Article: TME200224

Date: October 23, 2013

Time: 15:18

Advanced Emergency Nursing Journal Vol. 35, No. 4, pp. 332–343 C 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

Provider in Triage Is This a Place for Nurse Practitioners? Diana Bahena, MSN, FNP-BC, TNS, CEN Colleen Andreoni, DNP, FNP-BC, ANP-BC, CEN

Abstract The role of nurse practitioners (NPs) in emergency care continues to evolve. A new and exciting role is the provider-in-triage (PIT) role. This innovative role has been implemented in many emergency departments (EDs) across the country. It was developed primarily as a front-end strategy to improve throughput of patients receiving emergency care. The PIT process uses a provider, physician, NP, or physician assistant in the triage area. Patient satisfaction, quality measures, and financial improvements have been attributed to using a PIT. The emergency NP is an optimal choice for this role. Advanced emergency nursing knowledge, skills, and decision making confer the NP a cost-effective provider to improve throughput in the ED while providing quality emergency care. Key words: emergency nurse practitioner, emergency services, triage

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Affordable Care Act will no doubt bring further changes, which will affect the delivery of emergency care. It is anticipated that the increase in patients presenting to emergency departments (EDs) will lead to even more hospital and ED crowding (Brooks, 2012). Nurse practitioners (NPs) are recognized as emergency care providers, along with physicians and physician assistants (PAs). This article examines the strategy of placing a provider in triage (PIT) as a means to decrease the adverse effects of crowding, as well as the advantages to an emergency department nurse practitioner (EDNP) operating the PIT process. Emergency department nurse practitioners are keenly aware of the numbers uninsured, underinsured, and Medicaid recipients who use the ED for nonemergent conditions. The ED is often a site of primary care services to those who do not have affordable access to health care (Committee on the Future of Emergency Care in the United States Health System, 2006). Capabilities of EDs have been

MERGENCY CARE in the United States is dynamic. It changes and transforms in response to internal and external factors. Several factors contribute to the imbalance of resources and have led to the concept of crowding, defined as follows: “Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the emergency department, hospital, or both” (American College of Emergency Physicians, 2006, p. 1). The current transformation in health care accessibility anticipated by the implementation of the

Author Affiliations: VNA Healthcare, Aurora, Illinois (Ms Bahena); Loyola University Chicago Marcella Niehoff School of Nursing, Chicago, Illinois (Ms Bahena and Dr Andreoni); and Emergency Department, Delnor Hospital, Geneva, Illinois (Dr Andreoni). Disclosure: The authors report no conflicts of interest. Corresponding Author: Diana Bahena, MSN, FNP-BC, TNS, CEN, VNA Health Care, 350 S. Schmale Rd, Suite 150, Carol Stream, IL 60188 (diana.l.bahena@ gmail.com). DOI: 10.1097/TME.0b013e3182aa05ba

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overstretched as a result of increasing volume, patient acuity, and a decreased number of emergency care facilities (Committee on the Future of Emergency Care in the United States Health System, 2006). Pitts, Pines, Handrigan, and Kellerman (2012) examined the ED trends from 2001 to 2008 and found that although the U.S. population increased at a rate of 1.2% per year, the ED visits increased by 1.9% per year. Frequency of diagnostic testing and broader disease management also increased, causing length of stay (LOS) in the ED to rise to 21% (Pitts et al., 2012). Several factors contribute to the crowding problem, including increased influx in the number of patients, and lack of timely and efficient primary care for patients with nonurgent problems, influenza season, and the phenomenon of “frequent flyer” patients (Hoot, 2008). Lengthy wait times and impaired timeliness of care occur with crowding, which may increase leave without being seen (LWBS) rates (McCarthy et al., 2009). An increase in LWBS rates may result in a rise of patient morbidity and mortality and represent lost revenue for the facility (McCarthy et al., 2009). Furthermore, national payer groups will begin to require the reporting of ED measures such as turnaround time to discharge or admit, door to diagnostic evaluation, and LWBS rates (Pennsylvania Patient Safety Advisory, 2010). Several efforts have been made to evaluate and improve ED treatment and flow. The introduction of emergency care providers in triage is a means to facilitate ED throughput and a strategy to minimize ED and hospital crowding. PROVIDER IN TRIAGE Traditional models of nurse-led triage in the ED have been seen as a barrier to rapid throughput (Sanning Shea & Hoyt, 2012). Traditional nurse triage consists of checking in with the triage nurse, registration, and further assessment by the triage nurse. The patient will then wait until a bed becomes available, following which the Emergency Medical Treatment and Active Labor Act required

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medical screening examination (MSE) would be completed by a physician or NP. It has been recognized that the traditional ED uses serial processing in which one process cannot occur until another process has occurred, resulting in delayed throughput. A proposed front-end process modification consists of condensing the triage process to have the MSE by a medical provider early on in the ED visit (CEP America, 2011). Provider in triage (PIT) is the process in which a provider either performs triage along with the nurse or is available to evaluate the patient immediately after the nurse assigns acuity. The provider then performs the MSE and proposed disposition within minutes after patient arrival. If the patient requires an acute care bed for more urgent matters, the patient is assigned to one. Otherwise, diagnostics are ordered as needed. Patients are then either discharged without reaching the main ED or transferred to a bed if needed and when available. Several institutions have implemented the PIT process as described individually in Table 1. Review of the literature California Emergency Physicians (CEP) is a group of emergency medicine providers throughout California. The group has implemented “Rapid Medical Examination” (RME) since 2005 at various facilities throughout California (California ED Diversion Project, 2009). On average, RME has reduced doorto-provider (DTP) times by 48–35 min, decreased LWBS rates, and increased patient satisfaction (California ED Diversion Project, 2009). In Woodbridge, VA, Potomac Hospital instituted a rapid evaluation unit in place of traditional nurse-led triage (California ED Diversion Project, 2009). Evaluation of this PIT process demonstrated a decrease in LWBS rates from 9% to 1.5% and a decrease in average LOS by 25 min (California ED Diversion Project, 2009). Rady Children’s Hospital San Diego is a Level I trauma center with an annual census of 70,000 patients. This facility implemented

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Location

Presbyterian 47,147 Hospital Matthews (Novant Health) based in North Carolina

Love et al., 2012

70,000

Rady Children’s Hospital in San Diego

Tsai et al., 2012

56,485

Potomac Hospital Woodbridge, VA

Varies upon location

Annual Census

California ED Diversion Project, 2009

NP or PA in triage California ED Multiple locations Diversion owned by Project, California 2006 Emergency Physicians

Author

Table 1. Comparison of PIT programs

Description of Process

Rapid Medical NP, PA, or MD sees the patient in Examination triage and orders tests as needed. If the patient requires emergent care, the patient is placed in the main ED. Completion of care varies by institution but includes discharge from triage or placement in a main ED bed when available for completion of care. The patient goes to waiting room to await results or is discharged. Rapid NP, RN, and technician initiate evaluation triage and the NP performs MSE unit and initiates diagnostic testing. Patients move to main ED for completion of care. RMA Mid-level practitioner NPs or PAs are present during the initial triage process to perform MSE, initiate diagnostic testing, and treat and release low-acuity patients. Although the ED MD is available for consult, the RMA provider is able to see and treat and discharge patients without the ED MD. PIT Triage area staffed by an NP/PA, an RN, a phlebotomist/ECG technician, and a registrar. If no rooms available, the NP/PA sees the patient with a triage RN. MSE orders initiated. Depending

Name

↓ LWBS ↓ LOS

↓ LWBS ↓ DTP ↑ PS Lesson: Patient tracking software is useful.

Results and Lessons

ESI Levels 3, 4, ↓ LOS and 5 ↓ LWBS ↓ DTP Lesson: (1) Staffing with NP/PAs are more cost-effective than that with physicians. (2) Use experienced NPs when possible. All evaluated ↓ DTP by PIT. ↓ LWBS Lesson: The NP/PA should be highly experienced and skilled. (continues)

All patients coming through triage

Not specified

Patient Inclusion

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Urban community hospital with a Level II trauma designation in Louisiana county

Location

50,000

Annual Census

“RAPID” team triage

Name

Patient Inclusion

on the case, some patients will be discharged from triage by the NP/PA or move to a room to the ED bed when available. The team included an NP/PA, two Those nurses, an ED technician, the considered registrar, and a volunteer to be disgreeter. Patients greeted at the chargeable door and escorted to the triage and not need area. Any available team member an acute care initiates the triage and the bed. assigned NP/PA or MD performs the MSE within a few minutes to determine patients’ needs. Whether they would be discharged home, needed more care, or needed an acute bed in the main ED. While awaiting results, patients will go to the waiting room. Workups for those needing an acute care bed are started and then care transferred. When no acute bed is open, the chart is given to a physician to see whether the patient is still in the rapid triage area.

Description of Process

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(continues)

↓ LWBS ↓ LOS ↑ PS Lessons: (1) Dramatic increase in workload for NP/PAs. (2) Wound repair and radiological interpretation skills are essential.

Results and Lessons

October–December 2013

Sanning Shea & Hoyt, 2012

Author

Table 1. Comparison of PIT programs (Continued)

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Team triage

Patient Inclusion

Team triage operates with a Nonurgent doctor, a RN, and a technician. cases The patient is evaluated and triaged by a doctor to determine the need of an acute care bed or to swiftly dispose of the patient.

Nurse determines triage acuity. If ESI Level 3 ESI Level 3, TNT team consisting of an MD or PA, an RN, and a technician evaluates the patient, and disposition is made. If extensive workup is needed, the patient is transferred to the acute care bed.

NP/PAs are placed at triage and Mid- and perform MSE. If appropriate, low-level orders are initiated. Treatment is acuity collaborated with an MD. Patients are brought back to the main ED for completion of treatment.

Description of Process

↓ DTP ↓ LOS ↑ PS Lesson: Staff with providers who have experience and interest in this type of care rather than rotating providers (continues)

↓ LOS ↓ LWBS ↑ PS Lessons: (1) Fast track is closed and very low-acuity patients work with a social worker to make appointments at local federally funded health clinics. (2) MDs have concerns for increased responsibility of NP/PAs. ↓ LWBS ↓ DTP No other relevant information.

Results and Lessons

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Vanderbilt 55,000 University Medical Center, Nashville TN

TNT

Nameless?

Name

Date: October 23, 2013

MD in triage Slovis & Lemonds, 2008

65,000

Academic Military Hospital in Texas

Levsky et al., 2008

Annual Census 35,000

Location

DeLucia, 2012 St. Louis University Medical Center

Author

Table 1. Comparison of PIT programs (Continued)

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Location

Annual Census

QTrack

An MD sees the patient immediately after triage

Provider in Triage: Is This a Place for Nurse Practitioners?

Note. DTP = door to provider; ECG = electrocardiographic; ED = emergency department; ESI = emergency severity index; LOS = length of stay; LWBS = left without being seen; MSE = medical screening examination; NP = nurse practitioner; PA, physician assistant; PIT = provider in triage; PS = patient satisfaction; RMA = rapid medical assessment.

Two facilities: (1) 60,000 (2) 30,000

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Oschner Medical Center in New Orleans

↓ DTP ↓ LWBS ↓ LOS

Results and Lessons

↓ LOS ↓ LWBS ↑ PS Lesson: A physician in triage should be someone who provides precise diagnosis and efficient care, not someone who provides over- or undertesting. ESI Levels 3, 4, ↓ LWBS and 5. Ambu- ↓ DTP latory ↑ PS patients treatable in 2 hr. An MD sees the patient ESI Level 3 immediately after triage and the Those whose patient is placed into ambulatory conditions service unit above ED and care is are too coordinated by NPs. complex for fast track but not ill enough to require a bed immediately

Mid-track process

Patient Inclusion

Quick look by an RN instead of full triage to determine “sick or less sick.” The patient is then transferred to the ED bed if sick and seen by a team of MD and RN if less sick. Tests are ordered, and the patient remains dressed and sits in the “results pending” room.

Description of Process

Door to Doc

Name

October–December 2013 Date: October 23, 2013

Guarisco, 2008

Banner Healthcare. Originally started in Banner Mesa Medical Center in Mesa, AZ, piloted the program and then expansion occurred to 10 other hospitals in Arizona and Colorado. Sharma, 2011 Good Samaritan’s More than Hospital in Long 100,000 Island, NY

Roche, 2008

Author

Table 1. Comparison of PIT programs (Continued)

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“rapid medical assessment” (RMA) and compared pre- and postintervention results. Tsai, Sharieff, Kanegaye, Carlson, and Harley (2012) studied preintervention data from January to June 2007 and postintervention data from January to June 2008 (Tsai et al., 2012). This RMA process was modeled after California’s Emergency Physician’s RME. Pre- and postimplementation evaluation revealed a decrease of 27 min in DTP time, a decrease in LOS by 58 min, and a decrease in LWBS rates from 9.3% to 2% (Tsai et al., 2012). Tsai et al. (2012) conclude that ideally RMA will target the straightforward low-acuity complaints and occasionally participate in higher acuity and time-sensitive issues. Presbyterian Hospital Matthews (PHM) in North Carolina is a 113-bed hospital with an annual ED census of 47,147 patients. In March 2011, a PIT program was implemented to improve quality and patient satisfaction (Love, Murphy, Lietz, & Jordan, 2012). As a result of the PIT process at PHM, there has been a reduction in DTP time by 50 min and a decrease in LWBS rates from 3.39% to 0.93% (Love et al., 2012). Although one goal of PIT at PHM was limiting patients with minor complaints from occupying an ED bed, the triage area became a minor care treatment area and resulted in a backup of patients needing to be triaged. As a result, the goals changed to a focus on MSE and initiation of orders instead of assessment, treatment, and disposition from triage (Love et al., 2012). Sanning Shea and Hoyt (2012) describe the implementation of “RAPID” team triage at St. Mary Medical Center (SMMC), a Level II trauma community hospital in Long Beach, CA, which has an annual census of approximately 50,000 patients. RAPID is an acronym for Rapid Assessment, Plan, Intevention, and Disposition and was implemented on all nonambulance patients (Sanning Shea & Hoyt, 2012). The process at SMMC is continually being modified and improved, but results include 90% of MSEs completed within 30 min (Sanning Shea & Hoyt, 2012). St. Louis University Hospital (SLUH) is a Level I trauma center in Missouri, with an annual census of 35,000 patients. As an effort

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to decrease LWBS rates and enhance flow, an NP or a PA was placed in triage. At SLUH, the LWBS rates decreased from 10% to 3%, patient satisfaction increased, and average ED LOS was reduced by 45 min as a result of its PIT process (DeLucia, 2012). A military community hospital with an annual census of approximately 65,000 patients developed a protocol, accelerating triage and treatment (TNT) for emergency severity index (ESI) Level 3 patients to decrease LWBS rates (Levsky, Young, Masullo, Miller, & Herold, 2008). The TNT process has lowered the LWBS rates from 14.5% to 6.8%, decreased wait times by 11 min, and decreased ED LOS by 12.2 min (Levsky et al., 2008). In July 2005, Vanderbilt University Medical Center in Nashville, TN, implemented “Team Triage” with a goal of DTP time within 10 min (Slovis & Lemonds, 2008). As a result of the “Team Triage” PIT process, the proportion of LWBS patients has decreased from 5% to less than 1%, most patients are seen by the physician within 10 min of arrival to the ED, and ED patient satisfaction has improved significantly (Slovis & Lemonds, 2008). In 2006, Banner Mesa Medical Center in Mesa, AZ, a hospital with 100,000 annual patient visits, piloted “Door to Doc” PIT program (Sharma, 2011). This program was disseminated to other Banner Health hospitals in western United States. Eight Banner Health hospitals implementing the PIT process decreased their DTP time by 58%, decreased the proportion of LWBS patients by 76%, and realized a 14% decrease in ED LOS. Oschner Health Systems in New Orleans, LA, closed its fast track area and implemented a PIT program titled “qTrack” (Guarisco, 2008). Results of the program include a decrease in LWBS rates from 26% to 2%, a decrease in DTP time by 50 min, and an increase in patient satisfaction rates from the 55th percentile to the 99th percentile (Guarisco, 2008). Provider-in-triage features Despite different names of the PIT process in different facilities, many features are similar

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with shared goals. All of the PIT programs are run during peak census hours, ranging from 10 a.m. to 12 a.m. Features vary and are innovative, including dividing the waiting room into a “results pending” area (Roche, 2008), placing a licensed practical nurse or RN in the waiting room to watch over patients (Brooks, 2011), and scripting to validate patients’ complaints (Love et al., 2012). In the “qTtrack” in New Orleans, patients requiring symptomatic relief are set up in recliners (Brooks, 2011). The consensus goal among all PIT programs is to keep the patients moving throughout their ED visit. In all PIT processes reviewed, if the treatment requires excessive time in triage, patients are moved to acute care beds in the main ED (Brooks, 2011). Nurse practitioners as PIT The literature clearly supports that experienced NPs are capable providers in a PIT program and can have a positive impact on ED patient throughput. However, variations in NP autonomy occur across institutions. Both RMA and RAPID team triage state that although ER MDs are available for consult, patients are treated and released by NP/PAs from triage (California ED Diversion Project, 2009; Sanning Shea & Hoyt, 2012; Shea, 2012). However, the PIT process describes “certain” clinical situations, such as minor wound recheck or urinary tract infection, to be treated and released solely by NP/PAs without the involvement of physicians (Love et al., 2012). Both TNT process and the programs at St. Louis University Medical Center and Potomac Hospital send patients to the main ED for completion of care rather than discharge from triage (California ED Diversion Project, 2009; DeLucia, 2012; Levsky et al., 2008). All programs using an NP/PA in triage resulted in decreased LWBS rates and decreased LOS. Although patient satisfaction was not mentioned in all the programs led by an NP/PA, several programs were able to demonstrate an increase in patient satisfaction scores (California ED Diversion Project, 2009; DeLucia, 2012; Sanning Shea & Hoyt, 2012).

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Traditionally, in fast track, the NP will see the patient as time and patient flow allows. The NP serving as the provider in the PIT process must be ready to evaluate patients arriving with little time to pause in between (Sanning Shea & Hoyt, 2012). The NP must maintain a good rapport with the ED physicians for consultation on more complex cases (Sanning Shea & Hoyt, 2012). It has been proposed that agreed-upon order sets for use in PIT will decrease physician variability, thus promoting consistency (Sanning Shea & Hoyt, 2012). An NP in the PIT role is a viable and advantageous strategy to improve patient satisfaction and decrease LWBS rates. It is also cost-effective. A study by Gerton, Pimentel, Ercolano, Browne, and Barrueto (2009) at the University of Maryland School of Medicine found that a PIT 5 days a week per year would increase billing by $118,000. This would not cover the cost of an additional physician hire. Instead, Gerton et al. (2009) suggest an NP/PA would be a more cost-effective solution. Competencies/character attributes of PIT Whereas most of the studies focused on the outcome measures such as LWBS rates, LOS, and patient satisfaction, a few mentioned the competencies and character attributes necessary for a successful PIT program (see Figure 1). The competencies and character attributes mentioned in the literature and during personal interviews of physicians practicing in a triage role include the following: r experience in emergency medicine (Love et al., 2012; Scheck, 2010; Slovis & Lemonds, 2008); r sound clinical judgment and capable of quick concise assessments (Love et al., 2012; Sanning Shea & Hoyt, 2012) r decisive (Scheck, 2010); r unflappable (Scheck, 2010); r effective communicator and personable (Sanning Shea & Hoyt, 2012); and r highly skilled including the ability to read radiological tests and perform wound

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Figure 1. Character attributes of a provider in triage.

repairs (Love et al., 2012; Sanning Shea & Hoyt, 2012). NURSE PRACTITIONERS IN THE ED It has been speculated that despite an increase in the number of emergency medicine residencies, it will take a minimum of 30 years to meet the needs of the emergency population (Menchine, Wiechmann, & Rudkin, 2009). In ED settings, NP/PAs have been introduced to help ease the shortage and work collaboratively. Generally, NP/PAs are used in fast track areas where patient acuity is nonurgent (Quattrini & Swan, 2011). However, a data analysis of the National Hospital Ambulatory Medical Care Survey on ED visits in 1997 documented that NP/PAs saw 5.5% of ED patients whereas in 2006 NP/PAs saw 12.7% of ED patients (Menchine et al., 2009). Although NP/PAs are seeing fewer ill patients than their physician counterparts, they are seeing patients at varying levels of acuity, suggesting a lack of restriction to solely lower acuity patients (Menchine et al., 2009). In many areas, NPs already cover the

ED competently across all acuity levels. This is more common in rural areas. With the growing interest in use of EDNPs for decompressing wait times in the ED, an evaluation of patients’ perception of EDNPs was conducted. According to a survey of 190 patients seen by EDNPs in the fast track area, 65% stated that they were willing to be seen by an EDNP and 17% said that they did not want to see an NP. Chi-square analysis revealed that if an NP had previously treated a patient, then the patient was more willing to be treated by one again (Hart & Mirabella, 2009). PROPOSED MODEL FOR PIT With the growth in ED utilization and population, expansion of Medicaid, and the national payer requirements to report ED measures, it is expected that the focus on quality, efficacy, and cost-effectiveness will include greater numbers of EDNPs. On the basis of a review of the literature, a recommendation can be made for an NP to fulfill the provider role of the PIT process. Collaboration and

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multidisciplinary planning are essential for success. Ideally, a team of physicians and NPs will work collaboratively on protocol development. A proposed model PIT team may consist of an NP, an RN, and a technician. In institutions with large ED patient census, more RNs and perhaps two NPs may be required. An available team member will initiate the triage process, and the NP will perform MSE on all patients, delegate the patient to either an acute care bed (ESI Level 1 or 2), or initiate diagnostic testing as needed for ESI Levels 3,

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4, and 5 (see Figure 2). If a patient requires symptomatic relief, the patient may sit in a recliner in an optimized space and receive treatment. The “rule of two” is a reasonable way to subcategorize ESI Level 3 patients (Guarisco, 2008). The provider will determine whether this patient could be treated with fewer than two bags of fluid and two doses of medication, can stand on two feet, and whether testing and treatment will take more than 2 hr to complete (Guarisco, 2008). Emergency department policies will reflect the autonomous function of NPs in management and

Figure 2. Proposed provider-in-triage algorithm.

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disposition of patients. If the patient requires admission, the patient may obtain a bed in the main ED for care to be completed by the physician or another provider. However, if the patient can be discharged after diagnostic testing and completion of the PIT process, the patient will be discharged by the NP. Going forward with PIT Further research is necessary to provide the evidence needed to demonstrate the benefits the NP in this process can provide. Specifically, comparison of the NP versus physician in the PIT role and continued evaluation of LWBS rates, ED LOS, and DTP times must be ongoing and published. Analyses of direct and indirect cost–benefit ratios are also needed. In addition, research on the NP competencies required for the PIT process should be performed. This research will provide evidence for ED process development and evaluation. CONCLUSION Our nation’s health care system has been dramatically changing over the past 20 years. In the midst of a health care reform, the citizens of the United States will need a fail-safe system. For many years, people have depended on the ED as a portal for primary and emergency care, and until the implementation of appropriate access, the ED will continue to be in high demand. Crowding in the ED results from many factors, and strategies for improvement are essential. One in particular is the PIT process, where the front end of the process is expedited to ensure people are safe and facilities have the financial means to remain in existence. Nurse practitioners have shown positive outcomes comparable with physicians in the care they provide to their patients both outside the ED and in the fast track areas in the ED (Gershengorn et al., 2011; Mundinger et al., 2000). They are academically advanced, professional, and competent to provide emergency medical care, specifically in the PIT role. In the ED, NPs have already been suc-

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cessful in several roles across all acuity levels. An NP in the PIT role is an economically sound and plausible way to adjust with the impending increase in the demand for emergency services. However, the PIT NP needs to be experienced in emergency care, thorough in assessment skills, knowledgeable in emergency care, and skilled in radiographic interpretation and wound closure. The NP profession has grown dramatically in the past 40 years. The future relies on the NPs to promote new roles, obtain the skills needed, and advocate for the positions that they are qualified for. Using EDNPs in the PIT process is an intelligent strategy for both patients and institutions.

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Provider in triage: is this a place for nurse practitioners?

The role of nurse practitioners (NPs) in emergency care continues to evolve. A new and exciting role is the provider-in-triage (PIT) role. This innova...
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