Reflection On Experience Working In Accident And Emergency

Reflection On Experience Working In solidus And EmergencyThis fieldwork exercise was a visit to the excus equal league plane section indoors Accident and Emergency (AE) for a large capital of the United Kingdom National wellness Service (NHS) infirmary, to observe and interview an Emergency Nurse Practiti angiotensin-converting enzymer (ENP) within the Department, and link their role in relation to primary health apportion (PHC).I had expected to learn hike about the main connective between PHC and an sharp-worded cargon setting much(prenominal) as AE, expect that it would be due to poor PHC watchfulness and issues with botheribility. These assumptions were base on much or less experience in AE as an Agency Nurse, on with colleagues, patients and media reports.2.0 VISIT TO minor league IN ACCIDENT EMERGENCYMy fieldwork exercise began with c every come int observation in the AE wait room, waiting for my fellow Nurse Practiti one and only(a)r (NP) student to pay bac k for a Saturday night shift. on that point were al some 15 people and one child within the waiting room a relatively lull environment, albeit for quiet restlessness, sighing, guarding and rocking, questioning companions as to when they would be seen, alongside comparing with others who had got in. reception was a glass-shielded counter staffed by two personnel, informing patients registering, that there was a three hour wait. An electronic sign above reception welcomed patients, fri endings and relatives to the hospital, alike informing them that we endeavour to see you in 4 hours a credit entry to the Department of Healths (DoH) target, for patients to be discharged, admitted or transferred within four hours of presenting, in 98% of cases. The sign also requested for those with a minor illness, to attend the near walk-in centre (WIC).Of none, aside from a clear focus on hygiene, was a sign nonifying patients that treatment may not be emancipate if not a United Kingdom ( UK)/European Union citizen or resident. Such signage brings a principle of the Alma Ata declaration into question. The Alma Ata declaration arose following a joint World Health Organisation-UNICEF international conference, with a vision for health c ar for all people worldwide, with PHC at the heart (World Health Organisation, 2010). Although it whoremaster be argued that international guests ar not paying into the NHS, and health feel for in the UK is not essentially free, given the National Insurance levy, the declaration views health circumspection as a right for all, and not just those who are in a position to pay.On arrival, my fellow NP student showed me around AE. deep down the adults section, the Department can be broken down toTable 1 AE layoutDepartment/RoomCubicles/RoomsAdditional/Other InformationResuscitation5+1 paediatric cubicleMajors16Including 1 psychiatric cubicleMinors12Assessment/Triage3Clinical Decisions10Investigations and short term treatment (not more tha n 24-36 hours)Eye1Ear, wind up Throat1Plaster1X-Ray1 side by side(p) CT room universe built next to ResuscitationThe hospital is one of Londons major hospitals, opening in the 1700s in central London and ontogenesis into a main teaching hospital. With the increase in healthcare demands, more space was fatalityed, and the hospital relocated to its present day location in the 1950s. In the 1970s, construction on the present hospital building began, and by the early 2000s, building and the final relocation of one of its hospitals was complete (Hospital website, 2009a).The AE Department is a 24 hour service, comprehend around 100 000 patients per year, and of those, around 21% are admitted to hospital. Twenty two percent are children, to which a separate paediatric AE between the hours of 9am and 2am is available (Hospital website, 2009b).From April this year, the AE Department will become one of Londons four major trauma centres (MTC), and one of eight crisp crack centres (Heal thcare for London, 2010). Preparations for this new designation were evident by the building of a computerised tomography scanner next door to Resuscitation, enabling suspected stroke patients to be scanned within two minutes of arriving.I spent most of my visit in Minors, a Department with 12 cubicles, which is staffed by two to three ENPs, one Senior Ho engage Officer, Registrar support, and a common Practitioner (GP) on Saturday and Sunday evenings. Despite having an adjacent WIC, this section of AE is employ to patients with minor injuries and illnesses. The most common presentations are due to infections (mostly ears, nose and throat, and urology), impertinent bodies, wounds, fractures and head injuries.Numbers seen can vary, and around 150 patients had already been seen that day. on that point is a difference between days and nights, with days mostly seeing occupational injuries and GP referrals, with alcohol, drugs, domestic violence, assaults and foreign bodies featurin g in the nights. In addition, weekends and evenings can see Minors taking on the role of an extended hours GP practice supporting my hypothesis of poor PHC management and accessibility, as macrocosm a key cause of PHC in AE.The Department closes at 3am to skip costs, but is sometimes too busy to do so. From next year, Minors will be a 24 hour service, with the aim for a Nurse-led service with Registrar support. This is to release medical staff for the new MTC, and in response to recommendations in Lord Darzis review on healthcare for London, discussed further in this assignment.The most surprising element of my visit, was to find out that ENPs are viewed and treated as junior doctors. This was mirrored by the consultation story taking, examination, judgment, plan of care and documentation was that of seeing a medical doctor. while I was aware of the advanced and autonomous role of a NP, enabling diagnosing, prescribing and referring, I was taken back that NPs, certainly in thi s Department, induct shifted from the breast feeding side of healthcare, and are now affiliated with medicine. The ENPs line management is a Registrar, who also supervises and signs off competencies. Any problems or concerns which need to be escalated, are foldt with by the Consultant. The AE Matron, and ultimately, the Director of Nursing are nowhere in the ENPs describe line.The role of NP, reviews of urgent care, and PHC management are the topics I have elect to base my discussion on.3.0 DISCUSSION3.1 Urgent care reviewsThe key review of urgent care in London is Lord Darzis Healthcare for London A Framework for Action report. It was commissioned by NHS London in December 2006, in order to fulfil Londons healthcare needs everywhere the next 5 to 10 years. The report acknowledged that many patients presenting to AE for minor illnesses and injuries would be better looked after in polyclinics or urgent care centres (UCC) with lasting opening hours. Patients presenting to AE is n ot optimal due to the waiting gunpoint and being seen by junior doctors rather than GPs, who more suited to these complaints along with managing long-term health conditions (Healthcare for London, 2007a).The report proposes UCC with diagnostic equipment, where patients will have access to a Nurse or GP, recommending 24 hour access if based in AE (ie. Minors), or to be open on weekends and afterhours for those not hospital based (Healthcare for London, 2007a). A co-located UCC within AE can be important, in deviate urgent care away from attending AE/MTCs (Healthcare for London, 2007b). However, the ENP reported problems recruiting fellow ENPs with detach qualifications and experience, and was unsure whether Minors would be a Nurse-led 24 hour UCC, to approve with the transformation of the main part of AE into a MTC in April.The Darzi report current criticism, largely directed at cost cuttings, cashing in on privatisation, the demotion of acute hospital run, the question of elde rly care, and that forthcoming predictions on PHC and AE usage was an under(a)statement. There is also criticism that recommendations have been made without practicalities, including polyclinic staffing, failings and costs of minor injuries units, and the future of healthcare staff (London Health Emergency, 2007).The ENP reported a poor skills cockle at the adjacent WIC, such as not being able to read x-rays or suture, with patients being referred on to Minors. Alongside the question of resources being doubled up, such referring on leads to disjointed care and greater waiting lengths to be treated. It could also be confusing for patients to know where the best place to attend is, especially having been diverted from AE to the WIC on the advice of the Reception sign, only to end back up in AE. Clarity and streamlining of services is needed to remedy patient experience.The Royal College of Nursing (RCN) survey strand that Emergency Nurses were under huge strain to meet the DoHs f our hour target, termed as impractical (RCN, 2010 website). The survey also reported that the majority of respondents matte up that patients with various and multiform needs, have had their care rushed to meet targets, and 59% of respondents feeling the accountability lying solely within Nurses (RCN, 2010). Yet the ENP I spoke to was talented with the target, which gave momentum if a patient needed to be seen by a Registrar and had been waiting over an hour, this would then be escalated to a Consultant. On questioning, the ENP felt that the target was realistic, practical and they had the resources.3.2 Primary health care management and accessibilityLondon has the most AE attendances and admissions than anywhere else in England, and many of the 83% of patients not admitted could be treated elsewhere, with 40% of complaints able to be persistent through PHC. However, access to PHC services in London after hours is forgetful a main thought behind AE attendance. AE patients are more seeming to be fulltime workers and may take reassurance in knowing that they will be seen in four hours, rather than a wait of up to (or longer than) 48 hours to see their GP (Healthcare for London, 2007b). According to the ENP, patients report issues making GP appointments and that AE is quicker than seeing their GP, as the main reasons for presenting with PHC matters.The Healthcare Commissions (HCC, now the explosive charge Quality Commission) review on urgent care in England, found that more than 50% of patients have problems calling their GP surgery, and a cast of patients found GP hours were not convenient, and avoided going (HCC, 2008). Incentives for GP surgeries to provide afterhours care was a recommendation by The Royal College of General Practitioner (RCGP) in their review on urgent care (RCGP, 2007). Yet, the HCCs review found that where GP services provide afterhours care, less than half had organised a shout diversion with local GPs, to divert afterhours calls to their services. The majority of patients attending afterhours GP services are seen within two hours after an initial tele auditory sensation assessment (HCC, 2008). This is not only faster than attending AE, but a more appropriate use of resources.The review found that many people are not aware of healthcare services other than their own GP and AE, or they might be unsure of using them. There were also examples of patients being referred to services that were not accessible. Work needs to be do to increase both patients and healthcare professionals understanding of alternative healthcare services, and when to use them (HCC, 2008). This is a view shared by the RCGP, along with GP practices implementing systems to deal with urgent care and GP training (RCGP, 2007).The ENP expressed frustrations with GPs making improper referrals to AE, rather than to Specialists, generally noting the practice of defensive medicine. Despite referring back to the GP on discharge, patients were bou ncing back for simple things, such as to have their dressings attended to. The ENP rarely had time to speak with GPs, but when they did, it was mostly to phone to question why they had referred. In respect to patients, the ENP felt that they were either not taking responsibility for their health or there was poor egotism management, possibly due to poor or no patient education, such as not taking analgesia and attending AE to request. The RCGP also note the need for improved patient education and self management promotion in their review (RCGP, 2007).The ENP was also very critical of NHS Direct, Englands telephone advice line for healthcare. They felt that the service was inadequate, as it was not possible to make an assessment over the phone, and defensively referring to AE. Yet half of callers to NHS Direct were given advice on self management at home (NHS Direct, 2010).3.3 The role of the Nurse Practitioner4.0 thicksetThis fieldwork exercise has been a valuable experience. It has demonstrated the impact PHC has on AE, an already stretched resource, exacerbated by poor PHC management and accessibility.For these reasons, I will bear in mind my present practice and on qualification as a NP, to make seamless and appropriate referrals.