Nurse Practitioner Models of Care in Rural Northern British Columbian Emergency Care Settings Linda Van Pelt BHSc., Open University, 1999 Project Submitted in Partial Fulfillment Of The Requirements Of The Degree Of Master Of Science Ill Nursing (Family Nurse Practitioner) The University of Northern British Columbia December 2007 © Linda Van Pelt, 2007 UNIVERSITY OF NORTHERN BRITISH COLUMBIA LIBRARY Prince George, BC Nurse Practitioner Role in Emergency Care Abstract Emergency room congestion and long wait times have become prevalent in emergency departments across Canada. Emergency care providers in the Northern Health Authority region of Northern British Columbia also struggle to provide quality emergency care in the face of challenges that impact access to timely emergency care. Nurse Practitioners are a new class of health care provider in British Columbia that have the skills and knowledge to provide care for many of the patients who present to Northern Health Authority emergency departments. The question posed in this project is as follows. Would a model of emergency care utilizing the NP role increase patient access and decrease wait times in British Columbia's Northern Health Authority emergency departments as compared to the current model of care? The focus of this project is a review of literature related to the role of Nurse Practitioners (NPs) in emergency department settings, as well as consideration of NP models of emergency care that would increase access and decrease wait times for quality emergency care in the Northern Health Authority. The results of the literature review support the addition of a NP model of care to emergency care setting in northern British Columbia. As Nurse Practitioners are deployed across British Columbia and the Northern Health Authority, continued assessment, analysis, planning, pilot project implementation, change management, evaluation and research related to NP roles in emergency care settings are pivotal to the successful implementation of NP models of emergency care in the region. 11 Nurse Practitioner Role in Emergency Care Contents[LVPI] Abstract Table of Contents 11 Glossary lll List of Tables IV List of Figures IV Acknowledgements v Introduction 1 2 3 Background Current Model Theoretical Framework Levels of Emergency Care Factors that Impact Care Nurse Practitioners 9 Chapter Two Appraisal of Evidence Inclusion Criteria and Definitions Sources and Search Processes Literature Review and Analysis NP Models and Roles in Emergency Care Patient Satisfaction and Quality of NP Care 11 12 14 14 16 Chapter Three Limitations Implications for NP Practice from Evidence Models of NP Care for NHA Emergency Settings Areas for Future Consideration and Research Recommendations Conclusion 19 20 21 21 22 24 Chapter One 5 6 8 11 References 26 Appendix A 29 Appendix B 39 Ill Nurse Practitioner Role in Emergency Care List of Tables and Figures List of Figures Figure 1- Map of the Northern Health Authority, British Columbia 4 List of Tables Table One- Canadian Triage Acuity Score Levels •'I IV 7 Nurse Practitioner Role in Emergency Care Glossary For the purposes of this project, the following definitions are used: Access-In health care, the opportunity of individuals to receive health care Acuity- Is the extent to which a patient requires medical treatment. A high acuity patient may require resuscitation or intensive care, whereas a low acuity patient may be able to defer their care to a point in time when they could access a primary care provider Acute Care Nurse Practitioner- A nurse practitioner that practice in a hospital or acute care setting Community Hospital- Hospitals in communities outside large centres that provide a variety of health care services Emergency Care Team- The team of providers that delivers emergency care in emergency departments and other health care facilities, comprised of, but not limited medical staff, nursing staff, support staff, nurse practitioners, respiratory therapists, lab and radiology staff, physiotherapists, occupational therapists, social workers, mental health and wound care specialist and homecare. Emergency Department- The department of a hospital or health centre that provides emergency care Emergency Nurse Practitioner- A nurse practitioner that practices in an emergency care setting Emergency Service Providers- Emergency service, nursing, medical, and support personal that together provide emergency health care in an institution or community v Nurse Practitioner Role in Emergency Care Health Centre- Health care centers in small communities that provide a variety of services, which may include but is not limited to general practice, nursing, emergency care, diagnostics, public health, and physical therapy. Health centres normally do not provide inpatient care. Nurse Practitioner- Is a registered nurse who has achieved the College of Registered Nurses of British Columbia competencies required for registration as a nurse practitioner. These competencies are usually achieved through graduate nursing education and substantial nursing practice experience. Nurse practitioners have the competence to provide health care services from a holistic nursing perspective combined with a focus on the diagnosis and treatment of acute and chronic illnesses, including prescribing medications. (College of Registered Nurses of British Columbia, 2006) Primary Care Provider- a medical professional that can provide a broad range or health care services to patients, including diagnosis, treatment, diagnostic investigations, and health promotion and prevention Regional Hospital- A hospital that provides tertiary care for a geographic region Scope of Practice- Activities that registered nurses are educated and authorized to perform as set out in the Nurses (Registered) and Nurse Practitioner Regulation under the Health Profession Act and complemented by standards, limits, and conditions as set out by the College of Registered Nurses of British Columbia (College of Registered Nurses of British Columbia, 2006) Quality Care- The totality of features or properties of an entity, such as an emergency health care system, that bears on its ability to satisfy stated and implied needs VI Nurse Practitioner Role in Emergency Care Urgent Care- A health care service that provides care for unscheduled urgent health care issues, often beyond usual hours of General Practice Clinics Wait times- The period of time from when a patient arrives in an emergency department to the time they are seen by a physician or nurse practitioner. Vll Nurse Practitioner Role in Emergency Care Acknowledgments The few words committed to this page are not enough to express my deep gratitude for all of those who have supported me in my journey through graduate school. I am thankful for all of my formal and informal teachers, from my professors to my family, to the clients who have shown me what it really takes to provide outstanding client centred health and wellness care. Thank you to all of my instructors and mentors. I am very grateful for the generosity of the physicians and nurse practitioners, nurses, addictions specialists, cultural liaisons, physical therapists, administrators and support staff that shared their time and expertise. You have all taught me the incredible value of a team. My thanks to the university staff and the nursing program staff in particular. I simply could not have done it without you. Thank you to my family and friends for supporting me in all my endeavors, graduate school just being the latest one. You give me strength, inspiration, and joy so that I can always move forward no matter what challenge lies before me. Thank you to my classmates for walking the journey with me, through the challenges and triumphs. You have all generously shared your skills, knowledge, experiences, and insights that have inspired me to grow as a person and practitioner, and keep balance in my life. Finally, my sincere gratitude to each and every client that was willing to participate in my learning. I only hope that I can use the knowledge to become a practitioner that can provide the excellence in care each patient deserves. Vlll Nurse Practitioner Role in Emergency Care The Nurse Practitioner Role in the Northern Emergency Care Setting It is estimated that over 50% of patients seen in emergency department settings in Canada require less urgent or non-urgent care, versus emergency care (Canadian Institute for Health Information, 2006). Emergency departments are often stretched to the limit attempting to care for low acuity, primary care clients who decrease access for patients that require specialized emergency care. Solutions to the issue of emergency department congestion and wait times are as complex as the factors that create them. This paper will review the potential role of Nurse Practitioners (NPs) in emergency care provision in British Columbia's Northern Health Region, focusing on the following question, would a model of emergency care utilizing the NP role increase patient access and decrease wait times in British Columbia's Northern Health Authority emergency departments as compared to the current model of care? For the purposes of exploring the notion of a model of emergency care that includes NPs, the busy emergency room at Prince George Regional Hospital will be used as an example to assess the factors that impede and facilitate emergency care provision in emergency department settings in the Northern Health Region. In order to create a context for exploration, the current model of emergency care and factors than impact care delivery at Prince George Regional Hospital emergency department will be discussed related to structure, process and outcomes, as outlined in Donabedian' s model of quality care (Donabedian, 1988). To provide further context, the Nurse Practitioner role and scope of practice in British Columbia (BC) will then be explored, followed by a brief description of the Nurse Practitioner role in emergency departments internationally. A 1 Nurse Practitioner Role in Emergency Care review of literature on the NP role in emergency care will be presented, followed by a review of various models of care that are inclusive of Nurse Practitioners and how they could be added to the complement of emergency care providers in Northern Health Authority Emergency Departments. Finally, the limitations of this paper will be presented, along with areas for further consideration and research, recommendations and conclusions. Chapter One: Background Long wait times for patients, of four hours or more, with the associated decrease in access to medical care and treatment, are making emergency care delivery a continuing topic of concern in Northern British Columbia (Dussault, 2007). Nurse Practitioners are a new category of health care provider available to supply health care in British Columbia, with Nurse Practitioner (NP) programs preparing students at a Master's level of education. NPs are defined as " ... registered nurses who have achieved additional competencies required for registration ... with the College of Registered Nurses of British Columbia (CRNBC). They provide services from a holistic nursing perspective, integrating elements such as diagnosing, prescribing, ordering diagnostic tests, and managing common acute conditions and chronic illnesses in their practice" (British Columbia Ministry of Health, 2006b, p. 1.7). In 2003 the NP role was added to the complement of health care professionals available to provide care in the province with changes to the BC Health Professions Act (Government of British Columbia, 2006). The British Columbia government's goal in 2 Nurse Practitioner Role in Emergency Care introducing Nurse Practitioners was "to improve client health outcomes by increasing accessibility to health care services and filling gaps that presently exist in the health care delivery" (British Columbia Ministry of Health, 2006b, p. 1.3). The evolving role of Nurse Practitioners in BC will be discussed in a later section of the paper. Current Model The current model of emergency care at Prince George Regional Hospital includes initial triage and sorting of patients by a triage nurse. A triage nurse is a registered nurse with additional knowledge and skill in sorting patients presenting in emergency departments, using the Canadian Triage Acuity Scale (CT AS), which categorizes patients to estimate their acuity and associated acceptable wait times (Murray, 2004 ). The CTAS system will be discussed in more detail later in the paper (see figure 1). Patients are then assigned to wait in the waiting area until beds come available, or are placed in emergency department beds where nursing and medical care is provided. Patients are then treated and discharged, or admitted to hospital for further care and evaluation. Emergency physicians and nurses may seek out consultation or referral to specialist medical or nursing care, social work, home and community care, public health, or other services to aid in the care and appropriate disposition of emergency room clients. Prince George Regional Hospital is a referral centre for the entire Northern Health Authority of British Columbia (see figure one), which is the largest of six health authorities covering two thirds of BC's total area (Northern Health Authority, 2007). PGRH provides consultation and tertiary care services to health care facilities and their patients in outlying Northern Health areas (Dussault, 2007). 3 Nurse Practitioner Role in Emergency Care Figure One. Map of the Northern Health Authority, British Columbia ' ' ALBERTA Northern Interior Heahh Service Delivef}' Area U. S. A. Northwest Health Service Delivery Area From "Quick facts about the Northern Health Authority" 2006, by the Northern Health Authority. Copyri ght 2007. Reprinted with permjssion. Emergency care is provided throughout the Northern Health Region by several types of health care facilities. In smaller communities, Health Centers are facilities where nurses and physicians provide primary care as well as out-patient urgent and emergency care. In some locations nurses provide first call care, in which Registered Nurses triage and assess patients independently, and either care for them according to pre-determined protocols, or contact a physician for consultation, orders, or attendance for direct care. Patients needing 4 Nurse Practitioner Role in Emergency Care higher levels of care or requiring admission to hospital are transported by ground or air to the nearest appropriate facility. Smaller community hospitals throughout BC provide emergency outpatient care, with a limited number of in-patient beds available for patients that do not require care, treatment or diagnostics beyond the scope of the small hospital facility. Finally, there are community hospitals in several of the larger communities that provide emergency and outpatient care as well as a range of surgical and diagnostic services depending on the centre. Community hospitals may also transfer clients to tertiary care centers such as Prince George Regional Hospital as needed (Dussault, 2007). Theoretical Framework Donabedian's model of quality assessment of health care assesses the structures and processes in health care settings, and relates them to outcomes of care provided in the setting. Donabedian's structure-process-outcomes paradigm (SPO paradigm) is a classic model used in assessing health care quality (Rhee, 1987; Sibthorpe, 2004). Donabedian contended that without proper assessment and adjustments made to all three components in his model, quality of care could not be achieved or adequately measured (Donabedian, 1988). Structure, process, and outcomes will be discussed and defined in the context of the hospital emergency setting in the following section. Donabedian was an American physician, who wrote extensively on the quality assessment of medical care in emergency departments and other health care settings. His model lends itself to the consideration of the NP role in emergency care in the NHA and 5 Nurse Practitioner Role in Emergency Care Prince George Regional Hospital. Using Donabedian's framework, Northern Health Authority facilities could compare current quality of care indicators and outcomes with desired outcomes by analyzing structures and processes that impact emergency care. Any NHA facility providing emergency care might examine structure and its impact on care by assessing and analyzing structural components of care such as staffing mix, funding and budget, departmental and institutional organization, physical space, available equipment, care provider expertise, available health care resources in the community, and other factors. Process could be assessed and analyzed in a similar manner by identifying components of process that are impacting outcomes, such as patient flow arrangements, patient care delivery models, consultation processes, procedures for responding to demand surges, and admission and discharge disposition processes. Assessing and analyzing the current structures and processes in place in the Northern Health Authority, as described above, would make it possible to find gaps and obstacles to emergency care provision that affect patient outcomes. Once such gaps and obstacles inherent in structure and process are identified, potential solutions such as the addition of a model of emergency care delivery utilizing Nurse Practitioners could be more effectively considered and applied. Levels of Emergency Care All Emergency Department visits do not require high level emergency physician care. Fifty-seven percent of all emergency visits in Canadian hospitals are assessed as non-urgent, primary care visits (Canadian Institute for Health Information, 2006). Nurse practitioners are educated and licensed in British Columbia to provide quality primary care that includes 6 Nurse Practitioner Role in Emergency Care caring for common non-emergent complaints such as those of patients attending NHA emergency departments with a Canadian Triage Acuity Scale Score (CTAS) of four or more, see table one (Murray, 2004). Table One. Canadian Triage Acuity Score Levels Triage Level Levell Resuscitation Reassessment during waiting period Constant Care Level II Emergent Every 15 minutes Level III Urgent Every 30 minutes Level IV Semi-Urgent Every 60 Minutes Level V Non-Urgent Every 120 Minutes Category Note. The data in each column are from "Implementation Guidelines for the Canadian ED Triage & Acuity Scale (CT AS)," by Beveridge, R., Clarke, B. , Janes, L. , Savage, N. , Thompson J., Dodd, G., Murray, M, Nijssen-Jordan, C., Warren, D., Vadeboncoeur, A., Copyright 1998 by The Canadian Association of Emergency Physicians. Adapted with permjssion. Data from the Emergency Department Information System (EDIS), and electronic data collection system, at PGRH indicates that in the first three quarters of the 2006-2007 year, 47% of patients had a CTAS scores of four or five (Khohar, 2006). Common CTAS level four and five complaints are conditions that a NP could typically manage, such as urinary tract infections, sprains and strains, headaches, gastroenteritis, flu like symptoms, sexually transmitted diseases, pelvic pain, non-emergent ear, nose, and throat complaints such as ear ache, sore throat, and respiratory complaints such as mild or moderate respiratory tract infections (Haggerstone, 2007). 7 Nurse Practitioner Role in Emergency Care Factors that Impact Care In 2002 British Columbia developed a Province Wide Emergency Services Project to address the issues of emergency department (ED) congestion and wait times (British Columbia Ministry of Health, 2006a). The project allowed health regions to focus on solutions to the issues impacting their emergency departments directly. In May 2006, Prince George Regional Hospital (PGRH) released its emergency room services strategy, the strategy focused on several elements to improve emergency room care such as the creation of more primary care to health services in the community, and improving urgent surgery access at PGRH. Other elements of the strategy included response planning for demand surges, and short and long term strategies for creating enough acute and community beds. The Northern Health Authority (NHA), along with all other BC health regions, continues to develop strategies to address the factors affecting emergency care in all of its communities (Northern Health Authority, 2006) . Factors impacting emergency care delivery at PGRH include a number of structure and process issues that affect outcomes in emergency care. In relation to structure, several factors have been identified such as lack of nursing and medical staff, funding, lack of space in the ED waiting and care areas, a limited number of beds for admission of ED patients, decreased access to primary care due to a shortage of primary care providers in the area, as well as a lack of local long term and convalescent care beds in the community (Dussault, 2007). A number of process related factors have also been identified such as patients with non-urgent complaints congesting the emergency department, and prolonged wait times for diagnostic services and results. Other process factors such as lengthy discharge planning, 8 Nurse Practitioner Role in Emergency Care wait times for specialist consultation and care, and time spent by emergency physicians providing consultation to outlying facilities also impact emergency care delivery at PGRH. Disposition of emergency patients can be delayed by any of the above structure and process issues, which in turn affects the outcomes of emergency patients at PGRH (Dussault, 2007). Factors such as those listed above have been identified in emergency settings across Canada and the NHA (Canadian Institute for Health Information, 2006; Government of British Columbia, 2005; Northern Health Authority, 2006), and could be applied to most if not all facilities providing emergency care in the NHA. Nurse Practitioners Nurse Practitioners began independent practice in British Columbia in 2005 (Provincial Health Services Authority, 2005), and currently work in a variety of roles and practice settings from community family practice to tertiary hospital cardiology units. At the time of writing, two nurse practitioners practice in the Northern Health Authority, one in a small community providing primary and urgent care at a community Health Centre, the other providing primary care at an interdisciplinary downtown health clinic (Evanson, 2007). Nurse Practitioner scope of practice in British Columbia is governed by the College of Registered Nurses of British Columbia (CRNBC), and includes assessment, diagnosis, and treatment of medical conditions including the ordering of diagnostic tests and prescription of medications (College of Registered Nurses of British Columbia, 2006). NP's also provide a wide variety of other patient care activities such as counseling, public health care, and prevention and health promotion. NPs may also, depending on their work settings, carry out health program planning and individual and community health and wellness capacity 9 Nurse Practitioner Role in Emergency Care building activities. Nurse Practitioner models of care are holistic and comprehensive, most often focusing on an interdisciplinary team care approach (Canadian Nurses Practitioner Initiative, 2006). Nurse Practitioner practice and licensure are not yet standardized in Canada; making scopes of practice, types of practice, and licensure different in each province (Canadian Nurses Practitioner Initiative, 2006). Internationally, the roles of the Nurse Practitioners specializing in emergency care are at varied stages of development. In the United States, there are specialized emergency NP educational programs at the both the masters and doctoral level (Cole, Ramirez, & LunaGonzales, 1999), with NPs from varied educational backgrounds practicing across the entire spectrum of emergency care settings from rural hospitals to level one trauma centers (Cole & Ramirez, 2005; Cole, Ramirez, & Luna-Gonzales, 1999). In the United Kingdom, Accident and Emergency Nurse Practitioners work in varied roles and capacities (Barr, Johnston, & McConnell, 2000; Cooper, Lindsay, Kinn, & Swann, 2002; Sakr et al., 2003). Nurse Practitioner education and licensure is not, however, standardized in the United Kingdom as it is in the Unites States and British Columbia. NPs also work in emergency care settings in Australia in a variety of capacities, similar to the United Kingdom (Chang et al., 1999; Consindine, Martin, Smit, Winter, & Jenkins, 2006). Australia does not have standardized Nurse Practitioner education and licensure that spans all of its provinces (Canadian Nurses Association, 2002). The scope of practice of NPs in British Columbia focuses on the care of common episodic and chronic conditions, including their diagnosis and treatment (College of Registered Nurses of British Columbia, 2006). Implementing a NP role in the PGRH 10 Nurse Practitioner Role in Emergency Care emergency department or in a near by parallel clinic, for instance, could potentially provide care for up to 4 7% of the clients presenting to the department with CTAS level four and five scores (Khokhar, 2006). NP models of care would also be relevant to other facilities providing emergency care in the NHA, as the number of Canadian Triage Acuity Scale level four and five clients presenting at other NHA facilities would also be at or near that national average of 57% (Canadian Institute for Health Information, 2006). Chapter Two: Appraisal of Evidence Inclusion Criteria and Definitions The literature search completed for this project was intended to capture English language information on the topic of nurse practitioners providing emergency care in both rural and urban settings. The search was conducted for articles between 1990 and 2006, but early articles were considered if they filled obvious information gaps, published and unpublished works were considered. Studies were sought with adult or pediatric participants, measuring any or all of the outcomes of quality of treatment or care, wait times, access, and cost. Articles from Canada, the United States, Britain, and Australia were identified. Three randomized control trials (RTCs) were located. No systematic reviews (SRs) were located through the search process. No evidence based practice guidelines (EBPGs), or outcomes management reports (OMRs) were located using the outlined search parameters. One systematic review is in progress in Australia, which is due to be completed in late 2007. Studies from the US, Australia and the UK were utilized for this project. No specific exclusionary criteria were applied. 11 Nurse Practitioner Role in Emergency Care Sources and Search Processes The CINHAL, Medline, and Psyclnfo databases were searched to establish keywords. The results of a search of identified keywords can be found in Appendix B. These key words included: emergency, nurse practitioner, emergency nurse practitioner, acute care nurse practitioner, rural and remote underserved. An EBSCO multi database search of Medline, CINHAL, pre-CHINAL, Academic Search Premier, Alt Health Watch, Health Source: Nursing/Academic Edition, and Psyclnfo was completed, the results are shown in Appendix B, Table B 1. A search of Pubmed provided a total of 31 articles, as presented in Appendix B, Table B2, related to the topic, all of which had been captured in the EBSCO search. A search of the Joanna Briggs Institute located 11 potential articles for consideration, shown in Appendix B, Table B3, none of which were relevant to the topic after review. The Cochrane Database of Systematic Reviews provided 24 articles, none of which were relevant to the topic after review; the results are shown in Appendix B, Table B4. A further application of the remaining Cochrane Databases to search number four from the Cochrane Database of Systematic Reviews search yielded a total of 35 articles, Appendix B, Table B5. Of the six relevant articles identified, five had already been identified in the EBSCO search, leaving a total of one new article found. The following websites were also searched for relevant articles and studies: Health Canada, Ontario Association of Nurse Practitioners, American Association of Nurse Practitioners, The Canadian Rural Health Research Society, The Canadian Association for Health Services and Policy Research, The British Columbian Nurse Practitioners Association, The American College or Nurse Practitioners, the Australian Nurse Practitioners 12 Nurse Practitioner Role in Emergency Care Association, and the Royal College of Nursing; Nurse Practitioner Association website, though no articles were located by this method. The British Columbia Ministry of Health website was searched with two articles located, and the Northern Health Authority website was also searched with one relevant article located. In addition, bibliographies were searched to locate articles not found in database searches, and one additional article was found by this method. Hand searching of journals was not carried out. Attempts were made to contact experts in emergency NP practice and institutions utilizing ED NPs, no replies to queries have been received to date. Similarly, attempts were made to connect with the emergency medical staff at PGRH with no contact made at the time of writing. After the search process was complete, 112 articles were identified as potentially relevant to the topic at hand; thirty relevant articles have been retrieved. Of those thirty articles, fifteen were found to be appropriate for the literature review section of this project As a graduate NP student at the University of British Columbia, the author also gathered information NP practice models during a clinical rotation at Oregon Health Sciences University (OHSU) Emergency Department, in the NP led fast track and observation units (Rondeau, 2006). The author also made considered the potential NP roles during clinical rotations in Northern Health emergency departments in Masset and Smithers British Columbia, and received information regarding the actual NP role that exists at Fraser Lake Health Centre while attending two NP skills workshops there. 13 Nurse Practitioner Role in Emergency Care Literature review and analysis Three randomized control trials (RCTs) were located related to the topic of NP provided emergency care in multiple settings. Much of the literature on emergency nurse practitioners has been written in Great Britain, Australia and the USA, with the majority of RCTs being from the UK. The limitation the use of international literature places on this project will be discussed later in the paper. Details of the literature review can be found in Appendix A, a summary of the findings follows. NP Roles and Models in Emergency Care The information provided in Cole, Ramirez, & Luna-Gonzales' (1999) scope of practice document, that discusses emergency NP scope of practice in the United States provides valuable information for the foundation of scopes of practice for the NP in emergency settings in Canada (Cole, Ramirez, & Luna-Gonzales, 1999). NPs in the United States have master's level preparation, and practice under the jurisdiction of state laws. These similarities to the evolving situation in British Columbia, make Cole, Ramirez, and LunaGonzales' document a relevant reference to the development of emergency NP scopes of practice in the province and in Canada. While it does not provide statistical data, this document does address issues of emergency department NP education, practice environment, practice scope, practice arrangements, regulation, and ethics. Brook and Crouch's (2004) British nursing expert opinion paper does not contribute hard data to the consideration of emergency NP care models, however it does provide signposts for development of the role, such as ensuring standardization of emergency nurse practitioner of education, as well as the need for comprehensive workforce planning when considering the emergency nurse 14 Nurse Practitioner Role in Emergency Care practitioner role (Brook & Crouch, 2004). Dowling and Dudley's (1995) descriptive study of utilizing emergency department census data from one emergency department in the Southwest United States to implement an emergency NP role informs the emergency NP model creation process by providing a management perspective on the viability and value of the role (Dowling & Dudley, 1995). The studies by Griffin and Melby (2006), Ritchie (2004), and O'Meara, Burley, & Kelly (2002), each considered different issues related to the emergency NP role. Griffin and Melby's, 2006 United Kingdom questionnaire study considered the attitudes of emergency department physicians and RNs regarding the emergency NP role, utilizing a Likert scale questionnaire. Griffin and Melby found that support for the NP role in the emergency department was mainly positive, but found that role blurring and boundaries between NP and MD roles, and concern over educational consistency for emergency NPs were issues identified as being important by study participants. The study, as pointed out by the author, was open to many types of bias including those caused by social and cultural factors and those due to questionnaire design (Griffin & Melby, 2006). O'Meara, Burley, & Kelly's focus group study identified essential elements for rural urgent care systems, including education and support systems. The information in this study would contribute to the consideration of rural and remote urgent and emergency care design in Northern BC, as it provides a framework for identifying key infrastructure and personnel components of urgent care systems in rural and remote settings, identifying that rural and remote urgent care systems consist of a balance of integrated elements in personnel and infrastructure (O'Meara, Burley, & Kelly, 2002). The study was phenomenological and did not provide statistical data. 15 Nurse Practitioner Role in Emergency Care Mason, Fletcher, McCormick, Perrin, & Rigby's (2005) British study of the use of an Objective Structured Clinical Examination (OSCE), as an evaluation tool for emergency NP competency can inform the development of the NP role in BC by providing a structure to identify competencies for NP emergency practice in the region, and as a potential tool for evaluating baseline competency and evolution of practice over time. This study was well conducted but underpowered due to a small sample, N=17 from a single practice site, which potentially limits the generalizability of the study. The study found that the OSCE was valuable in assessing NP knowledge and skills and was valuable when used in conjunction with continuing education programs, but warned it was a labour intensive process, pointing out that there were many other methods of competency assessment that could be utilized such as direct observation, measurement of outcomes such as unplanned return rates and missed xrays, and other forms of testing such as multiple choice exams (Mason, Fletcher, McCormick, Perrin, & Rigby, 2005). Patient Satisfaction and Quality of NP Care Chang, Daly, Hawkins, McGirr, Fielding, Hemmings, O'Donoghue, &Dennis's (1999) Australian study compared the management and treatment of wounds and blunt limb trauma between NPs and emergency physicians. The study reported no significant difference between NPs and physicians in regard to patient satisfaction, wait times, and quality of care. The study has some methodological issues regarding analysis, as the authors did not provide details of statistical analysis including, p-values and confidence intervals (Cis), making assessment of validity difficult. Cooper, Lindsay, Kinn, & Swann (2002), completed a British randomized control trial to validate a data collection instrument specifically designed 16 Nurse Practitioner Role in Emergency Care to collect data on NP care, with the findings of the study related to NP versus physician care in the emergency department incidental to the validation of the data collection instrument. Cooper, Lindsay, Kinn, & Swann's study compared patient satisfaction and quality of documentation between NPs and physicians, finding that NPs had a higher overall satisfaction rating by patients, and had higher quality documentation with similar consultation times to that of physicians. Cooper et al. provided a detailed reporting of their statistical findings with confidence intervals and p-values included for all variables measured, control of confounders and bias were addressed, and study limitations discussed, allowing the reader to assess validity and reliability. Sakr, Kendall, Angus, Sunders, Nicholl, and Wardropes' (2003) prospective British study (2003) compared clinical effectiveness and cost of minor injury services provided by NPs in a minor injury unit compared to emergency physician care in the Great Britain. Sakr et al. provided a detailed statistical analysis for the tested variables in their clinical effectiveness study, p-values, confidence intervals, and control of biases and confounders was provided allowing for a positive assessment of the study's reliability and validity. They identified that emergency NPs working in the minor injury unit provided safe care that was equal an in some resects superior to that provided by physicians, with wait times that were much less (Sakr et al., 2003). The findings of Sakr et al. (2003) were positive regarding the NP role in emergency, congruent with those of Chang et al, ( 1999) and Cooper et al. (2002 ), finding high patient acceptance of the emergency NP role. Consindine, Martin, Smit, Winter, and Jenkins' (2006) Australian case control study which considered how emergency nurse practitioner care impacted emergency patient flow, 17 Nurse Practitioner Role in Emergency Care supported the NP role in the emergency setting. Consindine et al. (2006) found that there were no significant differences between physician and emergency NP length of stays, p>0.28, and treatment times, p >0.41(Consindine, Martin, Smit, Winter, & Jenkins, 2006). This study had a sample 102 patients' seen by NPs and 623 patients seen by emergency physicians, and provided detailed analysis including confidence intervals, p-values, and control of variables. Consindine et al. 's study limitations included the study being completed at a single site potentially decreasing its generalizability, and its small sample size of patients in the emergency NP group. Organ's 2005 British retrospective study, n=725, considering emergency NP patient satisfaction and emergency NP documentation and radiographic interpretation. Organ's study had positive findings indicating high patient satisfaction, high NP scores on the documentation audit, and a high level of radiologists agreement with NPs on radiographic interpretation (Organ, 2005). Ritchie, a British emergency NP, utilized a non-validated questionnaire to measure patient satisfaction of an emergency NP referral clinic that provided care for non-urgent client referred from the local emergency department. The study has positive findings related to NP care, although some clients were dissatisfied that they were referred to a next day clinic instead of being seen in the emergency department. The size of the study limits its power and generalizability; however, findings supporting the NP role in emergency care were consistent with other studies in terms of patient satisfaction with NP care in the emergency setting (Ritchie, 2004). 18 Nurse Practitioner Role in Emergency Care Chapter Three Limitations The literature cited in this paper originated from first world countries outside of Canada, including Australia, Great Britain, and the United States. While applying data from other countries is problematic due to differences in the definition, role, education, practice status, and licensure of Nurse Practitioners in the countries of comparison; it was necessary to include data from developed western countries, with similar medical traditions and models to Canada's, to supply sufficient data related to the NP role in the emergency department. There is no formal standard of education, protection of title, or legislation addressing the scope and independence of NP practice in Great Britain. New South Wales is the only state which has legislation related to recognition and accreditation of NPs in Australia, while other areas of Australia have no such legislation. In the United States legislation addressing scope and independence of practice and licensure of NPs are created by each individual state (Canadian Nurses Association, 2002). The literature review is limited to articles found in a non-exhaustive search utilizing specific search engines during a specific span of time. Further investigation is warranted to ensure that all relevant data and seminal articles on NPs in the emergency care setting have been identified. Further consultations with institutions currently utilizing NP models, and NHA emergency care teams also must be completed to provide adequate information upon which to base NP emergency model selection and creation for NHA facilities. In addition complete analysis of PGRH Emergency Department Information System data should be 19 Nurse Practitioner Role in Emergency Care undertaken, as the EDIS data accessed for the purposes of this paper represents less than one year of information regarding the PGRH emergency department. Implications for NP Practice from Evidence The studies and articles cited in the Review of Literature and information gathered during clinical rotations at NHA facilities and at Oregon Hospital Science University Emergency Department is applicable to the question posed by this project. Would a model of emergency care utilizing the NP role increase patient access and decrease wait times in British Columbia's Northern Health Authority emergency departments as compared to the current model of care? Data from the literature reviewed supports the integration of NP models in emergency care settings within the Northern Health Authority to decreased wait times and increased access to quality care. The work of Cummings, Fraser, and Tarlier (2003), suggests that Nurse Practitioner role design and implementation for acute care settings, such as emergency departments, should be planned and tailored to the needs of the setting for which they are being implemented (Cummings, Fraser, & Tarlier, 2003), with no one model being suited for all circumstances. Cummings, Fraser, and Tarlier's article describes the implementation of the NP role in a major Canadian tertiary care centre and identifies the key elements of role definition, support of key players, and organizational change as instrumental to the success of implementing the NP role within any acute care setting. Support of the province, the health region, the communities, and other health care providers would be essential to the success of emergency nurse practitioner models and role development in the Northern Health Authority. The utilization of Donabedian' s ( 1988) structure, process, and outcomes model for assessing 20 Nurse Practitioner Role in Emergency Care quality of care would provide a framework from which NP models of emergency care in the NHA could be created, implemented and evaluated. Models of NP Care for NHA Emergency Settings Model selection and creation for NP practice in NHA emergency settings should be based on the needs and characteristics of the emergency department or facility being considered. Some potential models for the emergency NP role in BC include mixed physician/NP staffing of emergency departments, including NPs first-call , NP led minor treatment or same or next day emergency department follow up clinics, and or emergency observation units (Chang et al., 1999; Cooper, Lindsay, Kinn, & Swann, 2002; Ritchie, 2004; Rondeau, 2006; Sakr et al., 2003). Tertiary care centres such as PGRH would benefit from NPs providing care in parallel or in department minor treatment units, same or next day emergency follow up clinics, and emergency short stay observation units. Community hospitals would benefit from similar NP models, as well as mixed physician/NP emergency department staffing. Similar benefits would be experienced by Health Centres in small NHA communities by utilizing a NP emergency care models, with NPs sharing emergency call, and providing both emergency and primary care during regular health centre hours. Areas for Future Consideration and Research There are several next steps in the consideration of NP models of care for NHA emergency settings. The first would be to ensure that all relevant local, national, and international articles and studies have been identified and reviewed. Further, consultations with Northern Health Authority Administration, and each NHA facility's administration and 21 Nurse Practitioner Role in Emergency Care emergency care team would be required, as well consulting with emergency departments and rural care facilities with established NP models in Canada, USA, Britain, and Australia. Such consultation would inform the model selection process for each NHA facility. Following the research and consultation processes, a situational analysis for each NHA facility considering a NP model of emergency care, as well as for the NHA as a whole would be necessary. Such a process would benefit from a theoretical framework such as Donabedian's structure, process, and outcome model, as it allows for a systematic approach to needs assessment with quality of care at its core. The situational analysis would be designed to identify the needs of the entire health authority as well as the needs of each individual community and setting. Consideration of all of the factors that impact emergency care in each facility, including but not limited to current models of care, organizational culture, current structures and processes, structure and process issues, philosophies of care, levels of acuity, emergency department use patterns, demographics, and human resources would be key to planning successful NP care models. Following the analysis, models of NP emergency care would be created for each setting in question, and planning, implementation and evaluation of a NP model of emergency care in each setting would then begin. Ongoing evaluation and development of the NP role in emergency care in Northern BC would then be important for assessing outcomes of NP model implementation as well as to inform future inquiry and research into the NP role in emergency care in B.C. Recommendations This project was completed as a requirement for the Family Nurse Practitioner program at the University of Northern British Columbia in Prince George BC. 22 Nurse Practitioner Role in Emergency Care Dissemination of the findings of this project will include presentations to project committee members, UNBC Nursing Department faculty and staff, and students; presentations to Northern Health Authority administration and emergency health care providers, as well as article submission to appropriate nursing and health care journals. The preliminary recommendations that follow are the author's personal view based on the data reviewed in the literature, already existing models of NP emergency care, and Northern Health Authority data, utilizing Donabedian' s structure, process, and outcomes model as a framework. The recommendation focuses on Prince George Regional Hospital's busy emergency department as a pilot site for the integration of Nurse Practitioner models of care into emergency departments and health centres in the Northern Health Authority. Prince George Regional Hospital experiences emergency department congestion and long wait times of up to four hours or more, with approximately 47% of its clients triaged with low acuity CTAS level four of five conditions. Given the space limitations of the PGRH emergency department, I would recommend that a parallel Nurse Practitioner clinic offering minor treatment and same and next day treatment and follow up be created outside of the emergency department, inside or near to the PGRH building. The clinic, would be aligned with the emergency department and have access to all PGRH services such as lab, diagnostic imaging, and support personnel, and have a dedicated staff and waiting area serving lower acuity, CTAS level four or five clients. Clients would be triaged directly from the emergency department, or referred to the next day clinic, with a specific appointment time, if they do not require same day care. Emergency room clients requiring follow up would also be booked into at next day clinics as required. The implementation of a parallel NP Clinic providing minor treatment and same and next day care could potentially decrease 23 Nurse Practitioner Role in Emergency Care PGRH emergency department traffic by over 40%, and increase access for clients seeking emergency care for both high and low acuity conditions. Implementation of such a model will follow the process outlined in the previous sections of this paper. It is recommended that continued research and consultation, and a situational analysis of NHA sites which provide emergency care occur, utilizing an NP model of development, implementation and evaluation. The project would consider budgetary and physical constraints, engage key players, and manage organizational change and role integration as a collaborative process with the goal of decreasing wait times and increasing access to high quality emergency care atPGRH. The creation of a NP Clinic pilot project at PGRH would provide an opportunity to explore not only potential NP models of emergency care for the NHA, but would also allow for exploration and evaluation of assessment, implementation, and evaluation processes that would best support integration of NP models of emergency care in the Northern Health Authority. Such a pilot project could also aid in identifying specific areas for future research. The creation of a well planned NP led parallel minor treatment and same or next day follow up clinic at PGRH would provide the opportunity for this exploration, while improving access and decreasing wait times for PGRH emergency room clients. Conclusion Providing access to quality, timely emergency health care is a priority for the NHA (Northern Health Authority, 2006). Based on the literature reviewed, the answer to the question posed by this project can be answered affirmatively, the NP role in emergency care provision in the NHA can decrease wait times and increase access to care as compared to 24 Nurse Practitioner Role in Emergency Care other models of care. Nurse Practioner models of care are well suited to increase access to quality emergency care, while reducing wait times. Nurse Practitioners are educated and licensed to provide high quality patient care for conditions that are commonly seen in emergency departments in the NHA, such as the CTAS level four and five clients that make up 47% of the patient visits in facilities such as Prince George Regional Hospital. NP care is client-focused and interdisciplinary, favoring a comprehensive team approach that contributes to positive outcomes for clients, communities, and the health care facilities. The literature outlines the high level of acceptance and satisfaction with NP care in the emergency setting, this project provides a summary of recommendations of models of care as well as identifying NPs as providers of quality care in the emergency setting. Integration of Nurse Practitioner models of care into or proximate to NHA emergency departments could be a valuable part of NHA's overall strategy to improve emergency care in all NHA facilities. 25 Nurse Practitioner Role in Emergency Care References Barr, M., Johnston, D., & McConnell, D. (2000). Patient satisfaction with a new nurse practitioner service. Accident and Emergency Nursing, 8, 144-147. British Columbia Ministry of Health. (2006a). Activities underway to improve emergency care. Retrieved November 2 2006. from http://www2.news. gov. bc.calnews releases 2005-2009/2006HEALTH004 7000923.htm. British Columbia Ministry of Health. (2006b ). Resource Manual for Nurse Practitioners. Retrieved May 22,2007, from http://www.hlth.gov.bc.calmsp/infoprac/np/slnurseprac in bc.pdf Brook, S., & Crouch, R. (2004). Doctors and nurses in emergency care: where are the boundaries now? Trauma, 6, 211-216. Canadian Institute for Health Information. (2006). Understanding Emergency Department Wait Times, Who is Using Emergency Department and How Long are They Waiting? Ottawa: Canadian Institute for Health Information. Canadian Nurses Association. (2002). Role of the nurse practitioner around the world. Fact Sheet Retrieved November 8, 2006, from http://www.cnanurses.ca/CNA/documents/pdf/publications/FS 11 Role Nurse Practitioner March 2 002 e.pdf Canadian Nurses Practitioner Initiative. (2006). Canadian Nurse Practitioner Initiative. Retrieved November 15, 2006, from http://www.cnpi.calindex.asp?lang=e 26 Nurse Practitioner Role in Emergency Care Chang, E., Daly, J., Hawkins, A., McGirr, J., Fielding, K. , Hemmings, L., et al. (1999). An evaluation of the nurse practitioner role in a major rural emergency department. Journal of Advanced Nursing, 30(1), 260-268. Cole, F., & Ramirez, E. (2005). Nurse Practitioners in Emergency Care. Top Emergency Medicine, 27(2), 95-100. Cole, F., Ramirez, E., & Luna-Gonzales, H. (1999). Scope of Practice for the Nurse Practitioner in the Emergency Care Setting. Des Plaines, a. College of Registered Nurses of British Columbia. (2006). Scope of Practice for Nurse Practitioners (Family). Vancouver: College of Registered Nurses of British Columbia. Consindine, J., Martin, R. , Smit, D., Winter, C., & Jenkins, J. (2006). Emergency nurse practitioner care and emergency department patient flow: Case -control study. Emergency Medicine Australasia, 18, 385-390. Cooper, M., Lindsay, G., Kinn, S., & Swann, I. (2002). Evaluating Emergency Nurse Practitioner services: a randomized controlled trial. Journal of Advanced Nursing, 40(6), 721-730. Cummings, G., Fraser, K., & Tarlier, D. (2003). Implementing Advanced Nurse Practitioner Roles in Acute Care. Journal of Nursing Administration, 33(3), 13-145. Donabedian, A. (1988). The Quality of Care: How can it be assessed? Journal ofthe American Medical Association. Dowling, D., & Dudley, W. (1995). Nurse Practitioners. Meeting the ED's Needs. Nursing Management, 24(1), 48c-48j. 27 Nurse Practitioner Role in Emergency Care Dussault, C. (2007). Discussion on Emergency Care at Prince George Regional Hospital. In Linda Van Pelt (Ed.). Prince George. Evanson, C. (2007). Nurse Practitioners in the Northern Health Authority. In L. V. Pelt (Ed.). Prince George. Government of British Columbia. (2005). Petformance Agreement between the Ministry of Health Services and the Northern Health Authority. 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Assessing the Qulaity of Care In a Hospital Emergency Unit: A Framework and its Application. Quality Review Bulletin, 13(1), 4-16. Ritchie, L. (2004). Meeting the challenge: an evaluation of the ENP clinic. 12(2), 10-13. Rondeau, D. (2006). NP lead emergency department observation unit at Oregon Hospital Sciences University. In L. V. Pelt (Ed.). Portland. Sakr, M., Kendall, R., Angus, J., Saunders, A., Nicholl, J., & Wardrope, J. (2003). Emergency nurse practitioner: a three part study in clinical and cost effectiveness. Emergency Medical Journal, 20, 158-163. 29 Nurse Practitioner Role in Emergency Care Sibthorpe, B. (2004). A Proposed Conceptual Framework for Perfomance Assessment in Primary Health Care. Retrieved May 20, 2007, from www.anu.edu.au/aphcri/Publications/conceptual framework.pdf 30 ' I I I I I (2000) Barr, M., Johnston, D.,& McConnell, D., Author& Date (Ireland) Patient satisfaction with a new nurse practitioner service Title Not stated Framework -Patient Satisfaction survey of patients seeingNP -Retrospective X-ray Audit Design -For x-ray study a comparison of x-ray interpretation between NP and ED MD groups Variables -85 x-ray reviews -241 Satisfaction questionnaires Sample 31 Details not provided other than percentages directly obtained from survey or x-ray audit Measurement Review of Literature Appendix A Not discussed Data Analysis -NP role was not known to most patients prior to attending hospital -The wait times for NPs, 22 minutes, was four times less than for MDs at 86 minutes -NPs were given an overall high satisfaction rating with 100% of those responding n=I87 who saw NPs stating they would recommend them to others -Both NPs and MDs had high level of diagnostic accuracy when interpreting x-rays, with similar false negatives and positives. X-rays were ordered appropriately by both groups. Findings -Results comparable with RTC and studies on patient satisfaction and clinical ability of NP vs. ED MDs -Not RTC Strengths Weaknesses Author& Date Cooper, M., Lindsay, G., Kinn, S., & Swann, I. (2002) (Scotland) Evaluating Emergency Nurse Practitioner Services a randomized controlled trial (RTC) Title Framework Not Stated RTC Design -Patient Satisfaction with NPcare vs. Senior House Officer (SHO)/MD care - NP vs. Senior House Officer (SHO)/ MD documentation Variables -Convenience sample of 199 eligible patients over 16 yrsold attending a emergency department in Glasgow over a two month period in 1998-1999 Sample 32 214 patients with specific minor injuries were randomized into NP or SHO group, following treatment a questionnaire was filled out by the patient. Clinical documentation was assessed using a documentation audit tool, a follow up questionnaire was sent to participants one month after the visit, and missed injuries and return visits to the ED were monitored. Measurement Data from previously validated satisfaction questionnaires, the documentation audit tool, and missed injuries & return visits were coded and entered into MS Access database. SPSS was used to analyze the data. Description stats were calculated for all variables and histograms were plotted to ensure that the data were normally distributed. Two tailed t- tests were applied to continuous variables. Categorical variable where chi-square tested for independent samples, or Fisher's exact test if values were less than 5 in any cell. The MannWhitney U-test was used to analyze ordinal data from patient questionnaires. Data Analysis -Patients were satisfied with both NP care and SHO care, with clients reporting NPs were easier to talk to, p= 0.009, and gave more information p=0.007. - Overall clients were more satisfied with NP care, p