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Systematic Review

Emergency care

Operationalizing the practice through a concept analysis

Davis, Wesley D. DNP, ENP-C, FNP-C, AGACNP-BC, CEN (Emergency Nurse Practitioner Specialty Coordinator and Assistant Professor)1,2; Dowling Evans, Dian PhD, FNP-BC, ENP-C, FAAN, FAANP (Clinical Professor, Family and Community Nursing, Emergency Nurse Practitioner Specialty Coordinator)3; Fiebig, William MSN, APRN, AGACNP-BC, ENP-C, FNP-BC, CEN1; Lewis, Chrystal L. PhD, RN (Assistant Professor)1

Author Information
Journal of the American Association of Nurse Practitioners: May 2020 - Volume 32 - Issue 5 - p 359-366
doi: 10.1097/JXX.0000000000000229
  • Free

Abstract

Among the professions providing emergency management of acute illnesses and injuries, an empirically driven definition of emergency care is lacking and profession-specific definitions vary. The definitions of emergency medicine and emergency nursing, which are often considered synonymous with emergency care, have created confusion over the meaning of emergency care and hindered its usefulness as it applies to the role of the emergency nurse practitioner (ENP). This lack of clarity and ambiguity has contributed to problematic barriers to practice for nurse practitioners (NPs) working in emergency care settings. According to the American College of Emergency Physicians (1998), “Emergency medicine is the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury.” According to the 2016 Model of the Clinical Practice of Emergency Medicine, this definition is unique to the practice of emergency physicians (Counselman et al., 2017). Emergency nursing is defined as a specialty in nursing where the application of the nursing process is applied to patients who need stabilization of illness or injury (Emergency Nurses Association [ENA], 1999). The definitions of emergency medicine and emergency nursing are limited in respect to defining the role and scope of advanced practice ENP. A definition that encompasses the unique work of the ENP underpins the rationale to examine the definition of emergency care through a formalized concept analysis.

Additionally, regulatory bodies have been inconsistent in developing policies for the regulation of ENP practice that are evidence based and congruent with national emergency department census data and workforce needs. According to the Assistant Executive Director for the Wyoming Board of Nursing, “Throughout the literature there is valid and substantial support for family nurse practitioners to obtain specialty education to provide emergency care. However, a definition of emergency care is not clearly stated within this literature. State boards of nursing and other regulatory organizations need an authoritative definition of emergency care to help regulate advanced practice registered nurse (APRN) scope of practice, define national professional standards, and ensure congruence among educational programs” (J. Burns, written communication, February 28, 2019). By establishing a formal definition, regulatory bodies will be able to use an empirically defensible definition to create practice guidelines and policies. A formal definition will also guide educators in developing curricular standards to prepare NPs for emergency care practice and in establishing criteria for assessing learner performance outcomes.

Using a strategic literature review, the aims of this article were to clarify the commonly used, but ambiguous, concept of emergency care, to identify its core attributes, and to provide a clear and defensible definition that can be broadly applied across professions and settings. In addition, this analysis will help differentiate the concept of emergency care from other concepts that it may be confused with, such as emergency medicine and emergency nursing. This concept analysis will contribute to the delineation of emergency care in its contemporary conceptualizations with intention to prompt future developments in ENP educational preparation, practice, theory, policy, and research.

Origins of emergency care

It is reasonable to conclude that the idea of emergent medical conditions existed before organized efforts to establish emergency care as a separate medical discipline. Wars dating back centuries have been instrumental in advancing the treatment of trauma and emergency medical conditions. From the times predating the American Revolution, to the Global War on Terror, advancements in the provision of emergent treatment during these episodes gave rise to what constitutes how emergency care is currently practiced both in low resource and in industrially advanced countries (Manring, Hawk, Calhoun, & Anderson, 2009).

The development of trauma centers arose from the mobile army surgical hospitals established during the Korean and Vietnam Wars (van Stralen, 2008). In the 1950s, within the United States, most hospitals only had a single room dedicated to emergency care that was staffed by nurses and physicians often inexperienced in acute resuscitative procedures (Kellermann, Hsia, Yeh, & Morganti, 2013). Prehospital emergency care was minimal to nonexistent and was provided by hearses from local funeral service providers (Institute of Medicine, 2007b). In 1966, the U.S. National Academy of Sciences and National Research Council Committee on Trauma (1966) published Accidental Death and Disability: The Neglected Disease of Modern Society. This report led to the eventual development of a national curriculum to train emergency medical technicians (EMTs) to provide emergency care and regional systems of emergency transport to emergency hospital units. Subsequently, in 1970, the inaugural emergency medicine residency program was opened and a formalized system for educating emergency medicine physicians began (Zink, 2005).

As prehospital emergency care grew into emergency medical services (EMS), and the emergency medicine specialty and residency training was established, emergency nursing training was advanced with the establishment of the Emergency Department Nurses Association and the Emergency Nurses Organization Association. These parallel agencies later merged to form the Emergency Department Nurses Association in December 1970 (Fadale, 2000; Frank, 2000; Schriver, Talmadge, Chuong, & Hedges, 2003). The organization would later change its' name to the ENA in 1985. Emergency Nurses Association has advocated for specialized educational preparation of emergency nurses to prepare them with the unique and specific knowledge and skills required to care for patients within emergency department (ED) settings (Hoyt et al., 2018). The specialty of emergency nursing and advanced practice was officially recognized in 2011, when the American Nurses Association designated emergency nursing as a unique specialty (American Nurses Association, 2011). However, this definition was broad and did not address the unique competencies, role, and scope of NPs practicing in emergency settings. With the rapid evolution of emergency care over the last 60 years, a concept analysis of emergency care as it pertains to the work of ENPs has not yet been undertaken. This concept analysis will focus on the competencies and interventions required by an ENP to address and stabilize the threats to a patient's health from pathophysiological events, psychological threats, and sociological threats to develop an operationalized definition of emergency care.

Methods

Concepts are abstract ideas generalized from particular instances that help form the foundation of scientific knowledge and theoretical frameworks for any field of study. The strength of theories that inform a field of study is dependent on the quality of the methodological process used in examining conceptual meanings. In defining emergency care, eight-step method of concept analysis by Walker and Avant (2005) was used to develop a reliable, valid, and operational definition. The eight-step method of concept analysis is summarized in Table 1.

Table 1
Table 1:
Eight steps of the Walker and Avant concept analysis method

To determine a clear understanding of the concept of emergency care and its uses, a broad database search within the disciplines of nursing, medicine, education, and social sciences was conducted using the keywords emergency care. Databases reviewed included PubMed, Embase, CINAHL, and Web of Science. These inclusive sources were systematically reviewed by the authors for their relevance to ENP role and scope of practice. Additional searches of nonmedical literature, such as dictionaries and thesauri, were examined to better understand the semantics of emergency care. Duplicate articles and articles from the sciences outside of human medicine and nursing (e.g., veterinary sciences) were excluded because they did not contribute to or add further understanding to the cognitive representations of emergency care. A total of 31 sources were used in the analysis.

Uses of emergency care

Taber's Cyclopedic Medical Dictionary defines an emergency as “any urgent condition perceived by the patient as requiring immediate medical or surgical evaluation or treatment” (Venes, 2013). The term emergency is derived from the Latin word emergentia, which translates to an event that emerges or becomes visible (emergency, 2018). Although dictionaries provide a consensus definition of an emergency, it is important to understand that an emergency is often defined by individual perception of risk to one's health. Care is defined (Care, 2018) as “watchful or protective attention, caution, concern, prudence, or regard usually towards an action or situation especially.”

According to Walker and Avant (2005), careful consideration must be given to how the concept is used in disciplines other than health care. The use of emergency care in disciplines outside of health care, law, and social sciences are likely unhelpful, and therefore were not explored in great depth. The literature search results were screened for relevance by review of the titles and abstracts. The literature search yielded a large number of sources across disciplines, including law and social sciences, as well as from health care.

In the US legal literature, the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 identifies an emergency medical condition as:

  • A condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health (or the health of an unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organ (Federal Register, 2012).

Under EMTALA guidelines, individuals are expected to receive an appropriate screening examination, including diagnostic testing, to determine if an emergent condition exists. In the event that an emergent condition exists, then appropriate stabilizing emergency care is to be rendered (American College of Emergency Physicians [ACEP], n.d.).

In the health care literature, emergency care is described as a continuum of the integrated processes of assessment, treatment, and disposition (American Academy of Emergency Nurse Practitioners [AAENP], 2018; Hori, 2010; Hoyt, 2017; Hoyt et al., 2010; IOM, 2007a; Ramirez, Tart, & Malecha, 2006; Tyler et al., 2018) that occurs in response to a perceived decompensation of an individual's psychological, sociological, or physiological well-being (Tyler et al., 2018). The assessment process of emergency care is the immediate evaluation of an unexpected illness or injury (Tyler et al., 2018). Unexpected or new onset “acute” illness or injury ranges from life-threatening health problems to minor injuries and illnesses (AAENP, 2018; Pitts, Carrier, Rich, & Kellermann, 2010; Sriram, Gururaj, & Hyder, 2017). The treatment phase of emergency care includes the stabilization of an unexpected illness or injury for ongoing treatment (AAENP, 2018; ACEP, n.d.; Hoyt, 2017; Razzak & Kellermann, 2002; Tyler et al., 2018). Disposition may include discharge to home, hospital admission, or appropriate transfer to another health care facility. Additionally, emergency care is limited to episodic, brief, and fragmented encounters between health care providers and the patient (Elmqvist, Fridlund, & Ekebergh, 2008; Hoyt et al., 2010; Hultsjo & Hjelm, 2005; Pitts et al., 2010).

Defining attributes

Defining attributes are hallmarks or common characteristics of a concept that occur frequently in the literature and help to distinguish emergency care from similar concepts. Based on the literature search conducted for this concept analysis, six defining attributes of emergency care were discovered and are shown in Table 2. Defining attributes that were functionally equivalent were combined.

Table 2
Table 2:
The most commonly used attributes of emergency care and their empirical referents

Emergency care includes the immediate evaluation and treatment in response to an unexpected illness or injury. Immediate evaluation and treatment includes physical examination, diagnostic evaluation, treatment, and disposition. Emergency care is provided in a variety of settings, including emergency departments, urgent care clinics, prehospital/home settings, or by telemedicine (American College of Emergency Physicians, 2015; Evans et al., 2018; Hoyt et al., 2010; Tyler et al., 2018). Setting locations include urban, suburban, rural, and remote areas (AAENP, 2018; Hoyt et al., 2010; Tyler et al., 2018).

Cases

Walker and Avant (2005) recommend the use of model, borderline, related, and contrary cases to assist with illustration of the concept. The inclusion of these cases in the concept analysis enhances the understanding of the concept of emergency care. These cases are representative of those managed by NPs across various practice settings.

Model case

The model case is a real clinical example and includes all the defining attributes of the concept (Walker & Avant, 2005). The following represents a model case for emergency care.

Mr. G is a 30-year-old man who presented to the local urgent care complaining of severe thoracic and mid-back pain that started while lifting weights at the gym. Mr. G was taken to a treatment room where he was immediately evaluated by an emergency care provider and a registered nurse for a life-threatening medical problem. The emergency care provider, through a series of examinations, diagnostic tests, and specialty consultations, diagnosed Mr. G with an acute myocardial infarction. Mr. G was emergently transferred to the closest hospital with a cardiac catheterization laboratory, where he underwent a life-saving cardiac stent placement. Mr. G was admitted to the hospital for continued care. Subsequently, Mr. G was discharged home in good condition.

Borderline case

The borderline case contains some, but not all, of the defining attributes of the concept (Walker & Avant, 2005). The following case does not include immediate evaluation and treatment and exemplifies a borderline case for emergency care.

Mrs. A is a 60-year-old woman who scheduled an appointment with her primary care NP for evaluation of abrupt onset of unilateral leg swelling and pain. At her appointment the next day, Mrs. A was evaluated, sent for diagnostic imaging according to American College of Radiology Appropriateness Criteria, and diagnosed with an uncomplicated deep vein thrombosis. She was started on oral anticoagulant therapy and scheduled to return for follow-up in 1 week.

Related case

A related case is a case that is similar to it, or a mimic, that could be confused with emergency care (Walker & Avant, 2005). Emergency care that is provided by an adult-gerontology acute care nurse practitioner (AGACNP) in an inpatient or intensive care setting is often confused with the care that is provided in emergency care settings by ENPs. Although the application of critical care and acute care knowledge and skills within emergency care is a common occurrence, some may contend that the competencies required to provide acute care and emergency care are essentially the same regardless of setting (Schumann, 2018). The defining attributes identified in this concept analysis makes a clear distinction between the two. The following scenarios depict related cases.

Scenario 1

Mr. J suffered from a cardiac arrest and was resuscitated in the emergency department. After he was stabilized, he was transferred to the intensive care unit (ICU) where an AGACNP took over his care. The AGACNP providing “acute care” in the inpatient setting was challenged with long-term stabilization of Mr. J and the goal of returning him to a state of maximum health. Hospital-based acute inpatient care provided by the AGACNP encompasses ongoing monitoring and intervention to prevent complications during a highly vulnerable period of Mr. J's illness contrasting with the acute resuscitative care provided within the emergency department/care setting. On discharge from the hospital, the AGACNP coordinated Mr. J's comprehensive treatment plan with his primary care provider for outpatient follow-up.

Scenario 2

Mrs. K, an inpatient in the ICU, was found in severe respiratory distress. The rapid response team was called to the bedside. As the leader of the team, the AGACNP provided emergency resuscitative care, including airway intubation. During this critical period of Mrs. K's illness, the AGACNP, as part of a collaborative team, continued to provide comprehensive treatment consisting of ongoing monitoring and intervention with a goal of returning her to a state of maximum health. Once she was stabilized and her condition improved, Mrs. K. was transferred out of the ICU and ultimately discharged home to follow-up with her primary care provider.

Contrary case

The contrary case has none of the defining attributes of the concept (Walker & Avant, 2005). The following case is a contrary case for emergency care. A 20-year-old single mother of a 10-month-old infant schedules an appointment with the infant's pediatric nurse practitioner (PNP) for a well-child visit and to update the child's immunizations. At the scheduled appointment, the mother states that the child has not received any immunizations. The PNP performs a well-child examination and updates the infant's immunizations. After providing education to the mother about the importance of preventative care and immunizations, the child was discharged home with a scheduled follow-up visit.

Antecedents

Antecedents are events or incidents that must occur or be in place before emergency care can occur. Figure 1 depicts a model of the concept of emergency care including its antecedents, defining attributes and consequences. The most obvious antecedent of emergency care is a precipitating event, such as an unexpected injury or illness. Without a precipitating event, emergency care is not needed and does not exist. Additionally, an individual must perceive an element of severity sufficient to warrant an unscheduled visit to see an emergency care provider. According to EMTALA, “an emergency medical condition would not actually have to exist… Instead, the individual presenting (or the prudent layperson observer) must believe he or she needs emergency care” (Centers for Medicare & Medicaid Services, 2002, p. 127). In other words, it must be recognized that emergent medical help is required. Once the individual has determined that medical help is required, there must be access to emergency care. Because emergency care is not specific to a certain setting, emergency care may be accessed at an emergency department, through an EMS, at an urgent care office or primary care office. Antecedents must also be considered from the patient's point of view. For example, a new onset problem may not meet the definition of a life-threatening emergency, however, but may constitute a need for emergency care if the patient has no other access to medical services. For example, patients may seek out “emergency care” for an acute onset episodic illness out of convenience or lack of access to other sources of care rather than because of severity of their problem. In fact, in an analysis of where patients seek care for new onset “acute” episodic medical complaints, Pitts et al., 2010 found that 28% of Americans seek care for these problems in EDs, and among those individuals, more than half are uninsured. As the ED has become a safety net for the poor and uninsured and for those lacking access to primary care providers, emergency care settings have become a primary source for accessing care for nonemergent problems. As a result, the NPs who work in emergency care settings must be competent in primary care practice.

Figure 1
Figure 1:
Model of emergency care.

Consequences

Consequences are the events or incidents that follow the occurrence of the concept. These consequences are useful in determining neglected ideas, variables, or relationships that may stimulate avenues for new research (Walker & Avant, 2005). When all the components of emergency care work together in a feedback loop as depicted in Figure 1, emergency care improves the health of individuals and populations (Razzak & Kellermann, 2002), reduces avoidable death and disability (Kobusingye et al., 2005), and improves outcomes of acute onset, unexpected illness, and injury (Marler et al., 2000; Newgard et al., 2015).

Death, as a consequence of emergency care as shown in Figure 1, has historically been considered a failure of emergency care resulting from diagnostic/treatment errors and considered in medicolegal terms, malpractice or negligence. Another way to consider the outcome of death in emergency care settings is within the context of initiating end of life and palliative care, a growing focus of care within emergency medicine (Wang, 2017). Emergency care providers are now encouraged to include an assessment of patient end-of-life goals, where appropriate (Goldonowicz, Runyon, & Bullard, 2018; Mierendorf & Gidvani, 2014). Therefore, death as a potential consequence of emergency care takes on a different meaning. For example, death may be the consequence of compassionately delivered, patient-centered emergency care when viewed within the context of carrying out a patient's end-of-life requests as an extension of palliative or hospice care. In considering this consequence of emergency care, the literature search key terms were expanded to include “palliative care,” “dignified death,” and “emergency.”

Adding this aspect to the definition of emergency care allows death to be seen as an acceptable consequence rather than a failure because not every patient is capable of or desires to survive an acute illness or injury. Additionally, there are numerous instances where the emergency care provider provides high-quality appropriate care yet the patient may still not survive. As the aging population increases and the number of patients of all ages living with terminal medical conditions grows, there is increasing support for initiating palliative care in the ED (Mierendorf & Gidvani, 2014; Wang, 2017). This shift from life-saving, resuscitative emergency care to noncurative treatment is creating a culture change within emergency care settings, with implications for the educational preparation of emergency care providers.

Empirical referents

Empirical referents are measurable ways to demonstrate the occurrence of the concept and operationalize its definition. Empirical referents are directly related to the defining attributes as they measure their presence or absence, as opposed to the presence or absence of the entire concept (Walker & Avant, 2005). The defining attributes of the emergency care concept are abstract, and therefore, empirical referents are used to operationalize the concept. These referents are shown in Table 2. For example, empirical referents of life-threatening illness or injury include cardiac arrest, stroke, and major traumatic injuries. Without immediate evaluation and treatment, these events would likely lead to death. Additionally, the Emergency Severity Index triage system is used to prioritize patients who need emergency care (Agency for Healthcare Research and Quality, 2012) and can serve as a proxy measure for life-threatening injury and illness requiring immediate evaluation and treatment.

Proposed definition of emergency care

Based on this concept analysis, a clarified definition of emergency care is proposed: Emergency care occurs after a precipitating event, with recognition that medical help is required, having an element of severity or perceived severity, and providing access to emergency care treatment/services. Emergency care itself is the immediate evaluation and treatment of individuals with unexpected illness or injury with a perception of severity, with variance from minor to life-threatening conditions. Emergency care is provided by a person who is prepared to recognize emergent problems, is able to prioritize, and provide competent skilled care based on professional knowledge or as a prudent layperson. Emergency care is not defined by a practice setting and may be provided within the clinical setting or external to a clinical setting.

Conclusion

To date, a consistent and standard definition of emergency care that spans nursing, advanced practice nursing, and medical practice has been lacking, resulting in conflicts and challenges for APRNs. Hence, this concept analysis sought to define emergency care explicitly to clarify issues that are now impacting state boards of nursing and nurse practitioners who are providing emergency care. For example, many ENPs have been threatened with job termination because their role, scope of practice, and the care that they provide has not been clearly defined or understood by regulators. Questions related to ENP scope of practice within the emergency care setting arose as a consequence of the implementation of the Consensus Model for Regulation and Education of APRNs (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). For example, emergency care has been confused with the nursing definition of acute care. As defined by the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties' Adult-Gerontology Acute Care and Primary Care Competencies (AACN, 2012; NONPF, 2016), “acute care” is that care provided to patients who are characterized as “physiologically unstable, technologically dependent, and/or are highly vulnerable to complications.” As clarified within this concept analysis, the defining attributes of emergency care are as follows: immediate evaluation and treatment; unexpected illness or injury; life-threatening, minor illness or injury; not setting specific; delivered by various providers (interdisciplinary team), including EMTs, NPs, physicians, nurses, and bystanders. This concept analysis demonstrates that emergency care is broader than the limited definition of acute care when expanded to include the patient's perspective and the sociocultural perspective and reality of access to health care within the United States. This analysis provides an expanded, operationalized definition of emergency care that can be applied to curricula and used by regulatory bodies, including certifiers and regulators, to meet societal needs for appropriate care delivered by appropriately prepared providers.

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Provider Accreditation:

This activity is approved for 1.0 contact hour of continuing education by the American Association of Nurse Practitioners. Activity ID 20034237. This activity was planned in accordance with AANP CE Standards and Policies.

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.0 contact hour. Lippincott Professional Development is also an approved provider of continuing nursing education by the District of Columbia, Georgia, and Florida, CE Broker #50-1223.

Payment:

  • The registration fee for this test is $12.95. AANP members are eligible for a 50% discount. Visit the member-benefit section on AANP website (https://aanp.org/membership/memberbenefits) to obtain the discount code. Use the code when asked for payment during checkout.
Keywords:

Concept analysis; emergency care; emergency medical services; emergency nurse practitioner education; emergency treatment; nurse practitioners

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