Guest Editorial: Nurse Practitioners in Emergency Care

The central tenet of any professional field of study is its well-established body of research, its ethics, and general public benefit. The role of the nurse practitioner (NP) in emergency care is supported by consistent research that underscores the excellent care quality provided by these professionals. Decades of scholarly literature attests to the safety, efficacy, patient-centricity, efficiency, equity, and evidence-based nature of NPs working in emergency care, with several studies showing that the outcomes achieved by NPs are similar to those achieved by their physician counterparts. It is clear that NPs provide comprehensive emergency care that is not only safe and effective but also patient-centered, timely, and based on the latest evidence-based practices. The evidence for nurse practitioners in emergency care may be found among several exemplars of empirical and peer-reviewed works as outlined in the following text, organized as an annotated bibliography: Carter, A., & Chochinov, A. (2007). A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department.Canadian Journal of Emergency Medicine, 9(4), 286–295. doi:10.1017/s1481803500015189 This comprehensive 36-article review evaluated the impact of NPs in the emergency department (ED) on wait times, patient satisfaction, and delivery of cost-effective, high-quality care. Hiring and utilizing NPs were associated with shorter waiting times, leading to greater patient satisfaction. Carter and Chochinov found that NPs possess an equal level of expertise to physicians in interpreting radiographs but proved to be more proficient at patient follow-up, conducting physical assessments, and making appropriate referrals. Fowler, L. H., Landry, J., & Nunn, M. F. (2019). Nurse practitioners improving emergency department quality and patient outcomes.Critical Care Nursing Clinics of North America, 31(2), 237–247. doi:10.1016/j.cnc.2019.02.010 The authors performed a literature search using the EBSCOhost and CINAHL databases with key words related to ED NP outcomes. Six hundred nineteen articles met the inclusion criteria, eight of which were selected for content review, including four systematic reviews, one randomized controlled trial, one qualitative study, one descriptive study, and one longitudinal cohort study. This analysis revealed that NPs provided enhanced patient satisfaction, reduced wait times, provided care similar to physicians, spent more face-to-face time with each patient, adhered to evidence-based guidelines, and collaborated effectively as a team. Jennings, N., Gardner, G., O'Reilly, G., & Mitra, B. (2015). Evaluating emergency nurse practitioner service effectiveness on achieving timely analgesia: A pragmatic randomized controlled trial.Academic Emergency Medicine, 22(6), 676–684. doi:10.1111/acem.12687 “A randomized controlled trial was conducted” to investigate the efficacy of NP-led emergency care as opposed to the standard medical care provided in the ED of a major referral hospital. “Patients presenting with pain were randomly assigned to receive either standard ED care or NP care.” The NP service proved far more effective in quickly providing analgesia to ED patients. Mafi, J. N., Chen, A., Guo, R., Choi, K., Smulowitz, P., Tseng, C. H., ... & Landon, B. E. (2022). US emergency care patterns among nurse practitioners and physician assistants compared with physicians: A cross-sectional analysis.BMJ Open, 12(4), e055138. doi:10.1136/bmjopen-2021-055138 Using 8 “years of data from the National Hospital Ambulatory Medical Care Survey,” a retrospective cohort study of adult patients compared three provider groups: NP/PA (physician assistant) alone, NP/PA with physician, and physician alone. After adjusting the data to account for observable patient characteristics, this study found the NP/PA-only group used fewer medications, diagnostic tests, procedures, hospitalizations, and low-value CT/MRI studies than physicians. Roche, T. E., Gardner, G., & Jack, L. (2017). The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: A multisite prospective longitudinal nested cohort study.BMC Health Services Research, 17(1), 445. doi:10.1186/s12913-017-2395-9 This study recruited 61 adult patients with chest pain, with a nested cohort of 41 participants suspected or confirmed to have an acute coronary syndrome. Outcomes included adherence to guidelines, diagnostic accuracy, service indicators, “satisfaction with care, quality of life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.” The emergency nurse practitioner service model demonstrated high adherence to clinical guidelines and diagnostic accuracy and was as effective as the standard care model in evaluating service indicators and patient-reported outcomes. Woo, B. F. Y., Lee, J. X. Y., & Tam, W. W. S. (2017). The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review.Human Resources for Health, 15(1), 63. doi:10.1186/s12960-017-0237-9 This review was composed of randomized controlled trials, “quasi-experimental studies, prospective and retrospective cohort studies,” and excluded “cross-sectional studies” and those “without comparison groups.” This investigation incorporated 15 studies, covering 23,681 participants “from five countries—Australia, Canada, New Zealand, the United Kingdom, and the United States.” Based on the narrative synthesis of the accessible data, NPs demonstrate “outcomes comparable to those of physicians in emergency settings,” indicating that the implementation of NPs in emergency care settings may result in improved patient outcomes. Wu, F., & Darracq, M. A. (2021). Comparing physician assistant and nurse practitioner practice in U.S. emergency departments, 2010-2017.The Western Journal of Emergency Medicine, 22(5), 1150–1155. doi:10.5811/westjem.2021.5.51988 This study examined the comparison between PA and NP practice in EDs in the United States, utilizing the data collected from ED visits reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). From 2010 to 2017, there has been a considerable rise in the number of visits attended to by PAs and NPs in the US EDs. Although emergency medicine has traditionally been a specialty of PAs, NPs have grown over the last few years. This increase is highlighted by the “greater than twofold increase in the number of visits” conducted by NPs during the same period. These visits bear a striking resemblance in many ways, “such as patient age, gender, insurance status, arrival by ambulance, diagnostic screening, procedures performed, imaging ordered, admission rate, and ED length of stay.” CONCLUSION Although clinical research and evidence are used daily by medical professionals to make informed decisions, the repercussions of poorly informed or executed studies can be far-reaching and dangerous. Violations of scientific integrity and publication ethics are especially problematic when results not only negatively impact the practice of advanced practice nurses but also carry the potential to remove patient access to quality care in areas where it is most needed. The practice environment and care provided by NPs in emergency care are unique. There is significant variation among practice standards, training, and clinical expertise between NPs in emergency care and those caring for different patient populations. Furthermore, the specialty of emergency medicine and the role of the NP in emergency care are rapidly evolving. Therefore, scientific inquiry into the discipline should be led by those with current expertise in the field. Although understanding emergency nurse practitioner (ENP) practice and how it affects health outcomes requires a broad range of content and methods experts, ENPs are uniquely positioned to lead research that is relevant to their complex practice settings. As clinicians educated in graduate-level research and scholarly methods, we must promote a critical approach to evidence appraisal. For educators, researchers and NPs in clinical emergency care, additional studies demonstrating NP outcomes are needed. Just as nurses have done for centuries, our ability to offer and implement evidence-based solutions in care delivery may well be what keeps our health care system intact. —Wesley D. Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN, FAANP, FAEN Family and Emergency Nurse Practitioner Program Coordinator and Assistant Professor, College of Nursing University of South Alabama Mobile, Alabama —Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP, FAAN Emergency Nurse Practitioner Program Director and Professor Vanderbilt University College of Nursing Nashville, Tennessee

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