Emergency nurse practitioners: a three part study in clinical and cost effectiveness

Changes in location and number of nurse consultations as the supply of general practitioners decreases in primary health care: six-year register-based follow-up cohort study in the city of Vantaa, Finland

OBJECTIVE

To investigate whether the location and the number of nurse consultations have changed in response to the continuously decreasing number of GP consultations in the fourth-largest city in Finland. It has been suggested that nurse consultations are replacing GP consultations.

DESIGN

A retrospective register-based follow-up cohort study.

SETTING

Public primary health care in the City of Vantaa, Finland.

SUBJECTS

All documented face-to-face office-hour consultations with practical and registered nurses, and consultations with practical and registered nurse in the emergency department of Vantaa primary health care between 1 January 2009 and 31 December, 2014.

MAIN OUTCOME MEASURES

Change in the number of consultations with practical and registered nurses between 2009 and 2014 in primary health care both during office-hours and in the emergency department.

RESULTS

Over the follow-up period, the monthly median number of practical nurse consultations in the emergency department per 1000 inhabitants increased from 1.6 (interquartile range [IQR] 1.3-1.7) to 10.5 (10.3-12.2) (p < 0.001) and registered nurse consultations from a median of 3.6 (3.0-4.0) to 14.5 (13.0-16.6) (p < 0.001). However, there was no significant change in the median monthly number of office-hour consultations with practical or registered nurses.

CONCLUSIONS

It appears that in primary health care, medical consultations have shifted from GPs to nurses with lower education levels, and from care during office-hours to emergency care.

US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis

OBJECTIVES

Nurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians.

DESIGN, SETTING AND PARTICIPANTS

Using nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination.

EXPOSURES

NPs/PAs.

MAIN OUTCOME MEASURES

Use of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines.

RESULTS

Before propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p<0.001) and worsening triage acuity scores (3.03, 2.85 and 2.67, p<0.001), respectively. After weighting, NPs/PAs-alone used fewer medications (2.62 vs 2.80, p=0.002), diagnostic tests (3.77 vs 4.66, p<0.001), procedures (0.67 vs 0.77, p<0.001), hospitalisations (OR 0.35 (95% CI 0.26 to 0.46)) and low-value CT/MRI studies (OR 0.65 (95% CI 0.53 to 0.80)) than physicians. Contrastingly, the NP/PA-physician combination used more medications (3.08 vs 2.80, p<0.001), diagnostic tests (5.07 vs 4.66, p<0.001), procedures (0.86 vs 0.77, p<0.001), hospitalisations OR 1.33 (95% CI 1.17 to 1.51) and low-value CT/MRI studies (OR 1.23 (95% CI 1.07 to 1.43)) than physicians-results were similar among EDs with >95% of NP/PA visits including the NP/PA-physician combination.

CONCLUSIONS AND RELEVANCE

While U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians

OBJECTIVE

This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs).

DATA SOURCE

Medicare Part A (inpatient) and Part B (office visit) claims for 2009-2010.

STUDY DESIGN

Retrospective cohort design using propensity score weighted regression.

DATA EXTRACTION METHODS

Beneficiaries cared for by a random sample of NPs and primary care physicians.

PRINCIPAL FINDINGS

After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were $207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well.

CONCLUSIONS

This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.

Review article: systematic review of three key strategies designed to improve patient flow through the emergency department

To explore the literature regarding three key strategies designed to promote patient throughput in the ED. CINAHL, Medline, PubMed, Scopus and Australian Government databases were searched for articles published between 1980 and 2014 using the key search terms ED flow/throughput, ED congestion, crowding, overcrowding, models of care, physician-assisted triage, medical assessment units, nurse practitioner, did not wait (DNW) and ED length of stay (LOS). Abstracts and articles not published in English and articles published before 1980 were excluded from the review. Quantitative and qualitative studies were considered for inclusion. The National Health Medical Research Council (NHMRC) Level of Evidence Hierarchy (2009) was applied to included studies. Twenty-one articles met criteria for review. The level of evidence assessed using the NHMRC guidelines of studies ranged from I to IV, with the majority falling into the Level II-2 (n = 6) and III-3 (n = 9) range. ED LOS was the outcome most often reported. Study quality was limited with few studies adjusting for confounding factors. Only one level I systematic review was included in this review. Advanced practice nursing roles, physician-assisted triage and medical assessment units are models of care that can positively impact ED throughput. They have been shown to decrease ED LOS and DNW rates. Confounding factors, such as site specific staffing requirements, patient acuity and rest-of-hospital processes, can also impact on patient throughput through the ED.

Improving emergency department throughput: An outcomes evaluation of two additional models of care

OBJECTIVE

The aim of this study was to explore the impact of incorporating a physician at triage (PAT) and the implementation of a medical assessment unit (MAU) on emergency department (ED) patient throughput.

METHODS

A retrospective comparative analysis of two additional models of care (standard care, T1; PAT, T2 and PATplusMAU, T3) was undertaken. Patient presentations to a large public teaching hospital in South-East Queensland between 10th January 2013 and 25th February 2013, and the same time period in 2012, were included. The impact of these care models on ED length of stay and other outcomes (time to be seen by a clinician, time from bed request to ward transfer, meeting 4 hour transit targets, admission rates and the proportion of patients who did not wait) were compared.

RESULTS

Compared to standard care, ED length of stay appeared to decrease with the introduction of both models, but was only significantly decreased after PATplusMAU was implemented (2013; T1, 186 min; T2, 181 min; T3, 175 min: T1 vs T3, P < 0.001). Outcomes that improved included: time to be seen by a clinician, proportion of patients who did not wait; increase in meeting 4-hour length of stay target for both admitted and not-admitted patients.

CONCLUSION

Placing a physician at triage and implementing a medical assessment unit were viable models of care that promoted patient flow and helped meet several time-sensitive health service targets.

A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department

Introduction:

US emergency personnel cared for 106% more patients in 1990 than they did in 1980, and national emergency department census data show that 60%–80% of those patients presented with non-urgent or minor medical problems. The hiring of nurse practitioners (NPs) is one proposed solution to the ongoing overcrowding and physician shortage facing emergency departments (EDs).

Methods:

We conducted a systematic review of MEDLINE and Cinahl to find articles that discussed NPs in the ED setting, looking specifically at 4 key outcome measures: wait times, patient satisfaction, quality of care and cost effectiveness.

Results:

Although some questions remain, a review of the literature suggests that NPs can reduce wait times for the ED, lead to high patient satisfaction and provide a quality of care equal to that of a mid-grade resident. Cost, when compared with resident physicians, is higher; however, data comparing to the hiring additional medical professionals is lacking.

Conclusion:

The medical community should further explore the use of NPs, particularly in fast track areas for high volume departments. In rural areas, NPs could supplement overextended physicians and allow health centres to remain open when they might otherwise have to close. These strategies could improve access to care and patient satisfaction for selected urban and rural populations as well as make the best use of limited medical resources.

Impact of a nurse practitioner on patient care in a Canadian emergency department

Objective:

Our objective was to determine whether the addition of a broad-scope nurse practitioner (NP) would improve emergency department (ED) wait times, ED lengths of stay (LOS) and left-without-treatment (LWOT) rates. We hypothesized that the addition of a broad-scope NP during weekday ED shifts would result in shorter patient wait times, reduced LOS and fewer patients leaving the ED without treatment.

Methods:

This prospective observational study was conducted in a busy urban free-standing community ED. Intervention shifts, with NP coverage, were compared with control shifts (similar shifts with emergency physicians [EPs] working independently). Primary outcomes included patient wait times, ED LOS and LWOT rates. Patient demographics, triage category, the provider seen, the time to provider and ED LOS were captured using an electronic database.

Results:

The addition of an NP was associated with a 12% increase in patient volume per shift and a 7-minute reduction in mean wait times for low-acuity patients. However, overall patient wait times and ED LOS did not differ between intervention and control shifts. During intervention shifts, EPs saw a smaller proportion of low-acuity patients and there was a trend toward a lower proportion of LWOT patients (11.9% v. 13.7%,p= 0.10).

Conclusion:

Adding a broad-scope NP to the ED staff may lower the proportion of patients who leave without treatment, reduce the proportion of low-acuity patients seen by EPs and expedite throughput for a subgroup of less urgent patients. However, it did not reduce overall wait times or ED LOS in this setting.

Emergency physician workload modeling

Background:

A variety of models are used by hospitals, provincial governments, and departments of emergency medicine to “predict” the number of physician hours of coverage necessary to staff emergency departments. These models have arisen to meet specific requirements—some for the purpose of determining hourly rates of compensation, others to determine the amount of funding that will be provided to “purchase” physician coverage, and others to determine the number of hours of coverage necessary to maintain patient waits within “acceptable” limits. All such models have their strengths and weaknesses and have been criticized as not reflecting the “real” needs of any given department.

Objective:

In the article that follows, a review of existing models is presented, annotating their strengths and weaknesses to derive the characteristics of an “ideal” workload model.

Conclusion:

None of the models currently used to measure emergency department workload can be relied on to accurately predict the number of staffed hours necessary. Models that may achieve this objective are suggested.

Paediatric ED reattendance rates: comparing nurse practitioners and other clinicians

OBJECTIVE

The aim of this project is to establish the unplanned reattendance rate for paediatric emergency nurse practitioners (PENPs) working in a designated paediatric emergency department (PED) while identifying the case mix of patients seen by PENPs compared with their medical counterparts.

DESIGN

Quantitative data regarding patient characteristics and reattendance were collected during retrospective review of case notes across two representative 2-week periods.

SETTING

The study site is a tertiary urban PED with an annual attendance of 32 000 patients aged from birth to 15 years.

MAIN OUTCOME MEASURES

Reattendance rates, patient characteristics, triage scores, presenting complaint and numbers of patients discussed with a paediatric emergency medicine consultant were evaluated.

RESULTS

The results showed that PENPs have a lower reattendance rate (1.75%) when compared with senior and junior doctors in training (4.29%, 5.76%); however, PENPs treat a different population of children. When the odds of PENP reattendance are adjusted for this, the significance of the difference becomes less certain.

CONCLUSIONS

PENPs work autonomously when seeing children presenting with minor trauma and make a positive contribution in achieving the reattendance Clinical Quality Indicator.

A nurse practitioner-led urgent care center: meeting the needs of the patient with cancer

Providing comprehensive care for patients with cancer is complex with regard to severe treatment-related side effects. Hundreds of thousands of patients with cancer visit the emergency department (ED) each year, and more than half report multiple visits. In the United States, few of the National Cancer Institute-designated cancer centers have an ED specifically for patients with cancer. EDs often are an overcrowded and expensive way in which to care for the urgent needs of patients with cancer. In addition, a looming shortage exists for both primary care providers and oncologists who can address symptom issues. As the Affordable Care Act is implemented, more patients will enter the healthcare system, placing a demand on providers that the current supply cannot meet. A report from the Institute of Medicine advocates that nurse practitioners (NPs) are more than competent to provide for the unique urgent care needs of patients with cancer. The aim of this article is to describe an NP-led urgent care center for patients with cancer and how that care center provides access to vital, expeditious, and cost-effective care.

The impact of nurse practitioners on care delivery in the emergency department: a multiple perspectives qualitative study

BACKGROUND

Despite well-articulated benefits, the introduction of Nurse Practitioners (NPs) in Australia has been slow. Poorly defined nomenclature relating to advanced practice roles in nursing and variations in such roles both across Australia and worldwide have resulted in confusion and uncertainty regarding the functions and roles of NPs. Qualitative studies focussing on the perceived impact on the care settings into which NPs are introduced are scarce, but are valuable in providing a complete contextual account of NPs in care delivery settings. This study aimed to investigate the perceived impact of the NP on the delivery of care in the ED by senior doctors, nurses, and NPs. Results will facilitate adoption and best use of this human resource innovation.

METHODS

A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior doctors (staff specialists and ED directors) and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the impact of the NP role on the ED. Member checking of results was conducted by revisiting the sites to clarify findings with participants and further explore emergent themes.

RESULTS

The impact of the NP role was perceived differently by different groups of participants. Whilst NPs were observed to deliver few quantitative improvements to ED functioning from the perspective of ED directors, NPs believed that they assisted doctors in managing the increasing subacute presentations to the contemporary ED. NPs also believed they embraced a preventative paradigm of care which addressed the long term priorities of chronic disease prevention and cost containment in the broader healthcare environment. The ambiguous position of the NP role, which crosses the gap between nursing and medicine, emerged and resulted in a duality of NP governance.

CONCLUSIONS

Interpretation of the NPs' role occurred through different frames of reference. This has implications for the development of the NP role in the ED. Collaboration and dialogue between various stakeholders, such as ED doctors and senior nursing management is required.

Perceptions of the advanced nurse practitioner role in a hospital setting

AIM

To explore perceptions of junior doctors, nurses and advanced nurse practitioners (ANP) in relation to the role of the ANP.

METHOD

A qualitative cross-sectional design was used, embedded in an interpretative philosophy. A non-probability sample of six junior doctors, six ward nurses and six ANPs took part in focus groups and individual semi-structured interviews. A mixture of phenomenological and grounded theory approaches were used to collect the data.

FINDINGS

Four major themes were identified - diverse definitions of the ANP role between medical and surgical wards in the hospital at day compared to hospital at night work; role vagueness and ambiguity; communication and education needs; and constraints and barriers. The study found varied perceptions and understanding of the role of the ANP within the hospital at day. Conversely, the hospital at night concept seemed correctly perceived - the role appeared well-established, organised and orchestrated the appropriate responses as required in both medicine and surgery. During the hospital at day, nurses on medical wards were more inclined to use the medical staff as their first responders. The absence of the bleep filtering system in medicine during the day was identified as one of the main barriers. A definitive understanding of the role during the hospital at day has been recognised as the second main barrier. A constraint well known to the ANP team was the inability to provide a bleep filter system in medicine during the day.

CONCLUSION

The study finds the need for improved education, clinical support and system management during the hospital at day, with more of an emphasis within medical wards.

A randomised trial comparing the cost effectiveness of different emergency department healthcare professionals in soft tissue injury management

OBJECTIVES

To evaluate the cost effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared with the routine care provided by doctors in an emergency department (ED).

DESIGN

Randomised, pragmatic trial of equivalence.

SETTING

A single ED in England.

PARTICIPANTS

372 patients were randomised, 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (16 years and older) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups.

INTERVENTIONS

Patients were randomised to treatment by an ESP, ENP or routine care provided by doctors (of all grades).

MAIN OUTCOME MEASURES

Economic cost-minimisation evaluation from a funder perspective of the National Health Service, England incorporating analysis of the direct, indirect and tangible costs of care in primary and secondary settings.

RESULTS

From a funder perspective in primary and secondary care, ESPs and ENPs are at best equivalent and could not cost less than routine care. Uncertainty in cost arises from ESPs and ENPs incurring greater indirect costs, such as those associated with follow-up appointments and subsequent primary care visits. Comparison from a funder perspective in secondary care, that is, considering those costs incurred in secondary care alone, demonstrates that ENPs are equivalent in cost to routine care, while ESPs are either equivalent or possibly cheaper than routine care.

CONCLUSIONS

These results question the notion that training the healthcare workforce to undertake extensions of their role is generally cost effective. While the randomised trial indicated that the three professional groups have equivalent clinical outcomes, this economic analysis suggests that substitution of routine care with a predominantly ESP or ENP workforce could prove more expensive. Further research is required to understand the underlying reasons for this. The trial has been registered with ISRCTN-ISRCTN 70891354.

Primary care professionals providing non-urgent care in hospital emergency departments

BACKGROUND

In many countries emergency departments (EDs) are facing an increase in demand for services, long-waits and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. It is not known, however, how this impacts the quality of patient care, the utilisation of hospital resources, or if it is cost-effective. 

OBJECTIVES

To assess the effects of locating primary care professionals in the hospital ED to provide care for patients with non-urgent health problems, compared with care provided by regular Emergency Physicians (EPs),

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialized register; Cochrane Central Register of Controlled Trials (The Cochrane library, 2011, Issue 4), MEDLINE (1950 to March 21 2012); EMBASE (1980 to April 28 2011); CINAHL (1980 to April 28 2011); PsychINFO (1967 to April 28 2011); Sociological Abstracts (1952 to April 28 2011); ASSIA (1987 to April 28 2011); SSSCI (1945 to April 28 2011); HMIC (1979 to April 28 2011), sources of unpublished literature, reference lists of included papers and relevant systematic reviews. We contacted experts in the field for any published or unpublished studies, and hand searched ED conference abstracts from the last three years.

SELECTION CRITERIA

Randomised controlled trials, non-randomised studies, controlled before and after studies and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs to attend to non-urgent patients, as compared to the care provided by regular EPs. 

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the risk of bias for each included study. We contacted authors of included studies to obtain additional data. Dichotomous outcomes are presented as risk ratios (RR) with 95% confidence intervals (CIs) and continuous outcomes are presented as mean differences (MD) with 95% CIs. Pooling was not possible due to heterogeneity.

MAIN RESULTS

Three non randomised controlled studies involving a total of 11 203 patients, 16 General Practioners (GPs), and 52 EPs, were included. These studies evaluated the effects of introducing GPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The quality of evidence for all outcomes in this review was low, primarily due to the non-randomised design of included studies.The outcomes investigated were similar across studies; however there was high heterogeneity (I(2)>86%). Differences across studies included the triage system used, the level of expertise and experience of the medical practitioners and type of hospital (urban teaching, suburban community hospital).Two of the included studies report that GPs used significantly fewer healthcare resources than EPs, with fewer blood tests (RR 0.22; 95%CI: 0.14 to 0.33; N=4641; RR 0.35; 95%CI 0.29 to 0.42; N=4684), x-rays (RR 0.47; 95% CI 0.41 to 0.54; N=4641; RR 0.77 95% CI 0.72 to 0.83; N=4684), admissions to hospital (RR 0.33; 95% CI 0.19 to 0.58; N=4641; RR 0.45; 95% CI 0.36 to 0.56; N=4684) and referrals to specialists (RR 0.50; 95% CI 0.39 to 0.63; N=4641; RR 0.66; 95% CI 0.60 to 0.73; N=4684). One of the two studies reported no statistically significant difference in the number of prescriptions made by GPs compared with EPs, (RR 0.95 95% CI 0.88 to 1.03; N=4641), while the other showed that GPs prescribed significantly more medications than EPs (RR 1.45 95% CI 1.35 to 1.56; N=4684). The results from these two studies showed marginal cost savings from introducing GPs in hospital EDs.The third study (N=1878) failed to identify a significant difference in the number of blood tests ordered (RR 0.96; 95% CI 0.76 to 1.2), x-rays (RR 1.07; 95%CI 0.99 to 1.15), or admissions to hospital (RR 1.11; 95% CI 0.70 to 1.76), but reported a significantly greater number of referrals to specialists (RR 1.21; 95% CI 1.09 to 1.33) and prescriptions (RR 1.12; 95% CI 1.01 to 1.23) made by GPs as compared with EPs.No data were reported on patient wait-times, length of hospital stay, or patient outcomes, including adverse effects or mortality.

AUTHORS' CONCLUSIONS

Overall, the evidence from the three included studies is weak, as results are disparate and neither safety nor patient outcomes have been examined. There is insufficient evidence upon which to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs versus EPs in the ED to mitigate problems of overcrowding, wait-times and patient flow.

The clinical effectiveness of nurse practitioners' management of minor injuries in an adult emergency department: a systematic review

Background  The increasing cost of healthcare in Australia demands changes in the way healthcare is delivered. Nurse practitioners have been introduced into specialty areas including emergency departments. Specific interventions are known to include the treatment and management of minor injuries, but little has been reported on their work. Objectives  Examine the best available evidence to determine the clinical effectiveness of emergency department nurse practitioners in the assessment, treatment and management of minor injuries in adults. Inclusion criteria  For inclusion studies had to include adult patients treated for minor injuries by nurse practitioners in emergency departments. All study designs were included. Search strategy  English language articles from 1986 onwards were sought using MEDLINE, CINAHL, Embase and Science Citation Index. Methodological quality  Two independent reviewers critically appraised the quality of the studies and extracted data using standardised tools. Data collection  Two independent reviewers assessed the eligibility of each study for inclusion into the review and the study design used. Where any disagreement occurred, consensus was reached by discussion with an independent researcher. Data synthesis  Studies were assessed for homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis was conducted. For each outcome measure, results were tabulated by intervention type and discussed in a narrative summary. Results from randomised controlled trials were pooled in meta-analyses where appropriate. Results  Nine studies from a total of 55 participants met the inclusion criteria. Two were randomised controlled trials. Metasynthesis of research findings generated five synthesised findings derived from 16 study findings aggregated into seven categories. Evidence comparing the clinical effectiveness of nurse practitioners to mainstream management of minor injuries was fair to poor methodological quality. When comparable data were pooled, there were no significant differences (P < 0.05) between nurse practitioners and junior doctors. Conclusions  The results emphasise the need for more high-quality research using appropriate outcome measures in the area of clinical effectiveness of nurse practitioners, particularly interventions that improve outcomes for presentations to emergency departments and address issues of waiting and congestion.

Development of a tool to describe the role of the clinical nurse consultant in Australia

AIMS AND OBJECTIVES

To develop a tool for defining and measuring the role characteristics and responsibilities of an advanced practice nursing role in Australia.

BACKGROUND

Internationally, there is considerable confusion about the precise role responsibilities of advanced practice nursing positions. In Australia, the clinical nurse consultant is an advanced practice role with five nominated domains of practice. However, there are no tools for measuring the performance of clinical nurse consultants against the listed domains.

DESIGN AND METHODS

Participants were 56 clinical nurse consultants at a tertiary public hospital. The existing literature, an online survey, and position descriptions were used to generate the a priori themes for the initial template. Semi-structured interviews were conducted (in 2010) to test the template characteristics. The template underwent multiple iterations in its development.

RESULTS

A 50-item tool was devised, which consisted of five domains with a ten-point hierarchical scale within each domain. In preliminary testing, the revised template was found to provide greater clarity regarding roles and grades than the original position descriptions.

CONCLUSIONS

Further testing and refinement of the modified rating scale is needed, but it offers the possibility of a new tool that can be used by health service managers to determine the grade of a clinical nurse consultant position and for evaluating role performance.

RELEVANCE TO CLINICAL PRACTICE

This preliminary study suggests that the tool provides a useful means of measuring advanced nursing practice and responsibilities across different domains and levels of appointment. The tool may be able to be adapted for use with other advanced practice nursing roles both within Australia and internationally.

Interprofessional working or role substitution? A discussion of the emerging roles in emergency care

AIMS

This article presents a discussion of emerging non-medical roles in emergency care against the current policy context and the issues of role substitution and interprofessional working.

BACKGROUND

Non-medical roles in emergency care have grown internationally in response to an increasing demand for emergency care services and to address the growing importance of the quality healthcare agenda. The blurring of role boundaries between professional groups has become more common. Data sources.  Searches were made of three electronic databases; CINAHL, Medline and EMBASE. The literature relating to interprofessional healthcare roles, and new roles in emergency care was searched from 1980 to 2010 and underpinned the discussion.

DISCUSSION

A theoretical framework that has emerged from the literature is that task, role substitution and interprofessional working lie on a spectrum and evolving non-medical roles can be plotted on the spectrum, usually starting at one end of the spectrum under task substitution and then potentially moving in time towards true interprofessional working.

CONCLUSIONS

There is still a great deal of progress to be made until non-medical roles in emergency care can truly be encompassed under the umbrella of interprofessional working and that a more robust critical mass of evidence is required to substantiate the theory that interprofessional working within teams contributes to effective, cost-effective care and better patient outcomes.

RELEVANCE TO CLINICAL PRACTICE

It is essential to understand the underlying motivation, policy context and key drivers for the development of new nursing and non-medical roles. This allows services to be established successfully, by understanding and addressing the key predicable barriers to implementation and change.

Patient throughput times and inflow patterns in Swedish emergency departments. A basis for ANSWER, A National SWedish Emergency Registry

OBJECTIVE

Quality improvement initiatives in emergency medicine (EM) often suffer from a lack of benchmarking data on the quality of care. The objectives of this study were twofold: 1. To assess the feasibility of collecting benchmarking data from different Swedish emergency departments (EDs) and 2. To evaluate patient throughput times and inflow patterns.

METHOD

We compared patient inflow patterns, total lengths of patient stay (LOS) and times to first physician at six Swedish university hospital EDs in 2009. Study data were retrieved from the hospitals' computerized information systems during single on-site visits to each participating hospital.

RESULTS

All EDs provided throughput times and patient presentation data without significant problems. In all EDs, Monday was the busiest day and the fewest patients presented on Saturday. All EDs had a large increase in patient inflow before noon with a slow decline over the rest of the 24 h, and this peak and decline was especially pronounced in elderly patients. The average LOS was 4 h of which 2 h was spent waiting for the first physician. These throughput times showed a considerable diurnal variation in all EDs, with the longest times occurring 6-7 am and in the late afternoon.

CONCLUSION

These results demonstrate the feasibility of collecting benchmarking data on quality of care targets within Swedish EM, and form the basis for ANSWER, A National SWedish Emergency Registry.

The impact of emergency nurse practitioners on referrals to a tertiary hand trauma service: a pilot of referral quality scoring system

Hand injuries account for 2000 referrals to the Northern Ireland plastic surgery trauma service each year. Emergency nurse practitioners are increasingly utilised to assess and manage minor injuries and independently refer patients to the hand trauma service. This paper uses a newly developed scoring system to assess the impact of varying grades of referring practitioner on the quality and appropriateness of referral.

Evaluating new roles within emergency care: a literature review

INTRODUCTION

In recent years economic and political drivers have strongly influenced the development and introduction of new roles such as medical substitution roles within emergency care in the National Health Service (NHS) in the United Kingdom (UK).

AIMS

The aims of this literature review were to establish the national and international evidence available which examine the scope of practice of emergency nurse practitioners, emergency care practitioners and extended scope physiotherapists; to establish the national and international evidence which explores patient satisfaction with non-medical roles in emergency care; to establish the national and international evidence which explores the acceptability of emergency nurse practitioner, emergency care practitioner and extended scope physiotherapists services from a healthcare professional perspective.

METHODS

A search of the literature was undertaken using BNI, CINAHL plus, International Bibliography of the Social Sciences, MEDLINE and SPORTDiscus databases combined with searches of the Cochrane library collection, NICE and the grey literature. Critical assessment of the literature is presented.

RESULTS

A high level of patient satisfaction was found with all the new roles. Interestingly the scope of practice of Emergency nurse practitioners appears to be most limited in the UK. Five major themes were identified from healthcare professionals' perceptions of these new roles.

CONCLUSION

There is general agreement that non-medical roles help to reduce waiting times in emergency departments, as well as attracting a high level of patient satisfaction, confidence and acceptance of these roles. Several issues were identified which warrant further study; including the current UK evidence surrounding the limited scope of practice of these roles.

Perceptions of nurse practitioners by emergency department doctors in Australia

BACKGROUND

The Australian Medical Association is strongly opposed to the nurse practitioner (NP) role with concerns that NPs may become doctor substitutes without the requisite training and education that the medical role demands. Despite this, NPs have been heralded by some as a potential solution to the access block, workforce shortage and increased demand affecting emergency departments (EDs).

AIMS

The purpose of this study was to determine the perception of NPs by medical staff working in Australian EDs.

METHODS

Semi-structured telephone interviews were conducted with closed and open-ended questions. Participants were drawn from a representative stratified sample of two city, two metropolitan and two provincial hospitals of each State/Territory.

RESULTS

A total of 95 doctors from 35 EDs participated in this study including 36 Departmental Directors; 36% of participating Directors indicated having an NP on staff. Doctors were strongly opposed to the statement that NPs could replace either nurses or other prevocational doctors; 71 interviewees commented on the role of NPs in the ED. Thematic analyses revealed polarised views held by doctors. Eight major themes were identified, the most common being that there is a lack of clarity of the NP role definition, their scope of practice and differentiation from the medical role.

CONCLUSION

Although ED NPs represent a highly skilled professional group their role is poorly understood by ED doctors. Opposition to the NP role is a significant barrier to the introduction of great numbers of ED NPs as a strategy to overcome the medical workforce shortage.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi:10.1007/s12245-010-0214-8) contains supplementary material, which is available to authorized users.

Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does the presumption of assent have an empirical basis?

Physician assistants (PAs), nurse practitioners (NPs), and medical residents constitute an increasingly significant part of the American health care workforce, yet patient assent to be seen by nonphysicians is only presumed and seldom sought. In order to assess the willingness of patients to receive medical care provided by nonphysicians, we administered provider preference surveys to a random sample of patients attending three emergency departments (EDs). Concurrently, a survey was sent to a random selection of ED residents and PAs. All respondents were to assume the role of patient when presented with hypothetical clinical scenarios and standardized provider definitions. Despite presumptions to the contrary, ED patients are generally unwilling to be seen by PAs, NPs, and residents. While seldom asked in practice, 79.5% of patients fully expect to see a physician regardless of acuity or potential for cost savings by seeing another provider. Patients are more willing to see residents than nonphysicians.

The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments

OBJECTIVE

We sought to assess the impact of the integration of the new roles of primary health care nurse practitioners (NPs) and physician assistants (PAs) on patient flow, wait times and proportions of patients who left without being seen in 6 Ontario emergency departments (EDs).

METHODS

We performed a retrospective review of health records data on patient arrival time, time of initial assessment by a physician, time of discharge from the ED and discharge status.

RESULTS

Whether a PA or NP was directly involved in the care of patients or indirectly involved by being on duty, the wait times, lengths of stay and proportion of patients who left without being seen were significantly reduced. When a PA or NP were directly involved in patients' care, patients were 1.6 (95% confidence interval [CI] 1.3-2.1, p < 0.05) and 2.1 (95% CI 1.6-2.8, p < 0.05) times more likely to be seen within the wait time benchmarks, respectively. Lengths of stay were 30.3% (95% CI 21.6%-39.0%, p < 0.01) and 48.8% (95% CI 35.0%-62.7%, p < 0.01) lower when PAs and NPs, respectively, were involved. When PAs and NPs were not on duty, the proportion of patients who left without being seen were 44% (95% CI 31%-63%, p < 0.01) and 71% (95% CI 53%-96%, p < 0.05), respectively.

CONCLUSION

The addition of PAs or NPs to the ED team can improve patient flow in medium-sized community hospital EDs. Given the ongoing shortage of physicians, use of alternative health care providers should be considered. These results require validation, as their generalizability to other locations or types of EDs is not known.

Introducing a nurse practitioner into an urban Canadian emergency department

OBJECTIVE

Our objective was to compare the emergency care provided by a nurse practitioner (NP) with that provided by emergency physicians (EPs), to identify emergency department (ED) patients appropriate for autonomous NP practice and to acquire data to facilitate the development of the clinical scope of practice recommendations for ED practice for NPs.

METHODS

Using a comprehensive 3-part process, we selected and hired the best NP from 12 applicants. The NP was oriented to the operations of our free-standing community ED and incorporated in the care team, working in real time with EP preceptors during a 6-month, prospective clinical assessment comparing NP care with EP care. ED preceptors reviewed every case in real time with the NP and completed an explicit evaluation form to determine whether NP assessment, investigation, treatment and disposition were "all equivalent to emergency physician care" (AEEPC) or whether they differed. The proportion of AEEPC interactions was determined for 23 patient presentation categories. Our a priori assumption was that a patient presentation category might be suitable for autonomous NP practice if 50% of NP encounters in that category were rated as AEEPC. Descriptive data were presented for patient case mix, teaching domains and time criteria.

RESULTS

Eighty-three NP shifts and 711 patient encounters were evaluated by 21 EP preceptors. The NP saw a median of 8 patients per shift. In 43% of encounters, NP care was AEEPC. Highest AEEPC rates were found in the patient follow-up categories general follow-up (55.4%), diagnostic imaging (91.7%) and microbiology laboratory results (87.6%). NP scores over 50% were also seen for lacerations (63.6%) and isolated sore throats (53%). With teaching, NP performance improved over time.

CONCLUSION

With the exception of follow up-related complaints, simple lacerations and isolated sore throats, NP care differed substantially from EP care. Although NPs with extensive emergency experience and training might ultimately be able to function as autonomous ED care providers, Canadian EDs currently developing job descriptions for emergency NPs should focus on a model of collaborative practice with EPs.

What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review

OBJECTIVES

To review and draw together the existing research evidence to assess the impact of advanced primary care nursing roles, particularly first contact nursing roles, for patients, nurses themselves and their colleagues in order to highlight salient issues for policy, practice and research.

BACKGROUND

Internationally, nurses' roles continue to expand in response to doctor shortages and policy drives to provide effective and efficient health services. A body of research exists from which to evaluate the impact of advanced nursing roles on various dimensions of healthcare delivery and organisation.

DESIGN AND DATA SOURCES

Medline, CINAHL, Applied Social Sciences Index and Abstracts, British Nursing Index, Cochrane Library, EMBASE, National Research Register, and PsycINFO databases were searched, including relevant websites. Studies were included if published in English and relevant to the primary/community care setting. Of a total of 211 papers identified, 88 were of relevance and included in the review.

RESULTS

Nurses working in many advanced primary care roles such as acute/minor illness, minor injury and long-term conditions provide safe and effective care, and patient satisfaction is generally high. Many factors influence patient satisfaction with, and access to, such services but are little understood. Evidence on cost-effectiveness, efficiency and impact on other health care professionals is inconclusive though research suggests the introduction of extended roles can create uncertainty and intra-/inter-professional tensions.

CONCLUSIONS

Evidence is of variable quality, often ignoring potentially important effect mediators such as the experience and educational level of advanced nurses, the effect of service 'maturation', organisational characteristics and differing patient preferences. The complex range of factors that influence patient satisfaction, access and outcomes of care need further investigation. Recent UK developments in nurse prescribing and the introduction of a national post-registration competency framework may improve working relations and patient understanding and experience of advanced nursing roles in primary care.

Integrating nurse practitioners into Canadian emergency departments: a qualitative study of barriers and recommendations

OBJECTIVE

The objective of this study was to identify the facilitators and barriers associated with integrating nurse practitioners (NPs) into Canadian emergency departments (EDs) from the perspectives of NPs and ED staff.

METHODS

We conducted 24 semi-structured interviews with key multidisciplinary stakeholders in 6 Ontario EDs to gain a broad range of perspectives on implementation issues. Data were analyzed using a grounded-theory approach.

RESULTS

Qualitative analysis of the interview data revealed 3 major issues associated with NP implementation: organizational context, role clarity and NP recruitment. Organizational context refers to the environment an NP enters and involves issues related to the ED culture, physician reimbursement system and patient volume. Role clarity refers to understanding the NP's function in the ED. Recruitment issues are associated with attracting and retaining NPs to work in EDs. Examples of each issue using respondent's own words are provided.

CONCLUSIONS

Our study identified 3 issues that illustrate the complex issues involved when implementing NPs in EDs. The findings may inform policy makers and health care professionals in the future development of the role of NPs in Canadian EDs.

Cost-effectiveness of the SEN-concept: Specialized Emergency Nurses (SEN) treating ankle/foot injuries

BACKGROUND

Emergency Departments (EDs) are confronted with progressive overcrowding. As a consequence, the workload for ED physicians increases and waiting times go up with the risk of unnecessary complications and patient dissatisfaction. To cope with these problems, Specialized Emergency Nurses (SENs), regular ED-nurses receiving a short, injury-specific course, were trained to assess and treat minor injuries according to a specific protocol.

METHODS

An economic evaluation was conducted alongside a randomized controlled trial comparing House Officers (HOs) and SENs in their assessment of ankle and foot injuries. Cost prices were established for all parts of healthcare utilization involved. Total costs of health care utilization were computed per patient in both groups. Cost-effectiveness was investigated by comparing the difference in total cost between groups with the difference in sensitivity and specificity between groups in diagnosing fractures and severe sprains. Finally, cost-effectiveness ratios were calculated and presented on a cost-effectiveness plane.

RESULTS

No significant differences were seen between treatment groups for any of the health care resources assessed. However, the waiting times for both first assessment by a treatment officer and time spent waiting between hearing the diagnosis and final treatment were significantly longer in the HO group. There was no statistically significant difference in costs between groups. The total costs were euro 186 (SD euro 623) for patients in the SEN group and euro 153 (SD euro 529) for patients in the HO group. The difference in total costs was euro 33 (95% CI: - euro 84 to euro 155). The incremental cost-effectiveness ratio was euro 27 for a reduction of one missed diagnosis and euro 18 for a reduction of one false negative.

CONCLUSION

Considering the benefits of the SEN-concept in terms of decreased workload for the ED physicians, increased patient satisfaction and decreased waiting times, SENs appear to be a useful solution to the problem of ED crowding.

Specialized emergency nurses treating ankle and foot injuries: a randomized controlled trial

OBJECTIVE

To cope with emergency departments (EDs) being progressively overcrowded, the concept of specialized emergency nurses (SENs) was conceived. In this study, the ability of SENs to treat ankle/foot injuries was assessed.

METHODS

Regular emergency nurses were trained in a 2-day session that addressed all aspects of ankle/foot injuries. A randomized controlled trial was set up in which the diagnostic accuracy of SENs was compared with that of house officers (HOs). Secondary outcome parameter was patient satisfaction measured by a standardized questionnaire.

RESULTS

In total, 512 consecutive patients were included. The sensitivity of SENs was 0.94 (95% confidence interval [CI], 0.78-0.99) compared with 0.78 (95% CI, 0.57-0.91) of HOs. Specificity was 0.94 (95% CI, 0.90-0.97) for SENs compared with 0.95 (95% CI, 0.91-0.98) for HOs. The delivered care by SENs was found to be significantly better and the median waiting time at the ED was significantly reduced (21 minutes for SENs vs 32 minutes for HOs).

CONCLUSIONS

Specialized emergency nurses are capable of assessing and treating ankle/foot injuries accurately with excellent patient satisfaction and with a reduction of waiting times. Other injury-specific courses are now developed for this approach.

Developing an advanced nurse practitioner service in emergency care: attitudes of nurses and doctors

AIM

This paper reports a study to determine the attitudes of nurses, doctors and general medical practitioners towards the development of an advanced nurse practitioner service within an emergency department.

BACKGROUND

The role of advanced nurse practitioner in emergency care has emerged in a number of countries, and has brought with it confusion about titles, role boundaries, clinical accountability and educational requirements. Initially, the role resulted from a need for healthcare professionals to provide a service to the increased numbers of patients presenting to hospital with less urgent problems. Since then, the service has evolved to one where nurse practitioners provide high-quality and cost-effective care to persons who seek help for non-urgent, urgent or emergent conditions in a variety of emergency care settings. However, little research could be identified on the attitudes of relevant nursing and medical staff towards the development of this role.

METHODS

A questionnaire survey was carried out, and a 29-item Likert rating scale was developed to measure attitudes. Along with some demographic variables, two open-ended questions were added to allow respondents to elaborate on what they perceived as benefits and difficulties associated with an advanced nurse practitioner service. All general practitioners, emergency nurses and emergency doctors in one health board in the Republic of Ireland were targeted, and 25 emergency nurses, 13 emergency doctors and 69 general practitioners were approached to take part. Data were collected in February 2004.

FINDINGS

An overall response rate of 74.8% was achieved. All respondents were positive towards the development of an advanced nurse practitioner service, with general practitioners being less positive. The principal differences appeared between general practitioners and hospital emergency care staff.

CONCLUSION

There is a need for a multidisciplinary approach to the planning of advanced nurse practitioner services. To achieve multiprofessional acceptance, an accredited and standardized education programme is required, and this must address existing role boundaries.

Change on the horizon: issues and concerns of neophyte advanced healthcare practitioners

AIMS AND OBJECTIVES

The aim was to interview new entrants to a Master's level programme of educational preparation for advanced healthcare practice roles. The objectives were to gain an understanding of their issues and concerns as they looked ahead to their future development and to illuminate issues concerning their experiences as students and as employees.

BACKGROUND

As advanced practice roles become more widespread in the United Kingdom and abroad, nurses and other healthcare professionals are becoming more involved in innovation and service development and experiencing greater autonomy in many areas, particularly in regard to clinical examination and diagnosis.

DESIGN

A qualitative design was employed to illuminate issues and concerns of new students on a Master's degree programme of educational preparation for advanced healthcare practitioners.

METHODS

Two focus group interviews were conducted in 2004. Sixteen students from two programme cohorts participated in the two groups.

FINDINGS

Two main themes were outlined. These were: 'opportunities for development' and 'time pressures'. Subcategories within these two themes are also discussed.

CONCLUSIONS

Students undertaking Master's level preparation for advanced healthcare practitioner roles perceive personal and professional benefits and opportunities to develop innovative services to improve patient care as accruing from the programme. These opportunities and benefits were related to the United Kingdom national health policy agenda. Some role difficulties were experienced. The additional burdens that the programme of study provided were an issue for some, but these were perceived as a temporary problem, worth undergoing for the likely long-term benefits.

RELEVANCE TO CLINICAL PRACTICE

Students undertaking educational preparation for advanced practice roles see themselves as innovators, specifically aiming to develop and improve aspects of service provision. Education for advanced practice roles should not be undertaken lightly, but can equip students with various skills, particularly regarding clinical assessment, and these skills should underpin practitioners' autonomy.

Genetic nurse counsellors can be an acceptable and cost-effective alternative to clinical geneticists for breast cancer risk genetic counselling. Evidence from two parallel randomised controlled equivalence trials

This study compared genetic nurse counsellors with standard services for breast cancer genetic risk counselling services in two regional genetics centres, in Grampian region, North East Scotland and in Cardiff, Wales. Women referred for genetic counselling were randomised to an initial genetic counselling appointment with either a genetic nurse counsellor (intervention) or a clinical geneticist (current service, control). Participants completed postal questionnaires before, immediately after the counselling episode and 6 months later to assess anxiety, general health status, perceived risk and satisfaction. A parallel economic evaluation explored factors influencing cost-effectiveness. The two concurrent randomised controlled equivalence trials were conducted and analysed separately. In the Grampian trial, 289 patients (193 intervention, 96 control) and in the Wales trial 297 patients (197 intervention and 100 control) returned a baseline questionnaire and attended their appointment. Analysis suggested at least likely equivalence in anxiety (the primary outcome) between the two arms of the trials. The cost per counselling episode was 11.54 UK pounds less for nurse-based care in the Grampian trial and 12.50 UK pounds more for nurse-based care in Cardiff. The costs were sensitive to the grade of doctor (notionally) replaced and the extent of consultant supervision required by the nurse. In conclusion, care based on genetic nurse counsellors was not significantly different from conventional cancer genetic services in both trial locations.

The Acute Care Nurse Practitioner: challenging existing boundaries of emergency nurses in the United Kingdom

AIM

This study explored the opinions of nurses and doctors working in emergency departments towards the development of the Acute Care Nurse Practitioner service in the United Kingdom.

BACKGROUND

Studies carried out in the United States and Canada suggest that the Acute Care Nurse Practitioner can have a positive impact on the critically ill or injured patients' experiences in the emergency department. This role is well developed in the United States and Canada, but is still in its infancy in the United Kingdom.

DESIGN AND METHODS

A descriptive, exploratory design incorporating questionnaires (n = 98) and semi-structured interviews (n = 6) was employed. The sample included nurses and doctors from seven emergency departments and minor injury units.

RESULTS

Respondents felt it was important for the Acute Care Nurse Practitioner to have obtained a specialist nurse practitioner qualification and that the Acute Care Nurse Practitioner should retain a clinical remit. While participants seemed comfortable with nurses undertaking traditional advanced skills such as suturing, reluctance was displayed with other advanced skills such as needle thoracocentesis. Three main themes were identified from the interviews: inter-professional conflict, autonomy and the need for the Acute Care Nurse Practitioner.

DISCUSSIONS

Doctors were reluctant to allow nurses to practise certain additional advanced skills and difficulties appear to be centred on the autonomy and other associated inter-professional conflicts with the role of the Acute Care Nurse Practitioner.

CONCLUSION

Nurses and doctors identified a need for the Acute Care Nurse Practitioner, but the blurring of boundaries between doctors and nurses can result in inter-professional conflict unless this is addressed prior to the introduction of such advanced practitioners. Relevance to clinical practice. As the role of the emergency nurse diversifies and expands, this study re-affirms the importance of inter-professional collaboration when seeking approval for role expansions in nursing.

Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses

OBJECTIVES

The ED is often confronted with long waiting periods. Because of the progressive shortage in general practitioners, further growth is expected in the number of patients visiting the ED without consulting a general practitioner first. These patients mainly present with minor injuries suitable for a standardized diagnostic protocol. The question was raised whether these injuries can be treated by trained ED nurses (specialized emergency nurses [SENs]). The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules (OAR) and Ottawa Foot Rules (OFR).

METHODS

In a prospective study, all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor (house officer [HO]) randomized for first observer. Before the study, SENs were trained in applying OAR and OFR. In all patients, radiography was performed (gold standard). The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics. Furthermore, from the paired results, reproducibility was calculated using kappa statistics.

RESULTS

In total, 106 injuries were assessed in pairs, of which 14 were ultimately found to concern acute fractures (prevalence, 13%). The sensitivity for the SEN group was 0.93 (95% confidence interval [CI], 0.64-1.00) compared with 0.93 (95% CI, 0.64-1.00) for the HO group (no significance [ns]). The specificity of the nurses was 0.49 (95% CI, 0.38-0.60) compared with 0.39 (95% CI, 0.29-0.50) for the doctors (ns). The positive predictive value for the SEN group was 0.22 (95% CI, 0.13-0.35) compared with 0.19 (95% CI, 0.11-0.31) for the HO group (ns). The negative predictive value for the nurses was 0.98 (95% CI, 0.87-1.00) compared with 0.97 (95% CI, 0.84-1.00) for the doctors (ns). The interobserver agreement for the OAR and OFR subsets was kappa = 0.38 for the lateral malleolus; kappa = 0.30, medial malleolus; kappa = 0.50, navicular; kappa = 0.45, metatarsal V base; and kappa = 0.43, weight-bearing. The overall interobserver agreement for the OAR was kappa = 0.41 and kappa = 0.77 for the OFR.

CONCLUSION

Specialized emergency nurses are able to assess ankle and foot injuries in an accurate manner with regard to the detection of acute fractures after a short, inexpensive course.