Emergency Nursing Initiatives to Improve

ED Quality & Efficiency

Valerie Small RGN, RNT, RANP

MSc, PGDip CHSE, A&E Cert

Nursing Lead Emergency Medicine Programme

Emergency Nursing – Towards Improving Quality of Patient Care

 Background to Emergency Nursing
• 1970s A&E Nursing Course
Schools of Nursing Mater & St Vincent's Hospital, Dublin

• 1980s-2000 A&E Nursing Course (Cert)

ACLS,TNCC,ATLS,PALS, Neonatal Resus
MIMMs /HMIMMS

• 2002 -Present
• Evidence Based Emergency Nursing.
• PG Dip (Specialist Nursing) 3rd Level Colleges
• Nurse Prescribing Medicinal Products.
• Nurse Prescribing Ionising Radiation.
• Masters in Nursing (Advanced Practice)
• Masters in Healthcare Management
• PhD by Research
• Clinical Doctorates Specialist area

Emergency Nursing – Towards Improving Quality of Patient Care

 Emergency Nursing Interest Group
ENIG
• National membership – all departments
represented
• Established in November 2010 in response to
high interest expressed in Lead Nurse Role.
• Opportunity for senior ED Nurses to provide
solutions to local & national problem areas
• Provides opportunities for networking and
sharing best practice
• VITAL to successful implementation of EMP

Emergency Nursing – Towards Improving Quality of Patient Care

 The DCSP Approach to Improvement
(1) Access, quality,
cost & compliance
targets
(6)
Implement (2) Lean Pathways
sustainable
change ? Symptoms
Ref

Dx
Tm

(5) Effective Patients & families

operational (3) Clear authority &
meetings responsibility

(4) Objective data

Access
Quality
Cost

Clinical Strategy and Programmes 8 Compliance

Emergency Nursing – Towards Improving Quality of Patient Care

 What is Emergency Nursing ?

• Emergency Nursing is defined as the provision

of immediate nursing care and intervention to
adults and children who have undiagnosed,
undifferentiated healthcare needs arising from
social, psychological, physical and cultural
factors (adapted from Emergency Nurses Association 2009).

Emergency Nursing – Towards Improving Quality of Patient Care

 Mission Statement
• Emergency Nurses work independently & interdependently with
the multidisciplinary team to provide the optimal level of emergency
nursing care that is patient focused, family centred, maximises
health and social gain, promotes excellence in nursing practice and
advocates for all patients who suffer sudden injury or illness.

Emergency nursing practice is underpinned by expert knowledge

gained through specialist education and clinical experience. It is
informed by best evidence and research (ENIG 2011)

Emergency Nursing – Towards Improving Quality of Patient Care

Toolkit for Nurse & Midwife Competency Determination

Emergency Nursing – Towards Improving Quality of Patient Care

 Models of Care
Emergency Nursing Specific Initiatives

• Competency Framework for Emergency Nursing

• Enhanced clinical skills and competencies for

emergency nurses

Emergency Nursing – Towards Improving Quality of Patient Care

 Emergency Nursing Team

• Staff Nurse – Prioritises care

based on needs of patient.
Initiates nursing specific
interventions. Implements
prescribed care. Communicates
on ongoing basis with patient and
family on all aspects of care
journey. Assesses effects and
quality of interventions and
documents patient outcomes.
• Involved in rapid assessment, fast
track and streaming initiatives post
triage – carry out specific
diagnostic tests, supply and
administer analgesia within a
protocol driven framework of
enhanced nursing practice.

Emergency Nursing – Towards Improving Quality of Patient Care

 Emergency Nursing Team
• Clinical Nurse Manager –
Co-ordinates activities in
department. Delegates
clinical workload to
appropriately skilled staff.
Supervises overall care
delivered to patients.
Communicates with
multidisciplinary team,
patients and relatives.
Manages and responds Office of Health Management
to patient flow issues. Frontline Competencies for Nurse &
Midwife Managers

Emergency Nursing – Towards Improving Quality of Patient Care

 Emergency Nursing Team
Clinical Nurse Specialist
• Criteria & Standards
Establishment of Service &
Individual
Manage patients with disease specific
conditions as part of the MDT
• CNS –ED
– Chest pain assessment
– Respiratory
• CNS – In-house teams provide
expertise and pathways of care
linking patient with services
outside ED
– Liaison Psychiatry
– Stroke
– Older persons
– Diabetes
– Respiratory

Emergency Nursing – Towards Improving Quality of Patient Care

 Emergency Nursing Team

• ANP - Criteria &

Standards for
Establishment of Service
& Individual
• ANP – Manages an
agreed caseload of
patients which involves
delivering a full episode
of care. Has the authority
to discharge patients or
refer on to other
appropriate services
Emergency Nursing – Towards Improving Quality of Patient Care
 Models of Care
Emergency Nursing Specific Initiatives

• Workforce Planning (Staffing Models)

• National Children’s Triage System
• National Job Descriptions - based on
competency frameworks for Staff Nurse, CNS,
CNM, ANP.

Emergency Nursing – Towards Improving Quality of Patient Care

 ED Workforce Survey
Staff Profiles

– Nursing Workforce Resource

– Health Care Assistant Resource
– Allied health professionals /Therapies
– Medical Resource
– Administrative staff
– Support staff

Emergency Nursing – Towards Improving Quality of Patient Care

ED Nursing Staff Profile - December 2010

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Emergency Nursing – Towards Improving Quality of Patient Care

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Emergency Nursing – Towards Improving Quality of Patient Care
 ED Nursing Qualifications

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• 735 (51%) All ED Nurses –Specialist Education

• 243 (79%) CNM Group -Management Qualification
• 40.2 (100%) ANP Group - Master’s Degree or higher (3 PHD scholars)
• 64 (5%) Nurse Prescribing Med / Ionising Radiation

Emergency Nursing – Towards Improving Quality of Patient Care

 Quality Improvement
Emergency Nursing Specific Initiatives

• National Triage Tool (Paediatric)

• Repeat of ED Workforce Survey 2011
• National EMP Guidelines for Practice
• Emergency nursing KPI’s and process measures
• Role development & capacity building of Advanced Nurse
Practitioners for Emergency Care Network

Emergency Nursing – Towards Improving Quality of Patient Care

 National Triage Tool (Paediatric)

• National Emergency Medicine Programme

Children’s Triage System (CTS)
• Paediatric Sub-group (ENIG)
• Collaboration between adult & paediatric
departments / hospitals
• Multidisciplinary involvement
• Pilot phase January 2012 in three departments

Emergency Nursing – Towards Improving Quality of Patient Care

 National Clinical Guidelines

• Multidisciplinary clinical guidelines which

standardise care pathways and management of
common clinical conditions
• Improve the quality of patient care delivered in
ED
• Academic Emergency Nursing Sub-group
(ENIG)
– Glossary for EMP Report
– Cache of Guidelines for EMP & Clinical Care Programmes
(Epilepsy, Asthma, ACS)

Emergency Nursing – Towards Improving Quality of Patient Care

 Emergency Nursing
Key Performance Indicators
• Patient Handover Time
• Triage Time
• Pain Assessment – Time to analgesia – Re-assessment
of pain
• Time to 1st ECG for suspected STEMI
• Rapid assessment initiatives
• Streaming of appropriate patients to Advanced Nurse
Practitioners for full episode of care leading to
Disposition Decision (Discharge or referral outside ED)

Emergency Nursing – Towards Improving Quality of Patient Care

 Registered ANP (Emergency)
Role & Scope of Practice
• Management of full episode of Injuries & Conditions
patient care within agreed • Minor Head & Facial Injury
caseload • Laceration face, trunk & limb
• Authority to discharge or refer • Skeletal & Soft tissue injury
to appropriate other service • Initial management of fractures
• Education of multidisciplinary • Hand & fingertip Injury
team
• Minor burns < 2% TBSA
• Audit of service – KPI’s
• Soft tissue infection
• Research & implementing
evidence into practice Emergency Cardiology
• Chest Pain
• Acute Coronary Syndrome
• Integrated Care Pathway

Emergency Nursing – Towards Improving Quality of Patient Care

 Advanced Nurse Practitioner
Services
• Total 23 / 40 Departments
Nationally with established ANP
service – Criteria & Standards of
NCNM
• 8 Departments ANP (Adult only)
Dublin / CUH
• 12 Departments ANP (Adult &
Paediatric) Regions
• 3 Departments ANP (Paediatric
only)
• 5 Departments recruiting /
developing ANP Role (Mid-West,
Naas, Midlands)

• RANP total = 43 (3 Paediatric)

• ANP (E) Candidates = 16

Emergency Nursing – Towards Improving Quality of Patient Care

 Sustaining Improvement & Building
Capacity
Emergency Nursing Specific Initiatives

• Strategic Plan for Emergency Nursing

• Leadership, Support & Collaboration - Directors of Nursing,
Centres for Learning & Development, Office of Director of
Nursing Services HSE, Third Level Institutions
– Post Graduate Education
– Enhanced Clinical Skills
– Career Pathway / Career Guidance
– Succession Planning

• Change management and embed continuous improvement

– LEAN Programme

Emergency Nursing – Towards Improving Quality of Patient Care

Patient Experience