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Diagnostic Accuracy of Emergency Nurse Practitioners Versus Physicians Related to Minor Illnesses and Injuries

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Introduction

Our objectives were to determine the incidence of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses and to evaluate diagnostic accuracy of the emergency nurse practitioners (ENPs) compared with junior doctors/senior house officers (SHOs).

Methods

In a descriptive cohort study, 741 patients treated by ENPs were compared with a random sample of 741 patients treated by junior doctors/SHOs. Groups were compared regarding incidence and severity of missed injuries and inappropriately managed cases, waiting times, and length of stay.

Results

Within the total group, 29 of the 1,482 patients (1.9%) had a missed injury or were inappropriately managed. No statistically significant difference was found between the ENP and physician groups in terms of missed injuries or inappropriate management, with 9 errors (1.2%) by junior doctors/SHOs and 20 errors (2.7%) by ENPs. The most common reason for missed injuries was misinterpretation of radiographs (13 of 17 missed injuries). There was no significant difference in waiting time for treatment by junior doctors/SHOs versus ENPs (20 minutes vs 19 minutes). The mean length of stay was significantly longer for junior doctors/SHOs (65 minutes for ENPs and 85 minutes for junior doctors/SHOs; P < .001; 95% confidence interval, 72.32-77.41).

Discussion

ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected.

Section snippets

Study Design and Setting

This retrospective cohort study was conducted in the emergency department of an urban community teaching hospital in the Netherlands. The annual ED patient volume is 48,000 visits. Because there was no manipulation of subjects, the Institutional Review Board of the Netherlands exempted the study from review.

Selection of Participants

Previous research by Cooper et al9 found a 2% difference in misdiagnoses between ENPs and SHOs. To detect a 2% difference in missed injuries and inappropriate management between ENPs and

Results

From January 1 to June 8, 2008, 21,365 patients visited the emergency department. Of these, 10,555 were triaged as low-care patients, of whom 748 were treated by an ENP. We excluded 7 patients: 6 had only received nursing care by an ENP and 1 was treated at another location in the hospital. This led to a study group of 741 ENP-treated patients who were compared with 741 patients treated by a junior doctor/SHO.

ENPs/ENPCs had a median emergency nursing experience of 7.6 years (range, 2-13 years)

Discussion

The purpose of this study was to compare ENPs with junior doctors/SHOs in terms of missed injuries and inappropriately managed cases in patients with minor injuries and minor illnesses. The sample size of this study was calculated based on results from a study by Cooper et al9 that suggested that 3% of ENP patients and 1% of SHO patients might be misdiagnosed or initially incorrectly managed. Our study showed comparable results: a total of 1.9% patients had a missed injury or inappropriately

Limitations

The most important limitations of this study are related to differences in patient characteristics. This study was conducted during a period when the ENPs were not working full time as ENPs but were also working as emergency staff nurses. Therefore they were primarily available for patients with minor injuries and illnesses during the daytime. Because we used within-day randomization, junior doctors/SHOs treated significantly more patients during night shifts. This could have influenced patient

Conclusions

ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences were detected between ENPs and physicians regarding missed injuries and inappropriate management. Similar to other studies, the overall incidence of missed injuries and inappropriate management in this study was very low. Still, further reduction of missed injuries and inappropriately managed cases may be achievable by giving ENPs the chance to develop their skills

Christien van der Linden, Member, ENA, Accident and Emergency Department, Medical Center Haaglanden, The Hague, The Netherlands.

References (18)

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Christien van der Linden, Member, ENA, Accident and Emergency Department, Medical Center Haaglanden, The Hague, The Netherlands.

Resi Reijnen, Accident and Emergency Department, Medical Center Haaglanden, The Hague, The Netherlands.

Rien de Vos, Department of Clinical Epidemiology and Biostatistics, Academic Medical Center and University of Amsterdam, Amsterdam, The Netherlands.

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