Ophthalmologic Emergencies: Assessment and Management.

There are an estimated 2-3 million emergency department (ED) visits in the United States for eye complaints. Although most patients who present to the ED have nontraumatic eye complaints, many seek treatment for eye trauma, which is a leading cause of unilateral blindness and vison impairment. Given the prevalence of eye-related emergencies, it is imperative that emergency care providers understand how to recognize and treat eye complaints to prevent permanent vision loss and disability. This article covers basic eye anatomy and physiology, discusses a systematic approach to the eye examination, and presents the evidence-based treatment of selected, common nonemergent and emergent eye complaints. For each complaint, essential history questions, examination techniques, differentials, and emergency management have been presented.

The Diagnostic Challenge of an Older Adult With Epigastric Pain in the Emergency Department: High Risk and High Volume.

Epigastric pain is a common complaint in patients who present to the emergency department (ED); abdominal pain is the most common chief complaint in older adult patients who request treatment by a provider (A. B. Friedman et al., 2022). These patients may experience atypical presentations, which can result in delayed or missed diagnosis altogether, increasing morbidity, and mortality. This is the case of an older adult man who presented with chest and epigastric pain. The clinical presentation, atypical signs, and symptoms of gangrenous gallbladder are presented herein along with the differential diagnoses and diagnostics for this patient. The care for and the "what not to miss" in the management of this patent are also examined in this article. It is imperative that ED providers diagnose gangrenous gallbladder early on, especially in the older adult population, who may present with covert signs and symptoms to prevent complications and avoid poor outcomes including death in this age group.

The Patient Perspective on Telemedicine.

Content available: Author Audio Recording.

Comparing nurse practitioners/physician assistants and physicians in diagnosing pediatric abdominal pain for ESI level 3 patients seen in the emergency department.

BACKGROUND: Accuracy of emergency department (ED) diagnosis affects care management including tests, discharges, and readmissions. PURPOSE: This retrospective study compared nurse practitioners/physician assistants (NPs/PAs) with physicians (MDs/DOs) on accuracy of diagnosing Emergency Severity Index (ESI) level 3 pediatric abdominal pain (AP) in the ED. Abdominal pain unrelated to trauma is a common ED pediatric visit. METHODOLOGY: Data acquired from four hospital sites of a multistate emergency group examined patients younger than 18 years who were initially admitted for AP ESI level 3. RESULTS: The accuracy of AP ESI level 3 diagnoses was 94.9%, 90.9%, and 96.5% by physicians, NPs/PAs, and a collaboration of NP/PA/physician, respectively (χ2 = 13.187, p < .001). Accuracy of AP ESI level 3 diagnoses was greater with general admissions, intensive care unit admissions, transfers, or left against medical advice (100%) than with those who were discharged (χ2 = 11.058, p = .001). Abdominal pain complaints were segmented into five areas (i.e., AP, back pain, chest pain, epigastric pain, and pelvic pain). Irrespective of provider, those with a final diagnosis of AP or epigastric pain were correctly triaged and those with a final diagnosis of chest or back pain were incorrectly triaged as AP ESI level 3. CONCLUSIONS: When comparing providers in this subset (n = 43), there was no significant difference in the accuracy of assigning AP ESI level 3 (χ2 = 0.467, p = .495). IMPLICATIONS: Only cases with a final diagnosis of pelvic/genitourinary pain saw disparity in the accuracy (27 correct, 16 incorrect, χ2 = 1,681.80, p < .001).

Clinical Research in Hepatology in the COVID-19 Pandemic and Post-Pandemic Era: Challenges and the Need for Innovation.

The severe acute respiratory syndrome coronavirus 2 pandemic has drastically altered all facets of clinical care and research. Clinical research in hepatology has had a rich tradition in several domains, including the discovery and therapeutic development for diseases such as hepatitis B and C and studying the natural history of many forms of chronic liver disease. National Institutes of Health, foundation, and industry funding have provided important opportunities to advance the academic careers of young investigators while they strived to make contributions to the field. Instantaneously, however, all nonessential research activities were halted when the pandemic started, forcing those involved in clinical research to rethink their research strategy, including a shift to coronavirus disease 2019 research while endeavoring to maintain their preexisting agenda. Strategies to maintain the integrity of ongoing studies, including patient follow-up, safety assessments, and continuation of investigational products, have included a shift to telemedicine, remote safety laboratory monitoring, and shipping of investigational products to study subjects. As a revamp of research is being planned, unique issues that face the research community include maintenance of infrastructure, funding, completion of studies in the predetermined time frame, and the need to reprogram career path timelines. Real-world databases, biomarker and long-term follow up studies, and research involving special groups (children, the homeless, and other marginalized populations) are likely to face unique challenges. The implementation of telemedicine has been dramatically accelerated and will serve as a backbone for the future of clinical research. As we move forward, innovation in clinical trial design will be essential for conducting optimized clinical research.

Appraisal of the emergency nurse practitioner specialty role.

The role of the Emergency Nurse Practitioner (ENP) has evolved as a specialty and is appreciated within the context of the 2008 Consensus Model document (APRN Consensus Work Group & National Council of State Boards of Nursing APRN Advisory Committee, 2008). The first in a series of five articles, this article describes the appraisal of the ENP role as well as the specialty and the distinctive role of the ENP. The second article, Emergency Nurse Practitioner Practice Analysis: Report and Implications of the Findings, presents research to support the scientific basis of emergency specialty practice and content validity for a national certification program. Article 3, Beyond Competencies; Practice Standards for Emergency Nurse Practitioners: A Model for Clinicians, Educators, and Employers, introduces a new conceptual model that defines the specialty of emergency care's knowledge, skills, and abilities identified by the ENP practice analysis as practice standards not traditional competencies. In Article 4, Proposed Standardized Educational Preparation for the Emergency Nurse Practitioner, essential content for ENP preparation within graduate, postgraduate, and doctoral programs. The fifth article, Envisioning the Future for ENPs: Implications for Clinical Practice, Education, Research, and Health Policy, describes how ENPs are envisioning and impacting the future of emergency care and how their evolution can serve as a model for development of other advanced practice nursing specialties.

Emergency nurse practitioner practice analysis: Report and implications of the findings.

BACKGROUND AND PURPOSE: A practice analysis of nurse practitioners (NPs) working in emergency care was undertaken to define their job tasks and develop a specialty certification by examination. METHOD: In phase I, clinical experts created a qualitative description of domains of practice, tasks performed, knowledge required, and procedures performed by NPs in emergency care. Phase II involved validating the qualitative description through a national survey (N = 474) of emergency nurse practitioners (ENPs). Evidence from the validation survey was used to create a test content outline for the ENP examination. FINDINGS AND CONCLUSIONS: The delineation of ENP practice validated by the survey (Cronbach alpha = 0.86-0.94 across rating scales) included 5 ENP practice domains: medical screening, medical decision-making/differential diagnoses, patient management, patient disposition and professional, legal and ethical practices. There were 22 job tasks across domains, 10 types of patient conditions/emergency types, 42 knowledge areas, and 68 procedures performed by ENPs. These resulted in a test blueprint providing the foundation for the ENP certification examination content validity. IMPLICATIONS FOR PRACTICE: Beyond certification, the practice analysis has the potential to further inform the scientific basis of emergency specialty practice. Additional uses include refining professional scope and standards of practice, job descriptions, performance appraisals, research, and policy development.

Beyond competencies: Practice standards for emergency nurse practitioners-A model for specialty care clinicians, educators, and employers.

BACKGROUND/PURPOSE: The growth of advanced practice nursing specialties requires additional expertise for practice that goes beyond entry-level competencies, knowledge, skills, and abilities. A practice standards model for specialty nurse practitioners (PSMSNPs) is introduced that differentiates entry-to-practice population foci competencies from advanced specialty practice standards. OBJECTIVES: (a) Differentiate competencies and practice standards in context to specialty NPs using the emergency specialty as the exemplar, (b) articulate the process to develop the PSMSNP that evolved from an evidence-based practice analysis of NPs working in emergency care, (c) apply the PSMSNP for adaptation to other specialties, and (d) provide implications for the utilization of the PSMSNP by educators, clinicians, and employers. DATA SOURCES: American Academy of Nurse Practitioners Certification Board's Practice Analysis of Emergency Nurse Practitioners, Consensus Model for APRN Regulation, Future of Nursing report, Peer Nursing Report, Strong Model of Advanced Practice, Entrustable Professional Activities, Emergency Medicine Milestones Project, and the Advancing Healthcare Transformation: A New Era for Academic Nursing report. CONCLUSIONS: The PSMSNP has been defined and adapted to other specialties and threaded through other models of practice for educators, clinicians, and employers. The adaptability of this model differentiates the core population foci and unique practice variables of specialty NPs. National boards of nursing, hospital credentialing committees, colleges, and universities can use this model to establish standards for specialty evaluation and guide clinical practice. IMPLICATIONS FOR PRACTICE: The implementation of the PSMSNP will support the delineation of the specialty. This model will fulfill the American Nurses Association and Consensus Model specialty constructs.

Proposed standardized educational preparation for the emergency nurse practitioner.

The dynamic climate within health care policy-making and academia, in conjunction with updated Emergency Nurse Practitioner (ENP) competencies and a recent role delineation study, supports development of standardized curricula to ensure appropriate preparation for practice. Emergency NP curricular content should align with the updated ENP Practice Standards and National Organization of Nurse Practitioner Faculties' competencies for the Core and Family NP. This article provides rationale for establishing standardized educational curricula for ENP programs, delineates core specialty curricular content for inclusion, and discusses applicability of ENP specialty competencies within graduate academic education and postgraduate fellowship programs. As national ENP program curricula are standardized, clarity of the ENP specialty role will be enhanced and educational outcomes can be uniformly evaluated.

Embracing the future for emergency nurse practitioners and specialty practice: Implications for research, clinical practice, education, and health policy.

The emergency nurse practitioner (ENP) specialty has grown rapidly, responding and adapting to changes within emergency care. Designation and advancement of nurse practitioner (NP) specialties follows a systematic process as defined by the profession. This includes establishment of scope and standards of practice, educational standards, and policy initiatives to ensure quality and safety within the profession. This article describes how the ENP specialty has used evidence to meet health system needs and chart a transformational future. Current recommendations for advancing health care transformation, as described by the American Association of Colleges of Nursing-Manatt Report, inform and frame the processes by which the ENP specialty has collaborated with diverse stakeholders to create a research and policy agenda to ensure that ENPs are appropriately prepared to lead and provide access to safe, affordable, quality health care. These processes provide a future-oriented model that promotes advancement of the NP profession through provision of new NP specialty designations as they emerge to meet changing health care system needs.

Comparing nurse practitioners/physician assistants and physicians in diagnosing adult abdominal pain in the emergency department.

BACKGROUND AND PURPOSE: This retrospective study compared nurse practitioners and physician assistants (NPs/PAs) with physicians on their assignment of Emergency Severity Index level 3 (ESI level 3) acute abdominal pain (AAP) in the emergency department (ED). METHODS: Data obtained from a large ED group staffing four hospitals yielded 12,440 de-identified, adult patients diagnosed on ED admission with AAP ESI level 3 for descriptive analysis with logistic regression. CONCLUSIONS: Results revealed that the comparison of ESI level 3 AAP diagnoses was consistent between admission and discharge 95.3% for physicians, 92.9% for NPs/PAs, and 97.1% for NP/PA and physician collaboration (χ = 46.01, p < .001). Logistic regression suggested that NP/PA had significantly reduced odds (31%) of consistent admitting/discharge diagnoses, whereas collaboration of NP/PA with physicians had significantly increased odds of consistent diagnosis (41%) compared with physicians alone. Two hospitals with similar distributions of NPs/PAs and physicians exhibited greater odds of consistent diagnoses over hospitals with disproportionate distributions; a secondary finding worth exploring. Consistent AAP ESI level 3 diagnoses by outcomes were admissions (>99%), discharges (94%), and left against medical advice/transferred (98%; χ = 102.94, p < .001). IMPLICATIONS FOR PRACTICE: The highest percentage of consistent AAP ESI level 3 diagnoses between ED admission and discharge was when NPs/PAs and physicians collaborated.

Evaluating models of healthcare delivery using the Model of Care Evaluation Tool (MCET).

BACKGROUND AND PURPOSE: Our aim was to provide the outcome of a structured Model of Care (MoC) Evaluation Tool (MCET), developed by an FAANP Best-practices Workgroup, that can be used to guide the evaluation of existing MoCs being considered for use in clinical practice. Multiple MoCs are available, but deciding which model of health care delivery to use can be confusing. This five-component tool provides a structured assessment approach to model selection and has universal application. METHODS: A literature review using CINAHL, PubMed, Ovid, and EBSCO was conducted. CONCLUSIONS: The MCET evaluation process includes five sequential components with a feedback loop from component 5 back to component 3 for reevaluation of any refinements. The components are as follows: (1) Background, (2) Selection of an MoC, (3) Implementation, (4) Evaluation, and (5) Sustainability and Future Refinement. IMPLICATIONS FOR PRACTICE: This practical resource considers an evidence-based approach to use in determining the best model to implement based on need, stakeholder considerations, and feasibility.

Steeple sign: a case of croup.

Croup, or laryngotracheobronchitis, is a common viral respiratory tract illness seen in the pediatric population (). This article describes the case of a child who presents with croup and the characteristic "steeple sign" seen on the radiograph. The patient received a diagnosis of croup secondary to the parainfluenza virus infection. It is imperative for advanced practice nurses to recognize the signs and symptoms of croup when these patient present to emergency care settings. Advanced practice nurses must also consider possible differential diagnoses, accurately interpret the radiographs, and intervene according with supportive care and appropriate management.