Nurse Practitioner in Emergency:The Bethesda Hospital Experience

Patti Fries Facility Manager

Bethesda Hospital/Bethesda Place204-346-5150

Bethesda Hospital• 64 Acute care beds,

including medicine, surgery, obstetrics

• Surgical Program with some Ortho

• 20 Rehabilitation beds with Rehab Therapy Services

• Cancer Care

Emergency Department

• See ~25 000 patients per year

• 2 beds in resuscitation room

• 3 private rooms• 2 stretchers with

privacy curtains• 2 hallway

stretchers

Staffing• 2-3 RN’s / shift• 1 physician 24

hours per day, with second physician 1400-2200 h daily

• One NP Monday – Friday 0800-1600 h

• One CRN Monday – Friday 0900-1545 h

How Did This Come To Be?• Need identified by current NP who

was working in ER as a casual nurse while a student in the NP program.

• Together with Facility Manager, a proposal was written and presented to Manitoba Health.

• Pilot project for 0.8 EFT started July 17, 2006, became a full-time permanent position July 17, 2008.

Why Did We Need An NP?• Recognized need for alternate practitioner

to provide care for less urgent patient population

• Improve patient flow in a busy ER• Decrease workload on existing practitioner

thereby improving overall wait times.

ER Visits• 125% increase since 1987/86• 35% increase since 1996/1997• 23,500 or 64 pts./day from 2004/05 with

slight decrease (alternate space)• 2/3 of region’s population increase; 29%

increase since 1998• Acuity (Level 1-3) 97% increase 2000 –

2004 with 200% increase from 2003 - 2005

Integration of the Role• Informal integration and education by NP

while current staff nurse attending school and during practicum

• Physician coach/mentor who completed chart audits

• Manitoba Health deliverables• 360° evaluation by peers• Collaborative Practice Agreement • Presentation by WRHA NP to all staff

Successes & Challenges

What Made It A Success?• Existing staff member• Supportive team – physicians,

allied health, management• NP’s key role in initiating

support for proposal• Advanced critical skill base

with pediatric specialty• Team player• Commitment to best practice

and high standard of care

What Were The Challenges?

• Lack of understanding of role, on both sides– Treating NP as NP and not

a staff nurse– Paving way for new

position – Slight transition with

assessments and writing orders

• Unable to write Rx independently for some items (i.e. air cast)

• Some insurance companies, organizations not accepting NP signatures (i.e. MPIC)

• Some specialists not wanting to discuss referral from NP (i.e. orthopedic surgery referral)

Supporting the NP• Flexibility of both NP and management• ER Team support• Dedicated office space with computer• Protected administration/education/research time• Education support• Inclusion on teams where input sought

– Nursing Practice– ER/EMS– NP Implementation (new)– Pandemic Planning– Primary Care Planning