Learning objectives. History International. History NP in The Netherlands

Transcription

1 Learning objectives To describe emergency nurse practitioners (ENPs) roles and to understand how ENPs impact delivery of care at the emergency department (ED) To describe how to clarify ENP roles at the ED To assess diagnostic accuracy of the ENP And PLEASE Interject questions and redirect content to suit your individual needs Christien van der Linden, clinical epidemiologist & emergency nurse practitioner Medical Centre Haaglanden, The Hague, The Netherlands History International 9 Charles Hudson, in editorial of JAMA, calls for midlevel provider 9 First NP program at University of Colorado 980 Australia & Great Britain 00 countries work with NPs History NP in The Netherlands 997 Start NP education in Groningen 009 BIG-registered 0 > 000 NPs in the Netherlands, of which [?] in acute care (EDs and ambulance services) MCH ED: 0 ED nurses, ED nurses in training, 7 ENPs, ENP in training. At least ENP per day shift and evening shift. Education & Training NPs in The Netherlands National: Must have a professional nursing degree prior to entrance into NP program Graduate from approved program with minimum Master s degree, program yrs (0 hs) specialism's: chronic care; acute care; intensive care; preventive care; mental care; Emergency Department MCH: Must have an Emergency Nursing certificate (post RN course, two years) MCH Antoniushove.000 patients/year Rural hospital GP-cooperative 7- uur MCH Westeinde.000 patients/year Trauma centre Neuro-vascular centre Inner-city hospital GP-cooperative 8-

2 7 8 Problems Westeinde/ possible solutions Manchester Triage System High input Shortage of rooms Increased waiting times Increased length of stay Triage (Manchester Triage System, MTS) New professionals - Emergency physicians (EPs) - Emergency Nurse Practitioners (ENPs) 9 0 Patient arrival ENP roles in MCH Low Care / GP-cooperative / Nurse Practitioner Unit (NPU) General Practitioner Nurse practitioner Registration TRIAGE Medium Care Unit (MCU) Emergency Physician Senior House Officer Junior House Officer High Care Unit (HCU) Trauma team, Resuscitation team Stroke Team. ENP: assessing patients with minor injuries and minor illnesses at the ENP unit (since 007). Primary care provider: assessing self-referrals at the General Practitioner Cooperative (GPC) (since February 0). Preventive health care & research: Alcohol Screening, Brief Intervention and Referral to Treatment & effectiveness of SBIRT-program (since 0) Role : ENP at the ENP-unit Setting up an ENP unit Education for ED nurses to become an ENP Assess which patient may be assessed and treated by an ENP Assess how many patients are suitable for ENP-treatment

3 Setting up an ENP unit II Develop ENP-protocols with clear bounderies Approval of ENP-protocols by medical specialists Arrange medical supervision of motivated EPs Start! ENP-Protocols Wounds requiring suturing Fractures and dislocations Burns Foreign objects in skin or body cavity Blunt limb trauma Infections of eye, ear or throat Urinary problems Sexually acquired infections Local infections and abscesses Deliberate self-harm Stream system 7 Stream system ENP 8 Diagnostic accuracy of ENPs vs. Physicians To determine the incidence and severity of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses To evaluate diagnostic accuracy of the ENPs compared to physicians To assess waiting times and length of stay To describe patient satisfaction

4 9 0 Methods months descriptive cohort study.8 patients (.00 patients needed for % difference, power 80%, 9% significance) All low care patients treated by ENP (n=7) A random selection of patients treated by physician (n=7) of low care triaged patients Excluded: patients only in need of nursing care Masked conditions at analysis 9 of.8 patients (,9%) had a missed injury / incomplete treatment. SHO 9 (,%) ENP 0 (,7%), RR 0., 9%CI Most common reason: misinterpretation X-rays (/7 missed injuries) Results Results Waiting time SHO 0, ENP 9 minutes LOS SHO 8, ENP minutes, p<0,00, 9% CI Patient satisfaction SHO 7, vs ENP 8, ENPs demonstrated high diagnostic accuracy with 97,% of the patients correctly diagnosed and managed Role : ENP as Primary Care Provider 0% of the ED patients are self-referred Triage at the Emergency Department Part of the self-referrals are referred to the ENP at the GP-cooperative

5 Stream system for ENP as Primary Care Provider ENP as Primary Care Provider According to GP-protocols According to ENP-protocols Communication and collaboration with GP Communication with ED triage and ED coordinating nurse and EP Referral to ED for ancillary diagnostics or admission 7 Differences between both roles 8 Role : ENP in preventive health care & research GP: patient is healthy until proven otherwise ED: patient is sick until proven otherwise. NP has to learn to think like a GP, when working at the GPC.. Preventive health care: Alcohol Screening, Brief Intervention and Referral to Treatment ED and GPC allow NPs to diagnose, treat, and refer patients independently. Autonomy: NP at ED is part of a team. NP at the GPC acts alone.. Study assessing the effectiveness of the SBIRT-program 9 0 ENPs at MCH WZ: ENPs+ ENP i.t. AH: ENP + ENP i.t. Course in minor injuries & minor illnesses for ENPs in the Netherlands Course in clinical reasoning Assessing & treating selfreferrals daily 7- h, weekends 8- h. at the GPC project leader of SBIRT ENPs at MCH -future Closure of smaller hospitals ED crowding need for ENPs to improve waiting times and lenght of stay of patients expanding role Role development from minor injuries and minor illnesses into treatment of medium care patients Integration of EDs with GPCs expanding role

6 Recommendations for start-up Objectives? Get the right people for the job Involve physicians for the training and supervision Know the national rules Clarify ENP role: write specific practice guidelines Thank you for your attention! Questions?