There is widespread concern that the implementation of the Affordable Care Act will lead to increased health care spending in the United States. One commonly proposed mitigation strategy is the expansion of the scope of practice for advanced practice registered nurses (APRNs). In the November 2013 issue of Health Affairs, several authors discuss using nurse practitioners (NPs) as a way to decrease health care costs (Iglehart, 2013). This is good news. But we need more advanced practice research, especially in the area of emergency department (ED) patient outcomes.
Historically, most of the patient outcomes studies with regard to emergency nurse practitioners (ENPs) have been published by ENPs in Australia, Canada, and the United Kingdom (Ducharme, Alder, Pelletier, Murray, & Tepper, 2009; Sandhu, Dale, Stallard, Crouch, & Glucksman, 2009). Only recently have ENPs from the United States offered research contributions with regard to ENPs and patient care outcomes.
In 2006, ENPs from Australia looked at ENP care and ED patient flow (Considine, Martin, Smit, Winter, & Jenkins, 2006). This study compared ED wait times for patient assessment and management. The study also looked at length of stay (LOS) and treatment times for patients cared for by an ENP candidate as compared with the traditional ED care method with a physician. The authors concluded that there were no significant differences in wait times, LOS, and treatment times. The authors also noted that patient flow outcomes for patients seen by ENPs are comparable with those of patients managed by the physician.
That same year Considine (2006) also set out to define the scope of practice of the ENP role in a metropolitan ED in Australia. In 2008, a group of researchers demonstrated shorter wait times and ED LOS associated with the use of ENPs in a major urban ED in Melbourne (Jennings, O'Reilly, Lee, Cameron, Free, & Bailey, 2008). The average wait time for emergency patients seen by the ENP was 12 min compared with 31 min for those seen by a physician. Length of stay in the ED was also significantly lower in the ENP group (94 min) than in the physician group (170 min).
Wilson (2008) investigated the effectiveness of ENPs in an adult ED and assessed patient satisfaction for the care received for minor injuries. A majority of patients were satisfied with the treatment received from NPs. The authors also noted that patient flow through the department was significantly improved.
Carter and Chochinov (2007) performed a systematic review of the literature about the impact of ENPs on cost, quality of care, satisfaction, and wait times in the ED. The researchers focused on four outcome measures: (1) wait times, (2) patient satisfaction, (3) quality of care, and (4) cost-effectiveness. They noted that ENPs decreased wait times while providing quality, comprehensive, and cost-effective ED care, resulting in higher patient satisfaction.
A 2008 study of patient satisfaction with NP care in Canadian EDs found that patients were satisfied with NP attentiveness and the comprehensiveness of their care and had a moderate understanding of the ENP role (Thrasher & Purc-Stephenson, 2008).
Another Canadian study looked at the impact on patient flow after the integration of NPs and physician assistants (PAs) in six Ontario EDs (Ducharme et al., 2009). That study concluded that the addition of ENPs and PAs to the ED team could improve patient flow in medium-sized community hospital EDs.
A 2009 study compared the communication skills and patient satisfaction ratings of ENPs and ED physicians (Sandhu et al., 2009). This study compared the content of, and satisfaction with, consultations made by ENPs and physicians when patients presented to the ED with primary care problems. In the study, the researchers noted that ENPs seemed to focus more on patient education/counseling than did their physician counterparts. The authors noted that there were no statistically significant differences in consultation length. The study also revealed that ENPs had higher levels of self-satisfaction with their consultations than did the ED physicians.
In a 2012 study about the effectiveness ED provider in triage (PIT), the authors reported a quality improvement initiative to improve patient flow by redesigning the triage process (Love, Murphy, Lietz, & Jordan, 2012). The ED PIT decreased the time from patient arrival to initial contact with a licensed medical provider from 75 to 25 min. Also, the proportion of patients who left without being seen decreased from 3.6% to 0.9%.
Bahena and Andreoni (2013) studied the use of the PIT. They found that using an ENP in triage was a cost-effective method to improve throughput in the ED while providing quality emergency care. Patient satisfaction, quality measures, and financial improvements occurred with the use of a PIT. The authors concluded that an ENP is an excellent ED triage provider option. In addition, the authors noted that by having advanced emergency nursing competencies and decision-making skills, the ENP is a cost-effective provider to improve throughput in the ED while providing quality emergency care.
A recent study provided evidence regarding the impact of NPs when compared with physicians. This study addressed the areas of health care quality, safety, and effectiveness from 1990–2009. “A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of ED visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs” (Stanik-Hutt et al., 2013, p. 492).
MORE RESEARCH IS NEEDED
We need more quantitative and qualitative studies focusing on patient outcomes when APRNs provide care in the ED. Studies indicate that ENPs can be a valuable resource to manage increased ED service demands, including wait times, LOS, and patient satisfaction. Increased use of ENPs may improve both access to care and patient satisfaction and help make the best use of limited health care resources. Research funding is available from the Centers for Medicare and Medicaid through the National Prevention Partnership Program at www.hhs.gov/ash/nppa-faq.html. For ED quality data, you can also access https://data.medicare.gov/data/hospital-compare/Timely%26&%Effective&20Care (Centers for Medicare & Medicaid Services, 2014). So, let's get researching and get writing.
—K. Sue Hoyt, PhD, RN, FNP-BC, CEN,
FAEN, FAANP, FAAN
Emergency Nurse Practitioner
St. Mary Medical Center
Long Beach, CA
—Jean A. Proehl, RN, MN, CEN,
Emergency Clinical Nurse Specialist
Proehl PRN, LLC
Bahena D., Andreoni C. (2013). Provider in triage: Is this a place for nurse practitioners? Advanced Emergency Nursing Journal, 35(4), 332–343. doi:10.1097/TME.0b013e3182aa05ba
Carter A. J. E., Chochinov A. H. (2007). A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. Canadian Journal of Emergency Medicine, 9(4), 286–295.
Considine J. (2006). Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department. International Journal of Nursing Practice, 12(4), 205–213.
Considine J., Martin R., Smit D., Winter C., Jenkins J. (2006). Emergency nurse practitioner care and emergency department patient flow: Case–control study. Emergency Medicine Australasia, 18(4), 385–390.
Ducharme J., Alder R. J., Pelletier C., Murray D., Tepper J. (2009). The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments. Canadian Journal of Emergency Medicine, 11(5), 455–461.
Jennings N., O'Reilly G., Lee G., Cameron P., Free B., Bailey M. (2008). Evaluating outcomes of the emergency nurse practitioner role in a major urban emergency department, Melbourne, Australia. Journal of Clinical Nursing, 17(8), 1044–1050. doi:10.1111/j.1365-2702.2007.02038.x
Love R. A., Murphy J. C., Lietz T. E., Jordan K. S. (2012). The effectiveness of a provider in triage in the emergency department: A quality improvement initiative to improve patient flow. Advanced Emergency Nursing Journal, 34(1), 65–74. doi:10.1097/TME.0b013e3182435543
Sandhu H., Dale J., Stallard N., Crouch R., Glucksman E. (2009). Emergency nurse practitioners and doctors consulting with patients in an emergency department: A comparison of communication skills and satisfaction. Emergency Medicine Journal, 26(6), 400–404. doi:10.1136/emj.2008.058917
Stanik-Hutt J., Newhouse R. P., White K. M., Johantgen M., Bass E. B., Zangaro G., Weiner J. P. (2013). The quality and effectiveness of care provided by nurse practitioners. Journal for Nurse Practitioners, 9(8), 492–500. doi:10.1016/j.nurpra.2013.07.004
Thrasher C., Purc-Stephenson R. (2008). Patient satisfaction with nurse practitioner care in emergency departments in Canada. Journal of the American Association of Nurse Practitioners, 20(5), 231–237. doi:10.1111/j.1745-7599.2008.00312.x
Wilson A. (2008). An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department. International Journal of Nursing Practice, 14(2), 149–156. doi:10.1111/j.1745-7599.2008.00312.x