Trinity College Dublin PhD Colloquium November 6 th 2012

1. Trinity College Dublin PhD Colloquium November 6th 2012 Using action learning research to help Emergency Department (ED) Advanced Nurse Practitioner’s (ANP’s) develop a tool to measure patient outcomes Jenny Hogan, BA (Hons) RGN, MSc (Research) Trinity College Dublin

2. Aim of the presentation 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 will 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 rationale for developing a tool was established at the first action learning set in July 2012. The rationale will be presented. Issues to be taken into consideration when devising the toolkit will be discussed, and finally the agreed outcomes to be considered will be presented. Conclusions and implications: The rationale for developing a toolkit has been articulated using an action learning research approach. The development of the toolkit has only just begun, it will allow 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.

3. Context for the study • 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

4. Methodology Why Action Research? • The attraction of using such a methodology (or orientation) is that too often practitioners are the subject of research or the recipients of interventions using or adopting other peoples research which may or may not be appropriate for the clinical setting (Reason & Bradbury 2009, Coghlan 2007, 2010, 2011). • Problem solving approach (Badger 2000). No such tool exists for the ED nor for the ANP in the ED. • Health care providers find solutions to their own identified problems and work as co-researchers with the action research facilitator, thus eliminating the need for the new knowledge or theory to be translated into practice as it has come from practice (Hallberg 2006). • The ED ANP’s asked me to help them develop a tool for measuring their patient outcomes. (McCormack et al 2004, Greenwood & Levin 2007). • Within the Irish health care system, the ANP is relatively new. However the role of the ANP and advanced practice are both clearly defined…. providing the operating mechanism to support the roles’ (Blanchfield & McGurk 2012) • (Koshy et al 2011) improving practice is an AR feature… • ‘an outcome is defined as a state, behaviour or belief that can be affected as a result of nursing care’ (Begley et al 2010)

5. Sample population • All 35 ED ANP’s invited to participate • 2 levels A & B • Response rate= (45%) N=16 • Level A = (27%) N=10 • Level B = (17%) N= 6 • X 5 ED ANP’s attended 1st ALS June 2012 – ‘opening the communicative space’ (Reason & Bradbury 2009) • Taped and transcibed

6. International evidence for outcomes • 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)

7. Rationale for developing a toolkit(from the ED ANP’s ALS) • Collaboration and national collation of outcome measures will lead to the development of a national database of ED ANP patient outcomes-a first in Ireland and perhaps internationally. • The ED workforce is going to be defined more clearly (EMP) and ED ANP’s need to be in a position to be able justify their posts in terms of hard data. • When developing the further potential capacity of ED ANP’s in Ireland, being able to demonstrate in specific terms of patient outcomes the effectiveness of the ED ANP will be beneficial and perhaps unique among healthcare professionals. • Will help inform the ED ANP’s about their CPD requirements. • Will assist in ABA re-accreditation. • Will help the ED ANP’s to become researcher practitioner’s at clinical level. • The Emergency Medicine Programme will NOT work if there is not a certain threshold of ED ANP’s. • Outcome study may also lend support for the definitive need for succession planning at local Hosp/HSE level for maintenance and protection of optimum cohort of ANP’s posts in each ED site

8. Rationale for developing a toolkit cont. • Will 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. • Will ensure that clinical supervision for ED ANP’s (novice to expert) continues to be assured. • Will (hopefully) allow ED ANP’s to demonstrate that their roles are not ‘quick fix’ solutions to the ED problem. • By capturing patient outcomes ED ANP’s will be able to demonstrate the complexity of their clinical decision making. • To ensure the high standards applied to the post of ANP’s in Ireland remains • It should help to demonstrate that ED ANP’s are autonomous practitioners who can manage the care and treatment of a defined cohort of patients. • Will help to continue to articulate the role of the ED ANP and perhaps more importantly what it may evolve into. • Other unforeseen and unintended outcomes not yet broached, which the ALS’s may (or may not) discover. • May stimulate more research activity on care pathways within individual EDs, e.g.comparativestudies..ANP/Medical which may yield results informing ED patient care • Study may again raise the overall profile and importance of specialist nursing roles within the broader health care budgetary context and re focus thinking around the invaluable resource...experience/ability and skills that is there to be tapped into within the profession.

9. Things to be considered when developing a tool: • 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).

10. 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.

11. What to measure 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%) • 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

12. Next steps • 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