Advanced nursing roles

Chapter 45 Advanced nursing roles



Barbara Daly, Sarah Hoy, Gordian W.O. Fulde, Kirsty McLeod


Advancing nursing practice is a global phenomenon: in the context of the Australian experience, this has evolved over the past three and a half decades. The evolution of advance nurse practice is an ongoing process moving nursing practice forward for the benefit of the patient.1 This change of practice is directly related to changes in the delivery of healthcare services and the implementation of new models of patient-focused care. An important driver in the development of the advance practice nurse is the political demand to meet government-set performance indicators and benchmarks aimed to reduce emergency department waiting times and patient length of stay and to increase patient satisfaction.2 Another factor that has contributed to evolving advance practice is medical and nursing workforce shortages and skill mix problems. These developments have provided the impetus for emergency nurses to take on new opportunities to develop and increase their scope and complexity of practice in the field of emergency medicine. These advance nursing roles are now core roles that work with and support the medical and clerical staff to expedite the patient’s journey through the emergency department.



THE TRIAGE NURSE


The patient’s journey in the emergency department begins at triage. Triage is an essential function in the delivery of care in all emergency departments. It is the point at which emergency care begins. Triage is a brief clinical assessment that determines the urgency of treatment and the time sequence in which patients should be seen in the emergency department. The purpose of the triage system is to ensure safe quality of care and equity of access to health services. In all healthcare environments, the triage process is underpinned by the premise that a reduction in the time taken to access definitive medical care will improve patient outcomes.3


Most importantly, triage is a dynamic and ongoing process in which patients are continually reassessed. Their clinical urgency and triage category may be changed as a result, depending on parameters such as changes in level of pain and haemodynamic stability. For example, if a patient’s level of pain increases compared to initial triage assessment, or they become tachycardic or hypotensive, the patient will be re-triaged to a higher category.


In Australasian emergency departments a standardised triage system known as the Australasian Triage Scale (ATS) is the primary clinical tool for ensuring patients are seen in a timely manner, commensurate with their clinical urgency. The practical application of the ATS is the process by which the triage nurse assesses a patient’s presenting complaint, which is identified by a brief history of the presenting illness or injury. Triage decisions using the scale are made on the basis of observation of general appearance, focused clinical history and physiological data.4 This decision-making process may also require consultation and discussion with medical staff.


In practical terms triage refers to two domains, which are:


Domain 1. The ATS has five levels of acuity that categorise patients according to a rating scale from 1 to 5. (Also see Chapter 39, ‘Psychiatric presentations’, Table 39.1 Mental health triage.)



Table 45.1 ATS categories for treatment acuity, performance thresholds and examples of possible presenting problems




Domain 2. Time-to-treatment criteria attached to the ATS.


Time-to-treatment criteria attached to the ATS categories identify the maximum time a patient can safely wait for medical assessment and treatment.


Please refer to Table 45.1 for triage examples.


There are five core components for a nurse undertaking the role of triage nurse:


1. patient assessment

2. initiation of nursing interventions

3. ensuring continuous reassessment/management of`waiting room patients

4. provision of public education

5. acting as a liaison for members of the public and other health care professionals.5

The ability to undertake effective and efficient triage is dependent on extensive knowledge of and experience with a wide range of illness and injury patterns. Therefore, it is essential that the triage nurse is appropriately prepared through education and experience.


The triage nurse will perform a seven step triage assessment, which identifies the following key points as physiological predicators underpinning the allocation of urgency using the ATS.


Step 1. Identify and manage risks to self, patients and the environment is the first principle of a safe triage practice.


Step 2. First impressions of general appearance should always be considered when making a triage decision.


Step 3. Always ask the question: ‘Does this person look sick?’


Step 4. The primary survey approach is used to identify and correct life-threatening conditions at triage.


Step 5. Other conditions in which timely intervention may significantly influence outcomes (such as thrombolysis, an antidote or management of acid or alkali splash to eye) must also be detected at triage.


Step 6. Timely access to emergency care can improve patient outcomes.


Step 7. Early identification of physiological abnormality at triage can inform focused ongoing medical assessment and investigation.6


Once the triage assessment is complete, the patient may follow a variety of treatment paths and interact with any of the following emergency department staff and teams:


• clinical initiatives nurse (CIN)

• aged care services team (ASET)

• rapid assessment team (RAT)/immediate initiation of care (IIOC)

• nurse practitioner (NP).

All of these advanced practice roles assist in expediting treatment and initiation of care and will now be discussed in terms of how they interact with the patient during their emergency department journey.



CLINICAL INITIATIVES NURSE (CIN)


The CIN role works as an adjunct to the triage position, initiating care of patients in the waiting room once they have been assessed by the triage nurse. The CIN is able to fast-track the care of patients with a variety of presenting problems prior to receiving medical care. This may be as a result of established clinical pathways, local standing orders or CIN guidelines. The CIN is not able to discharge patients and hands over care of the patient to another nurse once treatment has been initiated.


Nurses working at CIN level should have:


• significant triage experience

• confidence

• high level clinical skills

• advanced practice skills, or ready to be trained to an advanced practice level

• well-developed conflict resolution and negotiation skills with focus on customer satisfaction.

Initiated care may include:


• ordering radiological tests

• insertion of peripheral intravenous cannulae

• withdrawal of venous blood for pathology

• initiation of medication such as oral analgesia, anti-emetic agents and intravenous narcotic analgesics

• fracture management such as application of ‘back slab’ plaster

• wound management, including suturing

• referral to other hospital services, for example outpatient’s clinics or social worker.7

The CIN role enables the nurse to commence patient treatment via pre-approved standing orders for specific presentations under the supervision of an emergency department registrar or consultant.



Box 45.1 Example 1. Patient presenting with an ankle fracture



Patient presents to emergency department with painful left ankle following a simple trip and fall.

Triage assessment indicates pain and tenderness at posterior edge of lateral malleolus, ankle is swollen and deformed, and the patient is unable to weight bear. The left ankle is neurovascularly intact, and the patient describes pain severity as 6/10. Vital signs are within normal limits, Glasgow Coma Score 15, nil known allergies.

Triage category 3 is allocated by triage nurse.

Patient is referred to CIN nurse who orders left ankle X-ray according to Ottawa ankle rules, application of rest/ice/elevation. Due to level of pain, CIN inserts IV cannula, places patient on oxygen saturation monitoring and initiates administration of IV morphine 2.5 mg bolus as per nurse initiated protocol.

Patient’s ankle X-ray attended.

CIN nurse views X-ray with emergency department registrar. X-ray shows fracture to left lateral malleolus.

CIN applies back slab plaster as per standing order.

Ongoing medical treatment by emergency department registrar as required.

Patient is referred to orthopaedic team.


AGED SERVICE EMERGENCY TEAM (ASET)


ASET is led by a clinical nurse consultant, specialising in aged care. ASET is a multidisciplinary team including a nurse, physiotherapist, social worker and, in some areas, an occupational therapist.


The specific objectives of this team include:


• undertaking a comprehensive assessment of elderly patients over 70 years of age presenting to emergency department.

• aiming to prevent avoidable admissions by setting up services or accessing respite.

• identifying potential admission for patients who are considered at risk.

• commencing treatment for patients being admitted by providing physiotherapy and social work input while in the emergency department.

• encouraging health promotion by providing information on social and educational activities available for older people in the community.

Related posts:

Default ThumbnailOrthopaedic principles: fractures and dislocations Ultrasound in emergency medicine Default ThumbnailOphthalmic emergencies The seriously ill patient: tips and traps Neurosurgical emergencies Dermatological presentations to emergency

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Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Advanced nursing roles

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