NPs in the ER
Crisis in Emergency Departments:
The Nurse Practitioner Role
By: Patricia D. Abbott, PhD, RN, FNP-BC & Brenda Zierler, PhD,RN, RVT
Emergency department (ED) overcrowding is a major problem in the United States; current indicators suggest that this problem will worsen in coming years.1 Over the past several decades, the emergency medical system (EMS) has evolved into a safety net for the US healthcare system, but concern exists that, without changes, this safety net may fray and disintegrate.2 With ED overcrowding reaching a crisis level and with healthcare reform still in the process of being formulated, exploring how nurse practitioners can contribute to a more effective workforce in the ED setting is appropriate and timely.
The ED is often the healthcare site of last resort for persons in the United States who lack health insurance or an established primary care practitioner (PCP), or who have health insurance but cannot easily or quickly access care from their PCP.3,4 Community resources cannot consistently meet people’s primary care needs, prompting more and more of them to seek care for non-emergent problems in the ED. NPs are well prepared to provide care for a wide variety of complaints, including non-emergent problems, in the ED setting. With their emphasis on health promotion and disease prevention, NPs are a valuable adjunct to interdisciplinary teams in EDs. Although NPs as a group have been employed in EDs for more than 35 years, few studies have been conducted to ascertain how they—and their skills and experience—can best be utilized in a standard ED.
Scope of the Problem
Emergency health care in the 21st century is at a critical crossroads. Patient visits to EDs in the United States have been rising since 1994, with approximately 115.3 million ED visits made in 2005.5-7 This figure represents an 18% increase since 1994. During this same period, the number of EDs has decreased by 12.4%.
In June 2006, the Institute of Medicine (IoM) published three reports on the state of the EMS in this country.5,8 These reports suggested that the most prevalent and pressing problem facing the EMS was overcrowding in hospital EDs. Along with emergent conditions that bring patients to the ED, non-emergent problems prompt many patients, for a variety of reasons, to seek care in an ED. In fact, 60%-80% of patients who present to the ED do so for non-emergent or even minor health problems.9 Patients with relatively less urgent problems, as determined by a triage system, can sit in an ED waiting room for hours while patients with more emergent problems receive care first. Long wait times are frequently associated with poorer clinical outcomes.10 This finding is of particular relevance to persons who are poor, uninsured, or underinsured, who tend to go to an ED for less acute problems because they do not have access to a PCP in the community.11 For vulnerable and disenfranchised populations, the ED may be the only place to receive any health care—emergent, urgent, or routine.12
Utilization of NPs in the ED is a healthcare model that has evolved to address the non-emergent needs of patients at a lower cost. Although NPs have been working in EDs for more than 35 years,13,14 the most effective model to ensure optimal utilization of this workforce has not yet been determined. Few data are available to show how NPs are assigned to see patients in the ED, how they can best collaborate with other practitioners, and which models and staffing patterns are optimal.15 A comparative study by Sanchez et al16 showed that utilizing NPs and physician assistants (PAs) in the ED for non-emergent cases reduced wait times, lengths of stay, and the number of patients who leave without being seen. An Australian study noted that ED patient flow improved when NPs were utilized to see non-emergent cases so that physicians could focus on higher-priority cases.17 More studies are needed to confirm and extend these findings.
Access to Emergency Care
For decades, EDs have served patients requiring emergent care for an acute illness or injury. In the mid-1980s, the federal government saw a need for an emergency-care safety net because indigent ill or injured patients were being denied access to ED care because of their inability to pay.7,18 Since Congress mandated that emergency care could not be denied to anyone who needed it, EDs have become a resource and refuge for persons who would otherwise not have access to health care.19 Anyone who comes to an ED, regardless of his or her ability to pay or the severity of his or her presenting complaint, must receive a medical screening examination.7
Use of EDs has increased significantly since passage of the Emergency Medical Treatment and Active Labor Act, from 85 million visits per year in 1986 to more than 110 million visits in 2004, but more than 1100 EDs have closed during that same period.20,21 These EDs have been forced to close because payments for ED visits have been decreasing, in part because of decreased Medicare and Medicaid funding and the lack of reimbursement for charity care.22,23 Patients rely on EDs as safe places to receive care, but overcrowding has precluded EDs from being able to meet these expectations.18 Moreover, receiving care in large urban EDs, which are particularly overcrowded, can compromise patient safety and public health.24 An author of two recent reports called on the nursing profession to elevate ED overcrowding on hospital, community, and national agendas to garner resources to restore timely emergency care.25,26
Overcrowding, long wait times, and staff shortages are threatening the integrity of the EMS27 and EDs, which have become portals for patients to access general and primary care.28 In 2007, the US census reported that 45.7 million persons in this country lacked health insurance.29 A 2008 report indicated that approximately 17% of the 115 million ED visits each year were made by the uninsured.4 Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) in 2004 indicated that only 12.9% of patients who presented to the ED for care had emergent problems,30 suggesting that most patients presenting to EDs could be successfully managed by PCPs, including NPs.
One of the consequences of long wait times in the ED is that some patients leave without being seen (LWBS). A cross-sectional survey of 209,000 ED visits over an 8-year period showed that LWBS patients were more likely than those seen to be non-white, Hispanic, and uninsured.31 Therefore, LWBS visits in the ED disproportionately affect the most vulnerable populations.31 The potential role that NPs could play in these situations seems obvious; two of the hallmarks of the NP profession are proficiency in cross-cultural competencies and proficiency in caring for patients with non-emergent problems of an acute or a chronic nature. In addition, NPs’ emphasis on health promotion and disease prevention might resonate with patients who are being seen in the ED for a less-than-emergent problem. Utilization of NPs would help decrease the number of LWBS patients, perhaps providing them with tips to avoid future problems and future ED visits, and thereby improve access to the appropriate level of care for all patients.
Emergency Department Overcrowding
The American Academy of Emergency Physicians defines ED overcrowding as a situation in which the identified need for emergency services outstrips available resources. The academy considers ED overcrowding a systems problem, not a problem inherent in EDs themselves.32 Hoot and Aronsky27 reviewed the literature to ascertain the causes and consequences of ED overcrowding. Three overriding themes—input factors, throughput factors, and output factors (based on the conceptual model of emergency crowding by Asplin et al11,27)—emerged from the review. The Figure provides an overview of these factors. Three additional problems—boarding, diversion, and surge—are necessary for NPs to appreciate the complex issues surrounding ED overcrowding.
Boarding—The most important problem in the overcrowding crisis is the unavailability of inpatient beds for patients who are admitted to the hospital from the ED.3 When a hospital is at full census, patients are boarded in the ED, sometimes in the hallways, sometimes for days,33 until an inpatient bed becomes available. Boarding can endanger patients, cause delays in care, and cause more frequent ambulance diversions.32
Diversion—When an ED is fully occupied and crowding reaches dangerous levels, as determined by the staff on duty, hospitals may go on diversion to incoming ambulances.19 Incoming patients are diverted to another hospital that has available staff and beds.34 Sometimes, multiple facilities in an area are forced to go on diversion at the same time. In this event, the community’s access to care is compromised and all patients are affected, whether or not they have insurance. In 2003, EDs in the United States went on diversion more than 500,000 times, an average of once per minute.19 Diversion has become a major problem for most major US medical centers, representing an imbalance that can compromise patient safety, quality of care, and access to care within the EMS.35
Surges—The EMS represents the ultimate safety net for people requiring health care. As part of this safety net, the ED is designated to provide care during disasters, natural or manmade. However, federal funding for this presidential directive has been suboptimal, leading to further stress on the system.36 EDs throughout the country operate at near capacity on a daily basis,37 prompting concern regarding whether they would be able to respond to surges in volume. These surges can occur from disease outbreaks, such as the one Canada experienced with SARS in 2003; natural disasters such as hurricanes, earthquakes, or tornadoes; or a terrorist attack.38-40 The surge expected from H1N1 influenza this season will amplify these concerns.
Based on the concept that one aspect of the healthcare system affects another, an ideal solution to the ED overcrowding would be to implement an interdisciplinary approach to all three aspects of the crisis: input, throughput, and output.
Nurse Practitioners in the Emergency Department
With EDs across the country facing dangerous overcrowding, the EMS must address the problem now.8 The standard ED must be reorganized, and alternatives to the current methods of ED care provision must be sought. EDs need additional resources to expand beyond their historical role and enhance everyone’s access to healthcare services.33 NPs represent a growing workforce that can help mitigate the current EMS crisis, because the supply of emergency medical physicians is not expected to keep pace with the need for emergency care.41
History of NPs in the ED—Shortly after the first NP program was started in Colorado in 1965, the Robert Wood Johnson Foundation provided grants to start NP educational programs at several US universities. In 1972, Richard Edlich, a physician, and Denise Geolot, an NP, began an emergency NP (ENP) program.42 Since that first ENP program, NPs have been delivering care in the ED as ENPs, family NPs, or acute-care NPs. However, little research has been done in the past 35 years regarding how these NPs have been utilized in the ED. This time of increased awareness of the need for healthcare reform, combined with the fact that the current healthcare system has become unable to provide care for many patients with non-emergent problems, is opportune for further study and validation of NPs’ contributions in the ED.
The philosophy of care for all ED practitioners, including NPs, has been to evaluate the patient for the presenting complaint, ruling out any condition that could lead to death, bodily harm, or injury, and then to refer the patient to the community for further care.43 But with more and more patients with non-emergent problems presenting to the ED, and with fewer resources in the community to which to refer these patients, the role of the NP in this setting has become somewhat blurred. The role of NPs in the ED needs to be clarified; it is now well known that NPs do care for non-emergent patients for the sake of practicality and efficiency.
A UK review of the international literature on advanced nursing practice reported that confusion and disagreement exist regarding the NP role, particularly in the ED.44 NPs are held to an ED standard of care, but they find that they need to provide primary care instead—because of a lack of alternatives in the community. An international literature review by Considine et al45 showed that much of the research on the NP role in the ED has focused on patient satisfaction, wait times, lengths of stay, adequacy of documentation, use of radiography, patient education, health promotion, and communication factors. National surveys such as the NHAMCS have captured limited data on the utilization of NPs in the ED who work with physicians.46 Small surveys, conducted primarily in Canada, England, Ireland, and Australia, have focused on the attitudes of other practitioners toward the NP role, patient satisfaction with NP-delivered care, and educational preparation for the role.17,47,48 Despite all of these studies, the literature is not clear regarding how to effectively utilize NPs in the ED. Further research will help determine the impact of NPs on increasing access to high-quality, cost-effective care.15
The Future Role of NPs in the ED—The EMS in the United States is at a critical juncture. Increasing demands and fewer resources suggest that these problems will worsen. This situation comes at a time when the IoM is advocating change in the healthcare system. In Crossing the Quality Chasm: A New Health System for the 21st Century, 49 the IoM issued a national statement of purpose to improve the US healthcare system. Six aims for improvement were stated: Healthcare must be safe, effective, patient-centered, timely, efficient, and equitable. To accomplish this goal, rules were set forth to redesign the system. The 10th rule stated that cooperation among clinicians was a priority.49
Since publication of Crossing the Quality Chasm, the number of NPs has increased. NPs have been found to provide safe and effective care throughout the healthcare system, and patient satisfaction with NPs is high. In addition, NPs are cost effective.50
However, research and government reports about NPs’ contributions are lacking. A 2004 report by the US Department of Health and Human Services, Health Care in America, Trends in Utilization,30 failed to mention this workforce. The limitations section stated that “new and different” providers are contributing to the healthcare system. This document was the first attempt to integrate data from six surveys collectively called the National Health Care Survey. These six surveys provide essential information for the planning and analysis of health care in this country. But because these surveys are oriented toward physician practice, they do not represent NPs’ contributions to improve access to care.51 These limitations are a serious omission, because these reports are vital for workforce planning. Such failures diminish interest in the use of NPs in all settings, including the ED.
Sullivan et al52 published a profile of EDs, with the goal of improving access to emergency care. These authors created a National Emergency Department Inventory to determine the number and examine the basic characteristics of EDs as a way to determine EDs’ capabilities. However, utilization of NPs in the ED was not addressed in the article or in the limitations. In a later study, one of the authors did conclude that alternatives to staffing with emergency physicians merited further consideration.53
In the current environment of healthcare reform, the EMS will need to adapt to the changing healthcare workforce and find new ways to deliver care—specifically in terms of utilizing NPs to maximum advantage in the ED. Having NPs see the increasing number of patients who present for non-emergent care may be an optimal care model, regardless of whether this goal is accomplished in urgent-care centers, within fast-track streams of care, by being integrated into the standard ED, or via a new model that will facilitate flow through EDs. NPs excel in communicating with patients and in collaborating with other members of the healthcare team. NPs can make a unique contribution in terms of reorganizing the standard ED to address the current crisis. The multifaceted problems that the EMS is facing deserve further investigation into the utilization of NPs, and demand urgent attention from researchers and policymakers.31
Patricia D. Abbott is lead nurse practitioner in the emergency department at the University of Washington Medical Center and a clinical assistant professor in Psychosocial and Community Health at the University of Washington School of Nursing. Brenda Zierler is an associate professor and an associate dean of Technology Innovation in Education and Research, Biobehavioral Nursing and Health Systems, at the University of Washington School of Nursing, all in Seattle. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.
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- Institute of Medicine. The future of emergency care in the United States health system. Ann Emerg Med. 2006;48(2):115-120.
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- Lambe S, Washington DL, Fink A, et al. Waiting times in California's emergency departments. Ann Emerg Med. 2003;41(1):35-44.
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- Richardson LD, Hwang U. Access to care: a review of the emergency medicine literature. J Emerg Med. 2001;8(11):1030-1036.
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- Sanchez M, Smally AJ, Grant RJ, Jacobs LM. Effects of a fast-track area on emergency department performance. J Emerg Med. 2006;31(1):117-120.
- Wilson ASJ. An evaluation of the effectiveness and acceptability of nurse practitioners in an adult emergency department. Int J Nurs Pract. 2008;14(2):149-156.
- Taylor J. Don’t bring me your tired, your poor: the crowded state of America’s emergency departments. NHPF Issue Brief. 2006 Jul 7;(811):1-24.
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- Bitterman RA. Explaining the EMTALA paradox. Ann Emerg Med. 2002;40(5):470-475.
- Institute of Medicine. Emergency Medical Services: At the Crossroads. Washington, DC: National Academies Press; 2006.
- Hsia RY, Maclsaac M, Baker L. Decreasing reimbursements for outpatient emergency department visits across payer groups from 1996 to 2004. Ann Emerg Med. 2007;51(3):265-274.
- Vieth TL, Rhodes KV. The effect of crowding on access and quality in an academic ED. Am J Emerg Med. 2006;24(7):787-794.
- Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J. 2003;20(5):402-405.
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- American College of Emergency Physicians. Emergency Department Crowding: High-Impact Solutions. April 2008. Available at:http://www.acep.org/workarea/downloadasset.aspx?id=37960
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- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
- Lin SX, Hooker RS, Lenz ER, Hopkins SC. Nurse practitioners and physician assistants in hospital outpatient departments, 1997-1999. Nurs Econ. 2002;120(4):174-179.
- Morgan PA, Strand J, Østbye T, Albanese MA. Missing in action: care by physician assistants and nurse practitioners in national health surveys. Health Serv Res. 2007;42(5):2022-2035.
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