Using action learning research to help Emergency Department (ED) Advanced Nurse Practitioner’s (ANP’s) develop a tool to measure patient outcomes

TRINITY COLLEGE DUBLIN PHD COLLOQUIUM

NOVEMBER 6TH 2012Jenny Hogan, BA (Hons)RGN, MSc (Research)Trinity College Dublin

Aim:To examine the work done to date in developing a tool for measuring the outcomes of those patients who attend the ED with a minor injury and are seen and treated by an ED ANP.

Rationale:No toolkit exits internationally that enables ED ANP’s to measure their patient outcomes. Patient outcomes wil l be measured across the patient pathway from registration to discharge and beyond discharge. Post discharge outcomes for minor injury patients have not been measured in Ireland or internationally. The rat ionale for developing a tool was established at the first action learning set in July 2012. The rationale wil l be presented. Issues to be taken into consideration when devising the toolkit wil l be discussed, and final ly the agreed outcomes to be considered wil l be presented.

Conclusions and implications:The rationale for developing a toolkit has been art iculated using an action learning research approach. The development of the toolkit has only just begun, it wi l l al low ED ANP’s in Ireland to demonstrate the efficacy of their role in terms of patient outcomes along key milestones in the patients journey through the emergency department.

AIM OF THE PRESENTATION

ED ANP’s can assess, diagnose, treat & discharge 40-60 % who present to the ED with a ‘minor injury’ (HSE 2011)

Mean waiting time 6-7 hours - up to 61 hours (Tallaght, HIQA, 2012)

‘the provision of nurse-led minor injuries services..would effectively reduce the waiting times for patients, improve patient flow & could lead to a more effective utilisation of clinical staff’ (p.71 HIQA)

‘For many years the HSE has been counting waiting times in EDs by recording the numbers assessed in need of admission at 2pm each day. This is a poor indicator of the true extent of waiting times since it records only those who need to be admitted (ignoring those who do not)…’(DoH, 2011)

Some Irish studies examine one or two outcomes measures: Conlon et al (2009), Smith (2003)Kelleher Keane (2008), Thompson & Meskell (2012) x-ray, pain and time (s).

SCAPE (Begley et al 2010)–recommended the importance of on-going measurement of clinical outcomes

CONTEXT FOR THE STUDY

Why Act ion Research? The attract ion of using such a methodology (or or ientat ion) is that too often

pract i t ioners are the subject of research or the rec ip ients of intervent ions us ing or adopt ing other peoples research which may or may not be appropr iate for the c l in ica l sett ing (Reason & Bradbury 2009, Coghlan 2007, 2010, 2011) .

Problem solv ing approach (Badger 2000) . No such tool exists for the ED nor for the ANP in the ED.

Health care providers find so lut ions to their own ident ified problems and work as co -researchers with the act ion research fac i l i ta tor , thus e l iminat ing the need for the new knowledge or theory to be trans lated into pract ice as i t has come from pract ice (Ha l lberg 2006) .

The ED ANP’s asked me to he lp them develop a too l for measur ing the ir pat ient outcomes. (McCormack et a l 2004, Greenwood & Levin 2007) .

With in the I r ish hea lth care system, the ANP is re lat ively new. However the role of the ANP and advanced pract ice are both c lear ly defined…. provid ing the operat ing mechanism to support the roles ’ (B lanchfield & McGurk 2012)

(Koshy et a l 2011) improving pract ice is an AR feature…

‘an outcome is defined as a state, behaviour or bel ie f that can be affected as a resu l t o f nurs ing care ’ (Begley et a l 2010)

METHODOLOGY

All 35 ED ANP’s invited to participate2 levels A & BResponse rate = (45%) N=16Level A = (27%) N=10 Level B = (17%) N= 6X 5 ED ANP’s attended 1 st ALS June 2012 – ‘opening

the communicative space’ (Reason & Bradbury 2009)Taped and transcibed

SAMPLE POPULATION

Outcomes studies exist but very few for ED ANP’s: Cooper et al (2002), Sakr et al (1999)

But no systematic patient pathway toolkit or framework exists for ED ANP’s.Frameworks which include ANP evaluation include: (but not specifically ED) PEPPA Bryant-Lukosius & DiCenso, (2004). 9 steps Kleinpell (2009):

Burns (2009) Selecting Advanced Practice Nurse Outcomes Measures

Minnick (2009) General Design & Implementation Challenges in Outcomes Assessment

Role activities Vs. patient outcomes (Dayhoff & Lyon 2009)

INTERNATIONAL EVIDENCE FOR OUTCOMES

1. Col laborat ion and national col lat ion of outcome measures wi l l lead to the development of a national database of ED ANP patient outcomes-a first in I reland and perhaps international ly.

2. The ED workforce is going to be defined more clearly (EMP) and ED ANP’s need to be in a posit ion to be able justi fy their posts in terms of hard data.

3. When developing the further potential capacity of ED ANP’s in I reland, being able to demonstrate in specific terms of pat ient outcomes the effectiveness of the ED ANP wi l l be beneficial and perhaps unique among healthcare professionals.

4. Wil l help inform the ED ANP’s about their CPD requirements.

5. Wil l assist in ABA re-accreditat ion.

6. Wil l help the ED ANP’s to become researcher practit ioner’s at c l inical level .

7. The Emergency Medicine Programme wi l l NOT work i f there is not a certain threshold of ED ANP’s.

8. Outcome study may also lend support for the definit ive need for succession planning at local Hosp/HSE level for maintenance and protect ion of opt imum cohort of ANP’s posts in each ED site

RATIONALE FOR DEVELOPING A TOOLKIT(FROM THE ED ANP’S ALS)

1. Wil l inform GM’s/CEO’s/DoN’s/ADoN’s etc about the scope of the role and the level of decision making and raise the profile of the role by using hard data to demonstrate the benefits to patients.

2. Wil l ensure that cl inical supervision for ED ANP’s (novice to expert) continues to be assured.

3. Wil l (hopeful ly) al low ED ANP’s to demonstrate that their roles are not ‘quick fix’ solutions to the ED problem.

4. By capturing patient outcomes ED ANP’s wi l l be able to demonstrate the complexity of their cl inical decis ion making.

5. To ensure the high standards appl ied to the post of ANP’s in Ireland remains 6. It should help to demonstrate that ED ANP’s are autonomous practit ioners

who can manage the care and treatment of a defined cohort of patients. 7. Wil l help to continue to art iculate the role of the ED ANP and perhaps more

importantly what it may evolve into.8. Other unforeseen and unintended outcomes not yet broached, which the

ALS’s may (or may not) discover. 9. May stimulate more research activity on care pathways within individual

EDs, e.g.comparative studies..ANP/Medical which may yield results informing ED patient care

10. Study may again raise the overal l profile and importance of special ist nursing roles within the broader health care budgetary context and re focus thinking around the invaluable resource.. .experience/abi l i ty and ski l ls that is there to be tapped into within the profession.

RATIONALE FOR DEVELOPING A TOOLKIT CONT.

The toolkit needs to be able to ‘measure’ and/or allow for weighting of patients in terms of level of dependency/co-morbidites/age related disability.

Must be user friendly and not time consuming to complete. ‘ The tension between the need to identify quantifiable outcome measures and the challenge of capturing the indeterminate, qualitative aspects of advanced practitioners is acknowledged’ Begley et al (2010).

Ideally it should be built into the ED ANP’s documentation if possible.

IT infrastructure (or lack of) - We should look at using excel

Want to capture activity and quality.

Need to measure non-clinical time, i.e., time the ED ANP spends on teaching junior doctors, attending other patients, attending major incidents, attending meetings, organisational committees, etc. Bryant-Lukosius & DiCenso, (2004).

THINGS TO BE CONSIDERED WHEN DEVELOPING A TOOL:

We need to capture presenting condition.We need to capture x-ray hit rates.Use the patient pathway and measure key episodes along

the way: correct triage correct clinical assessment appropriate diagnostics correct interpretation of diagnostics, correct diagnosis correct treatment with different options discussed as appropriate correct treatment administered correct post-discharge advice/education and trouble-shooting

advice given follow-up appointment made and given as appropriate and follow

up (if we agree) at 1,3, 5 and 30 (TBD) days post attendance to enquire if the patient needed to re-enter the health care services with a problem relating to their presenting injury.

THINGS TO BE CONSIDERED WHEN DEVELOPING A TOOL:

Clinical pathway Arrival time at reception Time from registration at

reception to triage Time from triage to assessment by

ANP Time from assessment to

diagnostics (if required) Time from request for diagnostic

to actually having diagnostic Need to measure

pain/nausea/other clinical concerns at regular intervals? Assessments/Pain management/diagnostic accuracy/Care and treatment pathway

Time from having diagnostic to ANP receiving interpretation of report(assuming x-ray is most common diagnostic requested) from radiographer/radiologist

Time from diagnosis to initiation of treatment

Clinical pathway cont…

Time from treatment administration to discharge (from ANP)

Follow up patient at 3, 5, and 7 days to see if they required further health care intervention relating to their presenting complaint – to be discussed again

Overall time from admission to discharge.

Patient demographics The numbers of patients seen and

treated and discharged (from ANP care) by the ANP in hours/days/weeks/months/years.

The presenting conditions (top 90%)

WHAT TO MEASURE

2nd cycle of action learning to gain consensus/discussion on work to date from level B group and then how to measure….

References available on request E: jehogan@tcd.ie M: 087 967 8610

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