Nurse Practitioner in Emergency: The Bethesda Hospital Experience Patti Fries Facility Manager

1. Nurse Practitioner in Emergency: The Bethesda Hospital Experience Patti Fries Facility Manager Bethesda Hospital/Bethesda Place 204-346-5150

2. Bethesda Hospital 64 Acute care beds, including medicine, surgery, obstetrics Surgical Program with some Ortho 20 Rehabilitation beds with Rehab Therapy Services Cancer Care

3. Emergency Department See ~25 000 patients per year 2 beds in resuscitation room 3 private rooms 2 stretchers with privacy curtains 2 hallway stretchers

4. Staffing • 2-3 RN’s / shift • 1 physician 24 hours per day, with second physician 1400-2200 h daily • One NP Monday – Friday 0800-1600 h • One CRN Monday – Friday 0900-1545 h

5. How Did This Come To Be? Need identified by current NP who was working in ER as a casual nurse while a student in the NP program. Together with Facility Manager, a proposal was written and presented to Manitoba Health. Pilot project for 0.8 EFT started July 17, 2006, became a full-time permanent position July 17, 2008.

6. Why Did We Need An NP? Recognized need for alternate practitioner to provide care for less urgent patient population Improve patient flow in a busy ER Decrease workload on existing practitioner thereby improving overall wait times.

7. ER Visits 125% increase since 1987/86 35% increase since 1996/1997 23,500 or 64 pts./day from 2004/05 with slight decrease (alternate space) 2/3 of region’s population increase; 29% increase since 1998 Acuity (Level 1-3) 97% increase 2000 – 2004 with 200% increase from 2003 - 2005

8. Integration of the Role Informal integration and education by NP while current staff nurse attending school and during practicum Physician coach/mentor who completed chart audits Manitoba Health deliverables 360° evaluation by peers Collaborative Practice Agreement Presentation by WRHA NP to all staff

9. Successes & Challenges

10. What Made It A Success? Existing staff member Supportive team – physicians, allied health, management NP’s key role in initiating support for proposal Advanced critical skill base with pediatric specialty Team player Commitment to best practice and high standard of care

11. What Were The Challenges? Lack of understanding of role, on both sides Treating NP as NP and not a staff nurse Paving way for new position Slight transition with assessments and writing orders Unable to write Rx independently for some items (i.e. air cast) Some insurance companies, organizations not accepting NP signatures (i.e. MPIC) Some specialists not wanting to discuss referral from NP (i.e. orthopedic surgery referral)

12. Supporting the NP Flexibility of both NP and management ER Team support Dedicated office space with computer Protected administration/education/research time Education support Inclusion on teams where input sought Nursing Practice ER/EMS NP Implementation (new) Pandemic Planning Primary Care Planning