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• A way ahead or just a fork in the road?
  James J. Bethel
  Published on: 29 April 2016

• Published on: 29 April 2016

  A way ahead or just a fork in the road?

  • James J. Bethel, Senior Lecturer & Nurse Practitioner

  A commentary is, by its nature just that but I feel compelled to rebut some of the conjecture and lack of evidence apparent in Alan Leaman's recent piece 'an alternative way ahead'. [1] We are aware as the author suggests that we are all struggling 'a little' to achieve the four hour standard even at it's 95% threshold; and much publicity has centred upon this in the general media of late. Reasons for this are multi-fac...

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  A commentary is, by its nature just that but I feel compelled to rebut some of the conjecture and lack of evidence apparent in Alan Leaman's recent piece 'an alternative way ahead'. [1] We are aware as the author suggests that we are all struggling 'a little' to achieve the four hour standard even at it's 95% threshold; and much publicity has centred upon this in the general media of late. Reasons for this are multi-faceted and not quite as simplistic as other clinicians not pulling their weight as Mr Leaman appears to suggest. Given the nature of events surrounding catastrophic failings at an adjacent Trust to Mr Leaman's one would have expected a perhaps more constructive response to the findings of the investigative team within the department at Telford. In short there are several major failings in the commentary; the fact that the investigating team did not contain an emergency physician (or nurse actually) may actually be advantageous - the role of the impartial and unembroiled observer is well documented in enhancing objectivity in circumstances such as these. It is also suggested that the problems the department encounters began in 2004 when GP's ceased provision of out hours care. Whilst I would agree that this exacerbated matters is it really the case that we did not have patients lying around in the ED for prolonged periods of time prior to this? Whilst citing no sources for the data it is also identified that significantly less emergencies are seen by GP's and admitted directly to a ward rather than passing through an ED assessment prior to admission. The proposed solution for this is for specialty teams to see patients who present (at night time in particular), based on their presenting complaint without (it would appear) any form of ED assessment. Thus we have the potential scenario of the patient presenting with epigastric pain that having been seen by a general surgeon turns out to have lower lobe pneumonia or a myocardial infarct. Conversely the patient presenting with retrosternal chest pain being seen by a medical team who discover little more insidious than a history of hiatus hernia. The notion that the minor injury workload is 'undervalued' because it may be managed by Nurse Practitioners or GP's really says more about the perception of the nurse and GP than any undervaluing of the workload: as though some sort of second rate service is being offered to these patients. Nurse Practitioners have been a part of the ED workforce in the UK for 25 years now - many will have much experience which should be considered part of the resource that enables junior medical staff to learn about the management of minor trauma. They do not take this opportunity for learning away - they enhance it. The author knows of no paper comparing the treatment of minor injuries by a nurse practitioner compared with a trained emergency physician. He does however 'suggest' (despite this lack of evidence) that EM physicians will essentially see and manage these patients more safely and effectively than an NP. Can I please point out some potential items of interest to the author:

  * It is increasingly the case that NP's (and practitioners from other backgrounds such as physiotherapy and pre-hospital care) manage the care of any group of patients that attend the ED - this would not be the case had they not been considered initially effective in managing the minor trauma caseload * I would highlight an article in this months edition of 'Emergency Nurse' where it has been found that non-medical practitioners make more appropriate referrals, document more complete and legible prescriptions, improved clinical safety and effectiveness and manage the care of up to 53% of the total ED workload. [2] Links to other resources are also available within this work enabling the comparison of the medical and non- medical practitioner role It is difficult and provokes certain anxieties and insecurities when our practice is called into question or scrutinised in any manner. However with limited resources and increasing demand the way ahead should be collaborative rather than adversarial in nature. The fact that all disciplines working within ED have much to learn from each other should be seen as an opportunity to make this way ahead well signposted and reasonably well lit rather than a dark and dimly lit fork in the road

  References

  1 Leaman, AM. (2013) An alternative way ahead. Emerg Med J 30, 6, 433 -434

  2 Swann G., Chessum P, Fisher J. et al (2013) An autonomous role in emergency departments. Emergency Nurse, 21, 3, 12-15

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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