> <snip> They have the flexibility to work well as nurses
> > but do not have the flexibility to move from minors to majors.
>
> This of course depends on the way in which the systems are set up and
> the training AND education provided...
>
> There is a degree of skirting around this issue with such things as
> 'interventional assessment' and 'nurse led CDU protocols'
>
As a general rule a SHO can see the majority of patients in the department. Nurse practitioners in the various studies can see up to about a third of A and E patients. The actual figure varies, but it is certainly the case that they are more limited than SHOs in the type of patients they can see. While one sometimes comes across definitions of "Nurse Practitioner" or "Emergency Care Practitioner" along the lines of "An autonomous professional able to diagnose, refer and treat unselected patients in given settings", in practice ECPs/ ENPs tend either to see selected patients or to refer patients who don't fit one of their protocols (i.e. either the patients are selected by them or by someone else). Certainly this type of practice is where the research is drawn from.
Nurse led CDU protocols are something I hinted at in a previous post. I've not come across them personally (although obviously others on the list have). My understanding is that they are a little different in that the patient is assessed by a doctor first. This is the "Delegation" role I mentioned before. There is less published work around this, but my thinking is that there is a real possibility that it will save money and lead to a real improvement in care.
This is based on work done on ENPs in various countries. There is no theoretical reason why an ENP could not be trained to see a higher percentage of A and E patients. However, there will still be some patients who can be seen by a SHO and not by an ENP (patients who don't fit any particular category well). Training to this level would require longer training and be more expensive. The other point of note is that in minors, CCU or CDU a relatively large proportion of patients can be covered by a fairly small number of protocols. This has not been tested in majors.
The other point about NPs with trolley patients is that they are often ward based. In these cases they deal with already assessed patients and are dealing with patients selected by a single diagnosis or small range of possible diagnoses either to treat or exclude. In the majors side of an ED they would be dealing with patients selected by presentation which is a rather different way of working.
NPs working in trolleys in EDs is an interesting issue that warrants more research. There are a number of fairly large volume presentations that at first glance seem to me as though they could be dealt with by protocols- collapse ? cause; suspected neck injury from RTA; low back pain; dyspnoea in known asthmatic below a certain age; deliberate self harm including cutting and overdose. If looking at this role it would make sense to look at the workload of a particular department, see if you can get protocols to deal with a sufficient volume of patients during particular shifts to justify an ENP for those shifts and then recruiting rather than bringing in ENPs and then trying to find a job for them.
> Equally you pay 'ENP wages' for 'standard nursing work'
> every time you
> have more than 1 'management' band 6/7/8 and more than the agreeed
> number of ENPs whether band 6/7/8...
>
Yes you do. In staffing a department it is important to look at the needs of the department. As a general rule the more senior (and higher paid) someone is the more flexible they are, so it often pays to have more senior staff rather than more junior. But if you are finding that you are employing someone to do a job that someone less qualified could do in a predictable pattern, you might have your skill mix wrong.
What can actually happen with ENPs is that they will do "normal nursing" on a patient even when there is a "normal nurse" free. This has the advantage of continuity, but you have to weigh this up against the extra cost. Horses for courses.
> >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.
>
> Or indicates that your traige nurses don't have the skill,
> knowledge or
> experience to provide a proper initial assessment service -
I'm not entirely sure what you mean by this. If you are meaning triage nurses not being able to select patients for ENPs, that's not the issue: part of the point of "see and treat" is that you don't need triage. If you are meaning ENPs not having the expertise to provide a proper service, again that's not the issue- at busy times ENPs just can't (on the whole) work fast enough to triage patients as they arrive and initiate treatment or investigations.
> > 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.
>
> What is the accurcy of this figure?
>
Pretty accurate. Can't remember the source off hand, but it was a reliable one.
> >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.
>
> Depends on the locality and also on how nursing management sees
> theaccreditation of prior learning - something which
> medicine seems to
> manage a lot better
>
The original question came from Australia where imported SHOs are common so the cost of their training to that level is effectively free to the Australian health system. One problem with ENPs is that there is no standard national let alone internationally recognised qualification (or indeed standard list of competencies or standard length of training).
> > 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.
>
> Is it a similar quality or will we see / are we beginning to see a
> quality improvement from experienced ENPs especially those
> whowork in a
> mainly ENP role ratherthan equal split between management and ENP
> duties
>
There is certainly no evidence of any quality improvement with time. I wouldn't particularly expect to see one- right from the start the studies have all shown a very low incidence of significant errors by either ENPs or SHOs with the type of patients seen by ENPs. When you're getting it right to start with it's difficult to improve. This tallies with my own experience: in the sort of patients seen by ENPs neither my ENPs or my SHOs make mistakes. Similarly one could argue that the studies are out of date: these days in many departments SHOs see only a minority of patients with the majority being seen by middle grades or consultants so studies comparing ENPs to SHOs are not relevant (and in the UK, the SHO grade will soon disappear). Again, I wouldn't expect to see an improvement in quality between SHOs and consultants in this group of patients (although it may be that consultants are cheaper on a cost per case basis as they are quicker- but I don't think there's much published work on that).
If you look at what the studies on quality of work actually mean, they tend to mean that ENPs and SHOs can apply Ottawa ankle rules; check wrists for bony tenderness; apply the department protocols for dealing with sore throats etc. With seriously ill patients, Nurse Practitioners can apply protocols for thrombolysis for MIs safely etc.
Where one would expect an improvement with experience is in more complex cases where it is not easy to follow a protocol. However there is a lack of research into the safety of using ENPs for more complex cases at present let alone research into whether they improve with experience.
What may well change with time is the excess of bringing patients back for review by ENPs. I have not seen any evidence of this yet (it's probably happening, but nobody seems to have published on it). Complicating matters is the fact that many UK EDs don't run clinics any more. This being the case it may be that more ENP patients are asked to contact their GP. I would expect this to change less with time as there will probably be less feedback to the ENPs on this.
Matt Dunn
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