Development of the Role of Advanced Nurse Practitioner in Emergency Cardiology

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Development of the Role of Advanced Nurse
Practitioner in Emergency Cardiology

• Elizabeth Curtin
• Advanced Nurse Practitioner Emergency Cardiology
• RGN Cert ICU/CCU M.Sc

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Development

• Service need
• Existing successful development of ANPs in the
  St. Jamess
• Emergency service
• National Council for the Professional Development
  of
• Nursing Midwifery2001
• Developed the process for the establishment of
  Advanced Nurse Practitioner posts
• Part 1 Approval of site preparation and job
  description
• Part 2 Accreditation of Advanced Nurse
  Practitioner

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Role Development process for ANP

• Site preparation
• Healthcare need
• Chest pain assessment service
• Job description site proposal
• Clinical competencies
• Protocols
• Stakeholders

• Portfolio
• Education
• Supervised practice
• Scope of practice
• Clinical competencies

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Site preparation ANP in Emergency Cardiology
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Healthcare need

• Cardiovascular disease is the single largest
  cause of premature death in Ireland approx 43 of
  all deaths (DOH, 1999)
• Coronary artery disease accounts for 25 of all
  deaths (DOH 1999)
• Half of these deaths occur in the first 2 hours
• Chest pain is considered the major clinical
  presentation of patients with Acute Coronary
  Syndrome

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In the Emergency Dept

• Chest Pain is the Most common major presenting
  complaint seen in St Jamess Emergency Department
• Inappropriate discharge is associated with a
  5-fold increase in mortality (26)

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Diagnostic limitations

• History
• 25 have atypical histories
• ECG
• 55 of pts with AMI have a normal 1ST 12-lead
  ECG
• Cardiac Markers
• Normal for the first 4 hours

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Meeting healthcare need with Chest Pain
Assessment services

• Steering group for the development of the Chest
  Pain Assessment service 2000-2001
• Collaborative agreement and implementation of
  Critical pathway for chest pain patients in ED
• Development of a designated chest pain assessment
  unit based in ED
• Development of specialist nurses in the
  assessment of chest pain in emergency Department
  and in CPAU

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Stakeholders involved in the development

• Steering group
• Eastern Regional Health Authority
• Emergency and Cardiology physicians
• Deputy Chief Executive Officer (Hospital Board)
• Nursing management and Emergency Nursing staff
• Cardiac Department
• Diagnostic laboratory
• Bioengineering Department
• Outside agency commercial company providing
  medical equipment
• Information Management System
• Emergency Directorate administration
• Medical social work department
• CPAU staff

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Chest pain assessment service

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Critical pathway for Chest Pain patients
Emergency nurses ANP in Emerg Cardiology
Myocardial Infarction
Unstable Angina
Low moderate risk chest pain
Chest Pain Assessment Unit
CPAU nurses ANP In Emerg Cardiology
Average 7-12 hrs
Positive for a Cardiac event
Negative for a Cardiac event
D/C HOME

ANP in Emerg Cardiology
48 hr Review clinic
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Chest Pain Assessment Unit

• Protected 4-bedded Unit
• ST-segment monitoring
• 12-hour assessment model
• Designated nursing staff
• 24/7 consultant led service
• CPA Specialist nursing
• Exercise stress testing

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Nurse led CPAU review clinic
Symptom assessment since discharge
One to one identification education on
individual risk factors for CVD
Referral back to Primary care
Referral to specialist services
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Development of an ANP in Emergency Cardiology

• Job Description
• Site preparation

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Advanced Nurse Practitioner in Emergency
Cardiology

• Purpose of post
• To provide timely, expert assessment and
  intervention for patients with acute coronary
  syndrome and to promote lifestyle modification
  for cardiovascular risk

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Location of service and Patient population

• Spans 2 distinct areas in the Emergency
  Directorate
• Emergency Department
• Patients presenting to Emergency Department
  with symptoms of acute coronary syndrome
• Chest Pain Assessment unit Patients
  processing through the CPAU and the follow-up
  review clinic

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Advanced Nurse Practitioner Core Concepts
(National Council, 2001)

• Autonomy in clinical practice
• Pioneering Professional and Clinical Leadership
• Expert Practitioners
• Researcher
• Educated to masters level
• Advanced nursing practice is carried out by
  autonomous, experienced practitioners who are
  competent, accountable and responsible for their
  own practice

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Autonomy and expert practice
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Patient Caseload

• Assessment and management of patients presenting
  with symptoms of acute coronary syndrome in the
  Emergency Department
• To provide timely expert care and intervention
• monitor, evaluate and assess patients, arrive at
  a diagnosis with admission of suitable patients
  from the ED to the CPAU
• Referral of patients for anti-ischaemic,
  reperfusion therapy and Cardiology admission

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Patient Caseload

• Assessment of patients at the review clinic
  following discharge from CPAU
• Holistic assessment since discharge
• Assessment of absolute cardiovascular risk and
  appropriate referral
• Health education
• Referral to specialist services for risk
  management
• Discharge to primary care

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Scope of practice

• Comprehensive assessment, diagnosis and emergency
  management of the patients presenting with
  symptoms of acute coronary syndrome
• Supplies and administers named medicines under
  protocol on the basis of assessment and diagnosis
• Requisition and interpretation of ECGs, chest
  xrays and blood profiles
• Estimation of the patients cardiovascular risk
  and referral for primary or secondary prevention

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Clinical competencies
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Competencies based on the Core concepts of the
role

• Autonomy in clinical practice
• Demonstrate accountability and responsibility for
  decision-making
• Performs comprehensive health assessment, plans,
  initiates care and treatment for acute coronary
  syndrome to achieve optimum person outcomes
• Demonstrates intra-professional/inter-professional
  referral and communications

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Protocols

• Collaboratively developed and agreed between
  Cardiology and Emergency

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• Guidelines
• History taking and clinical examination
• Patient review and risk factor modification
• Protocols
• Supply and administration of specific medications
• Xray requests by the ANP

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Site preparation

• Healthcare need
• Rationale for improvement
• Laws regulations
• Employers Vicarious Liability
• Integration of role with multidisciplinary team

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Working group

• Director of Nursing
• Emergency Cardiology Consultants
• Nurse Managers Emergency Dept
• Advanced Nurse Practitioner Emergency
• ANP candidate
• NCNM support and review of draft document prior
  to submission

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Portfolio
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Professional nurse education and training for ANP
role

• M.Sc in Nursing Trinity College, Dublin

• Clinical module
• Anatomy
• Documentation and history taking
• Theory and practice of Clinical Cardiology
• Pharmacology
• Radiology

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Supervised Practice
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Submission Document to NCNM

• Site proposal
• Meeting with NCNM Dec 2004, Review draft April
  2005
• Application form, Financial form proposal
  submitted in June 2005
• Site accredited in July 2005
• 2. Personal portfolio
• September 2005
• ANP accredited in Sept 2005

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