The Emergency Practitioner's Handbook

For All Front Line Health Professionals

Mary Dawood

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000477023
• Edition: 1
• Topic: Medicine
• Subtopic: Emergency Medicine & Critical Care

The development of urgent care centres within emergency departments and the proliferation of minor injury units and walk in centres in recent years has led to a parallel rise in Emergency Practitioners (EPs) whose professional backgrounds range between nursing, physiotherapy and paramedical sciences with nurses being the predominant group. These hybrid groups of clinicians combine nursing and medical knowledge to deliver timely effective care to patients presenting with a wide range of injuries and illness. This handbook is an ideal companion and aide memoire for daily practice, and an essential tool for EPs - enabling them to assess, diagnose, treat and discharge or refer the patient effectively. Written by emergency nurse practitioners who understand the thought processes and complexities of clinical decision making, this guide offers straightforward practical advice, particularly for those in isolated nurse led units or those working in a pressurised environment of the emergency department. General Practitioners and foundation year 2 doctors also increasingly work in emergency/urgent care settings and will find this guide invaluable for current, easy to access information.

SECTION 1

General issues

CHAPTER 1

Practice advice for the emergency practitioner

GOLDEN RULES AND TIPS FOR BEST PRACTICE

• ➤ Remember, patient safety is paramount.
• ➤ Always introduce yourself and explain that you are an emergency nurse practitioner (ENP)/general practitioner (GP)/emergency practitioner (EP).
• ➤ Ensure your name badge is visible.
• ➤ Make pain relief your priority and offer analgesia prior to examination.
• ➤ Don’t forget to wash your hands and be ‘bare below the elbow’.
• ➤ Occasionally patients may request to see a doctor; this is usually because they do not understand the role and expertise of the ENP/EP. It is usually sufficient to explain your role.
• ➤ Do not become defensive if a patient prefers to see a doctor.
• ➤ Try to do your very best for each patient.
• ➤ Do not rush either the consultation or your documentation.
• ➤ Remember, your documentation is your only defence and you may have to rely on these notes at a later date in court. Make sure they are complete and comprehensive. Draw diagrams wherever you can and particularly in describing injuries attributable to alleged assault.
• ➤ By and large, patients want to be a partner in their own care so involve them.
• ➤ Ensure privacy and dignity for all your patients appropriate to their presenting problem.
• ➤ Assess each patient thoroughly, be fair and objective in your approach.
• ➤ Bear in mind that you rarely know the whole story so don’t make assumptions or jump to conclusions. Keep an open mind.
• ➤ In the case of regular attenders, do not allow the patient’s past behaviours to influence your assessment or govern your thinking.
• ➤ Don’t ignore your ‘gut feeling’ even if it has no scientific basis.
• ➤ Do not be influenced by the assumptions and judgements of others – draw your own conclusions.
• ➤ Reassure the patient that X-rays are reviewed by a consultant and that you would contact them if the radiological report recommended a different management plan. Explain that this is a safety mechanism and the need to recall patients is rare.
• ➤ Never dismiss the patient’s anxiety; if the patient does not seem satisfied with your assessment, ask them what is worrying them most. What may seem trivial and commonplace to you may well be terrifying for the patient.
• ➤ Patients understandably fear malignancy but are embarrassed to voice such fears and often need you to articulate that fear and reassure them.
• ➤ If the patient does not appear happy with your diagnosis and plan of treatment, ask a colleague to review the patient,
• ➤ If the patient does not speak reasonable English, get an interpreter; resist the temptation to just muddle through.
• ➤ Avoid using family members to interpret, especially if you are suspicious about the injury.
• ➤ Have a chaperone for intimate examinations.
• ➤ Always ask about the social circumstances of the patient; it may affect your management.
• ➤ Consider referral to occupational therapy/social services if you have any concerns about the ability of older patients to manage at home.
• ➤ Remember, domestic violence is prevalent at all levels of society. Do not be afraid to voice your concerns; the patient may be depending on you to recognise the clues.
• ➤ Consider non-accidental injury (NAI), including elder abuse, where history and presentation are inconsistent with injury
• ➤ Never admonish patients for attending the emergency department (ED) or for calling an ambulance. Deal with the presenting complaint in a professional way and then advise them appropriately.
• ➤ Remember alcohol misuse as a cause of falls, collapse, head injury and assault. The patient may have alcohol amnesia or have been unable to attend at the time of injury due to intoxication.
• ➤ Use every opportunity to promote health and screen for illness, particularly for problems such as falls and alcohol abuse, for which brief interventions may be helpful.

CHAPTER 2

Avoiding pitfalls and practising safely

‘Pitfalls are the bad things that happen to good people’

• ➤ The patient understands their complaint better than you do so listen to them.
• ➤ Don’t become defensive if a patient questions your diagnosis – explain why you think the way you do.
• ➤ Don’t rush patient assessment or writing notes; this is the surest way to make a mistake or miss something important.
• ➤ Always check the patient’s identity before administering medications.
• ➤ Always read over and sign your notes before closing the episode.
• ➤ Don’t ignore your intuition even if it has no scientific basis.
• ➤ Don’t allow your negative feelings or dislike of a patient to affect your objectivity.
• ➤ If a patient is being difficult, spend more time with them and try to reassure them.
• ➤ If you feel you cannot effectively manage the situation, ask a colleague to help you.
• ➤ Listen to your junior colleagues – they may offer valuable insights into the patient’s presentation.
• ➤ Wherever possible, give written instructions to the patient.
• ➤ Ensure that adequate follow-up arrangements are made for the patient but reassure the patient that they can return if they are still worried.

CHAPTER 3

Prescribing

Emergency nurse practitioners are increasingly being registered with the Nursing and Midwifery Council as non-medical prescribers, making this one of the most dramatic developments to have taken place in nursing. There are now approximately 40 000 nurses in the UK qualified to prescribe, and developments continue. The establishment of non-medical prescribing has not only ensured timely treatment for patients; it has also greatly enhanced the autonomy of nurse practitioners working in EDs and urgent care settings.

Nurse practitioners who are not registered as prescribers may use Patient Group Directions (PGD). In practice, this means that a PGD, signed by a doctor and agreed by a pharmacist, can act as a direction to a nurse to supply and/or administer prescription-only medicines (POMs) to patients following their own assessment of patient need. It is, however, preferable for ENPs to become qualified as prescribers to enhance their autonomy and to improve patient safety.

Further useful information in relation to all aspects of prescribing, including legal mechanisms for prescribing, supply and administration of medicines, can be found at the NHS National Prescribing Centre at www.npc.co.uk/prescribers/nmp.htm and at www.nurseprescribing.com.

CHAPTER 4

X-rays and Ionising Radiation (Medical Exposure) Regulations

The EP must be fully aware of the 2000 Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) which came into force on 13 May 2000, replacing the previous regulations known as POPUMET. Most EP education programmes incorporate teaching sessions on th...