Natasha Jennings

Emergency nurse practitioners: an underestimated addition to the emergency care team.

Major contributors reducing access to high-quality care in ED include staff shortages, lack of hospital beds and a shift from community-based treatments. Nurse practitioners (NP) could play a central role in health-care reforms and represent a new direction and mindset in health-care provision. An alternative model of care, involving training ‘healthcare professionals for the tasks required rather than for roles based on historical models’, has long been suggested as a possible solution to this ongoing crisis faced by our ED. The government’s recent proposal to recognize NP as ‘independent’ health-care providers with access to funds, such as PBS, has provoked heated debate within medical circles. Supporters view them as one potential solution to an overstretched health-care system, crippled by ‘access block’. In contrast, the Australian Medical Association (AMA) is strongly opposed to the role, being concerned that NP will become ‘doctor substitutes’ while having inferior training and qualifications. There are three key themes central to the understanding of the NP role. These include extended practice, autonomous practice and practice within a nursing model of care. In Victoria, an NP is defined as: ‘a registered nurse educated for advanced practice, who is an essential member of the interdependent health care team and whose role is determined by the context in which s/he practices’. The NP role encompasses the depth of knowledge and expertise associated with advanced clinical nursing practice, with five key extensions to practice. These are: prescribing medications, initiating diagnostic imaging and laboratory testing, referring to medical specialists, admitting and discharging patients, and approving absence from work certificates. NP are educated to a Master’s level, inclusive of a compulsory pharmacology unit. Candidates undertake a rigorous accreditation process conducted by the Nurses Board of Victoria to ensure a consistent level of competency between endorsed NP in Victoria. The role of the NP should not be confused with ‘practice nurses’ as the two titles are often misused interchangeably. A practice nurse is ‘a registered nurse who is employed by, or whose services are otherwise retained by, a General Practice’. This confusion often ignores the skills of a ‘nurse practitioner’, as practice nurses have not undergone formal education to a Masters level and Nurses Board of Victoria accreditation. Notably, this lack of distinction has incorrectly underpinned many arguments against the introduction of independent nursing roles. Victorian ED have seen the greatest recruitment of NP, with the role now firmly established within various Melbourne and regional hospitals. This has impacted positively on departmental key performance indicators, while providing an important resource to the multidisciplinary team. These outcomes are welcomed by both health administrators and emergency clinicians. As an example of institutional change, emergency care at The Alfred Hospital Emergency and Trauma Centre, Melbourne has been fundamentally redefined since the introduction of the emergency nurse practitioner (ENP)

Time to analgesia and pain score documentation best practice standards for the Emergency Department – A literature review

BACKGROUNDnEmergency Department pain management is an often overlooked aspect of acute care and is of paramount importance. Patients are often forced to wait extended periods of time without pain assessment or being offered analgesia for their painful condition. This has been associated with poor psychological and physiological consequences both for the health system and the patient. This is suggestive of a lack of clarity around best practice standards for time to analgesia and pain score documentation in the ED.nnnMETHODSnA literature review was undertaken to investigate best practice in relation to acute pain management. Key outcomes were pain score documentation and time to analgesia. After a search of the electronic databases, a total of 992 abstracts were screened and 38 potentially relevant full articles were reviewed. There were 23 articles excluded for a variety of reasons including poor methodology, indirect specialty and inappropriate focus or age of study. A total of 15 studies were appropriate for inclusion in the review.nnnRESULTSnOf the 15 studies, only eight included pain score as an outcome and 13 used time to analgesia as a measure. Four studies specifically investigated nurse initiated analgesia programs in relation to improving acute pain management. A higher incidence of pain assessment, reassessment and pain score documentation was generally correlated with decreased time to analgesia.nnnCONCLUSIONSnWhilst there is an abundance of evidence available on the current practice and challenges of quality acute pain management in the ED, there is a lack of well-controlled studies on best practice standards for health care services to benchmark their practice and improve. Mandating pain score reporting, pain assessment and reassessment within specific timeframes and analgesia administration within 30 min of arrival is highly recommended. The implementation of nurse led analgesia protocols should be encouraged to increase incidence of documented pain assessment and reduce time to analgesia.

Bite wounds and antibiotic prescription among patients presenting to an Australian emergency department.

INTRODUCTIONnEmergency department presentations after mammalian bites may be associated with injection of bacteria into broken skin and may require prophylactic antibiotics to prevent subsequent infection. We aim to describe the epidemiology of patients presenting with a mammalian bite injury and antibiotic choice to an Australian adult tertiary centre.nnnMETHODSnA retrospective cohort study was performed capturing all presentations after mammalian bite wounds between 01 Jan 2014 and 31 Dec 2014. An explicit chart review was conducted to determine management of each case. Cases were subgrouped into high- and low-risk groups as defined by the Australian Therapeutic Guidelines for animal bites.nnnRESULTSnThere were 160 cases of mammalian bite wounds included, with 143 (89.4%) patients grouped as high-risk and 17 (10.6%) patients identified as low-risk. High-risk features were delayed presentation >u20098 hours (57 patients, 35.6%), bites to the head, hand or face (113 patients, 70.6%), and puncture wounds unable to be adequately debrided (74 patients, 46.3%). There was a significant association with delayed presentation of more than eight hours and clinically established infection [OR 36.2; 95% CI: 12.6-103.6; Pu2009<u20090.001]. Prescriptions for antibiotics that adhered to current guidelines occurred in 99 (61.9%) cases.nnnCONCLUSIONSnThis study highlights variability in antibiotic prescription practice among clinicians and the need for ongoing education on antibiotic stewardship. Intervention strategies, including ongoing education, are indicated to improve adherence to antibiotic guidelines.

How do we capture the emergency nurse practitioners’ contribution to value in health service delivery?

The emergency nurse practitioner is now a well established and respected member of the healthcare team. Evaluation of the role has focused on patient safety, effectiveness and quality of care outcomes. Comparisons of the role continue to focus on cost, with findings based on incomplete and almost impossible to define, recognition of contribution to service delivery by paralleled practitioners. Currently there is no clear definition as to how nurse practitioners contribute to value in health service delivery. Robust and rigorous research needs to be commissioned taking into consideration the unique hybrid nature of the emergency nurse practitioner role and focusing on the value they contribute to health care delivery.

Profiling wound management in the emergency department: A descriptive analysis

BACKGROUNDnThe service profile of wound, skin and ulcer presentations to emergency departments is an area that lacks an existing published commentary. Knowledge of these presentations would inform the allocation of resources, staff training, and, in turn, patient outcomes. The aim of this study was to describe the discharge and referral status of adult patients presenting to one Australian emergency department with a wound, skin or ulcer condition.nnnMETHODSnA retrospective descriptive review was conducted of all emergency presentations including discharge and referral statuses for skin, wound and ulcer related conditions from 1st January 2014 until 31st December 2014.nnnRESULTSnA total of 4231 wound, skin and ulcer conditions were managed, accounting for 7% of the total emergency presentations. Wound conditions were the most prevalent (n=3658; 86%). Males were more likely to present for all three conditions. For all conditions, discharge to home was the most common destination. Following discharge to home, over half all patients were referred to the local medical officer.nnnCONCLUSIONSnNursing workforce models, education and training needs to reflect the skill set required to respond to wound, skin and ulcer conditions to ensure that high quality skin and wound care continues outside of the emergency department.