Download - Dr Adeline Wu and Grainne Lowe, Box Hill Hospital: Evaluating The Role Of The Nurse Practitioner Position In The ED: The Service Effect Of The Role From The Drs Perspective

Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,

Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health



Two perspectives of NP in an ED setting:

medical and nursing

Grainne Lowe Adeline Wu

Nurse Practitioner Consultant

Emergency Department Emergency Department

Box Hill Hospital Box Hill Hospital

Where we started

• Submission to DHS 2003/04

– Challenge to existing processes

– Look at new ways

– Improving pt journey

– Improving KPI’s

– Decrease frustration

Identify needs

• Services

– Create equitable delivery for patient groups

• Workforce

– Build capacity

– Strengthen capability

– Gaps in delivery of services

Politics of change

• Change is political

– Tactics

– Negotiation

– Lobbying

– Compromise

Stakeholders • Key partners working together

– Day to day colleagues

• Medical

• Nursing

– Pharmacy

– Pathology

– Radiology

– In/out patient units

Drivers/Champions

• From the top down

– Executive level support

• Across channels

– Referral pathways

• Community access

– Pt knowledge

Eastern Health

• 4 NP positions in ED

– all Endorsed

• Other positions

– Stroke Management

– Mental Health x 5

– Renal

– Palliative

NP as resource

• NP is “...”

• Compliment existing services

• Growth of decision making capability

• Pt satisfaction with access

• Increase volume of timely consultations

Key components

• Role clarity

– Identity

– Scope of practice

– Extensions to practice

– How the role “fits”

Key components

• Professional

• Leadership

• Recognition

• Collaboration

• Integration

Support for NP

• EH NP group

– Sharing ideas

– Problem solving

– Reducing isolation

– Regular meeting with DON

• Strengthening structure

• Professional issues

Future

• EH Nursing Scope of Practice Committee

– Various group representation

– EH Chief Nurse as chair

– Submission of interest

Scope of Practice

• NP scope of practice

– Locally determined

– Practical

– Constructive

– Without undue restriction

– Taking account of extensions to practice

Scope of practice ED

• Initially governed by CPG’s

– To structure extended practice

– Guide development of role

– Multi-disciplinary sign off

• Problems

– Restrictive

– Review and resvision ???

Model of Care • Minor injury / minor illness model

• Fast track guidelines

– Exclusion criteria

– Structure of ED

• Autonomous Collaborative

• Based on need

Value add to ED

• Increase efficiency

• More timely treatment

• Lower acuity presentations

• Increase patient satisfaction

• Provide resource for other staff

– Nursing

– medical





Doctor’s Perspective

My first thoughts….

• “if they want to practise medicine, then

they should go to med school”

Other concerns

• missed diagnoses

• Unnecessary or inappropriate

pathology/radiology requests and

specialist referrals

Other concerns

• ongoing training of junior medical staff

– in particular interns

• Emergency Medicine is a compulsory term to

complete internship

• fear of employment of NPs will eventually

replace medical staff

Resulted in

• specialist units refusing referrals from

nurse practitioners

• ED staff confusing roles of NPs

• perceived competition for patients

Other problems

• extent of scope of practice

– what can you do?

• lack of NP coverage

• loss of skilled nurses to become NPs

Acceptance is a BIG hurdle

In reality

• training of junior medical staff OK

– NPs now teaching

– gaps in rostering still provide opportunities

• NPs will see what they are comfortable

with

Other Benefits

• more cohesive clinical team

– NPs stay longer than interns/RMOs

• frees medical staff to see other patients

– may increase flow through the emergency

department

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Key Performance Indicators

• 4 hour discharge KPIs

• waiting times

• patients who did not wait

• MORE DATA NEEDED

Key Performance Indicators

• pt satisfaction

• unscheduled representations

• adverse events

My Opinion

• NPs are safe

– they are clear who they will and won’t see

My Opinion • NPs have a role in the ED

– increased patient satisfaction

• but further study is needed if there any effects on

ED flow

– greater teamwork

– will not replace doctors

• doctors should not feel threatened

My Opinion

• Teething problems

– training

– initial difficulty in acceptance

• Better education amongst non-NP staff

about scope of practice

Future for Other Departments

• Currently- NPs/NPCs in

– neurology

– psychiatry

• Increasing role in health care

– more widespread acceptance

– doctor shortages

[email protected]

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