Emergency nurse practitioners: a three part study in clinical and cost effectiveness

Abstract

Aims: To compare the clinical effectiveness and costs of minor injury services provided by nurse practitioners with minor injury care provided by an accident and emergency (A&E) department. Methods: A three part prospective study in a city where an A&E department was closing and being replaced by a nurse led minor injury unit (MIU). The first part of the study took a sample of patients attending the A&E department. The second part of the study was a sample of patients from a nurse led MIU that had replaced the A&E department. In each of these samples the clinical effectiveness was judged by comparing the "gold standard" of a research assessment with the clinical assessment. Primary outcome measures were the number of errors in clinical assessment, treatment, and disposal. The third part of the study used routine data whose collection had been prospectively configured to assess the costs and cost consequences of both models of care. Results: The minor injury unit produced a safe service where the total package of care was equal to or in some cases better than the A&E care. Significant process errors were made in 191 of 1447 (13.2%) patients treated by medical staff in the A&E department and 126 of 1313 (9.6%) of patients treated by nurse practitioners in the MIU. Very significant errors were rare (one error). Waiting times were much better at the MIU (mean MIU 19 minutes, A&E department 56.4 minutes). The revenue costs were greater in the MIU (MIU £41.1, A&E department £40.01) and there was a great difference in the rates of follow up and with the nurses referring 47% of patients for follow up and the A&E department referring only 27%. Thus the costs and cost consequences were greater for MIU care compared with A&E care (MIU £12.7 per minor injury case, A&E department £9.66 per minor injury case). Conclusion: A nurse practitioner minor injury service can provide a safe and effective service for the treatment of minor injury. However, the costs of such a service are greater and there seems to be an increased use of outpatient services.

Proactive Interventions

“…In the United Kingdom, this has generally led to benefits for patients (Byrne, Richardson, Brunsdon, & Patel, 2000;Sakr et al, 2003). Nurse practitioners perform advanced nursing interventions and their skills are utilized, which could also increase the quality of emergency department care in Sweden.…”

Physician extenders in the emergency department

“…5 Interestingly, when Sakr and colleagues compared their experience with an NP-led minor injury unit with similar care provided in their ED, the cost per case and frequency of postvisit follow up care were higher for patients seen in the NP-led minor injury unit. 6 However, even if throughput (and resultant cost) efficiency is lower than when care is provided by doctors, physician extenders can provide vital extra staff during peak periods, evenings, weekends, and holidays, when minor care needs may be disproportionately high.…”

Integrating nurse practitioners into Canadian emergency departments: a qualitative study of barriers and recommendations

“…Recent research in the United Kingdom comparing NPs and physicians in health care settings revealed that NPs working within agreed guidelines provide safe and effective care, comparable to that of physicians, for patients with minor injuries and that patients are satisfied with the quality of care they receive. 19,22,23 However, NPs tend to spend more time with patients making the costs of such a service greater. 19,22 Future research should evaluate the clinical and cost effectiveness of services provided by NPs in EDs working in the United States and Canada as well as patient's perspectives and preferences for health care delivery to determine whether NPs are needed in EDs.…”