> Emergency Medicine Nurse Practitioners are just starting out
> in Australia, unlike those of you in the UK who have several
> decades experience.
>
> I am wondering if anyone with experience in working with NPs
> can offer some advice on the roles, advantages and
> disadvantages of NP EM care?
>


Resurrecting the original thread to allow people to choose which strand of debate the prefer to follow:

Getting an accurate answer is only useful if you're sure you asked the right question. In this case you need to think about what you're wanting to do and why. As with any new post, the roles fall into 3 main categories (in this case I am taking a medical centred view as ENPs work is closer to that of doctors than to other workers):

Substitution:
This is probably the most common use of ENPs in EDs in the UK.
SHOs or equivalent can be replaced with ENPs. Depending on local circumstances ENPs can see up to about a third of patients in a general ED or pretty much all the patients in a minor injuries unit with telemedicine backup. As a substitute for SHOs, ENPs provide service of equivalent quality at a slightly higher cost. They are better at following protocols (but worse at acting when the patient doesn't fit the protocol). They have the flexibility to work well as nurses but do not have the flexibility to move from minors to majors.
ENPs in many cases prefer to follow the patient through from start to finish (i.e. assess and complete treatment). This has the advantage of reducing the number of steps in the process for the patient and reducing handover (and in theory should make it run more efficiently- although I've not seen evidence that it does in practice). It does mean that you are paying ENP wages for standard nursing work.
ENPs can also be used in "See and Treat". My experience of this is that effectiveness can vary. "See and Treat" only really works when the clinician doing it can keep up with the rate of arrival and prevent queues occurring (otherwise it isn't S and T). SHOs and ENPs on the whole aren't fast enough at busy times. The other problem is that on the whole ENPs can't see unselected patients. This means the patients have to be triaged first bringing another step into the process. It also leaves you two parallel walking streams- ENP and non ENP. A variation is where the ENP is the triage nurse and initiates treatment or investigations from triage. This can slow down triage, but can work in some cases.
Cost of training compared to SHOs is lower in terms of total cost (i.e. nursing degree + ENP course) but higher in terms of cost to the hospital (if the hospital pays for their training). Set against this, nurses tend to work for fewer whole time equivalent years during their working life than doctors. It is also possible to import ready trained SHOs with their training paid for elsewhere (often by the doctor themselves) but less easy to do this for nurses.
The advantage to the doctors in the department is that doctors spend a smaller proportion of their time in minors and thus have a more balanced minors: critically ill patients ratio. This can potentially improve training. It can be seen as being a disadvantage as some doctors find minors as a way to relax. We do not know the long term effects on doctors on dealing with nothing but complex cases.
An argument has been put that this allows nurses to progress their career but remain in a clinical context.
Overall this allows you to provide a traditional A and E service of a similar quality to but at a slightly higher cost than a traditional department without ENPs or a low volume minor injuries service at a (usually) lower cost.

Delegation:
Nurse practitioners can be used to take on part of a doctor's existing role to free the doctor up to see more patients. In one sense this could be done by having a separate nurse practitioner minor injuries/ minor illnesses unit with the ED being pure majors (I have a hunch that there may be a move towards this in any case in the UK with the combination of Modernising Medical Careers resulting in a reduction in doctors' numbers and Payment by Results encouraging Primary Care Organisations to look at funding their own minors units rather than paying EDs to do the work). However in general it would involve certain parts of history taking and documentation being done by nurse practitioners (e.g. brief medical note by doctor; full clerking- as already done by ward nurses- by nurse); filling in forms; making phone calls etc.
This could be used to speed up the consultation rate of doctors.
There is a lack of research beyond anecdotal into this area- although there is strong anecdotal evidence that some extended role of nursing speeds up consultation rates, there is little evidence on how far we should go with it or cost effectiveness.
Anecdotally, this allows high quality patient care at a low cost per consultation.
In times of shortage of doctors this may allow a department to see more patients with fewer doctors; although in lower volume departments a minimum number of doctors may be needed regardless of work rate.
It is probably more effective the more senior the doctors are.
It can be particularly flexible as this way of working can be applied to minors, trolley cases or resus cases. In particular it speed up the work of a clinical decisions unit.
On the whole this type of working is not Nurse Practitioner work as the NP role generally involves more autonomous working.

Service Enhancement:
Where a nurse practitioner provides a service not currently provided or a type of care that doctors are not good at.
Someone has mentioned psychiatric nurse practitioners in the ED which is a good example. In general this type of role has been studied in chronic care (for example care of COPD) rather than acute care. There are a number of studies for various types of this model showing improved outcomes but at high costs. Whether this was cost effective would depend on the exact details of the model being proposed.

Matt Dunn
Warwick


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