Canadians deserve the very best in emergency care . Let's work to restore their confidence in the emergency health care system.

Do Nurse Practitioners have any role in solving ER crowding?

Categories

The Winnipeg Health Authority has just committed to reducing ER wait times by 2015. There solution to hire nurse practitioners. NPs have a definite role to play in emergency care but resolving crowding is not one of them.

Following is a 2003 article written by myself and Mike Bingley explaining the situation. Still valid ten years later.

Nurse practitioners in the emergency department: a discussion paper
Editorials / Commentaries
Alan J. Drummond, MD CM;* Michael Bingley, BScN, RN (EC), ENC(C)†

*Dr. Drummond is with The Great War Memorial Hospital, Perth, Ont., the Department of Family Medicine, University of Ottawa, Ont., and Queen’s University, Kingston, Ont. †Mr. Bingley is a Nurse Practitioner, North Lanark Community Health Center, Lanark, Ont.

CJEM 2003;5(4):276-280

Introduction
In Canada there is a growing appreciation that alternative health care providers may have a useful role in the provision of emergency care. Given the increased utilization and overcrowding of emergency departments (EDs), it is understandable that government would look to the nurse practitioner (NP) for assistance.

Although the introduction of NPs into the ED setting is unlikely to have a meaningful impact on ED overcrowding, we believe that NPs may have a positive role in primary care delivery in EDs. That role is, as yet, ill defined, and we caution against a “one size fits all” approach. Canadian EDs have diverse needs and the function of NPs will vary between institutions.

Unfortunately, as we strive to define the role of the NP in the ED, we cannot rely on the literature for assistance. The bulk of published literature describes the practice of NPs in primary care settings and in other countries, and most is either descriptive or opinion based. This paper will identify potential roles for NPs, and discuss possible benefits and pitfalls of introducing NPs into Canadian EDs.

What is a nurse practitioner?
This is not a simple question, and the answer differs from province to province. In Ontario, the term “nurse practitioner” is not a protected title and, theoretically, anyone can call himself or herself an NP. There are, however, two specific groups who are commonly referred to as NPs.

Acute care/specialty nurse practitioners
Acute care/specialty nurse practitioners (ACNP) are members of the general class of nurses who have taken specialty training at the graduate level and are working within an extended scope of practice by means of medical directives that are institution specific. These people typically work in acute care areas and specialty clinics.1

Extended class nurse practitioners
Extended class NPs (RN[EC]) are registered nurses who have successfully demonstrated competence to the College of Nurses of Ontario (CNO) as primary health care NPs (PHCNPs). They are experienced nurses with additional education at a baccalaureate or masters-prepared level who have completed an approved PHCNP program and successfully completed a registration examination demonstrating that they are competent to provide primary health care services safely and effectively. They possess advanced knowledge and decision-making skills in health assessment, diagnosis and health care management. As defined by the CNO, PHCNPs have an expanded scope of practice and provide comprehensive health services encompassing health promotion, prevention of diseases and injuries, cure, rehabilitation and support services. In addition to the controlled acts authorized in the Nursing Act (1991) the RN(EC) has the authority to perform 3 additional controlled acts: communicating a diagnosis of disease or disorder; ordering a diagnostic ultrasound; and prescribing a limited range of drugs.

Through changes to other legislation, RN(EC)s have the authority to order specific x-rays and laboratory tests, and to pronounce death in prescribed circumstances. They have the right to practise independently in the community without the use of medical directives.1-5 The Public Hospitals Act in Ontario does not currently allow NPs to practise independently in the hospital; however, this is expected to change with the introduction of regulatory amendments later this year.

International perspectives on ED nurse practitioners
The international literature on NPs in the ED cannot necessarily be extrapolated to the Canadian system. For example, in the US, NPs initially became involved in emergency care because of the need to deliver care to a large number of patients with non-urgent problems in rural EDs.6,7 That role gradually expanded to urban settings,8 but despite several decades of experience, the percentage of emergency patients seen by alternative health care providers remains small.9 To illustrate, the American Academy of Nurse Practitioners estimates that only 1% of US NPs practise in EDs.6

Accident and emergency department NPs are more common in the United Kingdom.10-14 In 1991, 6% of departments in England and Wales provided emergency NP services,10 and by 1995, that number had increased to 63%.15 However, of the 202 major accident and emergency departments surveyed, only 9 had “dedicated” emergency NPs.15

What are the educational requirements for ED service?
There is currently no requirement for ED experience prior to obtaining NP registration; however, published consensus seems to be that a coherent educational strategy and a specialized curriculum are critical before NPs are approved for practice in EDs.6,12,16-18

What are the potential benefits and roles of nurse practitioners in the ED?
Studies have demonstrated that, in primary care settings, NPs can provide high quality care for patients with minor illness and injury, and that this care is associated with high levels of patient satisfaction.19-28 Given that between 40% and 55% of all ED visits involve non-urgent problems,29 NPs have a potential role in the provision of primary care in the ED.

Beyond the provision of care to patients with minor illness and injury, the advanced assessment skills of NPs may help improve the comprehensiveness of ED care. To illustrate, they may be useful for initial triage and patient assessment, in evaluating geriatric patients, in performing sexual assault exams, in admission screening, and in the follow-up of investigations and treatment initiated by emergency physicians. Their skills in patient education, health promotion, injury prevention and patient advocacy may reduce recidivism and help EDs fulfill broader primary care, preventive and social obligations. Several authors suggest that NPs improve access to care, shorten waiting times, reduce the number of patients who leave without being seen, prevent unplanned return visits, increase patient satisfaction and reduce costs;30 however, these conclusions are based on methodologically weak studies and upon experience in primary care settings rather than ED settings.

Currently, institution-specific needs will define the optimal role of the NP. In high-volume low-acuity departments, NPs may increase the efficiency of a fast-track system. In communities where there are large numbers of orphaned patients (e.g., the inner city), NPs could staff satellite primary care clinics. In an urban ED, they may be useful in ensuring comprehensiveness of care and in following-up ED investigations and treatments. Department-specific needs assessments will be fundamental to the successful incorporation of NPs into EDs.

What are the potential pitfalls of ED nurse practitioners?
Too much time spent with individual patients
Emergency practitioners must be efficient, particularly with respect to time management and patient throughput. When dealing with low-acuity problems, emergency physicians typically treat many patients per hour; however, several studies have suggested that NPs can be expected to evaluate and treat only 1 or 2 patients per hour.11,31,32 More studies are required to assess NP effectiveness in the ED but, certainly, in high volume departments, it is doubtful that a single NP will significantly improve patient flow.

Increased nursing workload
It is assumed that the introduction of an NP will, by increasing ED human resources, reduce workload. This may not be true. A 1994 study revealed that, while the introduction of NPs had a beneficial effect on the flow of patients with non-urgent conditions, it also had an adverse effect on ED nurses (2 health care providers working simultaneously generated more work for ED nurses).33

Increased costs
It has been repeatedly suggested that NPs may be a cost-effective alternative to primary care providers. This has not been studied in the ED, and a recent systematic review from the UK suggested that NP cost effectiveness may be less than expected, based on evidence that they perform longer consultations and order more investigations than primary care physicians.21

What is the real imperative for introducing nurse practitioners into the ED?
NPs could play a role in ED primary health care delivery, but it may be more relevant to ask whether they should, and whether their incorporation would mitigate any of the important problems that currently threaten emergency care delivery in Canada.

ED overcrowding?
The #1 problem in emergency care delivery is ED overcrowding.34,35 Governments and health care “experts” continue to suggest that the principal cause of overcrowding is excessive ED utilization by patients with minor illnesses. If this were true, then logical solutions might include deflecting patients to alternative primary care settings or increasing ED efficiency through the use of programs such as “fast-track.”

There is evidence that NPs can provide quality care to patients with minor illness and injury, but would this service reduce ED overcrowding? The likely answer is No. The primary cause of ED overcrowding is not an excessive “influx” of patients with minor illness, but rather a delayed “efflux” of admitted patients who languish on ED stretchers waiting for an inpatient bed to become available.35 This is the result of a shortage of acute care hospital beds or the inappropriate utilization of same. Furthermore, there is recent evidence to suggest that the over-utilization of the ED by the so-called “frequent flyer” is not due to inadequate primary care availability. In fact, many of these patients have adequate access to a family physician.36 The introduction of ED NPs will not ameliorate this problem because it does not address the main causes.

Inadequate human resources?
A major problem facing the ED is the lack of human resources.37 Service delivery is adversely affected by the shortage of both emergency nurses and physicians willing to staff the ED. It may be appropriate to train more emergency nurses and increase the number of full-time jobs to enhance retention, but it is hard to understand the logic of approaching the nursing problem by developing and introducing a higher cost alternative — the NP.

With respect to the shortage of trained emergency physicians, there is no confusion. The emergency NP cannot be considered an alternative to the emergency physician. Although some studies suggest that NPs may be equivalent to junior house staff in dealing with minor illness and injury,25 there is no evidence to suggest they can replace emergency physicians in dealing with higher acuity problems. Further, we believe the “gold standard” is not the junior house officer or similarly inexperienced physician.

The nurse practitioner as a “value added” component to emergency service delivery
Rather than solving existing ED problems, the introduction of the NP should be seen as adding value to the current level of practice. NPs can assist in the management of patients with minor conditions, but to limit them exclusively to low-acuity patients may be unnecessarily restrictive. In fact, their most appropriate role might well lie in the areas of patient education, health promotion, and injury and disease prevention.38-41 The ED is an important component of any disease surveillence network and a major access point for society’s disenfranchised. There are large untapped opportunities with respect to injury prevention and behaviour modification. We recognize the argument that suggests that these may be addressed by non-NP emergency nurses, but the present reality dictates that only with new dedicated and funded positions will these existing gaps in the system be closed.

How should nurse practitioners be incorporated into EDs?
The American College of Emergency Physicians has made recommendations guiding the incorporation of NPs into the ED.42 These guidelines define training and orientation goals and recommend specific limitations on the scope of practice and responsibilities of the NP. They also specify that EDs must develop protocols for credentialing, supervision and quality management.

What are the barriers to implementation?
Funding
There are a number of potential barriers to the introduction of NPs into the ED, but the most pressing and important is the issue of funding.43,44 Payment models for NPs and physicians that will facilitate a harmonious work environment need to be developed in the near term. Neither fee-for-service nor sessional payment models support the use of NPs as independent practitioners. Before NPs can become a permanent component of the Canadian health care system, a sustainable funding model must both address the financial needs of the NP and minimize the potential financial impact on physician incomes.

Malpractice insurance
The Canadian Medical Protective Association recently raised concerns with respect to the potential liability of physicians who work collaboratively with NPs.45 The issue of the extent and type of malpractice insurance coverage available to NPs and the potential liability of emergency physicians who share care in a supervisory capacity must be clarified.43

Conclusion
NPs can provide quality care for patients with minor conditions, and they have expertise in the areas of patient education, health promotion and disease prevention — skills that may enhance the comprehensiveness of ED care. Without evidence of effectiveness or cost-effectiveness in emergency settings, it is unclear whether this justifies their widespread incorporation into ED practice. Institution-specific needs will define the optimal role of NPs in different settings, and future methodologically sound prospective evaluations will define the most appropriate roles for NPs in EDs.

References
Southwest Emergency Systems Network (SESN) Nurse Practitioner Expert Panel: Final Recommendations. SESN Proposal to the Ontario Ministry of Health and Long-Term Care. 2002 Nov.
College of Nurses of Ontario. An RN(EC) primer. Quality Pract 2002;1(4):1-2. Available: http://www.cno.org/publications/qp/qpvol1no4.html#primer (accessed 2003 May 30).
College of Nurses of Ontario. Standards of practice for registered nurses in the extended class (revised Mar 2003). Document no 41038. Toronto: The College; 2002 Oct.
Nurse Practitioner Association of Ontario. Role of PHC and AC NPs. Available: http://www.npao.org/role.html (accessed 2003 May 13).
Council of Ontario University Programs in Nursing: Ontario primary health care nurse practitioner programs (1999). Available: http://www.ryerson.ca/calendar/1999-2000/sec_484.htm (accessed 2003 May 22).
Curry J. Nurse practitioners in the emergency department: current issues. J Emerg Nurs 1994;20(3):207-12.
Winson G, Fox J. Nurse practitioners: the American experience. Br J Nurs 1995;4(22):1326-9.
Roglieri J. Multiple expanded roles for nurses in urban emergency rooms: emergency room nurse-practitioner. Arch Intern Med 1975;135:1401-4.
Hooker R, McCaig L. Emergency department uses of physician assistants and nurse practitioners: a national survey. Am J Emerg Med 1996;14(3):245-9.
Read S, Jones N, Williams B. Nurse practitioners in accident and emergency departments: What do they do? BMJ 1992;305:1466-9.
Read S, George S. Nurse practitioners in accident and emergency departments: reflections on a pilot study. J Adv Nurs 1994;19:705-16.
Tye C. The emergency nurse practitioner role in major accident and emergency departments: professional issues and the research agenda. J Adv Nurs 1997;26:364-70.
Tye CC. Blurring boundaries: professional perspectives of the emergency nurse practitioner role in a major accident and emergency department. J Adv Nurs 2000;31(5):1089-96.
Chang E, Daly J, Hawkins A, McGirr J, Fielding K, Hemmings L. An evaluation of the nurse practitioner role in a major rural emergency department. J Adv Nurs 1999;30(1):260-8.
Meek S, Ruffles G, Anderson J, Ohiorenoya D. Nurse practitioners in major accident and emergency departments: a national survey. J Accid Emerg Med 1995;12:177-81.
Cole F, Ramirez E. Activities and procedures performed by nurse practitioners in emergency care settings. J Emerg Nurs 2000;26(5):455-63.
Cole FL, Ramirez E, Luna-Gouzales H. Scope of practice for the nurse practitioner in the emergency care setting. Des Plaines (IL): Emergency Nurses Association; 1999 Sept. Available: http://www.ena.org/publications/scopes/scopenp.asp (accessed 2003 May 30).
Sanning-Shea S, Selfridge-Thomas J. The ED nurse practitioner: pearls and pitfalls of role transition and development. J Emerg Nurs 1997;23(3):235-7.
Powers M, Jalowiec A, Reichelt P. Nurse practitioner and physician care compared for nonurgent emergency room patients. Nurs Prac 1984;42-52.
Larabee J, Ferri J, Hartig M. Patient satisfaction with nurse practitioner care in primary care. J Nurs Care Qual 1997;11(5):9-14.
Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002;324:819-23.
Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000;320:1048-53.
Alongi S, Geolot D, Richter L, Mapstone S, Edgerton M, Edlich R, et al. Physician and patient acceptance of emergency nurse practitioners. J Am Coll Emerg Phys 1979;8(9):357-9.
Moser MS, Abu-Laban RB, van Beek C. Attitude of emergency department patients with minor problems towards being treated by a nurse practitioner [abstract]. Can J Emerg Med 2001;3(2):135.
Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomized controlled trial. Lancet 1999;354:1321-6.
Spisso J, O’Callaghan C, McKennan M, Holcroft J. Improved quality of care and reduction of housestaff workload using trauma nurse practitioners. J Trauma 1990;30(8):660-5.
Keough V. Emergency nurse practitioners lighten patient loads, boost satisfaction. Nursing Spectrum Career Fitness online Web site. Nursing Spectrum [Chicago & Tri-state edition] 2001 Aug 13. Available: http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=4695 (accessed 2003 May 30).
Rhee K, Dermyer A. Patient satisfaction with a nurse practitioner in a university emergency service. Ann Emerg Med 1995;26(2):130-2.
Kellermann A. Nonurgent emergency department visits: meeting an unmet need [editorial]. JAMA 1994;271(24):1953-4.
Dowling D, Dudley W. Nurse practitioners: meeting the ED’s needs. Nurs Manage 1995;48C-E, 48J.
Walrath J, Levitt M, Styka M. Innovative ED nurse practitioner group practice. Emerg Nurs 1984;10(5):239-41.
Buchanan L, Powers R. Establishing an NP-staffed minor emergency area. Nurse Pract 1997;22(4):175-87.
Wilson C, Farrell M, Bove S. Emergency department nurse practitioners: the AtlantiCare Medical Center program in review. J Emerg Nurs 1994;20(3):195-8.
Canadian Association of Emergency Physicians, National Emergency Nurses Affiliation. Joint Position Statement on emergency department overcrowding. Can J Emerg Med 2001;3(2):82-4.
Drummond AJ. No room at the inn: overcrowding in Ontario’s emergency departments. Can J Emerg Med 2002;4(2):91-7.
Chan B, Ovens H. Frequent users of emergency departments. Do they also use family physician’s services? Can Fam Physician 2002;48:1654-60.
Canadian Association of Emergency Physicians Working Group on the Future of Emergency Medicine in Canada. The future of emergency medicine in Canada: submission from CAEP to the Romanow Commission. Part 2. Can J Emerg Med 2002;4(6):431-8.
Sheahan SL. Documentation of health risks and health promotion counseling by emergency department nurse practitioners and physicians. J Nurs Scholarsh 2000;32(3):245-50.
Lenehan G. Timing is everything: the growing need for emergency nurse practitioners [editorial]. J Emerg Nurs 1993;269-70.
Way D, Jones L, Baskerville B, Busing N. Primary health services provided by nurse practitioners and family physicians in shared practice. CMAJ 2001;165(9):1210-4.
Keane A, Richmond T. Tertiary nurse practitioners. Image J Nurs Sch 1993;25(4):281-4.
American College of Emergency Physicians. Guidelines on the role of nurse practitioners in the emergency department [policy statement]. June 2000. Available: http://www.acep.org/1,583,0.html (accessed 2003 May 30).
Ontario Medical Association (OMA) Task Force on the Working Relationship Between Physicians And Registered Nurses (Extended Class). The working relationship between physicians and registered nurses (extended class): OMA discussion paper. Ont Med Rev 2002;69(10):17-27.
Van Der Horst M. Canada’s health care system provides lessons for NPs. Health Care Issues 1992;17(8):49-54.
Rogers D. MDs worry nurse practitioners won’t be covered by insurance: doctors say they’ll be liable for errors under new Ontario plan. Ottawa Citizen 2002;Nov 19.
Acknowledgement: This article has been peer reviewed.
Competing Interests: None declared.
Correspondence to: Dr. Alan Drummond, 20 Drummond St. W, Perth ON K7H 2J5; fax 613 267-8770, drummond@perth.igs.net

Received: Mar. 14, 2003; final submission: May 12, 2003; accepted: May 20, 2003

2 Responses »

  1. This article is misleading. NP is a protected title in Ontario and you must be registered as a nurse in the extended class to use the title. Many EDs see a high volume of patients that are seeking primary health care services and including NP services in an ED would reduce wait times for these patients. Providing PHC in the ED is well within the scope of an NP. Of course, long term solutions would lie in getting patients to access care through primary care providers in the community rather then accessing services at a tertiary care facility. Furthermore NPs could and are utilized in some EDs as outreach practitioners dispatched to long term care facilities and heading off unnecessary transfers to the ED for episodic illness that are easily treated in the community. Avoiding unnecessary transfers to the ED reduces wait times. The reality is that ED’s in Ontario are unfortunately not necessarily used as emergency only centers and patients seeking PHC services such as treatment of minor to moderate episodic illnesses in an ED is common. These patients can be well served by seeing an NP in the ED-and in so doing reducing wait times.

    • Thanks for your comment and taking the time to read the article.
      I obviously don’t agree with you.
      I think Nurse Practitioners certainly have a role in health care delivery and possibly in a value added role in the emergency department.
      Since access block and ED overcrowding is principally an issue of inadequate bed capacity to allow outflow of patients from the emergency department hard to see your logic.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: