ArticlesCare of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial
Introduction
Accident and emergency departments in the UK face an increasing workload and a reduction in the number of doctors available to treat patients.1 To cope with this increase, other models of emergency care are emerging, such as minor injury units led by nurse practitioners. Most patients who attend accident and emergency departments in the UK are seen and treated by junior doctors (senior house officers). Our aim was to compare the package of the care for patients with minor injuries provided by nurse practitioners with that provided by junior doctors. Previous studies of the effectiveness of nurse practitioners focus on patients' satisfaction or the particular practical skills of nurses such as radiography.2, 3, 4, 5, 6, 7 None have attempted to assess longer term follow-up.
Section snippets
Training of nurse practitioners and junior doctors
There is no universally accepted definition of an accident and emergency nurse practitioner, but most are experienced accident and emergency nurses who have had additional training in the assessment and treatment of a range of defined conditions. The range of skills that they can use varies. In this study, we define the nurse practitioner's role by independence of practice in that they are able to see, assess, and treat patients without necessarily asking the advice of a doctor.
The nurse
Recruitment
The study took place between Feb 10 and Aug 4, 1997. Consecutive patients were recruited in sessions during the day and evening. The research nurse kept a separate record of patients with minor injuries who were not eligible or who did not enter the trial.
Eligibility and consent
Ethical approval was obtained for the study from the local research ethics committee. Patients who attended the Accident and Emergency Department of the Northern General Hospital, Sheffield, UK, were all seen by the triage nurse. Patients with minor disorders were then passed on to the research nurse who assessed their eligibility. Patients were eligible if they were selfreferred, older than 16 years, had a recent injury (<10 days) that came within the treatment guidelines for nurse
Randomisation
An independent experienced clinical trials group generated a simple random sequence of 1500 binary digits with a computer program and prepared a set of sequentially numbered sealed opaque envelopes that contained details of treatment-group allocation. Consecutive patients with minor injuries were assessed by the research nurse. The next envelope in the numbered sequence was then opened for eligible patients. The patient's card was marked to indicate the randomisation. The patient then waited
Initial clinical and research assessments
The nurse practitioner or the junior doctor did an initial clinical assessment. After this assessment, the patient was seen by an experienced accident and emergency physician (research registrar) who did a separate research assessment—recording the patient's medical history, examination, and formulation of treatment, advice, and follow-up plan. This research assessment took place in a separate room. The researcher might have known the identity of the nurse practitioner or junior doctor, but
Outcome measures
The primary outcome measure was the adequacy of care provided by the nurse practitioner or junior doctor. The secondary outcome measures were the patient's satisfaction with the quality of their care, improvement and return to usual activities, and need for unplanned follow-up.
Questionnaires
At the time of attendance at the accident and emergency departments the patients were given a questionnaire about their satisfaction with the care they received. This questionnaire has been validated by Carey and Seibert.8 The questionnaire is used to measure the degree of satisfaction with the care and courtesy of the staff and with the care facilities provided during the initial visit.8 28 days after attendance, we sent patients a follow-up questionnaire. We used this questionnaire to find
Masked conditions
After the patient's initial assessment, the clinical notes were transcribed by typists not involved in the study on to a form that included the patient's study number but no other means to allow identification of whether the patient was seen and treated by a nurse practitioner or junior doctor. At the end of this process a folder that contained the transcription of the clinical assessment, the research assessment form, details of any followup treatment, and the radiologist's report was reviewed
Adequacy of care
A standard form was used to compare the adequacy of the clinical assessment of the nurse practitioner or junior doctor with the research assessment of the research registrar. The criteria for this comparison were: record of the patient's medical history, examination of the patient, request for radiography, treatment decision, advice, and follow-up. The difference between the two assessments was judged to be: the “same”; “clinically not important” when an error or omission would have resulted in
Work rate and costs
We reviewed costs by: comparing the use of investigations, treatment, and follow-up; examining the employment costs of the two groups; and with a separate work study. The work study was done by direct observation of the time taken by the junior doctors and nurse practitioners to take the history, examine the patient, interpret the radiographs, and record their findings for 100 patients. Both experienced and new junior doctors were observed. Employment costs were obtained from the unit
Statistical analysis
The sample size was calculated to have 80% power to detect a significant increase in the frequency of any inadequacy in care from 2·5% to 5%. We calculated that 793 patients would be needed in each group.
All the data forms were entered into an access database and analysed by Access (version 2), Excel '97, and SPSS software (version 6). x2 and Fisher's exact tests were used to compare the proportions of clinical errors. The data on work rate was approximately normally distributed and the mean
Results
During the 6-month study, 31 165 new patients came to our department. 20 340 patients were deemed to have minor disorders (UK triage category 4), 16 943 of whom did not arrive by ambulance. 3475 of these patients attended the department during the study sessions. We excluded 1975 patients: 550 had non-traumatic disorders; 421 had injuries to parts of the body not included in guidelines for nurse practitioners (eg, neck and back); 253 were younger than 16 years; 181 patients had been assessed
Primary outcome measures
Table 2 shows the number of important or very important errors in the care of patients in both groups. Very important errors were rare. There was only one major failure in history-taking and examination, a missed flexor tendon injury, by a junior doctor. When compared with the gold standard of the experienced research registrar, there was at least one important error in history, examination, interpretation of radiography, treatment, and follow-up in 65 (9·2%) of the 704 patients in the
Follow-up questionnaires
831 patients completed the quality-of-care questionnaire (398 [56·5%] in the nurse-practitioner group and 433 [57·8%] in the junior-doctor groups). There was no significant between-group difference in the age or sex of responders.
Patient's were satisfied with their overall care most of the time. 11 of the 813 patients reported that their care was “poor” or “very poor”—three (0·8%) of the 387 patients in the nurse-practitioner group and eight (1·9%) of the 415 in the junior-doctor group
Unplanned follow-up
One marker used to assess the adequacy of care is the number of unplanned follow-up visits at which the patient needed further treatment or assessment that had not been arranged at the initial assessment (table 5). There was a significant difference between the groups in the number of unplanned follow-up visits: 37 (8·6%) of 432 patients in the nurse-practitioner group had at least one unplanned follow-up visit, compared with 64 (13·1%) of 488 in the junior-doctor group (p=0·03).
Work study and costs
There were no significant between-group differences in the treatments or investigations. For the direct observational work study, results were analysed for 46 patients seen by a nurse practitioner and 48 patients seen by a junior doctor. We excluded four patients in the nurse-practitioner group and two in the junior-doctor group because the treatment took place at the same time as the consultation and it was not possible to isolate the time taken to take and record the history. The nurse
Discussion
Experienced accident and emergency nurses have been assisting and advising junior doctors in the treatment of minor injuries for many years. However, a major cultural and medicolegal leap is needed before nurses can take the responsibility for seeing, treating, and discharging these patients. Previous studies have investigated patients' satisfaction or the performance of specific skills, but none have tried to assess the overall performance of nurse practitioners. There are fears that
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