This article describes an innovative program to provide safe, evidence-based psychiatric care at the Baltimore Convention Center Field Hospital (BCCFH), set up for COVID-19 patients, to alleviate overextended hospitals.

This article describes the staffing and workflows utilized at the BCCFH including universal suicide risk assessment and co-management of high acuity patients by an NP-led psychiatry service.

The Columbia-Suicide Screening Rating Scale (C-SSRS) proved feasible as a suicide screening tool. Using the SAFE-T protocol, interdisciplinary teams cared for moderate and low risk patients. The NP psychiatry service evaluated over 70 patients, effecting medication changes in more than half and identified and transferred several decompensating patients for higher-level psychiatric care. Group therapy attendees demonstrated high participation. There were no assaults, self-harm incidents, or suicides.

The BCCFH psychiatry/mental health program, a potential model for other field hospitals, promotes evidence-based, integrated care. Emphasizing safety, including suicide risk, is crucial within alternate care sites during disasters. The engagement of dually-certified (psychiatric and medical) nurse practitioners boosts safety and provides expertise with advanced medication management and psychotherapeutic interventions. Similar future sites should be ready to handle chronically ill psychiatric patients, detect high-risk or deteriorating ones, and develop therapeutic programs for patient stabilization and support.

As nurse practitioners and physician assistants (APPs) become more prevalent in delivering pediatric care, their involvement in antimicrobial stewardship efforts increases in importance. This project aimed to create and assess the efficacy of a problem-based learning (PBL) approach to teaching APPs antimicrobial stewardship principles.

A PBL education initiative was developed after communication with local APP leadership and focus group feedback. It was offered to all APPs associated with Lurie Children’s Hospital of Chicago. Participants completed a survey which assessed opinions on antimicrobial stewardship and included knowledge-based questions focused on antimicrobial stewardship. Prescriptions for skin and soft tissue infections associated with APPs were recorded via chart review before and after the education campaign.

Eighty APPs participated in the initial survey and teaching initiative with 44 filling out the 2-week follow-up and 29 filling out the 6-month follow-up. Subjective opinions of antimicrobial stewardship and comfort with basic principles of AS increased from pre-intervention. Correct responses to knowledge-based assessments increased from baseline after 2-week follow-up (p < 0.01) and were maintained at the 6-month follow-up (p = 0.03). Simple skin and soft tissue infection prescriptions for clindamycin went from 44.4% pre-intervention to 26.5% (p = 0.2) post-intervention.

A PBL approach for APP education on antimicrobial stewardship can be effective in increasing knowledge and comfort with principles of antimicrobial stewardship. These changes are maintained in long-term follow-up. Changes in prescribing habits showed a strong trend towards recommended empiric therapy choice. Institutions should develop similar education campaigns for APPs.

There is overwhelming evidence to show that achieving full remission in depression is important — especially in reducing the indirect costs of depression. Evidence further demonstrates that in primary care, clinicians are not optimising treatments for depression in a timely way —resulting in them not being able to achieve early remission for their clients experiencing depression. Presently, secondary care is unable to provide specialist input for this client cohort.

This project is implementing a model which extends specialist care to primary care. This project assists GP’s through optimising treatments for clients presenting with moderate to severe depression This model uses nurse practitioner led care, with ‘Psynary’, an online system which optimises treatments for moderate to severe depression.

Mixed methods pilot service implementation study, utilising: literature review of published service implementation models; service data gap analysis; qualitative interviews and focus group methodology.

GP and client focus group outcomes, as well as client remission rates in the OptiMA2 trial demonstrate that this healthcare pathway is effective.

The OptiMA2 trial focused on the qualitative analysis of the co-design process to implement the initial care pathway.The OptiMA3 trial will examine the cumulative clinical outcomes to consider if increased rates of remission are achieved and identify potential predictive factors. The long term goal for the system is to support the development of community based care-extender models, including specialist nurses, pharmacists and GPs, to extend specialist mental health expertise to larger primary care populations where the greatest burden of mental illness occurs.

No significant relationships.

Education of paediatric advanced practice providers takes a generalist approach which lacks in-depth exposure to subspecialties like paediatric cardiac intensive care. This translates into a knowledge gap related to congenital cardiac physiology and management for APPs transitioning to the paediatric cardiac ICU.

A specialised interprofessional peer-reviewed curriculum was created and distributed through the Pediatric Cardiac Intensive Care Society. This curriculum includes a textbook which is complemented by a didactic and simulation review course. Course evaluations were collected following each course, and feedback from participants was incorporated into subsequent courses. Pediatric Cardiac Intensive Care Society partnered with the Pediatric Nursing Certification Board to develop a 200-question post-assessment (exam) bank.

From December 2017 to January 2022, 12 review courses were taught at various host sites (n = 314 participants). Feedback revealed that courses improved preparedness for practice, contributed to advanced practice provider empowerment, and emphasised the importance of professional networking. 97% of attendees agreed/strongly agreed that the course improved clinical knowledge, 97% agreed/strongly agreed that the course improved ability to care for patients, and 88% agreed/strongly agreed that the course improved confidence to practice. 49% of participants rated the course as extremely effective, 42% very effective, 6% moderately effective, and 3% as only slightly effective.

A standardised subspecialty curriculum dedicated to advanced practice provider practice in cardiac intensive care was needed to improve knowledge, advance practice, and empower APPs managing critically ill patients in the cardiac ICU. The developed curriculum provides standardised learning, increasing advanced practice provider knowledge acquisition, and confidence to practice.

Advanced practice providers (APPs) are being employed at increasing rates in order to meet new in-hospital care demands. Utilising the Paediatric Acute Care Cardiology Collaborative (PAC3) hospital survey, we evaluated variations in staffing models regarding first-line providers and assessed associations with programme volume, acuity of care, and post-operative length of stay (LOS).

The PAC3 hospital survey defined staffing models and resource availability across member institutions. A resource acuity score was derived for each participating acute care cardiology unit. Surgical volume was obtained from The Society of Thoracic Surgeons database. Pearson’s correlation coefficients were used to evaluate the relationship between staffing models and centre volume as well as unit acuity. A previously developed case-mix adjustment model for total post-operative LOS was utilised in a multinomial regression model to evaluate the association of APP patient coverage with observed-to-expected post-operative LOS.

Surveys were completed by 31 (91%) PAC3 centres in 2017. Nearly all centres (94%) employ APPs, with a mean of 1.7 (range 0–5) APPs present on weekday rounds. The number of APPs present has a positive correlation with surgical volume (r = 0.49, p < 0.01) and increased acuity (r = 0.39, p = 0.03). In the multivariate model, as coverage by APPs increased from low to moderate or high, there was greater likelihood of having a shorter-than-expected post-operative LOS (p < 0.001).

The incorporation of paediatric acute care cardiology APPs is associated with reduced post-operative LOS. Future studies are necessary to understand how APPs impact these patient-specific outcomes.

To evaluate the organizational processes that influence the quality of care for patients with multimorbidity at nurse practitioner-led clinics (NPLCs).

People are living longer, most with one or more chronic diseases (mulitmorbidity) and primary healthcare for these patients has become increasingly complex. One response was the establishment of new models of primary healthcare. NPLCs are an example of a model developed in Ontario, Canada, which feature nurse practitioners as the primary care providers practicing within an interprofessional team. Evaluation of the extent to which the processes within NPLC model addressed the needs of patients with multimorbidity is warranted.

Eight nurse practitioners were interviewed to determine their perception of the quality of care provided to patients with multimorbidity at NPLCs. Interpretive description guided the analysis and themes were identified.

Three themes arose from the analysis, each of which has an impact on the quality of care. The level of patient vulnerability at the NPLCs was high resulting in the need to address social and financial issues before the care of chronic conditions. Dynamics within the interprofessional team impacted the quality of patient care, including NP recruitment and retention, leaves of absence and turnover in staff at the NPLCs had an effect on interprofessional team functioning and patient care. Finally, coordination of care at the NPLCs, such as length of appointments, determined the extent to which attention was given to individual clinical issues was a factor. Strategies to address social determinants of health and for recruitment and retention of NPs is essential for improved quality of care. Comprehensive orientation to the interprofessional team as well as flexibility in care processes may also have positive effects on the quality of care of patients with complex clinical issues.

Memory clinics, typically led by multidisciplinary teams and requiring health professional referral, are one means of providing diagnosis and care coordination for dementia. Nurse-led clinics may provide an effective and alternative means to dementia diagnosis, and open referral policies may minimize existing barriers to accessing a diagnosis, but evidence is needed.

Patients attending a one-day per week nurse-led memory clinic over a 25-month period during 2011–2013 (n = 106) completed comprehensive cognitive assessments and were diagnosed by an aged care nurse practitioner. Descriptive statistics detail the demographics, assessment scores, and diagnostic profiles of patients. Comparable data from published literature was identified, and the differences were analyzed qualitatively.

One hundred and six patients were assessed with the key differences from other data sets being history of falls more common, higher mean Mini-Mental State Examination scores, and fewer dementia diagnoses. Sixty-four patients (60%) were self-referred to the nurse-led memory clinic, of which 19 (30%) were diagnosed with mild cognitive impairment (MCI) or dementia. Overall, forty-eight patients (45%) received diagnoses of MCI or dementia.

An open referral policy led to a high proportion of patients being self-referred, and nearly a third of these were diagnosed with cognitive impairment or dementia. Open referral policies and nurse-led services may overcome some of the barriers to early diagnosis that are currently experienced. Considering an aging population worldwide and the associated increases in cognitive impairment, which benefits from early identification and intervention, this paper provides an alternative model of nurse-led assessment.

To identify the appropriate service provider attendees of emergency departments (EDs) and walk-in centres (WiCs) in North East London and to match this to local service provision and patient choice.

An anonymous patient survey and a retrospective analysis of a random sample of patient records were performed. A nurse consultant, general practitioner (GP) and pharmacist used the presenting complaints in the patients’ records to independently stream the patient to primary care services, non-National Health Services or ED. Statistical analysis of level of agreement was undertaken. A stakeholder focus group reviewed the results.

Adult health consumers attending ED and urgent care services in North East London.

The health user survey identified younger rather than older users (mean age of 35.6 years – SD 15.5), where 50% had not seen a health professional about their concern, with over 40% unable to obtain a convenient or emergency appointment with their GP. Over a third of the attendees were already receiving treatment and over 40% of these saw their complaint as an emergency. Over half of respondents expected to see a doctor, one-quarter expected to see a nurse and only 1% expected to see a pharmacist across both services, although WiCs are nurse-led services. More respondents expected a prescription from a visit to a WiC, whereas in the ED a third of respondents sought health advice or reassurance.

A number of unscheduled care strategies are, or have just been, developed with the emphasis on moving demand into community-based services. Plurality of services provides service users with a range of alternative access points but can cause duplication of services and repeat attendance. Managing continued increase in emergency and unscheduled care is a challenge. The uncertainties in prospective decision making could be used to inform service development and delivery.

This study aimed to compare an experienced ENT treatment room nurse's ability to assess nasal injuries with that of junior doctors.

One hundred consecutive patients with nasal injuries were assessed prospectively in two phases, followed by a telephone survey.

Comparison of nasal injury assessment, advice, and outcomes regarding cosmesis, airway obstruction and patient satisfaction.

In the first phase, there was almost perfect agreement between doctor and nurse assessments regarding the management of nasal fractures (p < 0.0001). There was no deterioration in outcomes in the nurse assessment only patient group with regards to cosmesis and airway obstruction. Ninety-four per cent of patients were satisfied with nurse-only assessment.

Our study showed that an experienced treatment room nurse was as effective as experienced junior doctors in assessing and advising patients with nasal injuries. Following this study, the nurse involved began to independently assess patients with nasal injuries attending the unit.

We sought to assess the impact of the integration of the new roles of primary health care nurse practitioners (NPs) and physician assistants (PAs) on patient flow, wait times and proportions of patients who left without being seen in 6 Ontario emergency departments (EDs).

We performed a retrospective review of health records data on patient arrival time, time of initial assessment by a physician, time of discharge from the ED and discharge status.

Whether a PA or NP was directly involved in the care of patients or indirectly involved by being on duty, the wait times, lengths of stay and proportion of patients who left without being seen were significantly reduced. When a PA or NP were directly involved in patients' care, patients were 1.6 (95% confidence interval [CI] 1.3–2.1, p < 0.05) and 2.1 (95% CI 1.6–2.8, p < 0.05) times more likely to be seen within the wait time benchmarks, respectively. Lengths of stay were 30.3% (95% CI 21.6%–39.0%, p < 0.01) and 48.8% (95% CI 35.0%–62.7%, p < 0.01) lower when PAs and NPs, respectively, were involved. When PAs and NPs were not on duty, the proportion of patients who left without being seen were 44% (95% CI 31%–63%, p < 0.01) and 71% (95% CI 53%–96%, p < 0.05), respectively.

The addition of PAs or NPs to the ED team can improve patient flow in medium-sized community hospital EDs. Given the ongoing shortage of physicians, use of alternative health care providers should be considered. These results require validation, as their generalizability to other locations or types of EDs is not known.

Our objective was to determine whether the addition of a broad-scope nurse practitioner (NP) would improve emergency department (ED) wait times, ED lengths of stay (LOS) and left-without-treatment (LWOT) rates. We hypothesized that the addition of a broad-scope NP during weekday ED shifts would result in shorter patient wait times, reduced LOS and fewer patients leaving the ED without treatment.

This prospective observational study was conducted in a busy urban free-standing community ED. Intervention shifts, with NP coverage, were compared with control shifts (similar shifts with emergency physicians [EPs] working independently). Primary outcomes included patient wait times, ED LOS and LWOT rates. Patient demographics, triage category, the provider seen, the time to provider and ED LOS were captured using an electronic database.

The addition of an NP was associated with a 12% increase in patient volume per shift and a 7-minute reduction in mean wait times for low-acuity patients. However, overall patient wait times and ED LOS did not differ between intervention and control shifts. During intervention shifts, EPs saw a smaller proportion of low-acuity patients and there was a trend toward a lower proportion of LWOT patients (11.9% v. 13.7%, p = 0.10).

Adding a broad-scope NP to the ED staff may lower the proportion of patients who leave without treatment, reduce the proportion of low-acuity patients seen by EPs and expedite throughput for a subgroup of less urgent patients. However, it did not reduce overall wait times or ED LOS in this setting.

This longitudinal study was designed to address four research questions and the hypothesis; that adults living in a rural community receiving primary health care and emergency services from a team that included an on-site nurse practitioner (NP) and paramedics and an off-site family physician would, over time, demonstrate evidence of improved psychosocial adjustment and less expenditure of health care resources.

In Canada, there is a growing awareness and commitment to addressing the challenges of providing primary health care services in rural areas. A literature review supported the role of NPs in primary health care and a potential role for paramedics. No studies were found that evaluated the combination of NPs, paramedics and physicians as providers of primary health care.

Structured questionnaires, individual and group interviews with patients, health and social service care providers and administrators and community members were used to describe and evaluate the impact of the model of care over the three years of the study.

The innovative model of care resulted in decreased cost, increased access, a high level of acceptance and satisfaction and effective collaboration among care providers. Organizational structures to support the innovative model of primary health care were identified.

Our objective was to compare the emergency care provided by a nurse practitioner (NP) with that provided by emergency physicians (EPs), to identify emergency department (ED) patients appropriate for autonomous NP practice and to acquire data to facilitate the development of the clinical scope of practice recommendations for ED practice for NPs.

Using a comprehensive 3-part process, we selected and hired the best NP from 12 applicants. The NP was oriented to the operations of our free-standing community ED and incorporated in the care team, working in real time with EP preceptors during a 6-month, prospective clinical assessment comparing NP care with EP care. ED preceptors reviewed every case in real time with the NP and completed an explicit evaluation form to determine whether NP assessment, investigation, treatment and disposition were “all equivalent to emergency physician care” (AEEPC) or whether they differed. The proportion of AEEPC interactions was determined for 23 patient presentation categories. Our a priori assumption was that a patient presentation category might be suitable for autonomous NP practice if 50% of NP encounters in that category were rated as AEEPC. Descriptive data were presented for patient case mix, teaching domains and time criteria.

Eighty-three NP shifts and 711 patient encounters were evaluated by 21 EP preceptors. The NP saw a median of 8 patients per shift. In 43% of encounters, NP care was AEEPC. Highest AEEPC rates were found in the patient follow-up categories general follow-up (55.4%), diagnostic imaging (91.7%) and microbiology laboratory results (87.6%). NP scores over 50% were also seen for lacerations (63.6%) and isolated sore throats (53%). With teaching, NP performance improved over time.

With the exception of follow up–related complaints, simple lacerations and isolated sore throats, NP care differed substantially from EP care. Although NPs with extensive emergency experience and training might ultimately be able to function as autonomous ED care providers, Canadian EDs currently developing job descriptions for emergency NPs should focus on a model of collaborative practice with EPs.

US emergency personnel cared for 106% more patients in 1990 than they did in 1980, and national emergency department census data show that 60%–80% of those patients presented with non-urgent or minor medical problems. The hiring of nurse practitioners (NPs) is one proposed solution to the ongoing overcrowding and physician shortage facing emergency departments (EDs).

We conducted a systematic review of MEDLINE and Cinahl to find articles that discussed NPs in the ED setting, looking specifically at 4 key outcome measures: wait times, patient satisfaction, quality of care and cost effectiveness.

Although some questions remain, a review of the literature suggests that NPs can reduce wait times for the ED, lead to high patient satisfaction and provide a quality of care equal to that of a mid-grade resident. Cost, when compared with resident physicians, is higher; however, data comparing to the hiring additional medical professionals is lacking.

The medical community should further explore the use of NPs, particularly in fast track areas for high volume departments. In rural areas, NPs could supplement overextended physicians and allow health centres to remain open when they might otherwise have to close. These strategies could improve access to care and patient satisfaction for selected urban and rural populations as well as make the best use of limited medical resources.

The objective of this study was to identify the facilitators and barriers associated with integrating nurse practitioners (NPs) into Canadian emergency departments (EDs) from the perspectives of NPs and ED staff.

We conducted 24 semi-structured interviews with key multidisciplinary stakeholders in 6 Ontario EDs to gain a broad range of perspectives on implementation issues. Data were analyzed using a grounded-theory approach.

Qualitative analysis of the interview data revealed 3 major issues associated with NP implementation: organizational context, role clarity and NP recruitment. Organizational context refers to the environment an NP enters and involves issues related to the ED culture, physician reimbursement system and patient volume. Role clarity refers to understanding the NP's function in the ED. Recruitment issues are associated with attracting and retaining NPs to work in EDs. Examples of each issue using respondent's own words are provided.

Our study identified 3 issues that illustrate the complex issues involved when implementing NPs in EDs. The findings may inform policy makers and health care professionals in the future development of the role of NPs in Canadian EDs.