Examining the effectiveness, feasibility and impact of an embedded rural emergency department Nurse Practitioner model of care

The intervention consists of two components: the Emergency Department Nursing Practitioner (ED-NP) Model of Care (MoC) and the Implementation strategies. 1. The ED-NP MoC is focused on providing safe, equitable, and timely service to rural communities accessing emergency care. The role involves a hybrid advanced nursing MoC that includes nursing care, diagnostic activities, intervention-based treatments, and the use of medicines. The role is underpinned by robust clinical governance systems and compliance with PD 2020_034 Nurse Practitioners in NSW, an NP scope of practice, key performance indicators, evaluation measures, and directives for escalation of care. The model is focused on the Australasian Triage Scale (ATS) category 3-5 (low acuity) presentations. The rural Nurse Practitioner position will be developed to respond to local community needs for each of the participating sites (Bingarra Multipurpose Medical Centre, Gunnedah Hospital, Glenn Inness Hospital, and Wee Waa Hospital) located within Hunter New England Local Health District NSW, Australia, and the individual Nurse Practitioner's endorsed scope of practice. The Nurse Practitioner will be accredited to provide First Line Emergency Care for Category Triage 1 and Triage 2 presentations to the Emergency Department to undertake assessment and implement treatment plans in line with the Rural Adult Emergency Clinical Guidelines and Rural Paediatric Emergency Clinical Guidelines in collaboration with Referral (Armidale, Tamworth, and John Hunter) Hospitals Emergency Department's Fellow Australiasian College Emergency Medicine (FACEM), and Retrieval Services via Telehealth. Based on historical service data for each of the participating sites the majority (>85%) of the Nurse Practitioners' service interventions will be directed toward providing autonomous emergency services for Triage 3,4, and 5 (low acuity conditions) categories for children and adults presenting with; minor wounds, superficial burns, uncomplicated throat infections, and tonsillitis uncomplicated ear problems such as otitis external, otitis media or foreign body in the auditory canal, children (>2 yrs) or adults presenting with diarrhoea or constipation, mild gastroenteritis, adults presenting with uncomplicated urinary tract infection, minor wounds not complicated by tendon, nerve injury requiring closure, musculoskeletal and soft tissue injuries such as sprains, soft tissue injury, bites, fractures, uncomplicated fractures, eye problems including conjunctivitis, unembedded foreign body, flash burn, and skin infections including uncomplicated abscess, paronychia, and cellulitis. Complicated conditions/presentations for example burns involving the face, throat, genitals, joints, or extensive burns, peri-tonsillar abscess and/or imminent airway obstruction, wounds with tendon/nerve involvement, fractures requiring specialist intervention or sedation will be dealt with collaboratively with the FACEM medical officers accessed via My Emergency Doctor 24/7 on-call support and when appropriate by accessing specialist clinicians and retrieval services from larger regional hospitals and tertiary referral centers located within the Hunter New England Local Health District. The proposed model of care differs from current standard care in that an endorsed Nurse Practitioner will be responsible for autonomously triaging, assessing, diagnosing, and delivering treatment for Triage Category 3-5 (low acuity) presentations, and collaborating with FACEM and specialist services for Triage Category 1-2 (high acuity) presentation, compared to the current model that includes variable and unreliable medical staffing of participating sites emergency departments that result in extensive wait times for patients to receive care, expensive inter-hospital transfers for low acuity conditions, patients traveling long distances to access care, and delays in treatment for life-threatening conditions. The intervention will be implemented over a 12-month period. 2. The implementation strategies will be refined and targeted through engagement with key stakeholders, (healthcare providers, general practitioners, emergency care clinicians from supporting regional hospitals, experienced nurse practitioners, health service executives and managers, and Aboriginal health service clinicians and health workers) over an 8-week period prior to implementation. These will be identified through a local service-wide survey of healthcare providers from each participating site. The survey will be constructed utilising the Theoretical Domains Framework (TDF) and will be instrumental in identifying potential barriers to implementing the model. Service, facility, clinician, and community stakeholder consultation occurred in the 12 months leading into the study. This stakeholder engagement has been instrumental in developing the proposed model of care, requisite clinical, service, and professional supports for the incumbent nurse practitioners, an agreed scope of practice for the respective sites that respond to community needs, professional and governance infrastructures to ensure quality, safe and effective care provisions, and a business case to support the model. The study will be undertaken over 24 months and will include a 12-month pre-implementation and 12 months post-implementation period. Uptake and adherence to the intervention will be monitored by reviewing service level activity data, and NSW emergency treatment performance.