scholarly journals Introducing a nurse practitioner into an urban Canadian emergency department

CJEM ◽  
2008 ◽  
Vol 10 (04) ◽  
pp. 355-363 ◽  
Author(s):  
Ivan P. Steiner ◽  
Sandra Blitz ◽  
Darren N. Nichols ◽  
Dwight D. Harley ◽  
Leneela Sharma ◽  
...  
Keyword(s):  
Emergency Department ◽  
Real Time ◽  
Nurse Practitioner ◽  
A Priori ◽  
Care Providers ◽  
Job Descriptions ◽  
Free Standing ◽  
Physician Care ◽  
Patient Presentation

ABSTRACTObjective: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.

Low-Income Senior Housing Residents’ Emergency Department Use and Care Transition Problems

2017 ◽  
Vol 31 (6) ◽  
pp. 610-616 ◽  
Author(s):  
Antoinette B. Coe ◽  
Leticia R. Moczygemba ◽  
Kelechi C. Ogbonna ◽  
Pamela L. Parsons ◽  
Patricia W. Slattum ◽  
...  
Keyword(s):  
Emergency Department ◽  
Low Income ◽  
Personal Health Record ◽  
Primary Care Providers ◽  
Adverse Outcomes ◽  
Transitions Of Care ◽  
Care Providers ◽  
Senior Housing ◽  
Follow Up Care

Older adults may be at risk of adverse outcomes after emergency department (ED) visits due to ineffective transitions of care. Semi-structured interviews were employed to identify and categorize reasons for ED use and problems that occur during transition from the ED back to home among 14 residents of low-income senior housing. Qualitative thematic and descriptive analyses were used. Ambulance use, timely ED use or a wait-and-see approach, and lack of health-care provider contact before ED visit were emergent themes. Delayed medication receipt, no current medication list, and medication knowledge gaps were identified. Lack of a personal health record, follow-up care instruction, and worsening symptoms education emerged as transition problems from ED to home. After an ED visit, education opportunities exist around seeing primary care providers for nonurgent conditions, follow-up care, medications, and worsening condition symptoms. Timely receipt of discharge medications and medication education may improve medication-related transition problems.

scholarly journals P080: Clinical lead nurse practitioner Strathcona Community Hospital

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S85-S85
Author(s):  
D. K. Klemmer ◽  
C. Ziebel ◽  
N. Sharif ◽  
S. Grubb ◽  
S. Sookram
Keyword(s):  
Emergency Department ◽  
Quality Improvement ◽  
Patient Satisfaction ◽  
Service Delivery ◽  
Nurse Practitioner ◽  
Community Hospital ◽  
Clinical Care ◽  
Family Physicians ◽  
Lost To Follow Up

Introduction: Prior to opening Strathcona Community Hospital (STCH) site leadership were tasked to develop an innovative care model. The central aim was quality improvement and patient safety optimization in the emergency department (ED) utilizing a nurse practitioner (NP) model. They developed 3 pillars: collaboration, multidisciplinary approach, and integration with the plan of improving patient satisfaction and ensuring no patient gets lost to follow up. NPs work in the STCH ED and the NP led Emergency Department Transition (EDT) Clinic in Ambulatory Care. In the ED NPs provide direct clinical care, judicious review of DI and microbiology reports, and care coordination for patients at risk of lost to follow up. The EDT clinic is an innovative NP lead clinic with the purpose of providing timely, high-quality follow up care for ED patients. Methods: Data for the service delivery indicators came from data repository and manual data collection looking at the following outcomes: timely review of DI/micro results; decreased ED visits for non-urgent/emergent issues; safe transitions in care and improved patient satisfaction. Quantitative data from service delivery, patient and surveys were analyzed using Microsoft Excel and SPSS 19. Results: From June 2016 to January 2017 ED NPs at STCH reviewed 3000 positive microbiology reports and made 517 f/u calls to those patients, and reviewed 3181 DI results. This has freed up approximately 2 hrs per day of ED physician time. When NPs were working in the ED, the number of patients who left without treatment (LWT) was approximately 50% less, and improved STCH ED wait times to be among the lowest in the Edmonton Zone. From June 2016 to January 2017, EDT NPs completed 837 patient visits; 371 letters to family physicians (FPs); 215 referrals; and connected 520 patients to a new FP. Patient satisfaction survey show 88-90% of the patients were satisfied with their care. Conclusion: NPs are integral members of the ED team at STCH, providing direct clinical care and several valuable follow up services for ED patients. The EDT clinic provides urgent follow up for ED patients unable to get a timely appointment with their FP or no access to primary care. The clinic also prevents unnecessary returns to ED, and aids to bridge ED services to family physicians or specialist. NPs are the common thread through all departments at STCH, contributing to quality improvement and high patient satisfaction.

Abstract NS8: The Effects of Introducing a Nurse Practitioner Stroke Champion into the Emergency Department

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Lindsay Olson-Mack ◽  
Jacqueline Reardon ◽  
Elton Hedden ◽  
Rowena Carino ◽  
Cynthia VanWyk ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Nurse Practitioner ◽  
Treatment Effectiveness ◽  
Stroke Care ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
Assessment And Treatment ◽  
Iv Tpa

Background and Purpose: Emergency Department (ED) physicians often manage acute stroke patients without Neurology support at the bedside. Without guidance, they are left to rapidly assess, diagnose and treat acute stroke patients with minimal follow up on treatment effectiveness and patient outcomes. We hypothesized that introducing a Nurse Practitioner (NP) as Stroke Champion into an ED that did not have access to in-house Neurology would drive awareness of acute stroke care, and positively change practice to decrease door to needle times. Methods: The NP started in the 24-bed ED in June 2012. The average daily census of the ED for 2012 was 135 patients per day, and from January to June 2012, ED physicians initiated 46 stroke codes. Although Neurologists were available via telephone, ED physicians were left to accurately assess and initiate stroke codes, determine eligibility, and order IV tPA. In collaboration with the Stroke Medical Director, the Stroke NP conducted multiple education sessions regarding timing metrics in acute stroke care and door to tPA goals with ED clinicians, radiology, lab and pharmacy departments. Data was shared with stakeholders monthly to drive performance improvement initiatives. Results: Rapid improvements were made in all metrics. Mean time to CT first image improved by 19.3 minutes (37.3 to 18.0 minutes) in 6 months, and to 14.7 minutes in 1 year. CT result mean turn-around-time decreased by 19 minutes (from 54.0 to 29.1 minutes) in the first 6 months, and by 22.6 minutes (from 54.0 to 26.0 minutes) at 12 months. Likewise, laboratory result turn-around-times dramatically decreased by a mean of 15.9 minutes (54.4 to 38.5 minutes) over 6 months, and by a mean of 23 minutes (54.4 to 31.0 minutes) within 12 months. IV tPA treatment rates increased from 5% to 14.4% of all ischemic strokes. Door to IV tPA treatment times decreased by a mean of 33.9 minutes (104.5 to 70.6 minutes) in 6 months, and by 46.8 minutes (from 104.5 to 57.7 minutes) within the year. Conclusions: Introducing an NP into the ED to serve as Stroke Champion can provide added support to improve care of acute stroke patients by expediting assessment and treatment.

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

CJEM ◽  
2009 ◽  
Vol 11 (03) ◽  
pp. 207-214 ◽  
Author(s):  
Ivan P. Steiner ◽  
Darren N. Nichols ◽  
Sandra Blitz ◽  
Lloyd Tapper ◽  
Andrew P. Stagg ◽  
...  
Keyword(s):  
Emergency Department ◽  
Nurse Practitioner ◽  
Wait Times ◽  
Free Standing ◽  
Patient Demographics ◽  
Lengths Of Stay ◽  
Broad Scope ◽  
Triage Category ◽  
Included Patient ◽  
And Control

ABSTRACTObjective: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.

scholarly journals Management of Pain in the Emergency Department

2013 ◽  
Vol 2013 ◽  
pp. 1-19 ◽  
Author(s):  
Stephen H. Thomas
Keyword(s):  
Emergency Department ◽  
Pain Management ◽  
Acute Care ◽  
Acute Pain ◽  
Drug Information ◽  
Future Research ◽  
Care Providers ◽  
The Past ◽  
Pain Care ◽  
Patient Presentation

Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research.

scholarly journals Mobile App for Mental Health Monitoring and Clinical Outreach in Veterans: Mixed Methods Feasibility and Acceptability Study (Preprint)

2019 ◽  
Author(s):  
Lisa M Betthauser ◽  
Kelly A Stearns-Yoder ◽  
Suzanne McGarity ◽  
Victoria Smith ◽  
Skyler Place ◽  
...  
Keyword(s):  
Mental Health ◽  
Behavioral Health ◽  
Real Time ◽  
Veterans Affairs ◽  
Mobile App ◽  
Care Providers ◽  
Health Symptoms ◽  
Digital Phenotyping ◽  
Primary Model

BACKGROUND Advances in mobile health (mHealth) technology have made it possible for patients and health care providers to monitor and track behavioral health symptoms in real time. Ideally, mHealth apps include both passive and interactive monitoring and demonstrate high levels of patient engagement. Digital phenotyping, the measurement of individual technology usage, provides insight into individual behaviors associated with mental health. OBJECTIVE Researchers at a Veterans Affairs Medical Center and Cogito Corporation sought to explore the feasibility and acceptability of an mHealth app, the Cogito Companion. METHODS A mixed methodological approach was used to investigate the feasibility and acceptability of the app. Veterans completed clinical interviews and self-report measures, at baseline and at a 3-month follow-up. During the data collection period, participants were provided access to the Cogito Companion smartphone app. The mobile app gathered passive and active behavioral health indicators. Data collected (eg, vocal features and digital phenotyping of everyday social signals) are analyzed in real time. Passive data collected include location via global positioning system (GPS), phone calls, and SMS text message metadata. Four primary model scores were identified as being predictive of the presence or absence of depression or posttraumatic stress disorder (PTSD). Veterans Affairs clinicians monitored a provider dashboard and conducted clinical outreach when indicated. RESULTS Findings suggest that use of the Cogito Companion app was feasible and acceptable. Veterans (n=83) were interested in and used the app; however, active use declined over time. Nonetheless, data were passively collected, and outreach occurred throughout the study period. On the Client Satisfaction Questionnaire–8, 79% (53/67) of the sample reported scores demonstrating acceptability of the app (mean 26.2, SD 4.3). Many veterans reported liking specific app features (day-to-day monitoring) and the sense of connection they felt with the study clinicians who conducted outreach. Only a small percentage (4/67, 6%) reported concerns regarding personal privacy. CONCLUSIONS Feasibility and acceptability of the Cogito Corporation platform to monitor mental health symptoms, behaviors, and facilitate follow-up in a sample of veterans were supported. Clinically, platforms such as the Cogito Companion system may serve as useful methods to promote monitoring, thereby facilitating early identification of risk and mitigating negative psychiatric outcomes, such as suicide.

scholarly journals LO23: Reducing time to disposition for treat & release patients in the emergency department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S14-S14
Author(s):  
V. Woolner ◽  
S. Ensafi ◽  
J. De Leon ◽  
L. George ◽  
L. Chartier
Keyword(s):  
Health Care ◽  
Emergency Department ◽  
Health Care Providers ◽  
Initial Assessment ◽  
Teaching Hospitals ◽  
Care Providers ◽  
Patient Disposition ◽  
Forcing Function

Introduction: Treat and Release (T&R) patients are seen and discharged home from the emergency department (ED), and asked to return within 12-72 hours for follow-up care (e.g., ultrasound, repeat blood work). Our two academic teaching hospitals see approximately 2,000 T&R patients per year. Handover of care for T&R patientsdone through charting only and therefore dependent on the charts adequacy and completenessis crucial to the safety and quality of care they receive. An 18-month retrospective chart audit at our sites identified quality gaps, including suboptimal documentation that ultimately impedes patient disposition. Our projects aim was to reduce the time-to-disposition (TTD; time spent by patients between provider initial assessment and discharge from the ED) by a third (from 70min) in 6-months time (March 2017), a target felt to be both meaningful and realistic by our stakeholder team. Methods: Our primary outcome measure was the TTD (in minutes). Our process measure was the quality of documentation, using a modified version of QNOTE, a validated tool used to assess the quality of health-care documentation. PDSA cycles included: 1) Involvement of stakeholders for the creation and refinement of an improved T&R handover tool to cue more specific documentation; 2) Education of health-care providers (HCPs) about T&R patients; 3) Replacement of the previous T&R handover tool with a newly designed and mandatory tool (i.e. a forcing function); 4) Refinement of the process for T&R patients and chart hold-over. Results: Run charts for both the median TTD and median modified QNOTE scores over time demonstrate a shift (i.e., run chart rule) associated with the second and third clustered PDSA cycles. After the first three clusters of PDSA cycles (i.e., before-and-after), mean TTD was reduced by 40% (70min to 42min, p=0.005). The quality of documentation (mean modified QNOTE scores) was also significantly improved (all results p<0.0001): patient assessment from 81% to 92%, plan of care from 58% to 85% and follow-up plan from 67% to 90%. Conclusion: We reduced the time-to-disposition for T&R patients by identifying gaps in the quality of documentation of their chart. Using iterative PDSA cycles, we improved their time-to-disposition through improved communication between health-care providers and a new T&R handover tool working as a forcing function. Other centers could use similar assessment methods and interventions to improve the care of T&R patients.

scholarly journals Errors, near misses and adverse events in the emergency department: What can patients tell us?

CJEM ◽  
2008 ◽  
Vol 10 (05) ◽  
pp. 421-427 ◽  
Author(s):  
Steven M. Friedman ◽  
David Provan ◽  
Shannon Moore ◽  
Kate Hanneman
Keyword(s):  
Emergency Department ◽  
Adverse Events ◽  
Medical Record ◽  
Reporting System ◽  
Care Providers ◽  
Event Reporting ◽  
Near Misses ◽  
Patient Reports ◽  
Incident Rate

ABSTRACTObjective:We sought to determine whether patients or their families could identify adverse events in the emergency department (ED), to characterize patient reports of errors and to compare patient reports to events recorded by health care providers.Methods:This was a prospective cohort study in a quaternary care inner city teaching hospital with approximately 40 000 annual visits. ED patients were recruited for participation in a standardized interview within 24 hours of ED discharge and a follow-up interview 3–7 days after discharge. Responses regarding events were tabulated and compared with physician and nurse notations in the medical record and hospital event reporting system.Results:Of 292 eligible patients, 201 (69%) were interviewed within 24 hours of ED discharge, and 143 (71% of interviewees) underwent a follow-up interview 3–7 days after discharge. Interviewees did not differ from the base ED population in terms of age, sex or language. Analysis of patient interviews identified 10 adverse events (5% incident rate; 95% confidence interval [CI] 2.41%–8.96%), 8 near misses (4% incident rate; 95% CI 1.73%–7.69%) and no medical errors. Of the 10 adverse events, 6 (60%) were characterized as preventable (2 raters; κ = 0.78, standard error [SE] 0.20; 95% CI 0.39–1.00;p= 0.01). Adverse events were primarily related to delayed or inadequate analgesia. Only 4 out of 8 (50%) near misses were intercepted by hospital personnel. The secondary interview elicited 2 out of 10 adverse events and 3 out of 8 near misses that had not been identified in the primary interview. No designation (0 out of 10) of an adverse event was recorded in the ED medical record or in the confidential hospital event reporting system.Conclusion:ED patients can identify adverse events affecting their care. Moreover, many of these events are not recorded in the medical record. Engaging patients and their family members in identification of errors may enhance patient safety.

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