Urgent And Unscheduled Care Nursing Essay

Scenario 1: Tom is a 45 year old car mechanic who has sustained a laceration across the palm of his right hand on a piece of machinery whilst at work. The wound has been covered with a sterile dressing but is still bleeding as he arrives with a work mate who has driven him to the nearby Accident and Emergency department. As you greet him, Tom tells you he is HIV positive and takes antiretroviral medication regularly, and that he is very well at the moment

Using the above scenario this paper will critically explore the nursing decision making process in the urgent and unscheduled care setting, with consideration given to the relevant theories and current policies surrounding this process. Consideration will be given to the risk assessments required to actively manage treatment whilst evaluating the contribuation of the Multi-disciplinary team in the process:

Urgent and unscheduled care can be defined as any unplanned contact within the NHS by a person seeking care or advice which may be delivered by a number of providers in various settings with an expectation of 24/7 availability (DoH 2006). On an average day in the National Health Service (NHS) 34,700 people attend an accident and emergency (A&E) department, 11,700 need urgent transport to hospital by ambulance and over one million people contact their general practitioner (GP). (DoH 2001). The NHS Plan (2000) was the Government's plan for reform and investment in the NHS and one aspect of this plan was that everyone attending accident and emergency departments would be seen within 4 hours with the assumption that this would lead to better clinical outcomes (DoH 2000) and whilst there have been no clinical measure to support this assumption what has become apparent is that emergency admissions have increased by 66% over the last ten years for the over 75’s (Clay & Longman, 2010. These figures highlights the need to address the problems associated with increased use of unscheduled care services by reforming the services available and providing services that are responsive to people and more efficient in the deployment of resources (DOH 2010).

The implications of providing 24/7 urgent and unscheduled care in the NHS are far-reaching with huge financial implications in terms of provision of staff, access to out of hours medications, clinical decision makers....

With the encouragement of central government intitaive the last ten years has seen a rise in PCT’s setting up centres to broaden access to urgent care services and whilst this has produced some good results in terms of access it can be seen that often these services are working against each other in redirecting activity to another part of the system resulting in a morea fragmented service that is difficult for patients to understand or navigate (Carson, et al, 2011). In an attempt to manage this confusion around access identified in the Deparment of Health’s Our NHS, Our Future (2007) the government have introduced a new NHS help line, NHS 111, currently being piloted in parts of the country with a view to it being rolled out nationally in 2013 supersedeing the current NHS Direct service, offering free service providing advise 24/7, 365 days a year (Harmoni, 2012). Initial assessment is carried out at the first point of contact by fully trained NHS 111 call advisers, supported by experienced nurses. Using NHS Pathways to assess callers needs safely and effectively patients are then directed to the appropriate NHS service such as rapid response teams, community matrons, minor injuries units, and out of hours services (Harmoni, 2012). The aim is to improve and simplify access to non-emergency healthcare for patients by providing access to a full range of services including referrals into community, primary and secondary care services. The service aims to both enable the best outcome for the patient as well as deliver an improved patient experience (DoH, 2010). However, critics of the service have suggested that the lack of clinical training of the call handlers will result in mis-direction and consequently delays in treatment for patients with additional burden of costs for already financially stretched NHS (RCN, 2012), a point supported by a recent independent report on the service which suggests an increase in A&E attendances in some piloted areas (Calkin, 2012). With regards to the above scenario the use of NHS 111 for Tom may have been appropriate and direction to a minor injuries unit may have been advised.

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The decision making process begins with the identification of a problem and ends with the evaluation of choices and taking a course of action (Bernhard & Walsh, 1990) with nurses actively using decision making in various situations from planning patient care to prioritising their work load (Finklemann, 2006). The process of decision making is a dynamic one carried out in a complex and changing environment, having an awareness of approaches to decision making will enable the nurse to develop her skills of crititical thinking and subsequently make more effective decisions (Marquis & Houston, 2009). Aloi (2006 ) suggests that many experienced nurses use intuition in decision making, that is relying on their gut-level feelings to take appropriate action however some argue that intuition should only be used as a complement to more empirical decision-making models (Ward, 2009) arguing that relying soley on intuition may result in mis-judgement. This model requires a level of experience in order to subconsciously recognise similarities with previous experiences (Benner, 1984) and is inextricably linked with expertise (Manchester Triage Group, 2006), and for this reason would not be a suitable model for a newly qualified nurse in the case of Tom presenting in A&E, however intuition may form part of a strategy in the overall decision making process (Manchester Triage Group, 2006).

The information-processing model is a psychological theory much used in research in medical decision making and characterized by a scientific approach to making decisions (Joseph & Patel, 1990). . Hamers et al. described four major stages of this process in nursing as, gathering preliminary clinical information about the patient, generating tentative hypotheses about the patients’ condition, interpreting the initially registered cues in light of the tentative hypotheses, and weighing the decision alternatives before choosing the one that fits best in light of the evidence collected. Earlier knowledge acquired about the situation at hand is included in this process. Critics of this theory argue that it requires problems that have some basis of understanding in your own experience and argue that often problems faced by nurses are complex and ill-defined making the this process difficult to apply (Crumbie, 2000).

Decision making is an essential and integral part of nursing practice and requires both thought and intuition based on professional knowledge and skill with an expectation of being able to gather, interpret, distriminate and evaluate data. These decisions require a framework of reference in order to make sound decisions that are safe and patient focused (Purcell, 2003). Triage is a nursing function developed in the 1990 ’s that has been adopted nationally in Accident and Emergency departments to deliver an auditable method of assigning clinical priority (Walsh & Kent, 2001).

Utilising the information-processing model and integrating with a triage system of assessment with regards to Tom could appropriately applied the decision making process for a graduate nurse. Manias et al., (2004) in their review of decision-making models used by newly qualified nurses found this was the prevalent model used and was observed in 25 out of the 37 client interaction. The triage approach to decision making follows five steps; identifying the problem and selecting the relevant flow diagram, the second step utilises the flow diagram and pattern recognition and suggests structured questions to aid rapid assessment. Once the data has been collected it can be analyised by drawing on knowledge of previous experience and using the flow diagrams to link the decision making process into the clinical setting. From the 5 possible triage categories the appropriate one is selected, with ongoing monitoring and evaluation.

On presentation to A&E Tom would be seen by a Nurse Practioner, ( a qualified nurse with the competencies to autonomously assess, treat and discharge patients without referring to any other clinician (NHS, 2011)) , where preliminary clinical information would be gathered to identify the problem and baseline observations made and accurately recorded with any anomalies reported to a senior staff member. Providing that no life-threatening problem has been identified the main goal of intervention would be pain-relief and stopping the bleeding (Walsh & Kent, 2001). An assessment of pain would be made using a pain ladder scale(REF)and if necessary analgesia would be prescribed. Any relevant past medical history including any allergies would be noted as well as any current medication being taken. The wound assessment and evaluation is critically important all information will determine the overall management of the wound (Toulson, 2001). It would be appropriate to ascertain how the accident occurred, the time elapsed since occurrence, was the wound caused by machinery and if so ascertaining current tetanus status would appropriate. Referring to the management guidlines for tetanus-prone wounds (DoH, 2006) a decision would be made as to the requirement for passive or active immunisation (Toulson, 2001). Wearing appropriate PPE as standard universal precautions which states that all patients should be assumed to be infection risk (Wilson, 2006), the wound would be assessed for size, obvious sign of foreign body , possible underlying structural damage and if deemed necessary a referral to xray would be made. From this initial assessment utilising the wound flow chart (Manchester Triage Group, 2006) would prioritise Tom’s care between urgent and standard depending on the ability to stop the bleeding. Due to Tom’s positive HIV status, and therefore possible immunocompromised status, and the potential for the wound to be dirty he would be considered at higher risk for possible infection (Meyers, 2011) and for this reason would need to be referred to a nurse prescriber or doctor for prophylaxis antibiotic treatment. Treatment for Tom would consist of closure of wound with sutures and ascepticly applying a wound dressing. Information would need to be given to Tom for care of the wound and a referral made to the District Nurse Team at his GP practice for removal of the sutures. Following the Nursing and Midwifery Council guidelines consent would be sought before undertaking any treatment and Tom’s rights to to accept or decline treatment would be upheld (NMC 2008).

Collaboration is key to meeting the core objective of unscheduled care which to ensure that patients are able to to access the right help and receive prompt and rigorous assessment followed by the right care, in the right place and the right time (NHS, 2011). A multi-disciplinary approach to urgent care offers a continuity of treatment supported by appropriate referral pathways to meet the whole needs of the patient with the possible reduction of service duplication and faster assessment process leading to effective and timely treatment.

On his journey through the A&E department Tom can expect to come into contact with various practioners who will be providing a holistic approach to his care. The Triage system could be effectively and safely implemented by a relatively junior nurse following the algorithm to deliver an acceptable level of assessment, however without additional experience and expertise the assessment would be closely tied to the physiological findings with little consideration of other factors (Walsh & Kent, 2001). The Nurse Practioner (NP) is an autonomous nursing role that implies the ability to consult with and prescribe care for patients without referral to a doctor providing a more individually tailored package of care whilst being accountable practioners able to justify their actions at all times (Walsh, 2000). The employment of the NP benefits the patient by providing continuity of care and subsequently a more expedient delivery of care (Pines & Everett, 2007). In the case of Tom the NP would be able to make a clinical decision regarding his treatment, assessing the need for xray or referral to a orthopaedic specialist for further assessment. The ability to interpret xrays would be fundamental to this NP role, enabling the NP to proceed with treatment based upon these findings. If the NP has independent prescribing status then it would possible for medications to be prescribed for Tom from either a limited or extended formularly (Hatchett, 2003), without this status Tom would need to be seen by a doctor or prescribing pharmacist.