Emergency Nurses Extended Practice Project
31 March 2015 Last updated:
17 April 2015
Emergency Nurses Extended Practice Project
Standardising South Eastern Sydney Local Health District (SESLHD) Emergency Department Nurse Protocols and Standing Orders
This project focused on ensuring that patients presenting to the Emergency Department (ED) are able to receive appropriate treatment by an appropriate person, within triage benchmark timeframes, and provided escalation of care to a senior medical officer as required. It was implemented with a supporting clinical governance structure, clinical nurse protocols and standing orders, as well as an education and training program, which defines the extended scope of the emergency registered nurse.
To reduce clinical variation and increase the application, compliance and documentation of emergency adult nurse protocols and standing orders in FirstNet across SESLHD EDs by 50% within 12 months of implementation.
- Improved patient safety and increased escalation of care for patients waiting for definitive care.
- Improved appropriate implementation, escalation of care and documentation of nurse protocols and standing orders in adult patients presenting to the ED.
- Improved appropriate diagnostic ordering in adult patients presenting to the ED, reducing patient harm and cost of diagnostic tests, such as quick order sets in FirstNet.
- Ongoing monitoring and evaluation of patient safety practices and escalation of patient care to reduce patient complications or adverse events.
Project started: 1 December 2013
Project status: Implementation - the initiative is ready for implementation, is currently being implemented, piloted or tested.
A health practitioner with an extended role is one who undertakes clinical tasks traditionally associated with another profession. In an ED setting, this may include investigation ordering and interpretation, diagnosis, procedures and prescriptions. Since 2002, the Clinical Initiatives Nurse (CIN) role has contributed towards timely patient interventions, investigations and care in NSW. Emergency nurses can bring a quality difference in the delivery of ED services through extended role practices. The aim of the CIN is to facilitate the following:
- Patient safety through clinical reassessment
- Care initiation with an emphasis on pain management and diagnostics.
ED Nurse Approved Protocols
During 1-30 November 2013, there were 13,157 ED attendances across SESLHD. Of those, 8092 patients (61.5%) had ED-approved nurse protocol care commenced and/or documented in FirstNet.
291 ED nurses initiated care for 8092 patients and attended 8011 nurse interventions with an average of 27.5 interventions per nurse.
Patients representing the highest number of nurse protocols initiated included Triage Category 3 (39%) and Category 4 (44%) patients waiting for definitive care.
Problems were identified with the existing processes and nurse protocol practices across SESLHD facilities in five key areas:
Nurse Protocols and Standing Orders
- No standardisation across LHD (varied from site to site)
- Revision of protocols and standing orders, with one to two yearly by clinical nurse consultants or nurse educators required
- Labour intensive task not always based on evidence or best practice
- Protocols and pathways not always clearly identified
- Analgesia and medications initiated and other treatments not identified.
Documentation (electronic medical record (eMR) / FirstNet)
- No minimum documentation standards in FirstNet
- Intervention details field was free text
- Limited information was provided by registered nurses
- No FirstNet downtime form to identify interventions initiated
- Limited use of electronic documentation in FirstNet
- Mix of medical record, electronic and National Inpatient Medication Chart (NIMC) documentation.
Compliance and auditing
- Done on an ad hoc basis and rarely completed
- Auditing of compliance with protocols is difficult and manually draining
- Click of the button ‘stops the clock’
- No ongoing auditing of compliance and minimum standards.
Handover and escalation of care
- Limited handover of care initiated for next clinician
- Limited transparency of information and care attended
- No escalation of care pathways documented for quality and safety of patients waiting for definitive treatment.
Education and training
- No standardisation within existing training and education programs
- LHD education approach but varying nurse protocols
- Confusing for nursing and medical staff who work across the LHD.
- Standardised SESLHD-approved nurse protocols, standing orders of medications, and pathology/radiology sensible test ordering protocols. These were incorporated into Australian College Emergency Medicine (ACEM) and Royal College of Pathologists of Australasia (RCPA) guidelines for adult patients presenting to the ED.
- Standardised the FirstNet documentation template and provided minimum standards for documentation of nurse interventions.
- Improved appropriate diagnostic ordering in adult patients presenting to the ED, reducing patient harm and cost of diagnostic tests such as quick order sets in FirstNet.
- Developed SESLHD policy and procedure guidelines for standard practice, to guide implementation of the program.
- Provided standardised LHD education packages to support implementation, in line with current CIN education programs.
- Ensured all nurse protocols and standing orders are easily accessible electronically in the one location, on SESLHD intranet and in hard copy for downtime forms.
- Encouraged a culture of patient safety and quality, while minimising competing demands to allow ED nurses to extend their skills within their current scope of practice.
- Ongoing monitoring and evaluation of patient safety practices and escalation of patient care, to reduce patient complications or adverse events.
- Clinical Excellence Commission
- ACI Emergency Care Institute
- Prince of Wales Hospital, Emergency Department
- St George Hospital, Emergency Department
- The Sutherland Hospital, Emergency Department
- Sydney / Sydney Eye Hospital, Emergency Departments
Outcomes and results will be evaluated in five key areas:
- protocol usage and compliance rates
- documentation standards
- cost efficiency of nurse pathology and radiology orders
- consumer and staff satisfaction
- complications or adverse events.
Ongoing audits will occur every three months, with further opportunities for Plan, Do, Study, Act (PDSA) cycles. There are plans to broaden the project to improve other aspects of nurse-initiated care as required.
- Australian College of Emergency Medicine. March 2013. Guideline on Pathology Testing in the Emergency Department.
- Australian College of Emergency Medicine. March 2014. Policy on Extended Role Nursing & Allied Health Practitioners Working In Emergency Departments.
- Emergency Care Institute. 2014. Clinical Initiatives Nurse (CIN) Role.
- Emergency Care Institute. 2011. Clinical Initiatives Nurse (CIN) in Emergency Departments Educational Program Resource Manual.
- Fry, M., & Jones, K. 2005. The clinical initiative nurse: Extending the role of the emergency nurse, who benefits?. Australasian Emergency Nursing Journal (ANEJ), Volume 8, Issues 1-2, Pages 9-12.
- Fry, M., Ruperto, K., Jarrett, K. et al (2012). Managing the wait: Clinical initiative nurses’ perceptions of an extended practice role. Australasian Emergency Nursing Journal (ANEJ), Volume 15, Issue 4, Pages 202-210.
- NSW Ministry of Health. 2013. Medication Handling in NSW Public Health Facilities PD2013_043.
- SESLHD. 2014. Adult Emergency Nurse Protocols.
Clinical Stream Nurse Manager, Critical Care / Emergency & Redesign
South Eastern Sydney Local Health District
Phone: 02 9947 9853
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