Accident & Emergency Nursing

Accident & Emergency Nursing... A Contribution to the Future VALUING DIVERSITY... A WAY FORWARD - WORKING PAPER. 1. 2000 Department of Health, Social Services & Public Safety An Roinn Sláinte, Seirbhísí Sóisialta agus Sábháilteachta Poiblí

Contents Page Recommendations 2 1.0 Introduction 8 2.0 Background 10 3.0 New Models of Service 18 4.0 Education and Training 23 5.0 Quality 25 6.0 Services for Children 28 7.0 Technology in Support of Care 32 8.0 Aggression and Violence 34 9.0 Recruitment and Retention 37 10.0 Appendices 39 1

Recommendations Models of Service 1. The group envisages a service with main A&E departments based at the major acute hospitals, with multi professional specialist teams led by Consultants in Accident & Emergency Medicine. As an integral part of this team, nurse led departments, such as minor injuries units could be established. These nurse led departments would be based either within the core A&E department or at a remote distance from it. 2. Key to these Minor Injuries Units will be the development of a clinical network and the rotation of staff between the core and peripheral units. As part of the continuing professional development and maintaining professional standards of practice, staff in minor injuries units should work a minimum of one week and ideally one month a year in an A&E environment. This period should be tailored and extended to meet individual needs as required. Nursing Competencies 1. This report recommends the following model which defines nursing roles in the Accident and Emergency and related departments. Level 1 - This is entry level to the A&E environment. This period could normally be expected to last a minimum of one year. Level 2 - This period begins the consolidation of experience and practical skills with knowledge and academic support. This period could be normally expected to last a minimum of two years. Level 3 - Nurses at this level would be expected to plan, deliver nursing care, play an active role in education, training and support to other members of staff. At Level 3 it is suggested that the term used to describe the nurse is Nurse Practitioner irrespective of what emergency care environment the practitioner is working in. 2

2. While it is essential that this nurse will have moved through levels 1 and 2 it is not essential that they have completed their specialist practice module before taking on this role. It would be expected that academic programs would be developed to support the nurse s move into this role. The knowledge, experience and skills acquired in levels 1and 2 are strengthened by an understanding of assessment and physical examination techniques, decision making, a recognition of the scope and limitations of professional practice and an indepth appreciation and understanding of professional regulation and medico legal issues. 3. These levels are not necessarily essentially defined by academic qualifications but by the skills and competencies required to complete the roles at each level. 4. The Group welcomes the development and implementation of the new Nurse Consultant role. It is envisaged that these posts would create a level 4 nurse who as an expert practitioner would lead nurses in the development of practice, education, standard setting and audit and advance the development of new roles in emergency nursing in rthern Ireland. Education 1. The Group recommends that education programmes should: Be competency based; Have core elements to help ensure a consistent approach throughout rthern Ireland, ensuring the best use of transferable skills; Be flexible providing a pathway to higher level qualifications if so desired by the practitioner; Equip nurses with the skills to practice within all A&E environments; Be developed in partnership with clinical practitioners; Where appropriate must make the best use of opportunities for multi professional learning; Be delivered in innovative ways, through for example work based and on line learning. 3

Provide a pathway to differing levels of qualification other than that of specialist practice. Quality 1. The ultimate aim of developing regional guidelines and protocols is to reduce variations in nursing practice in A&E departments in rthern Ireland to ensure the best possible care to all patients. 2. The development of clinical guidelines needs to take into account their acceptability to patients, professionals, commissioners and the public and reflect the needs of the new equality legislation. 3. Protocols for care and treatment cannot be developed by any one professional group, but should be developed by the clinical team. It is vitally important that all professionals involved in the care and treatment of patients are involved in and agree with their content and application. Research 1. The Group have not had sufficient time to develop a research plan for A&E Nursing within the context of completing this report. It is recommended that further work needs to be completed and that research activities in A&E nursing should be co-ordinated and results disseminated to nurses working in the service. It is suggested that Central Nursing Advisory Committee ask a regional group such as the RCN A&E Association to take this forward. Services for Children 1. Appropriate nursing staff (Parts 8(RSCN) &15 RN(Children), PALS, APLS) should be available at all times, in all A&E departments. Skills must be maintained with ongoing training and education combined with rotation into and out of the tertiary centre. 4

2. Effective procedures for communicating with GP s, community nursing staff and social services staff between primary, secondary and tertiary care must be in place. This is particularly important in the identification of children who are subject to or at risk of abuse and/or neglect. 3. There should be adequate provision of appliances and equipment appropriate for the treatment of children, e.g. resuscitation equipment. A&E units must ensure appropriately trained staff are available to ensure a safe, caring environment and effective onward transfer to a secondary or tertiary centre if required. 4. Separate facilities for children must be provided including waiting space, play facilities and examination, treatment and recovery rooms furnished and equipped to meet children s needs in safe conditions. 5. The development of guidelines for the care of children needs to be co-ordinated through uni and multiprofessional groups at a regional level, supported by a network of interested professionals with sufficient resources available to ensure development and monitoring of implementation. 6. Joint protocols should be developed between primary, secondary and tertiary care for the treatment of children. This could include how and in what circumstances should children be transferred between units. Procedures should be developed for the inter-departmental / inter-hospital transfer of children to another unit within 2 hours of admission to A&E. These procedures should include the use of standard A&E documentation. 7. Procedures and facilities for counselling and support in the event of a sudden death of a child should be provided. Technology in Support of Care 1. The development of technology in the A&E environment must be within the context of: Clear technical and practice standards. Appropriate education and training. 5

Clarity about clinical and social care governance, ethical, patient confidentiality and data security issues. Evidence of clinical and cost effectiveness. A co-ordinated approach which crosses professional and organisational boundaries. Aggression and Violence 1. Nursing staff need to be trained adequately to anticipate and deal with violent patients. This training should be regularly updated and involve all staff who work in the A&E and minor injuries environments. 2. Risk assessments should form part of a regular review of services and should involve alongside relevant members of the A&E team, including appropriate security staff. 3. A system, which records violent incidents or acts of aggression, verbal or physical, should be in place. These records should be reviewed regularly so that lessons can be learnt, and action taken to reduce the risk. 4. A key and integral part of the management process is the support and care of patients and staff following violent and aggressive incidents. A review of violent or aggressive incidents should be incorporated into regular clinical supervision sessions. Recruitment and Retention 1. The Group recommends that employers consider embracing the concept of the magnet hospital when developing a recruitment and retention plan for nursing the A&E. 2. Employers must ensure there are mechanisms for professional update through the development of professional networks throughout rthern Ireland. 6

3. While this report highlights some of the areas which impact on A&E it is clear that further work on skill mix needs to be undertaken. To facilitate this work there needs to be a clear understanding by all providers of data definitions and their appropriate applications. 7

1.0 Introduction 1.1 All Health and Social Services have undergone significant change over the past decade. Many of these developments have occurred because of advances in medical technology and increasing public demands for high quality services. Accident and Emergency (A&E) services have had to respond to these changes. Key to these changes has been nursing, with nursing taking on increasingly autonomous roles in the care and treatment of patients. 1.2 Hospital accident and emergency departments treat patients with major illness, major trauma, minor illnesses and minor injuries. Up to 75% of patients may attend A&E with less serious conditions, with children accounting for over 25% of all new attendances. Many of these patients have conditions that could be managed by general practitioners and nurses. In contrast to widespread perception, less than 1% of patients have life threatening injuries 1, estimated in the province at around one patient per day. 2 1.3 While local Accident and Emergency (A&E) services are valued by local communities, patients and their families must have confidence in the clinical standards of care delivered. Many A&E units do not have specialist multi professional teams providing care, nor do they provide the full range of services required to support the management of patients with major trauma or major illnesses. 1.4 In response to the potential changes in the delivery of acute hospital services the Chief Nursing Officer commissioned a group to conduct a review and make recommendations on the future of A&E nursing in rthern Ireland. The group was chaired by Mr Robert Sowney and the remit agreed with the Central Nursing Advisory Committee. (Membership of the Review Group is set out in Appendix A) 8

1.5 The remit of the group was: To review current models of care delivery and assess whether there is a particular model to be recommended. To review current education and training requirements for all A&E nurses including those working in minor injuries units. To develop core guidelines and protocols for care and treatment. To review current developments in nursing research in Accident and Emergency To review current and anticipated workforce issues. 9

2.0 Background 2.1 The organisation and management of A&E services have come under scrutiny for some time. The Royal College of Surgeons identified shortcomings in the delivery of care in 1988. 3 This report suggested that services were neither effective nor designed to meet the particular needs of seriously injured patients. The Royal College of Surgeons Report demonstrated that up to 20% of the 1000 seriously injured patients studied, died from treatable causes following admission to A&E departments. 2.2 There are currently 16 A&E departments in rthern Ireland providing a wide range of services and several minor injuries units, some nurse led and some led by medical staff (Appendix B). Currently the range of services provided in each unit varies, as does the methods of data collection. Its is recommended that a consistent approach to data collection is developed to enable meaningful comparisons particularly with regards to workforce planning. Current Trends 2.3 The current national trends in providing A&E services are towards; having a smaller number of larger units, with highly trained specialist teams. treating minor conditions in more appropriate local facilities, such as minor injuries units, GP practice or walk in centres. providing advice by telephone, such as NHS direct and decision support systems. the development of nurse practitioners 4 in A&E and minor injuries units treating patients with a range of conditions. 2.4 These trends have been developed as a result of shortcomings identified in the delivery of care, by the Royal College of Surgeons in 1988. There has also been growing pressures on A&E departments with attendance s 10

increasing by an average of 2% each year. And in response the role of nurses has been developing particularly in the treatment of patients with minor injuries. 1,5 The development of any service needs to strike the balance between meeting clinical standards, which help ensure high quality care and treatment, and local accessibility to services. Workforce 2.5 The British Association for Accident and Emergency Medicine 6, the Audit Commission 5 and the Clinical Standards Advisory Group 7 each recommend that accident and emergency departments should have a multi professional team of specialists, led by a consultant trained in accident and emergency medicine. In addition, there is evidence that a team trained in Advanced Trauma Life Support will provide more effective care. 8 2.6 It has been suggested, that to maintain the expertise of doctors and nurses, 35,000 new patients should be a minimum level of attendance for a main A&E department. 9 In addition it has been recommended that, in order to provide adequate cover, departments seeing in excess of 30,000 patients per year require three and at 55,000 a minimum of four, consultants in accident and emergency medicine. 5 In rthern Ireland half of all accident and emergency departments treat less than 35,000 new patients per year. 2.7 The British Association of Emergency Medicine believes that hospitals, which have less than 35,000 new patients each year, are unlikely to have adequate support from other specialities. It suggests that these departments should be developed into minor injuries units which may not accept ambulance borne patients. 11

Major Trauma 2.8 It is estimated that major trauma is rare and accounts for less than 1% of the attendances at accident and emergency departments in rthern Ireland. The public perception is that patients who have suffered major trauma should be taken to the nearest hospital to be resuscitated. The Royal College of Surgeons 10 illustrated, in the late 1980 s, that in the cases they reviewed, at least one in every five deaths from trauma was avoidable and that inadequate clinical care in accident and emergency departments was a major factor. The report s proposals included: The majority of patients should be managed in large district general hospitals with a wide range of facilities and experienced supporting staff under the supervision of consultants in A&E medicine, and Patients with life threatening injury beyond the facilities or capabilities of a district general hospital should be transferred by high quality transport to a Trauma Centre established at a regional or multi district centre. 2.9 For a seriously injured person to be given the best chance for survival then, they must be given effective pre hospital care and moved quickly to hospital for specialist care. For resuscitation to be most effective it must be co-ordinated, efficient and needs to be carried out by a specialist multiprofessional team who have additional training in advanced trauma life support. A report published in 1993, Management of Major Trauma in rthern Ireland recommended that, outside greater Belfast, patients with major trauma should be taken to the nearest appropriate hospital. This was defined as a hospital with immediate availability of consultant surgeons and consultant anaesthetists, availability of laboratory services and 24 hour radiography cover. However, opinion varies about the mix of specialities which should be on site or close to a major A&E department. Suggestions have included the immediate availability of specialists in, general medicine; general surgery, anaesthetics, intensive care obstetrics and gynaecology, paediatrics, radiology (24 Hour CT Scanning), pathology, orthopaedics and acute psychiatry. 12

2.10 There is evidence to suggest that delays in accessing specialist treatments will result in adverse consequences for patients. 11, 12 While time is of the essence in treating all of these patients, bringing a severely injured patient to a hospital which is not equipped with the appropriately trained staff or resources to manage such patients can simply delay full investigation and treatment. 2.11 Treatment at a specialist centre may require a longer journey to hospital. The advantage to the patient of a specialist centre is that: the patient will be seen by a specialist multiprofessional team; will have the benefit of the full range of diagnostic and support facilities, and there are fewer secondary transfers to a specialist centre required. Medical Conditions 2.12 There are some conditions however, where the travelling time to a specialist centre could have a harmful effect on the patient unless special arrangements are in place to provide safe care. This is particularly true of some medical conditions, such as coronary thrombosis. 2.13 Most deaths, after a first attack occur within the first 2 hours. Lives can be saved by the immediate availability of trained personnel such as paramedics, who can provide defibrillation and resuscitation. The rthern Ireland Ambulance Service now endeavours to have a trained paramedic on each emergency ambulance. They also have equipment which allows an immediate diagnosis of the patient condition. 13

2.14 The care of these patients can often be enhanced with the use of thrombolytic therapy and aspirin. The important factor in this treatment is that they are given as early as possible, within 6 hours. The European Society of Cardiology states that a realistic aim is to start thrombolysis within 90 minutes of the patient calling for medical treatment. These drugs have the potential to be given by General Practitioners (GPs) or paramedics in primary care. Minor Injuries and Illnesses 2.15 The treatment of minor injuries and illnesses has always been an integral part of A&E nursing. There have been many studies which report large numbers of patients presenting at A&E departments with minor injuries, illnesses or primary health care problems. In a study by Myers (1982) 54% of a sample of 1000 patients presented with primary health care problems, with similar studies suggesting that anything from 35% to 51% of patients attending some A&E departments could be managed by their GP. 13 2.16 The role of nurse practitioners in A&E was recommended by the Tomlinson Report and Audit Commission Report. 14, 15 Research into the role of nurse practitioners in A&E has identified; A marked decrease in both waiting times for minor injury attenders with a subsequent reduction in complaints; 16 A reduction in the levels of aggression towards staff, attributed to reduced waiting times; 17 Clinical effective practice in requesting and interpreting X- rays; 18 Effective performance when compared to A&E research registrars, with evidence that fewer of the patients of the nurse practitioners had to seek unplanned follow up advice about their injury; 19 Enhanced patient satisfaction and improved quality of care. 20, 21, 22, 23, 24 14

2.17 A more recent initiative has been the development of stand alone minor injuries units. They are to provide, an open access minor injury service to patients not requiring the specialist investigative and support services of an acute general hospital. 25 Some concern has been expressed that patients may judge their needs inaccurately and attend minor injuries units with inappropriate conditions or create a new demand for care. Several studies have found no evidence to support these concerns 26, 27 concluding that given adequate publicity, most members of the public use these services appropriately. 28 However to sustain this it has been recommended that a sustained advertising campaign is required. 29 A study completed in rth Staffordshire Hospital A&E departments suggested that approximately 70% of patients attending had minor injuries. 30 2.18 Most minor injuries units are staffed by nurse practitioners working either on their own or in partnership with local GPs. Many of these departments have on site X ray facilities, but are not usually open 24 hours a day. More recently technology has been used to support the development of remote care such as stand alone minor injuries units. Tele-medicine and tele-radiology facilities provide access to advice from specialist centres supporting the nurse in providing accessible high quality care, an approach endorsed by the British Association for Accident and Emergency Medicine. 31, 32 2.19 Reviews of Minor Injuries Units suggest that for them to be effective there must be a close professional/managerial relationship with the nearest A&E department. This network model assists in clinical supervision and rotation of staff ensuring that expertise and clinical standards are maintained. This network should be extended to primary care as approximately 25% of patients who attend A&E with minor illnesses have conditions which are often more appropriately treated by their GP or other primary care professionals. 15

2.20 There is considerable variation in the range of treatments provided by nurse practitioners within A&E units or minor injuries units. This variation has been attributed to: Location of the unit; Hours of availability of Nurse Practitioners; The development of the scope of nursing practice; Nursing culture and philosophy of unit; Management culture; Availability and access to facilities such as x rays, and The experience / skills of nurse practitioners. 33 One factor to success identified is a management culture which promotes and encourages the increasing scope of the nurse, particularly in the area of requesting and interpreting X rays. 2.21 The Council of International Hospitals (1998) suggests that while there are no real cost savings using nurse practitioners, both the quality of care and efficiency is improved. This is supported by the Audit Commission Report (1996) which acknowledges that while Nurse Practitioners may appear more expensive than Senior House Officers (SHO) the assessment of SHO costs did not include the care carried out by the nurse on the direction of the doctor, the SHO cost is therefore significantly under estimated. Current Profile of Services 2.22 Accident and Emergency services in rthern Ireland are provided through a number of Health and Social Services Trusts, in a variety of environments and with a range of support services. (Appendix C) 2.23 The development of Minor Injury Units is in its infancy in rthern Ireland. There are currently three units, Armagh Community Hospital, Ards Community Hospital and Bangor Community Hospital, some of which are 16

undergoing a formal review of effectiveness. There is evidence that this model has a potentially useful role in acute care, especially in terms of responsiveness and accessibility to services. 34, 35, 36 Hospital 24 hr. on Labs ICU Emergency Tele- A&E site CT in patient medicine Obs services links beds Antrim 24hr Mid Ulster 9-5 Coleraine 24hr Altnagelvin 24hr Tyrone County 9-5 Erne 24hr South Tyrone 9-5 Craigavon 24hr Armagh Downe Teleradiology Lagan Valley 9-5 Off-site Daisy Hill 24hr Ulster 24hr Ards Off-site UHD UHD Bangor Off-site UHD UHD Belfast City 24hr Hospital Royal Victoria 24hr Hospital Mater Hospital 9-5 24hr Pressures to continually improve standards of service, education of professionals and public demands for high quality services means that the current model of service cannot be sustained into the medium to long term. Indeed in some areas there have been difficulties in sustaining services in the short term. A new way must be found which combines the need for clinical excellence with the need for accessible services. 17

3.0 New Models of Service 3.1 Change is inevitable, and will happen whether or not organisations or individuals are prepared for it. The map of A&E and acute hospital services in rthern Ireland will change dramatically over the next few years. 37 This report is A&E nurses contribution to this debate. 3.2 The group envisages a service with main A&E departments based at the major acute hospitals, with multi professional specialist teams led by Consultants in Accident & Emergency Medicine. As an integral part of this team, nurse led departments, such as minor injuries units could be established. These nurse led departments would be based either within the core A&E department or at a remote distance from it. This clinical network forms the model on which accident and emergency nursing services can be further developed. Key to these Minor Injuries Units will be the development of a clinical network and the rotation of staff between the core and peripheral units. As part of the continuing professional development and maintaining professional standards of practice, staff in minor injuries units should work a minimum of one week and ideally one month a year in an A&E environment. This period should be tailored and extended to meet individual needs as required. The Role of Accident and Emergency Nursing Services in a Clinical Network. 3.3 Nursing practice is developing rapidly, influenced not only by the reduction in junior doctors hours but by developments in nursing practice through the Scope of Practice. 3.4 Valuing Diversity a way forward the strategy for nursing, outlines the challenges and opportunities faced by nurses in the future and recognises the dynamic approach developed by many nurses A&E nurses are no exception. 18

3.5 The demands and pressures placed on A&E nurses are already immense. In meeting the challenge of the future A&E nurses must build on the current good practice demonstrating; flexible and innovative working practices and professional thinking; commitment to life long learning and ongoing training; an acknowledgement of capabilities and limitations; appropriate standards of education, clinical skills and competencies to provide quality services to patients. Developments in Accident and Emergency Nursing 3.6 Many of the developments in A&E nursing have been associated with the development of A&E nurse practitioners. There have been many definitions of the characteristics of the nurse practitioners. 38 The RCN A&E Association Policy and Practice Group defines an Emergency Nurse Practitioner as: an A&E nurse who has a sound nursing practice base in all aspects of A&E nursing with formal post-basic education in holistic assessment, physical diagnosis, prescription of treatment and promotion of health. 39 They identify the role as: 1. A key member of the emergency health care team. 2. Directly available to members of the public. 3. An autonomous practitioner, able to assess diagnoses, treat and discharge patients without reference to a Doctor, but within pre-agreed protocols. 4. Able to make independent referral to other health care professionals. 3.7 This report recommends the following model which defines nursing roles in the Accident and Emergency and related departments. 19

Level One 3.8 This is entry level to the A&E environment. This period could normally be expected to last a minimum of one year. While gaining experience in A&E nursing it would be expected that nurses would utilise opportunities for continuing professional development which would support their practice in the A&E environment. These could include access to education and training opportunities in areas such as, communication skills, wound care, managing aggression and violence and health promotion. Nurses at this level would be expected to plan and deliver nursing care in a supported and supervised environment. The period spent in A&E itself can be seen as a development opportunity for some nurses. Level Two 3.9 This period begins the consolidation of experience and practical skills with knowledge and academic support. Nurses would be expected to learn new additional practical skills within a theoretical framework. They would be expected to work towards and attain qualifications which will support their practice which could include Advanced Trauma Life Support (ATLS), Advanced Life Support (ALS) Advanced Paediatric Life support (APLS) or Paediatric Advanced Life Support (PALS) as component parts of the need for continuing professional development. This period could be normally expected to last a minimum of two years. Level 3 3.10 The development of nurses to specialist practice level as defined by the UKCC should be an integral part of the overall workforce plan of the unit, linked in to the development of services to meet patient needs. Nurses would be expected to plan, deliver nursing care, play an active role in education, training and support to other members of staff. 20

In the same way the development of what is commonly referred to as Nurse Practitioners in A&E must be within a workforce plan which is designed to meet the needs of service. Key to this role is defined decision making required to fulfil the role of an autonomous practitioner. The nurse practitioner would be expected to assess, diagnose, prescribe and deliver care, in partnership with medical colleagues and working to agreed protocols. These nurses would have the authority to either discharge patients home or refer patients on to appropriate health and social care professionals. 3.11 While it is essential that this nurse will have moved through levels 1 and 2 it is not essential that they have completed their specialist practice module before taking on this role. It would be expected that academic programs would be developed to support nurse s move into this role. The knowledge, experience and skills acquired in levels 1 and 2 are strengthened by an understanding of assessment and physical examination techniques, decision making, a recognition of the scope and limitations of professional practice and an indepth appreciation and understanding of professional regulation and medico legal issues. 3.12 These levels are not necessarily essentially defined by academic qualifications but by the skills and competencies required to complete the roles at each level. Nurse Consultant 3.13 The development of the nurse consultant is in its infancy. The Group welcomes the implementation of this initiative and looks forward to the development of nursing services in a positive and energetic way to ensure that nursing makes its full and appropriate contribution to effective emergency care services for the community in rthern Ireland. It is envisaged that these posts would create a level 4 nurse who as an expert practitioner would lead nurses in the development of practice, education, standard setting and audit and advance the development of new roles in emergency nursing in rthern Ireland. 21