This assignment will aim to define and apply the parameters of urgent and unscheduled care. In order to achieve this, the above case study of Tom will be used as a comparative. Current healthcare policy and the contribution of the multi-disciplinary team will be critically analysed. For the purpose of this assignment, the intuitive reasoning model will be used to critically analyse the decision making process in meeting the urgent nursing care needs of Tom. The concept of risk to vulnerable patients and their families and the impact that this has on urgent and unscheduled care will be explored. The assignment will focus on Accident and Emergency departments (A&E), as outlined in the case study of Tom. In accordance with the Nursing and Midwifery Council's (NMC) Code of Conduct (The Code, 2008) confidentiality will be maintained throughout and a pseudonym will be used. A personal reflection will be used within the conclusion, to determine how the exploration of the subject has contributed to learning and future practice development.
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The Department of Health (DoH, 2011a) define urgent and unscheduled care as the delivery of health and social care services 24 hours a day, 7 days a week to those who are suspected of requiring unplanned care, advice or treatment. Unplanned care entails, but is not exclusive to, traumatic injuries, exacerbations or emergency sexual health advice. Confusion surrounding terminology is apparent. For the purpose of this assignment, urgent care 'requires assessment and planned intervention within seven days, or is likely to lead to an emergency within four weeks'. Unscheduled care 'may not be life threatening, but prompt assessment and planned intervention within 24 hours is needed' (DoH, 2012).
The NHS Plan (DoH, 2000) was one of the first policies to suggest radical reforms to the National Health Service (NHS). It highlighted the need for modernisation of A&E facilities and a reduction in the length of waiting times. The introduction of agreed standards, facilitated by the National Institute for Clinical Excellence (NICE) and introduction of partnership working placed the focus on patient centred care. The development of roles, such as Nurse Practitioners and Nurse Prescribers, through extensive training allowed senior consultants more time for patient care. The Code (NMC, 2008) states that, in order to deliver high quality care, a nurse must 'must recognise and work within the limits of their own competence'. Failing to recognise an urgent or unscheduled care need or escalating care where necessary has great implications for professional practice, such as failure to provide adequate care (NMC, 2008).
Direction of Travel for Urgent Care (DoH, 2006a) confirms the need for integrated high quality care. Six clear principles set the framework for urgent care: be heard; know how to access services; quick and simple access; patient safety; right care, right time, right place; appropriate care for patient need. This is achieved through compliance with clinical governance and national frameworks. A national telephone number such as 999 in life threatening situations or 111 when urgent care is required has been set up (DoH, 2013a). This enables care to be directed to the appropriate source, simple 24/7 access to a consistent assessment by suitably qualified staff and personalised care plans allow the public to be informed and in control of their care.
The NHS Outcomes Framework 2012/13 (DoH, 2011b) states that practitioners must be held accountable for the service they provide. To aid practitioners in providing the best care, they have implemented 6 national standards which must be applied across the NHS. Three of the standards are applicable to Tom, provide a positive experience of care in a safe environment, protecting him from further harm and support the recovery from illness or injury. These frameworks guide the practitioner through appropriate responses to care and allow for individuals to take responsibility for the care they provide.
The NHS choices website (DoH, 2013b) details how urgent or unscheduled care provision can be accessed. There are several health and social care services available, depending on the care required. An urgent problem that arises outside of General Practitioner (GP) opening hours can be dealt with through the GP out of hour's service. A pharmacist or NHS direct can also give advice on common minor illnesses such as coughs, headaches or cystitis. Primary Care services such as NHS Walk-in Centres, Minor Injury Units or Sexual Health Units are run by qualified nurses and can treat minor injuries, illness, stomach upsets or emergency contraception. Emergency services, which include 999 and A&E departments, provide unscheduled care for incidents such as loss of consciousness, difficulty breathing, serious accidents, bleeding or deep wounds. The patient should seek advice through NHS Direct if they are unsure of which service is appropriate to their need (NHS, 2011c).
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A report issued by the NHS Information Centre (DoH, 2013c) showed that 17.6 million attendances were recorded in 2011-12 by major A&E departments, walk-in centres and minor injury units in England. This volume puts a large strain on NHS resources, therefore an understanding of what constitutes urgent and unscheduled care is important for practice, as it will enable a nurse to correctly deal with or direct patient care (NPSA, 2007).
As mentioned in the case study of Tom, he attended his local A&E department seeking treatment to a hand laceration. An A&E department will consist of a multi-disciplinary team (MDT), which includes lead consultants, who are in control of the overall department, specialised doctors and nurse practitioners trained in resuscitation and other life-saving techniques. The team also includes nurses, health care assistants, radiographers and administration staff. Trauma surgeons and psychiatrists are on standby if required. The Care Quality Commission (CQC, 2012) states that an A&E department must consist of an appropriate skill mix, thus enabling the delivery of appropriate care.
Within the MDT, each member has a specific role to play depending on the care need of the patient. According to the Royal College of Nursing (RCN, 2012a) the nurse practitioner (NP), is a registered nurse that has completed extended training to gain competence in additional tasks. A NP is able to lead care and delegate to others, complete patient assessments, request transfers of care and discharge patients without consulting a doctor, which is essential in an urgent and unscheduled care environment. However, if a patient arrives with a care need out of the NP's competencies then the care must be assigned to a senior clinician with the ability and competency to provide the necessary care (DoH, 2010a).
As a nurse advances from novice to expert practitioner, improvement of sound clinical judgement and decision making skills will be developed and incorporated into practice. According to Thompson and Dowding (2002), intuitive reasoning in clinical decision making involves immediately knowing the course of action needed, without conscious thought, which is complexly linked to expertise. There are five steps used in this process that can be developed over time. The first step in sorting relevant information is reasoning, which comes in two forms. Inductive reasoning is the need to consider all possible solutions from the information gathered. This is a timely exercise and can include symptoms or signs of illness or injury and the history of the patient. However, deductive reasoning is the ability to determine the most likely solution whilst gathering data. The second and third step is problem solving and pattern recognition, which is the ability to make rapid decision based on comparison of previous experience. Repetitive hypothesising, which can be inductive or deductive depending on expertise, is the fourth step and is used to test diagnostic reasoning. Mental representation, the fifth step, is often used in complex problems and allows for narrowing of relevant information to reach a decision. It is not generally appropriate in the assessment of an urgent patient as triage decisions need to be rapid.
Therefore, the ability to make complex clinical decisions, combining cognitive, intuitive and first-hand experience is based on the knowledge and expertise of the NP carrying out the assessment and is why extensive training is required. The Essence of Care (DoH, 2010b) benchmarks allow professionals to measure their ability and performance against national standards. One of which is communication, this is a core skill required of a NP, aiding effective team work and patient centred care. To avoid errors in patient assessment, a clear framework is used by professionals to ensure that the correct procedures are highlighted in the correct time.
A&E departments have adopted the triage priority framework developed by the Manchester Triage Group (Mackway-Jones et al, 2008). Triage priority is essential in allowing a patient access to the right care, by the right practitioner, in the right time (DoH, 2008a). Priority is titrated through five levels, level one is immediate care and colour coded red, whereas level five is non-urgent and is colour coded blue. This framework uses presentational flowcharts, which structure the triage process by guiding the professional through a series of key discriminators at each level of priority. Discriminators are specific to the flowchart selected, although there are six general discriminators included in each chart. These are life threat, pain, haemorrhage, conscious level, temperature and acuteness. An understanding of these six discriminators is essential in enabling the professional to complete the assessment accurately (Mackway-Jones et al, 2008). Prioritisation within A&E can also depend on staffing levels and the number of acute patients triaged (RCN, 2012b).
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Consent needs to be obtained from a patient before any form of care can commence. If consent is unobtainable, the NP must be able to demonstrate that they acted in the best interest of the patient (NMC, 2008). Tom's wound is covered by a sterile dressing and still bleeding. Therefore, a further dressing must be applied over the existing one and slight pressure applied to the wound to stem the bleeding (The Royal Marsden, 2011). NP's have a duty to provide care for any individual who seeks treatment, however is it not legally or ethically required to provide this care if the practitioner is at risk. Tom has disclosed that he is HIV positive and HIV infection is possible through all bodily fluids, such as blood or semen (NAT, 2013). A NP must ensure that hand hygiene procedure are followed and use personal protective equipment, such as gloves and apron. As well as this, soiled dressing must be disposed of appropriately. This is to protect the nurse and the patient, as safety is paramount (WHO, 2007). Each NHS Trust will have their own policies which must also be adhered to.
An initial assessment is completed by taking a detailed patient history establishing the presenting complaint. Which is a laceration to the palm of his right hand, with no apparent complications, thus the Wound flowchart will be used. Following this selection, information must be gathered and analysed to allow a triage priority to be determined. A history of Tom's injury, including mechanism of injury and possibility of foreign body/infection, together with a wound assessment will be completed. Upon examination, the site, shape and edges of the wound, as well as damage to underlying structures will be noted. If deemed necessary an x-ray may be required. A pain assessment needs to be completed, and if appropriate, analgesia administered. Effective pain control is a high priority for patient satisfaction and can assist in reprioritising patient care need (Mackway-Jones et al, 2008).
Analyse of patient history and a thorough assessment of the wound will allow the practitioner to evaluate the alternatives and select an appropriate one. By implementing the alternative, a triage priority is selected. Tom will need monitoring to determine if repositioning on the scale is required.
Thorough documentation of the assessment, including when the patient needs to be reassessed is important. The NMC (2008) states that, "good record keeping is the mark of the skilled and safe practitioner". This is to include a record of any allergies, current medications, relevant past medical history, first aid measures applied at triage, baseline observations taken and whether any drugs were administered.
If an x-ray or referral to a more senior practitioner is not deemed necessary, the NP is free to complete Tom's care. The wound will require cleaning following an aseptic technique, suitable sutures to close and a comfortable dressing applied. Information regarding follow up care of the wound and suture removal procedures should be given (The Royal Marsden, 2011).
As Tom has disclosed that he is HIV positive and is taking antiretroviral medication regularly, he is potentially at risk of becoming a vulnerable adult. A vulnerable adult is aged 18 or over and is generally at a greater than normal risk of abuse such as those who may require care services in the community due to age, disability or illness (DoH, 2011d). There are several categories of abuse: physical, psychological, neglect, discriminatory. All of which may be as a result of intent, negligence or ignorance. The Safeguarding Vulnerable Groups Act (DoH, 2006b) states that any individual who requires access to health services can be classed as a vulnerable adult.
Tom is at risk of abuse in the form of discrimination from healthcare providers, such as receiving poor practice. The Code (NMC, 2008) states, "a practitioner should have the skills to confidently recognise and effectively manage situations where you suspect a person in your care is at risk of harm, abuse or neglect, including poor practice". The DoH Action Plan: HIV Related Stigma and discrimination (2005) details legislation regulations to eliminate all forms of discrimination against people living with HIV and members of vulnerable groups. The aim is to ensure fair access to education, employment and healthcare, whilst developing strategies to combat stigma and social exclusion. Indicators of abuse, such as reluctance to disclose information or inappropriate history, can highlight the fact something may be wrong. This does not confirm that abuse is occurring, but suggests further enquiries are needed (DoH, 2011e)
It is an ethical and legal duty to not disclose information to anyone else, without prior consent from Tom. It is stated in the Code (NMC, 2008) that confidentiality must be maintained at all times, except in the circumstance of providing adequate care or the need for safeguarding. Safeguarding is an action intended to uphold an adult's fundamental right to be safe and is part of a practitioner's duty of care (NMC, 2008). Confidentiality respects the privacy of a patient with HIV and protects them from discrimination, harassment and abuse (Pratt, 2003). However, in order to minimise the risk to Tom's work colleague, consideration must be given to ascertain whether there is a chance of infection through an opening of the skin and blood contact. Firstly, consent to disclose his HIV status should be sought from Tom. In this circumstance, the information is important as it will significantly reduce the risk of Tom's colleague contracting HIV. A thorough risk assessment will need to be carried out if a risk of infection is probable. If deemed necessary, immediate post exposure prophylaxis can be administered (DoH, 2008b).
In conclusion, urgent and unscheduled care has been radically reformed over the last decade. Policies have been introduced to improve practice and patient experience. There are now several options available to patients in need of urgent care, such as walk-in centres, minor injury units and emergency departments. This has made better provision of available resources and allowed for the integration of the multi-disciplinary team and role expansion, such as the nurse practitioner. Clinical frameworks and agreed standards of care are available to aid the practitioner in providing patient centred care. These guidelines are always being updated as new evidence is apparent, which is positive for clinical staff and patients accessing the service.
Following a process of reflection, this assignment has assisted in personal learning through raised awareness of accountability, policies, procedures and protocols. It has highlighted the need for clinical knowledge, experience and understanding in order to provide the best possible care. The stringent need for universal precautions has been made even more apparent, for the protection of patients, oneself, and fellow colleagues. Sensitivity to patient vulnerability and need is important, as all practitioners have a duty to protect a patient, and an ethical responsibility to keep them safe. The knowledge gained will assist in developing future practice as a nurse will advance from novice to expert practitioner.