Evaluating outcomes of the emergency nurse practitioner role in a
major urban emergency department, Melbourne, Australia
Natasha Jennings
CCC, Grad Dip Adv Clin Nurs, MN, BN, RNEmergency Nurse Practitioner, The Alfred Emergency and Trauma Centre, Prahran, Vic., Australia
Gerard O’Reilly
MBBS, FACEM, Grad Cert CT, MPHEmergency Physician, The Alfred Emergency and Trauma Centre, Prahran, Vic., Australia
Geraldine Lee
BSc, PGDE, RGNPostgraduate Course Coordinator, School of Nursing and Midwifery, Latrobe University, Melbourne, Vic., Australia
Peter Cameron
MBBS, MD, FACEMProfessor, The Alfred Emergency and Trauma Centre, Prahran, Vic., Australia
Belinda Free
Grad Dip Crit Care, BN, RNEmergency Nurse Practitioner Candidate, The Alfred Emergency and Trauma Centre, Prahran, Vic., Australia
Michael Bailey
PhD, MSc, BSc (Hons)Consultant Statistician, Epidemiology and Preventatire Medicine, Monash University, Melbourne, Vic., Australia
Submitted for publication: 12 December 2006 Accepted for publication: 19 February 2007
Correspondence: Natasha Jennings
The Alfred Emergency and Trauma Centre Commercial Road Prahran Vic., Australia 3004 Telephone:þ613 9276 3405 E-mail: [email protected] J E N N I N G S N , O ’ R E I L L Y G , L E E G , C A M E R O N P , F R E E B & B A I L E Y M J E N N I N G S N , O ’ R E I L L Y G , L E E G , C A M E R O N P , F R E E B & B A I L E Y M ( 2 0 0 8 )
( 2 0 0 8 ) Journal of Clinical Nursing17, 1044–1050
Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia
Aims and objectives. The aim of this study was to evaluate the impact of the introduction of Emergency Nurse Practitioner Candidates (ENPC) on waiting times and length of stay of patients presenting to a major urban Emergency Department (ED) in Melbourne, Australia.
Background.As part of a Victorian state funded initiative to improve patient out-comes, the role of the Emergency Nurse Practitioner has been developed. The integration and implementation of this role, is not only new to the Alfred Emergency and Trauma Centre but to EDs in Melbourne, Australia, with aims of providing holistic and comprehensive care for patients.
Design. A retrospective case series of all patients with common ED diagnostic subgroups were included. The ENPC group (n¼572) included all patients managed by the ENPC and the Traditional Model (TM) group (n¼2584) included all patients managed by the traditional medical ED model of care. Outcome measures included waiting times and length of stay.
Results.Statistically significant differences were evident between the two groups in waiting times and length of stay in the ED. The overall median waiting time for emergency patients to be seen by the ENPC was less than for the TM group [median (IQR): ENPC 12 (5Æ5–28) minutes; TM 31 (11Æ5–76) minutes (Wilcoxon
p<0Æ001)]. Length of stay in the ED was also significantly reduced in the ENPC group [median (IQR): ENPC 94 (53Æ5–163Æ5) minutes; TM 170 (100–274) minutes (Wilcoxonp<0Æ001)]. The comparison of overall waiting times for ENPC shifts vs. non-ENPC shifts revealed significant differences [median (IQR): ENPC rostered 24 (9–52) minutes; ENPC not rostered 33 (13–80Æ5) minutes (Wilcoxonp<0Æ001)].
Conclusions. This study has demonstrated that ENPCs implementation in Mel-bourne, Australia were associated with significantly reduced waiting times and length of stay for emergency patients. Emergency Nurse Practitioners should be considered as a potential long term strategy to manage increased service demands on EDs.
Relevance to clinical practice.This study is the first in Australia with a significant sample size to vigorously compare ENPC waiting times and length of stay outcomes with the TM model of care in the ED. The study suggests that ENPCs can have a favourable impact on patient outcomes with regard to waiting times and length of stay.
Key words:emergency department, nurse practitioners, nurses, nursing, triage
Introduction
Emergency Departments (ED) are faced with rapidly increasing healthcare service demands. Difficulties accessing primary health care in the community, growth in the number of emergency patient presentations and an ageing population are contributing to these demands (Sykes et al. 2006). Studies in Australia and internationally have found that this increasing demand is leading to longer waiting times and length of stay for patients in the ED setting (Sykes et al.
2006). At the same time, many EDs are having difficulty in recruiting sufficient medical staff to service current service demands.
The term nurse practitioner (NP) is a generic termed used throughout the literature to describe a nurse who has completed additional courses and specialized training to provide a broad range of healthcare services that may include autonomous and independent clinical decision making. The scope of practice, requirements for authority to practice and function of the role is dependent upon the country they work in and its legislative requirements. The emergency nurse practitioner (ENP) is a nurse whom primary role is based in the ED providing emergency care to patients’ within Melbourne, Australia. The NP role is an alternative model of healthcare service delivery to patients. The role of the NP has evolved as its inception in the USA 40 years ago (Department of Human Services 2000, Hamric 2000, Tye & Ross 2000, Loveridge 2001). The literature surrounding
the implementation of the NP role has demonstrated several themes: decreased waiting times, improved patient and staff satisfaction and cost-effectiveness all leading to improved health outcomes (Bruceet al.1988, Tyeet al.1988, Cooper & Robb 1996, Jones 1996, Robertset al.1998, Changet al.
1999, Pinkerton & Bush 2000, Tye & Ross 2000, Loveridge 2001, Benger 2002, Fry 2002, Roblinet al.2004). One study suggests that ENPs can manage up to 30% of the ED caseload using evidence based clinical practice guidelines (Tye 1997).
The development of the ENP role in Melbourne, Australia has enabled experienced registered nurses in the ED setting to extend their skills in the development of clinical decision making and incorporation of evidence-based practice. The ENP practice broadens the nursing role outside the current scope of practice for the registered nurse in five extended practice areas. These extensions include prescribing medica-tions, initiating diagnostic imaging and laboratory tests, approving absence from work certificates, referral to special-ists and admitting and discharging patients (Department of Human Services 2005).
The aim of this study was to assess the impact of the implementation of the emergency nurse practitioner candi-date (ENPC) on waiting times and length of stay for patients presenting to the ED. Only common diagnostic groups commonly seen by the ENPC were included to allow meaningful comparisons between the ENPC and traditional model (TM) patients.
Methods
SettingThe Alfred Emergency and Trauma Centre is one of only two adult level one trauma centres in Vic., Australia. Annual attendances have been increasing by a rate of 17% over the last three years and in 2005 there were 40,084 attendances. The admission rate was 33%. Two ENPCs were rostered to cover peak patient presentation times which included all days except Tuesdays. There was one ENPC rostered per shift allowing greater coverage in the ED over the week.
Emergency nurse practitioner candidate role
In the state of Victoria, the NP role was introduced in 1998. The Department of Human Services (DHS) began developing the NP role in an action-learning model with key stakeholders to fund and evaluate demonstration projects (Department of Human Services 2005). The DHS funded the Alfred in July 2004 as a pilot site and two ENPCs commenced. The title NP is protected by legislation and prevents unauthorized use (Department of Human Services 2006). Nurses who are practising within the role and seeking accreditation as NPs are called candidates. Hence throughout this study the ENPs are referred to as ENPCs. Initially, the ENPCs focussed on Australasian Triage Scale (ATS) (Australasian College for Emergency Medicine 2000), categories 3–5 emergency patient presentations. The ATS is designed for use in hospital-based emergency services throughout Australia and New Zealand. It is a scale for rating clinical urgency. All patients presenting to EDs are triaged on arrival and an ATS code allocated. The ATS is the clinical tool that ensures patients are seen in a timely manner that is commensurate with their clinical urgency. Patients considered within ATS categories 3–5 can wait from 30 minutes to two hours for treatment in the ED.
The ENPC completed the episode of care for each presen-tation from initial assessment, intervention, prescribing, diag-nosis, treatment and disposition, within a collaborative ED team using Clinical Practice Guidelines for each presentation. This new model of care was a change from the traditional ED medical model employed in the ED. The TM group was defined as medical officer managed care with assistance from nurses.
Patients
This study was a retrospective case series of ATS category 3–5 patients presenting to the Alfred ED for treatment between 1 September 2004–31 August 2005. To be included in the study, patients must have presented between 07:00 and 23:00 hours
(the hours ENPCs were rostered). Furthermore, patients were selected by common diagnostic subgroup as classified by ICD-10-AM (Statistical classification of Diseases and Related Health Problems, 10th Revision, Australian Modification) (Table 1). Common diagnostic subgroups were defined as more than 15 patients for each diagnostic subgroup. This allowed for the ENPCs most commonly encountered discharge diagnoses to be directly compared with identical diagnostic subgroups of the TM group.
Data collection
All outcome measurement data were entered on the ED patient information system, a patient attendance registry which has been used at the site for 10 years. The log is a computerized system which collects surnames of individual practitioners that manage ED patient care. All patients were de-identified prior to data analysis. Identification of the type of practitioner was analysed by the ENPC or TM surnames. Data were collected on time of arrival, time waiting to be seen by the ENPC or TM, length of stay and disposition. It is important to note that the next patient to be seen in the ED was identified by ATS category and time. According to departmental protocol, patients were seen according to highest ATS and waiting time. The ENPCs used their Clinical Practice Guidelines within their scope of practice to assess the next patient. The ENPCs initially started working in the fast track area of the department and as their experience and skills were enhanced they began managing patients in all areas of
Table 1 ICD-10-AM groups included
ICD-10-AM
code Description
L039 Cellulitis, skin, any site. Excludes cellulitis of finger or toe L03Æ01/L03Æ02
S0180 Open wound of face (excludes eye) S019 Bite (non-venomous) of head (excludes face) S519 Open wound of forearm
S619 Open wound of wrist, hand, bite to wrist, hand S628 Fracture of wrist, hand
S637 Sprain/strain of hand (includes finger) S669 Injury to muscle/tendon of wrist, hand S819 Open wound of lower leg, bite S836 Sprain/strain of knee
S929 Fracture of foot (includes toes) S9340 Sprain/strain of ankle
S936 Sprain/strain of foot (includes toes)
Z099 Attendance for follow-up (includes injections)/ Review following earlier treatment
Z480 Attention to or removal of surgical dressings and sutures
the ED. The fast track area is a geographical location of the ED where patients are expected to be assessed and treated within a four-hour target usually encompassing minor injuries including trauma and non-complex medical admissions.
Outcome measures
The primary outcome measure examined was time waiting to be seen by a practitioner, either ENPC or TM groups. Waiting time was defined as time in minutes taken for treatment commenced by either the ENPC or the TM. Other outcome measures included comparisons between the ENPC and TM with regard to: length of stay in the ED; number of patients seen and disposition. Length of stay was defined as the time the patient spent in the ED from initial registration on the ED computer log until time of disposition from the ED. Disposition was defined as the final destination of the patient’s acute care. An overall waiting time when the ENPC was rostered and when no ENPC was rostered was also measured. Waiting times for this comparison were limited to ATS category 3–5 patients, with the same identical diagnostic subgroups and presentation times from 07:00 to 23:00 hours. It was considered that medical staffing was relatively constant during these times and provided homogeneity of the com-parison. The purpose of this comparison was to ensure that the restricted practice of the ENPC did not impact adversely on overall waiting times.
Statistical analysis
Data analysis was performed using STATASTATA STATISTICALSTATISTICAL
software, release 8.0 (StataCorp, College Station, TX, USA) and no formal sample size calculation was undertaken. The data were not normally distributed and hence continuous variables have been described using medians and interquartile ranges, with comparisons between groups made using the Wilcoxon rank sum test. Retrospective power calculations indicated that based on a standard deviation of 1 hour, with 311 cases and 3110 controls, this study had an 80% power to detect a significant difference in waiting time equivalent to 10 minutes. A two-sided p-value of <0Æ05 was considered statistically significant.
The Alfred Hospital ethics committee approved the research project as a retrospective audit for the purpose of quality improvement.
Results
A total of 3156 patient presentations were included in this study. The ENPC group accounted for 18Æ1% (n¼572) of
the sample, whilst the TM group accounted for 81Æ9% (n¼2584) (Table 2).
Patients in the TM group waited 19 minutes longer to be seen than those seen by an ENPC. Patients waited a median time of 31 minutes (IQR 11Æ5–76) when compared with the ENPC group who waited 12 minutes (IQR 5Æ5–28; Wilcoxon
p<0Æ001). When wait to be seen times were stratified by ATS category, patients were consistently waiting longer to be seen by the TM group. Table 3 describes the waiting times stratified by ATS categories three to five.
The overall length of stay also differed significantly between the two groups. ENPC length of stay was 76 min-utes less than the TM group. ENPC length of stay was 94 minutes (IQR 53Æ5–163Æ5) compared with the TM group 170 minutes (IQR 100–274; Wilcoxon p<0Æ001). When length of stay were stratified by ATS category, the ENPC group showed a significantly reduced length of stay than the TM group in category 3–5 patients (Table 4).
The comparison of overall waiting times for ENPC shifts (on duty) vs. non-ENPC shifts (no ENPC on duty) also revealed significant differences [median (IQR): ENPC shifts 24 (9–52) minutes; non-ENPC shifts 33 (13–80Æ5) minutes (Wilcoxonp<0Æ001)].
Table 2 Number of patients seen (by ATS category)
Triage category TM,n(%) ENPC,n(%)
ATS Cat 3 504 (19Æ5) 35 (6Æ1)
ATS Cat 4 1509 (58Æ4) 364 (63Æ7)
ATS Cat 5 571 (22Æ1) 173 (30Æ2)
Total 2584 (100) 572 (100)
ATS, Australasian Triage Scale; ENPC, emergency nurse practitioner candidates.
Table 3 Patient wait to be seen time (by ATS category) Wait to be seen
time median
min (IQR) TM ENPC
Wilcoxon rank-sum p-value ATS Cat 3 22 (10–43Æ5) 6 (4–15) <0Æ001 ATS Cat 4 37 (13–87) 14 (6–30) <0Æ001 ATS Cat 5 27 (9–82) 11 (5–25) <0Æ001
Table 4 Patient Length of stay in ED (by ATS category) Length of Stay
in ED Median
min (IQR) TM ENPC
Wilcoxon rank-sum p-value ATS Cat 3 252Æ5 (162–412Æ5) 144 (72–230) <0Æ001 ATS Cat 4 167 (102–264) 106 (66–175) <0Æ001 ATS Cat 5 120 (72–190) 74 (36–118) <0Æ001
Discussion
This study has shown that the implementation of the ENPC had a significant association with reduced waiting times and length of stay for ATS category 3–5 patients in the ED setting. These findings suggest that the ENPC role may be a useful strategy in managing the increasing service demands on EDs in Melbourne, Australia.
There has been a limited research on the emerging ENPC role. Extrapolations of results from international studies to the Australian context are made difficult because of different funding and service models and definitions of the NP role. A recently published case–control study conducted by Considine
et al.(2006) examined waiting times, treatment times and ED length of stay between ENPC managed patients and patients managed via traditional ED processes. Their study showed no significant difference in the process measures used in our study. Their study used a considerable smaller sample size compared with the present study and the proportion of patients seen in ATS categories was also very different. Another possible explanation for the disparity between their findings and ours may be that they conducted the study from monday to friday between 08:00 and 22:30 hours. The present study included patients seen in the ED, on all days except tuesday. The ENPCs at the Alfred ED work 10 hour shifts on days that have the highest number of patient presentations: Friday, Saturday and Sunday evening. The ENPC appears to have greatest impact on waiting time and length of stay when the ED is busiest. The very restricted practice of shift times may have also had a negative impact. Integration with the medical staff for teaching and training may also be a factor.
A further Australian study reported no statistically signi-ficant difference between waiting times in patients seen by nurses who had extensions to practice, in comparison with the TM group patients (Charles et al.1999). However this was a limited role, restricted to several specific skills only. International studies appear to have findings more consistent with our study (Tye & Ross 2000, Loveridge 2001, Bruce
et al.1988, Tye et al.1988, Cooper & Robb 1996, Jones 1996, Robertset al.1998, Changet al.1999, Pinkerton & Bush 2000, Benger 2002, Fry 2002, Roblin et al. 2004, Woods 2006, Beales 1997, Allerston & Justham 2000, Barr
et al. 2000, Byrneet al. 2000, Sakret al. 2003). Although several studies have methodological limitations that also include small sample sizes and lack of statistical rigour.
Stratifying patients into each of their ATS categories displayed statistical significant differences in waiting times between the ENPC and TM groups. The greatest reduction in waiting time was 23 minutes for patients within ATS category 4. A study conducted in the United Kingdom
demonstrated a reduction in the mean waiting time for care by an ENP from 86–22 minutes when compared with the TM group (Barr et al. 2000). The study compared patients presenting to a minor injuries clinic with similar patient presentations to those used in the present study. This result is consistent with our study with an overall reduction in waiting times measured. Another study examined waiting times at a minor injuries clinic, operated solely by ENPs. Mean waiting times were 19 minutes compared with 56 minutes for the TM group (Sakret al.2003).
The Work Analysis Report commissioned by the DHS in June 2005, evaluated the innovation of the ENPC role in two EDs in Melbourne, Australia. The findings of the report suggested that the role of the ENPC would increase the number of clinical practitioners able to facilitate health service delivery and reduce waiting times in EDs (Sykeset al.
2006). A national study examining the role of NPs in many specialities is planned and has been funded by the Australian Research Council which will allow further investigation into the role and its effectiveness on patient outcomes (Queensland University of Technology 2006).
There were no previous studies to compare the impact on length of stay following the implementation of the ENPC role, except for the Considine et al. (2006) study. The reduction in the median length of stay for the ENPC group by 76 minutes in comparison with the TM group has benefits for the ED as a whole. Increasing flow through the ED can have direct impact upon quality outcomes and improve access to ED resources. Reducing the pressure on already strained resources can help to facilitate managing waiting time targets and key performance indicators.
Limitations
This study has some limitations. Being retrospective, there is the likelihood that some of the data collection was incom-plete and inaccurate. Nevertheless, it is unlikely that patients were not entered into the ED computer log. The possibility exists that there were unmeasured variables that could have contributed to the difference in waiting times and length of stay between the ENPC and TM groups. The ENPC patients suffered a lower acuity condition compared with the TM group. We have attempted to address this issue by stratifying the results by diagnostic subgroups and ATS categories. A further possibility is that the ENPC selected patients with short waiting times ahead of the queue. This seems unlikely as the ENPC saw the next patient in order of priority according to ED protocol. The fact that the ENPC had a significant improvement in overall waiting times for the shifts worked also means that this is unlikely.
For the purposes of rostering, the ENPC was counted as one of the nursing staff on each shift; therefore, there was one less nurse performing traditional nursing duties with the ENPC performing their nursing duties, as well as ENPC duties on their patients. As the extended role of the ENPC also included disposition and patient management, it was anticipated that waiting times would be positively affected. This extended role was not previously a nursing responsibility so it could be argued that there was an ‘extra medical’ staff member rostered when the ENPC was on duty but there was also one less nursing staff member.
Access Block is a major determinant of length of stay in the ED. Access block is referred to as a prolonged wait for an inpatient hospital bed after ED treatment. Stratifying patients according to triage category showed that there was similar disposition between ENPC and TM groups for ATS category 4–5 patients. These were the groups with the most significant differences in length of stay. It seems unlikely, therefore, the issue of access block would have resulted in significant differences between the groups as most were sent home.
Throughout the study period, the knowledge and skills of the ENPCs would have increased with their clinical experi-ence, impacting upon the efficiency of their care and the key performance indicators measured in this study. After initial assessment and provisional diagnosis the ENPCs were required to discuss their plan of care and disposition with the ED consultant on duty. The requirements to complete these processes for each individual patient may have resulted in time delays in relation to length of stay for ENPC patients. It is important to note that both ENPCs were candidates at the time of the study and not endorsed by the Nurses Board of Victoria. It is envisaged that when the ENPCs become endorsed that further enhancement of the role and processes may have greater positive impact on waiting times and length of stay.
Conclusion
This study has demonstrated that the implementation of the ENPC was associated with significant reductions in waiting times and length of stay in the ED. It is envisaged that the role could be expanded into other defined areas of emergency care. The ENP role in Melbourne, Australia has the potential to be part of longer term strategies to manage increased service demands on EDs.
Author contribution
Study design: NJ, PC, GL and GO; data collection and analysis: NJ, MB, GO and GL and manuscript preparation: NJ, GO, PC, GL
Competing interests
None declared by authors 1–3, 5 and 6. Peter Cameron is an Assistant Editor and Section Editor (Original Research) of EMA.
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