266 26 Accid Emerg Med 1998;15:266-268

Can nurse practitioners offer a quality service? An J Accid Emerg Med: first published as 10.1136/emj.15.4.266 on 1 July 1998. Downloaded from evaluation of a year's work of a nurse led minor injury unit

Abbas F Mabrook, Barbara Dale

Abstract recent years this role has been utilised in Objective-To evaluate activities of a various ways in A&E departments for the ben- nurse led minor injuries unit based in a efit of patients.23 Current developments in the community situated eight miles provision of minor injury care showed that away from its sister district hospital in nurses could successfully provide such a to demonstrate whether nurses service.4 In the light of this Crawley can provide an alternative service. NHS Trust took the decision to overcome cur- Design-"Walk in" service provided by rent difficulties and to continue providing a emergency nurse practitioners (ENPs) minor trauma service at Horsham by using working within protocols and parameters emergency nurse practitioners (ENPs) super- with supervision from the accident and vised by the A&E consultant based at Crawley emergency consultant during the period Hospital. The senior house officer on call for ofMay 1995 to April 1996. care of the elderly would be called upon in an Results-Within the 12 month period, emergency. This service started in May 1995. ENPs treated 6944 new patients. Alto- The decision to use ENPs to deliver the gether 234 patients were transferred to service provoked considerable pressure from Crawley Hospital for further treatment. the local community who wanted the status The ENPs reviewed 1611 patients and the quo maintained. Both lay persons and profes- consultant 1342; 1945 patients required sionals questioned the ability of nurses to radiographs and 793 were given deliver an adequate service. The local ambu- medication; 553 patients were referred to lance service expressed concerns of possible other health care professionals. Almost all increased demands to transfer patients to patients were happy to see a nurse and all Crawley Hospital and the on site outpatient were satisfied with the treatment they departments feared that an increased number received. of referrals to their clinics would create an

Conclusion-With careful planning, ad- overload to the already very busy clinics. It was http://emj.bmj.com/ equate supervision, and support from therefore important to closely monitor the new multidisciplinary teams nurses can pro- service to ascertain whether nurses could pro- vide a worthwhile and effective service for vide an alternative worthwhile service for the a local community. community. (JAccid Emerg Med 1998;15:266-268) Keywords: nurse practitioners; minor injury unit; quality Methods A public awareness campaign was conducted on September 24, 2021 by guest. Protected copyright. before the start of the service. All local general Concerns about the "casualty unit" at Hor- practitioners were informed of the change in sham Community Hospital working in isola- service. Leaflets were distributed to house- tion without senior medical supervision made holds in the local area stating the types and it necessary to review the service being extent of injuries the ENPs could treat. Posters provided. A survey of the facilities, attend- were distributed to schools, clinics, and to gen- ances, and activities of the unit was conducted. eral practitioner surgeries. The local papers This showed that 80% of injuries treated were and radio station also played their part in edu- Department of minor trauma. The survey also revealed a need cating the local community as to the type of Accident and to retain a service at Horsham as the large service the ENPs would provide. Emergency Medicine, numbers of attendances would create an extra Considerable care and effort was taken to Crawley Hospital, West Green Drive, Crawley, workload for the accident and emergency select suitable experienced nurses to run the RHll 7DR (A&E) department at Crawley Hospital situ- unit. Nurses with a minimum offive years A&E A F Mabrook ated eight miles away. Several options were experience were appointed and they had to be considered as to how best to maintain the serv- fully committed to the new venture. The Emergency Nurse ice including the possibility of a nurse unit as nurses attended a formal three month ENP Practitioner, Horsham minor could be assessed and treated course. The A&E consultant addi- Hospital, Horsham, injuries by provided West Sussex nurses. tional training at Crawley Hospital. This B Dale The concept of nurse practitioners is not a consisted of six weeks of observation plus six new one.' For many years senior nurses in out- weeks of supervised work of assessment, Correspondence to: lying community for all intents and diagnosis, and treatment of various minor inju- Mr Mabrook, consultant. purposes have carried out the role when using ries. Accepted for publication their clinical judgment to decide when and The role of the ENP was based on the Royal 16 March 1998 where to refer patients to medical personnel. In College of Nursing guidelines5 and the United Can nurse practitioners offer a quality service? 267

Kingdom Central Council directive.6 The patients treated were referred by local general nurses carried out a full assessment, provided practitioners and 169 were referred by other J Accid Emerg Med: first published as 10.1136/emj.15.4.266 on 1 July 1998. Downloaded from treatment, care, and discharge or referred professionals, for example physiotherapists, patients to other health care professionals. opticians, and other hospitals. All children Health promotion advice was incorporated in under 1 year were referred to the paediatric the overall care given. department at Crawley Hospital. Other refer- Wide ranging protocols and parameters were rals from the unit included 352 patients to the written and agreed based on activities high- physiotherapy department, 159 to their general lighted in the review. These included radiogra- practitioner, seven to their dentist, 68 to the phy, medication, treatment, and referral proto- eye clinic, and 25 to the ear, nose, and throat cols. Within the previously agreed protocols, clinic. Of the 6944 new patients treated 234 ENPs could request and interpret radiographs were transferred to Crawley A&E department of upper limb (shoulder to fingers), lower limb for further management. These included head (knee to toes), and chest and abdomen in cases injuries, fractures with displacement, lacera- of ingestion of foreign bodies, for example bat- tions involving deep structures, Achilles ten- teries. Patients under 2 years and pregnant don rupture, compartment syndrome, deep women were excluded. Within the agreed venous thrombosis, facial injuries, and chest treatment protocol ENPs were allowed to pains. Transportation by ambulance was re- administer simple analgesia, antibiotics, and quired for 28 of the referrals to Crawley A&E tetanus toxoid. Stronger analgesia required for department. Of the 760 fractures treated, 70 patients with displaced fractures was pre- were referred to Crawley A&E department by scribed by the senior house officer on call for the ENPs; 690 fractures were treated by ENPs care of the elderly. and were followed up in the unit by the During the first year all radiographs re- consultant during the twice weekly clinic quested by the ENPs were retained in the unit sessions. Seventy four of the ENP follow up with the patient' notes for review by the A&E fractures were referred to the fracture clinic by consultant. This formed part of the monitoring the consultant. ofthe nurses' work and ongoing education. The Of the 8555 patients treated by ENPs 1945 films were then returned to the x ray depart- required radiography investigations. There ment for a formal report by a radiologist. were 22 missed fractures and 57 false positive Patients who had their radiographs misinter- readings. The misinterpreted radiographs were preted by the ENPs were informed by 10 flake fractures of fingers, six flake fractures telephone and a consultant review appoint- of toes, two flake fractures of ankle, two possi- ment was given. All patients diagnosed as hav- ble crack fracture of head of radius, one possi- ing possible fractures, that is false positives, ble greenstick fracture of clavicle, and one pos- were automatically given a consultant review sible crack fracture of epiphyseal plate of tibia. appointment. In both instances of misinterpre- A patient satisfaction questionnaire was con- ofthree six months tations of radiographs, patients' symptoms ducted over a period weeks, http://emj.bmj.com/ were treated. after the start of the service. From 313 Seven part time staff provide a "walk in" questionnaires handed out 269 were returned. minor injuries treatment service between the Analysis of the returned questionnaires indi- hours of 9 am and 5 pm Monday to Friday cated that 263 patients examined by a nurse excluding Bank Holidays. The staff comprises were satisfied with the treatment or advice four ENPs (F grade), two support nurses (D given and had no objections to being treated by grade), and a receptionist. Two ENPs and a a nurse. Six patients stated that they would support nurse cover each shift. The A&E have preferred to be treated by a doctor, on September 24, 2021 by guest. Protected copyright. consultant based at Crawley Hospital provides although they had no complaints about the medical advice, support, and supervision. The treatment they received. There were no written consultant holds twice weekly clinic sessions in complaints during the first year. the unit to review patients' notes and radio- graphs, all patients with simple fractures Discussion treated by the ENPs, and any other soft tissue Careful planning and preparation have been injury referrals. ENPs may discuss cases and or key factors to the apparent success of the nurse obtain advice from senior medical personnel in led unit. Using information based on previous Crawley A&E department at any time. service provision and existing nurse units, a In order to reflect accurately the day to day service based on the needs of the local activities ofthe unit, special forms were devised community and facilities available was estab- to facilitate concurrent audit. Data collection lished. This is reflected in the wide range of was carried out by the nurses on a daily basis. previously agreed protocols that determine the scope of practice and level of intervention. Results Allowing the ENPs to request radiographs and Patients of all ages were assessed. During the to administer certain medications within the period May 1995 to April 1996 a total of 9897 agreed protocols were major factors in deter- patients were treated. Of these 6944 were new mining the apparent effectiveness of the service patients and 1611 were ENP follow up as these allowed the nurses to treat and patients. The consultant reviewed 690 patients discharge the majority of patients who at- with fractures and 652 patients with soft tissue tended without the need for referral to medical injuries. Altogether 3427 of the patients treated personnel. During its first year the unit has were under 17 years of age; 96% of patients provided treatment for 9897. The level and were self referred. One hundred and one breath of activities show that the local com- 268 Mabrook, Dale

munity has used the service, and interestingly A&E department, nurses can provide an effec- clients of all ages attended for treatment. tive and worthwhile locally based service. J Accid Emerg Med: first published as 10.1136/emj.15.4.266 on 1 July 1998. Downloaded from Altogether 98% of the patients surveyed 1 Stilwell B, Greenfield S, Drury V, et al. A nurse practitioner were happy to be seen by a nurse and were sat- in general practise: working styles and patterns of consulta- isfied with the treatment they received. The tions. Journal of Royal College of General Practitioners 1987;37: 154-7. level of transfers, referrals to clinics, and the 2 Potter T. A real way forward in A&E: developing the nurse practitioner role. Professional Nurse 1990;5:586-8. number of clients treated by the ENPs suggest 3 Woolwich C. A wider frame of practice. Nursing Times that all the fears and scepticism expressed 1992;88:34-6 (11 Nov). 4 Baker B. Model methods. Nursing Times 1993;89:33-5 (24 before the start of the service appear to be Nov). unfounded. 5 Royal College of Nursing A&E Association and Emergency Nurse Practitioner Special Interest Group. Emergency nurse The authors conclude that this study has practitioners: recommendations of special interest group. London: RCN, 1993. demonstrated that given suitable training, pro- 6 United Kingdom Central Council. The scope of professional tocols, and close liaison with a neighbouring practice. London: UKCC, 1992.

Hong Kong Academy ofMedicine First International Congress, Hong Kong 26-29 November 1998

Challenges to Specialists in the 21st Century Plenary lectures: Challenges to the specialist beyond 2000; Evidence based medicine; Survival of the generalist in a specialist world; The quest for transplantation tolerance; The training of our specialists into the next millennium; Pain-free state: is it possible? The scientific programme includes symposia on trauma, pain management, and substance abuse. http://emj.bmj.com/ For further information, contact the Congress Secretariat, Hong Kong Academy of Medicine, First International Congress, GPO Box 41, Hong Kong; tel: 852 2515 5737; fax: 852 2505 3149; e-mail: hkamghkam.org.hk on September 24, 2021 by guest. Protected copyright.