Changing emergency department practice: nurses have a key role to play as innovations are introduced into emergency departments to eliminate ever-increasing waiting times and enhance client satisfaction.

THE EVER-increasing number of attendees and increased waiting times at emergency departments (EDs) throughout New Zealand have be come a fact of life. Furthermore, the shortage of medical and nursing staff is compounding the stressors patients and staff have to deal with. (1) There is no quick fix and, unfortunately, even in the unlikely event further funding is made available, simply throwing money at the problem is not the answer.

Those of us involved in this field of nursing need to take on board new ideas and strategies, and develop innovative processes and practices, to challenge the existing system. The ultimate goal is to constantly change working practices to provide a modern professional service that effectively meets the needs of our client group.

In most EDs in New Zealand, recommended triage treatment times are constantly exceeded and many people have to wait inordinate lengths of time for treatment. Paradoxically, those who present with relatively minor complaints generally have to wait the longest.

There are several theories as to why this situation exists. However, one of the primary causes must be the chronic shortage of nurses and doctors. New Zealand is not alone in this respect--Australia, the United Kingdom (UK) and the United States are all experiencing this phenomenon.

Compounding the situation is the fact more people are attending an ED. Many of these people are presenting with primary health care problems and minor complaints that could be dealt with by other health care professionals such as doctors at After Hours surgeries, GPs and pharmacists. Yet, for whatever reason, many individuals choose to attend the ED rather than access health care elsewhere.

Emergency care has been, and always should be free at the point of delivery. However, historically, hospitals have been built in and around areas of lower socioeconomic status. It is inevitable, therefore, that financial considerations will have some bearing on who presents at the ED.

Innovations for nurses

An excellent example of innovative practice in this area now operates at Auckland Hospital. Since March 2001, a nurse-led minor injuries service has been provided. It has selected as its target group those presenting at the ED with minor injuries, mostly triage groups four and five. This enables medical staff-to concentrate on more acute presentations. A staff of four clinical nurse specialists (CNS) provides cover seven days a week between midday and midnight.

One of the four involved in the project, Michael Geraghty, presented a paper at last year's emergency nurses' conference, outlining the results of a survey conducted at the ED. Preliminary results showed clients were satisfied with the service, and many believed they were seen within an acceptable time frame and by an appropriate health care professional. Initial resistance from medical staff dissipated as the project began to yield positive results.

A similar nurse-led initiative is now being trialed at Hutt Hospital. Called Nurse Track, it involves five ED nurses, including myself, all of whom are clinical nurse specialists, have had extra training to take on the responsibilities and are level three or four on the Hutt Valley District Health Board clinical career pathway. We have been accredited by ACC and the hospital to assess, treat, refer if appropriate, discharge and arrange follow-up for minor presentations. Our scope of practice includes wound and limb assessment, suturing and plastering. After some further training and education, we will also be able to order and read below-knee and below-elbow x-rays.

Unfortunately, we do not have the funding to employ the two extra nurses needed to run this service to its optimum level. However, within these staffing constraints, we are receiving a good response from the public and other ED staff. My long-term vision would be for all ED nurses to be able to practise autonomously within such a system. The staff involved are grateful for the invaluable guidance and advice Geraghty and his colleagues have given in developing this project. Tribute also goes to our clinical nurse manager Lindsay Wilde, without whose support this project would not have eventuated.

Nurse practitioner's role

With the advent of the nurse practitioner (NP) in New Zealand, it is easy to see how the role could be integrated with that of the clinical nurse specialists. An NP, however, would have a broader scope to triage, treat, refer if appropriate, discharge and arrange follow-up for attendees from all triage categories. The NP would also have the authority to triage out if appropriate, eg to GPs. Recent studies demonstrate that the standard of clinical competence of NPs working in EDs compares favourably with that of house surgeons working in this setting. (2) Moreover, research published this year demonstrates that, in some instances, the overall quality of care provided by NPs from a variety of settings is superior to that of medical colleagues. Paradoxically, this research was presented in an eminent medical journal. (3)

As already stated, many people attend an ED with conditions that could be more suitably treated within a primary health care setting. Among hospital sub-cultures, these people are often referred to as "inappropriate" attendees, and are consequently treated as if they, themselves, are the problem. In fact, they are the product of a system that demands a fee for service in one sector, working alongside another service that is free at the point of delivery. A GP visit costing $30-$40 may not seem much to those on high incomes: others from less privileged backgrounds have an entirely different perspective.

In the UK, discussions are taking place about whether to employ GPs in EDs to cover those times where a high proportion of attendees are those with primary health care complaints. (4) Bearing in mind the NP role here, there is no reason why nurses qualified in primary health could not be integrated within the system to provide a similar service.

Other initiatives such as employing specialist paediatric and mental health nurses within the ED could also be considered. (5) I have been fortunate enough to work in two units in the UK where these services have been available and have seen how successful they have been. These nurse specialists can deliver care at an advanced level to their client group. Moreover, working with colleagues who have this expertise can be extremely satisfying in practical, professional and educational terms. This is a concept that could possibly dovetail with the NP role in the future.

At last year's emergency nurses' conference, keynote speaker Brian Dolan, who is editor of the UK journal Emergency Nurse and original nurse adviser for the television drama Casualty, spoke of past and current initiatives that have been or are being implemented in Ireland and the UK. He urged nurses not to make the same mistakes made in these countries, but rather to learn from them. Many of these mistakes concerned the lack of any nationally recognised training scheme. He believed many practices could be adapted to the New Zealand situation, eg the development of medical and surgical assessment units. These are units within the hospital, totally independent of the ED, where GP referrals are assessed, initially treated and then admitted to the appropriate beds.

Figures from a recent study at one of our major hospitals show that for a given 12-month period (May 2001 to April 2002), 16.5 percent of the total admissions through the ED were GP-medical referrals alone. The average time spent in the department was nearly three hours.

Somewhere along the line, ED nurses have been responsible for caring for these patients prior to the arrival of the medical/ surgical staff. Furthermore, they are then expected to deliver care and assist in procedures that should ideally be carried out in the setting where the patient will be admitted. This care is often delivered in addition to the nurse's allocated workload. I have worked in two hospitals where medical assessment units were implemented and the workload stress was immediately relieved. Both patients and staff benefited from a decrease in waiting times, more individual patient contact time and improved quality of care.

However, implementing such units should not be a case of robbing Peter to pay Paul. Suitably qualified nurses, along with adequate funding and resources, is needed, if such initiatives are to be successful.

Conclusion

Many health professionals believe there are too many "inappropriate" attendees presenting at EDs. I believe there is no such phenomenon as "inappropriate attendee", only inappropriate service delivery. There are ways of addressing this situation. Practices working in other countries can be adopted and adapted to the New Zealand setting and we can develop our own initiatives to assist in addressing the situation here. If health professionals wish to eliminate lengthening waiting times, enhance client satisfaction and improve our service to meet the needs of clients to whom we are ultimately accountable, then we need to adopt new working practices and embrace change. We need to be pro-active, not reactive in our response to these new challenges and work in collaboration with other health care providers. In short we need to "think outside the box".

REFERENCES

(1) Frank, I.C. (2001) ED crowding and diversion: strategies and concerns from across the United States Emergency Nursing; 27: 6, 559-65.

(2) Tye, C. and Ross, F. (2000) Blurred boundaries. Professional perspectives of the emergency nurse practitioner role in a major A/E department. Journal of Advanced Nursing; 31: 5, 1089-96.

(3) Horrocks, S. (2002) Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal; 324, 819-823.

(4) Department of Health United Kingdom (2001) Reforming Emergency Care 2001-2 2002-3. Author.

(5) Harrison, A. (2001) The mental health needs of patients in physical care settings. Nursing Standard; 15: 51, 47-54.

Mark Davies, RN, BSc (Hons), specialist practitioner in accident and emergency on the UKCC Nurses' Register, is a clinical nurse educator at Hutt Valley District Health Board's emergency department.