Nurse Practitioners in Emergency Care

There is widespread concern that the implementation of the Affordable Care Act will lead to increased health care spending in the United States. One commonly proposed mitigation strategy is the expansion of the scope of practice for advanced practice registered nurses (APRNs). In the November 2013 issue of Health Affairs, several authors discuss using nurse practitioners (NPs) as a way to decrease health care costs (Iglehart, 2013). This is good news. But we need more advanced practice research, especially in the area of emergency department (ED) patient outcomes. Historically, most of the patient outcomes studies with regard to emergency nurse practitioners (ENPs) have been published by ENPs in Australia, Canada, and the United Kingdom (Ducharme, Alder, Pelletier, Murray, & Tepper, 2009; Sandhu, Dale, Stallard, Crouch, & Glucksman, 2009). Only recently have ENPs from the United States offered research contributions with regard to ENPs and patient care outcomes. AUSTRALIAN STUDIES In 2006, ENPs from Australia looked at ENP care and ED patient flow (Considine, Martin, Smit, Winter, & Jenkins, 2006). This study compared ED wait times for patient assessment and management. The study also looked at length of stay (LOS) and treatment times for patients cared for by an ENP candidate as compared with the traditional ED care method with a physician. The authors concluded that there were no significant differences in wait times, LOS, and treatment times. The authors also noted that patient flow outcomes for patients seen by ENPs are comparable with those of patients managed by the physician. That same year Considine (2006) also set out to define the scope of practice of the ENP role in a metropolitan ED in Australia. In 2008, a group of researchers demonstrated shorter wait times and ED LOS associated with the use of ENPs in a major urban ED in Melbourne (Jennings, O'Reilly, Lee, Cameron, Free, & Bailey, 2008). The average wait time for emergency patients seen by the ENP was 12 min compared with 31 min for those seen by a physician. Length of stay in the ED was also significantly lower in the ENP group (94 min) than in the physician group (170 min). Wilson (2008) investigated the effectiveness of ENPs in an adult ED and assessed patient satisfaction for the care received for minor injuries. A majority of patients were satisfied with the treatment received from NPs. The authors also noted that patient flow through the department was significantly improved. CANADIAN STUDIES Carter and Chochinov (2007) performed a systematic review of the literature about the impact of ENPs on cost, quality of care, satisfaction, and wait times in the ED. The researchers focused on four outcome measures: (1) wait times, (2) patient satisfaction, (3) quality of care, and (4) cost-effectiveness. They noted that ENPs decreased wait times while providing quality, comprehensive, and cost-effective ED care, resulting in higher patient satisfaction. A 2008 study of patient satisfaction with NP care in Canadian EDs found that patients were satisfied with NP attentiveness and the comprehensiveness of their care and had a moderate understanding of the ENP role (Thrasher & Purc-Stephenson, 2008). Another Canadian study looked at the impact on patient flow after the integration of NPs and physician assistants (PAs) in six Ontario EDs (Ducharme et al., 2009). That study concluded that the addition of ENPs and PAs to the ED team could improve patient flow in medium-sized community hospital EDs. U.K. STUDIES A 2009 study compared the communication skills and patient satisfaction ratings of ENPs and ED physicians (Sandhu et al., 2009). This study compared the content of, and satisfaction with, consultations made by ENPs and physicians when patients presented to the ED with primary care problems. In the study, the researchers noted that ENPs seemed to focus more on patient education/counseling than did their physician counterparts. The authors noted that there were no statistically significant differences in consultation length. The study also revealed that ENPs had higher levels of self-satisfaction with their consultations than did the ED physicians. U.S. STUDIES In a 2012 study about the effectiveness ED provider in triage (PIT), the authors reported a quality improvement initiative to improve patient flow by redesigning the triage process (Love, Murphy, Lietz, & Jordan, 2012). The ED PIT decreased the time from patient arrival to initial contact with a licensed medical provider from 75 to 25 min. Also, the proportion of patients who left without being seen decreased from 3.6% to 0.9%. Bahena and Andreoni (2013) studied the use of the PIT. They found that using an ENP in triage was a cost-effective method to improve throughput in the ED while providing quality emergency care. Patient satisfaction, quality measures, and financial improvements occurred with the use of a PIT. The authors concluded that an ENP is an excellent ED triage provider option. In addition, the authors noted that by having advanced emergency nursing competencies and decision-making skills, the ENP is a cost-effective provider to improve throughput in the ED while providing quality emergency care. A recent study provided evidence regarding the impact of NPs when compared with physicians. This study addressed the areas of health care quality, safety, and effectiveness from 1990–2009. “A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of ED visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs” (Stanik-Hutt et al., 2013, p. 492). MORE RESEARCH IS NEEDED We need more quantitative and qualitative studies focusing on patient outcomes when APRNs provide care in the ED. Studies indicate that ENPs can be a valuable resource to manage increased ED service demands, including wait times, LOS, and patient satisfaction. Increased use of ENPs may improve both access to care and patient satisfaction and help make the best use of limited health care resources. Research funding is available from the Centers for Medicare and Medicaid through the National Prevention Partnership Program at www.hhs.gov/ash/nppa-faq.html. For ED quality data, you can also access https://data.medicare.gov/data/hospital-compare/Timely%26&%Effective&20Care (Centers for Medicare & Medicaid Services, 2014). So, let's get researching and get writing. —K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN Emergency Nurse Practitioner St. Mary Medical Center Long Beach, CA —Jean A. Proehl, RN, MN, CEN, CPEN, FAEN Emergency Clinical Nurse Specialist Proehl PRN, LLC Cornish, NH

The Emergency Nurse Practitioner role was introduced to an Emergency Department, Melbourne in 2004 as an alternative health-care model to provide accessible and efficient patient care. The aim of the study was to explore patient satisfaction using a questionnaire from their emergency department experience comparing Emergency Nurse Practitioners and emergency department doctors. Patients who received care from either Emergency Nurse Practitioners or emergency department doctors were given a self-administered questionnaire to complete. Descriptive statistics and non-parametric tests were used for data analysis. A total of 202 patients completed the survey with 103 seen by the Emergency Nurse Practitioners and 99 seen by emergency department doctors. Significant differences were reported in 12 of the 16 questions comparing patient satisfaction with either Emergency Nurse Practitioners or emergency department doctors with greater patient satisfaction demonstrated with the Emergency Nurse Practitioners. The Emergency Nurse Practitioner model demonstrates consistent levels of patient satisfaction with patients reporting more favourable satisfaction with the Emergency Nurse Practitioners compared with emergency department doctors.

To examine how the role of the Emergency Nurse Practitioner has evolved in Scotland. In 2001, Cooper and colleagues published a report on their survey (carried out in 1998) which described the extent and nature of Emergency Nurse Practitioner services in Scotland. They described a nascent nursing role and service that existed in almost half of Emergency Departments and that concentrated its activity on the management of minor distal limb trauma and wound management. Since that date, several relevant and important political, professional and local issues have combined to accelerate the development of this role. Longitudinal survey of Scottish Emergency Departments (n = 97 in 1998, n = 93 in 2009). Census survey of all Scottish Emergency Departments identified by NHS National Services Scotland's Information and Statistics Division Accident and Emergency Waiting Times dataset 2006-07. Emergency Nurse Practitioners are now practising in the majority (89%) of Emergency Departments and Minor Injury Units compared with 47% in 1998. Most departments (78%) use Emergency Nurse Practitioners in dual roles, and most departments (67%) differentiate their Emergency Nurse Practitioners from other nursing staff by use of a title. Wide variations in pay, role and scope of practice still exist. The role of the Emergency Nurse Practitioner has increasingly become part of mainstream health care delivery in Emergency Departments across Scotland and can now be considered to be common place. This study demonstrates that 'Advanced Nursing Practitioners' and 'Nurse Practitioners' cannot necessarily be considered to be synonymous, and nursing roles that are allowed to evolve naturally adopt a non-uniform level of practice. This paper is of interest to Nurse Practitioners and workforce planners.

BackgroundEmergency department (ED) visits in the US have risen dramatically over the past 2 decades. In order to meet the growing demand, mid-level providers (MLPs) – both physician assistants (PAs) and nurse practitioners (NPs) – were introduced into emergency care. Our objective was to test the hypothesis that MLP usage in US EDs continues to rise.FindingsWe analyzed ED data from the National Hospital Ambulatory Medical Care Survey to identify trends in ED visits seen by MLPs. We also compared MLP-only visits (defined as visits where the patient was seen by a MLP without being seen by a physician) with those seen by physicians only. During 1993 to 2009, 8.4% (95%CI, 7.6–9.2%) of all US ED visits were seen by MLPs. These summary data include marked changes in MLP utilization: PA visits rose from 2.9% to 9.9%, while NP visits rose from 1.1% to 4.7% (both Ptrend < 0.001). Together, MLP visits accounted for almost 15% of 2009 ED visits and 40% of these were seen without involvement of a physician. Compared to physician only visits, those seen by MLPs only were less likely to arrive by ambulance (16% vs 6%) and be admitted (14% vs 3%).ConclusionsMid-level provider use is rising in US EDs. By 2009, approximately one in seven visits involved MLPs, with PAs managing twice as many visits as NPs. Although patients seen by MLPs only are generally of lower acuity, these nationally representative data confirm that MLP care extends beyond minor presentations.

In many countries emergency departments (EDs) are facing an increase in demand for services, long waits, and severe crowding. One response to mitigate overcrowding has been to provide primary care services alongside or within hospital EDs for patients with non-urgent problems. However, it is unknown how this impacts the quality of patient care and the utilisation of hospital resources, or if it is cost-effective.This is the first update of the original Cochrane Review published in 2012. To assess the effects of locating primary care professionals in hospital EDs to provide care for patients with non-urgent health problems, compared with care provided by regularly scheduled emergency physicians (EPs). We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library; 2017, Issue 4), MEDLINE, Embase, CINAHL, PsycINFO, and King's Fund, from inception until 10 May 2017. We searched ClinicalTrials.gov and the WHO ICTRP for registered clinical trials, and screened reference lists of included papers and relevant systematic reviews. Randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series studies that evaluated the effectiveness of introducing primary care professionals to hospital EDs attending to patients with non-urgent conditions, as compared to the care provided by regularly scheduled EPs. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We identified four trials (one randomised trial and three non-randomised trials), one of which is newly identified in this update, involving a total of 11,463 patients, 16 general practitioners (GPs), 9 emergency nurse practitioners (NPs), and 69 EPs. These studies evaluated the effects of introducing GPs or emergency NPs to provide care to patients with non-urgent problems in the ED, as compared to EPs for outcomes such as resource use. The studies were conducted in Ireland, the UK, and Australia, and had an overall high or unclear risk of bias. The outcomes investigated were similar across studies, and there was considerable variation in the triage system used, the level of expertise and experience of the medical practitioners, and type of hospital (urban teaching, suburban community hospital). Main sources of funding were national or regional health authorities and a medical research funding body.There was high heterogeneity across studies, which precluded pooling data. It is uncertain whether the intervention reduces time from arrival to clinical assessment and treatment or total length of ED stay (1 study; 260 participants), admissions to hospital, diagnostic tests, treatments given, or consultations or referrals to hospital-based specialist (3 studies; 11,203 participants), as well as costs (2 studies; 9325 participants), as we assessed the evidence as being of very low-certainty for all outcomes.No data were reported on adverse events (such as ED returns and mortality). We assessed the evidence from the four included studies as of very low-certainty overall, as the results are inconsistent and safety has not been examined. The evidence is insufficient to draw conclusions for practice or policy regarding the effectiveness and safety of care provided to non-urgent patients by GPs and NPs versus EPs in the ED to mitigate problems of overcrowding, wait times, and patient flow.

The role of the Emergency Nurse Practitioner (ENP) has been established in other countries for a few decades, such as the United Kingdom (UK) and the United States where it has developed rapidly in these countries. The concept of the nurse practitioner is to empower those nurses who have a sound clinical base and specialty skills to enable them to make autonomous judgements and decisions regarding patient care. Evidence shows that the expanded role enables greater continuity and consistency in the delivery of “holistic care”. Moreover, the ENP service also helps the accident &amp; emergency department to be more effective in its use of available nursing and medical resources. In view of the situation in Hong Kong, because of the unsatisfactory primary health care system, health care providers in emergency care have to deal with huge numbers of patients with minor illnesses and injuries. Patients in this category have to wait for long periods to see a doctor. So the development of the role of ENP for the management of minor injury would be a good option to better utilise departmental manpower to meet patient needs. The author has finished training for minor injury in UK which prepared emergency nurses to take up the ENP role in accident &amp; emergency departments. In this article, the author will share her ENP training experience in the whole process of learning.

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

We sought to assess the impact of the integration of the new roles of primary health care nurse practitioners (NPs) and physician assistants (PAs) on patient flow, wait times and proportions of patients who left without being seen in 6 Ontario emergency departments (EDs). We performed a retrospective review of health records data on patient arrival time, time of initial assessment by a physician, time of discharge from the ED and discharge status. Whether a PA or NP was directly involved in the care of patients or indirectly involved by being on duty, the wait times, lengths of stay and proportion of patients who left without being seen were significantly reduced. When a PA or NP were directly involved in patients' care, patients were 1.6 (95% confidence interval [CI] 1.3-2.1, p < 0.05) and 2.1 (95% CI 1.6-2.8, p < 0.05) times more likely to be seen within the wait time benchmarks, respectively. Lengths of stay were 30.3% (95% CI 21.6%-39.0%, p < 0.01) and 48.8% (95% CI 35.0%-62.7%, p < 0.01) lower when PAs and NPs, respectively, were involved. When PAs and NPs were not on duty, the proportion of patients who left without being seen were 44% (95% CI 31%-63%, p < 0.01) and 71% (95% CI 53%-96%, p < 0.05), respectively. The addition of PAs or NPs to the ED team can improve patient flow in medium-sized community hospital EDs. Given the ongoing shortage of physicians, use of alternative health care providers should be considered. These results require validation, as their generalizability to other locations or types of EDs is not known.

The Advanced Emergency Nursing Journal (AENJ) is now the official journal of the American Academy of Emergency Nurse Practitioners (AAENP). The founder of the organization, Elda Ramirez, PhD, RN, FNP-BC, FAEN, FAANP, remarked, “I am so pleased to have a successful, internationally recognized professional journal like AENJ agree to be our official journal. It simply solidifies the emergency nurse practitioners' place in healthcare today!” This partnership aligns with the mission statement of the AAENP, which is to “promote high quality, evidence based practice for nurse practitioners providing emergency care for patients of all ages and acuities in collaboration with an interdisciplinary team” (AAENP 2015, p. 1). More specifically, AAENP seeks to “establish guidelines for quality and safety in emergency health care, encourage continuing clinical education of emergency nurse practitioners, support education in emergency care, facilitate research in emergency care, and collaborate with professional health organizations and academic institutions” (2015, p. 1). The AAENP is dedicated to sustained partnerships such as this one with AENJ. Jennifer Wilbeck, DNP, ACNP, FNP, CEN, Chair of AAENP, also stated, “We are thrilled to see this partnership emerge and look forward to our members receiving regular journals which highlight the new pertinent research in emergency care.” Wolters Kluwer, Lippincott Williams & Wilkins, the publisher of the Advanced Emergency Nursing, is pleased to offer the opportunity for all members of AAENP to access Advanced Emergency Nursing online. Highlights of the affiliation include recognition that the AENJ is affiliated with AAENP and will be provided to AAENP members as a benefit of membership. Watch for the AAENP logo that will be imprinted on the cover of the journal and journal website. The American Academy of Emergency Nurse Practitioners will also be recognized on www.AENjournal.com website with a link to the AAENP website. From time to time, AAENP will promote society/member news and events in the journal. We welcome AAENP members as readers, reviewers, and authors. —K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN Emergency Nurse Practitioner St. Mary Medical Center Long Beach, CA —Jean A. Proehl, RN, MN, CEN, CPEN, FAEN Emergency Clinical Nurse Specialist Proehl PRN, LLC Cornish, NH

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Emergency Physicians Seek Their Place in a Pay-for-Value World

It has been reported that the outcomes of care are affected not only by the educational preparation and experience of the practitioner but also by the parameters of his or her practice. Given differences that exist internationally in the enactment of the emergency nurse practitioner (ENP) role, a synthesis of research articles was conducted to examine the educational preparation and experience of ENPs, the role(s) they assume as determined by their patient population, and the outcomes used to evaluate their practice. The synthesis was informed by Sidani and Irvine's (1999) conceptual framework for evaluating the nurse practitioner role in acute care settings. The synthesis included 43 research articles, which were retrieved following a search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) bibliographic database. Approximately 60% of the articles were descriptive or qualitative studies, whereas only 7% were randomized controlled trials. Findings suggest that although many outcomes of care have been evaluated, no outcomes have been evaluated consistently and many are not specific to the intervention or actions of nurse practitioners. In addition, few research articles provide information on the educational preparation and experience of the ENPs or the parameters of their practice. Such information is needed to explain the variability observed in the outcomes achieved and to build a body of evidence supporting the role of nurse practitioners in the emergency department.

In recent years the complex process of managing services for patients requiring emergency care has been increasingly under scrutiny and considerable diversity has arisen in the organization of emergency care in both hospital and community settings. One innovation which has been particularly widespread is the development of Emergency Nurse Practitioners (ENPs): experienced Accident and Emergency nurses who assume entire responsibility for patients with minor injuries, in emergency settings. The present paper reports on a study which compared patients' satisfaction with care given by Emergency Nurse Practitioners with that provided by doctors and nurses working together in a traditional A & E. Patients were significantly more likely to have received health education and first aid advice from an ENP than from a doctor. They were also significantly more likely to have been given written instructions to take home and told whom to contact if they needed more help and advice following discharge. Those seen by an ENP also reported that they were subsequently significantly less worried about their health, than did patients seen in a traditional A & E.

Collaborating With NPs and PAs: Best Practices for Comanagement of Patient Care

To provide a 10-year update on the best available evidence evaluating the impact of nurse practitioner services on cost, waiting times, patient satisfaction, representation rates, and length of stay in emergency and urgent care settings. Systematic review. The search was completed on January 28, 2025, in Embase (Elsevier), Medline (EBSCOhost), CINAHL (EBSCOhost), Cochrane Library (Wiley), Emcare (Ovid), Web of Science Core Collection (Clarivate) and Scopus (Elsevier). The data range (2014-2024) was used to limit the search. The search was conducted with results imported into Covidence. In Covidence, two reviewers conducted screening, data extraction, and quality appraisal of articles, and findings were analysed using a narrative synthesis approach. Eligible studies examined nurse practitioner services in emergency or urgent care settings, reporting outcomes of cost, waiting times, patient satisfaction, representation rates, and length of stay. Title and abstract screening were performed on 2329 records. Of these, 236 full-text articles were reviewed, and 17 underwent critical appraisal and data extraction. Narrative analysis of outcome measures yielded mixed results, with both favourable and unfavourable findings reported regarding nurse practitioner services. Global evaluation of nurse practitioner services in emergency care remains inconsistent. Nevertheless, emerging evidence supports their positive impact, particularly in improving patient outcomes. To effectively inform policy, workforce planning and clinical integration, there is a need for professional benchmarks that provide clear frameworks for the evaluation of patient-centred outcomes and operational impacts in emergency departments. Evidence related to nurse practitioner services in emergency and urgent care clinics highlights the positive impact of nurse practitioner services on patient wait times and satisfaction; however, there is limited and variable evidence of impact on health care costs and outcomes. This paper recommends that evaluating emergency nurse practitioner services requires homogeneous research using consistent professional benchmarks and evaluation frameworks. This systematic review follows the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. This study did not include patient or public involvement in its design, conduct, or reporting. PROSPERO 2025 CRD420250645148.