceived, designed and established the NP service. SP also drafted the original manuscript. LP contributed to the conception and critical review of the manuscript. CF provided expertise and intellectual input on the content and revision of the manuscript. JB and DM provided critical review of the manuscript. Conflict of interest None. Ethical statement This manuscript describes a personal experience establishing a service and is a quality improvement study therefore ethics approval was not required. Acknowledgements We acknowledge the following persons involved in this journey: Ms Caroline Weaver (Chair of the initial steering committee); Dr Charley McNabb and Dr Rob Cardwell (Consultant medical staff in the formative years). We would also like to thank the Redcliffe Hospital executive, all the ED NPs and staff (past and present) for their continued support. Finally, we would like to thank Dr Julia Hocking, Emergency Medicine Foundation for final review of the manuscript. This manuscript was developed using in kind support from the authors and Metro North Hospital and Health Service. References ACEM. (2000). https://acem.org.au/Content-Sources/Advancing-EmergencyMedicine/Better-Outcomes-for-Patients/Triage.aspx.
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