Table 2 Characteristics of study

Colligan et al. (2011), New Zealand [33]

High

To determine if emergency NPs (ENPs) were equivalent to emergency medicine (EM) registrars in managing minor injuries

ED of a tertiary hospital

Prospective cohort study

Patients > 15 years presenting with trauma (n = 420)

Intervention (n = 305):

ENP.

Median age 30; 70% male; 62% Caucasian; 81% triage 4; 35% procedures performed.

Comparator (n = 115):

EM registrars.

Median age 41; 59% male; 66% Caucasian; 72% triage 4; 32% procedures performed.

ENP managed minor injuries. ENP administered anesthetic and rendered treatment procedure as required independently.

ED length of stay (LOS)

David et al. (2015), USA [35]

Medium

To determine if the addition of a cardiac acute care NP (ACNP) to care teams could improve utilization outcomes

Cardiovascular ICU (CCU) of a large urban and academic medical center

Retrospective cohort study

Patients admitted directly to the CCU with the primary diagnosis of either ST or non-ST segment elevation myocardial infarction (non/STEMI) or heart failure (HF) (n = 185)

Intervention (n = 109):

Cardiac ACNP in collaboration with CCU physician house staff team.

Mean age 69.2; 62.4% male; 28.4% HF; 71.6% non/STEMI.

Comparator (n = 76):

CCU physician house staff team.

Mean age 70.6; 65.8% male; 26.3% HF; 73.7% non/STEMI.

Cardiac ACNP and physician worked together within a multidisciplinary team. Responsibilities of ACNP include routine medical care, discharge planning, care coordination, patient education on disease process and self-care, and post-discharge telephone follow-ups.

30-day return to ED; 30-day readmission rate; LOS; time of discharge

Dinh et al. (2012), Australia [30]

Medium

To compare the quality of care provided by an ENP and emergency doctors

Fast-track unit within the ED of a suburban hospital

RCT

Patients between age 16 and 70 years presenting to the ED with Australasian Triage Scale (ATS) category 4 or 5, who had normal vital signs and mental state, without complex medical or surgical comorbidities, and did not require multiple diagnostic tests or specialty consultations (n = 233)

Intervention (n = 133): ENP.

Median age 37; 60% male; 73% musculoskeletal presenting problem.

Comparator (n = 103):

ED doctors ranged from resident medical officers, emergency registrars, career medical officers, and emergency physicians.

Median age 33; 64% male; 71% musculoskeletal presenting problem.

ENP worked independently, assessed and managed patients within the fast-track unit, and consulted senior medical staff when required.

Patient satisfaction scores; follow-up health status at 2-week follow-up; adverse events (readmission to ED within 14 days or missed fractures); waiting time to be seen

Goldie et al. (2012), Canada [31]

Medium

To compare the effectiveness of ACNP-led care to hospitalist-led (physicians trained in general medicine) care in a post-cardiac surgery patients

Post-operative cardiac surgery unit in a tertiary hospital

RCT

Patients ≥ 18 years who had been scheduled for either urgent or elective coronary artery bypass graft (CABG) and/or valvular surgery (n = 103).

Intervention (n = 22):

ACNP-led post-operative care, guided by previously established clinical pathway.

Mean age 67; 86% male; 85% urgent procedure; 71% CABG.

Comparator (n = 81):

Hospitalist-led post-operative care, guided by previously established clinical pathway. Mean age 65; 81% male; 43% urgent procedure; 62% CABG.

The ACNP functioned solely as a clinician, performs focused physical assessments and comprehensive health history-taking, and reviewed the patients’ medications and diagnostic tests to develop care plans for the patients to augment established clinical pathway. Upon discharge, the ACNP communicated with the family physician of patients whom she anticipated complications post-discharge to discuss plan of care for the patient.

LOS; hospital readmission within 60 days; post-operation complications; attendance at cardiology or cardiac rehabilitation appointments; overall patient satisfaction; overall team satisfaction

Hiza et al. (2015), USA [36]

Medium

To analyze the effect of an orthopedic trauma NP on LOS and cost

Level I trauma center

Retrospective cohort study

Patients who were treated operatively and non-operatively or who were transferred from other services to the orthopedic trauma team and who were then discharged from the orthopedic trauma team (n = 1 584)

Intervention (n = 871):

NP as an additional member of the orthopedic trauma team. 80.25% <60 years; 64.41% ED admission.

Comparator (n = 713):

Orthopedic trauma team without NP.

85.27% <60 years; 76.6% ED admission.

A single full-time NP added to the orthopedic trauma team. The NP assisted the orthopedic intern in daily floor work such as arranging social service needs, discharge planning, and paperwork. The NP acted as a liaison for the orthopedic trauma team in daily multidisciplinary meetings between other physicians, allied health professionals, nurse managers, and social workers.

LOS; cost

Hoffman et al. (2006), USA [37]

Medium

To compare the outcomes of patients when medical management was provided by an attending physician in collaboration with a unit-based ACNP or an attending physician and critical care/pulmonary care fellows who rotated coverage

Subacute medical ICU (MICU) of a university medical center

Prospective cohort study

Patients admitted to the subacute MICU who required prolonged mechanical ventilation (≥ 7 days) with tracheostomy (n = 192)

Intervention (n = 98):

An attending physician in collaboration with a unit-based ACNP.

Mean age 61.9; 51% male; 85.6% white; 56.1% acute pulmonary diagnosis.

Comparator (n = 94):

An attending physician and critical care/pulmonary care fellows who rotated coverage.

Mean age 61.2; 53.2% male; 87.1% white; 48.9% acute pulmonary diagnosis

The ACNP was responsible for assessment, diagnosis, and documentation of patient care, including weaning and extubation. The ACNP was responsible for the admission of patients and discharge decisions. During the rounds, the attending physician would review and revised the plan of care.

ICU LOS; days on mechanical ventilation; readmissions to MICU; ICU mortality

Jennings et al. (2008), Australia [28]

Medium

To assess the impact of the implementation of ENP candidate (ENPC) on waiting times and LOS for patients presenting to the ED

Emergency and trauma center

Retrospective cohort study

Adult patients in ATS categories 3 to 5 (n = 3 156)

Intervention (n = 572):

ENPC completed care of patient.

6.1% ATS 3; 63.7% ATS 4; 30.2% ATS 5.

Comparator (n = 2 584):

Medical officer completed care of patient with assistance from nurses.

19.5% ATS 3; 58.4% ATS 4; 22.1% ATS 5.

ENPC are nurses who are practicing within the role and seeking accreditation as NPs. The ENPC completed the care for each presenting patient from initial assessment, intervention, prescribing, diagnosis, treatment, and disposition within a collaborative ED team using Clinical Practice Guidelines for each presentation.

LOS; time to be seen

Jennings et al. (2015), Australia [29]

High

To compare the effectiveness of NP service with standard medical care in the ED

ED of a major referral hospital

Pragmatic RCT

Adult patients presenting with verbal numeric pain scale score > 1 and in ATS categories 2 to 5 (n = 258)

Intervention (n = 130):

NPs managed patient care with assistance if necessary from a registered nurse.

Mean age 30; 53% male; 66% ATS 4.

Comparator (n = 128):

Medical officers managed patient care with assistance from a registered nurse.

Mean age 33; 61% male; 63% ATS 4.

The ENP manages the care of the patient. After the initial assessment, the ENP initiated the management of the patient and completed the episode of care. Analgesics were prescribed by NPs when required.

Proportion of patients who received analgesia within 30 min; time to analgesia from ED arrival; changes in pain score; documentation of pain scores

Landsperger et al. (2016), USA [38]

High

To evaluate the safety of the continuous in-house ACNP care as compared to in-house resident care

MICU of a university hospital

Prospective cohort study

Adult patients admitted to a MICU team (n = 9 066)

Intervention (n = 2366):

Team led by ACNP, supervised by critical care fellows and attending physicians.

Mean age 55.9. 51% male; 78% Caucasian; 53% ED admission; 28% mechanical ventilation; 27% vasopressors.

Comparator (n = 6 700):

Team led by 1st year resident and 1 upper level resident, supervised by critical care fellows and attending physicians.

Mean age 56.7; 52% male; 76% Caucasian; 52% ED admission; 33% mechanical ventilation; 36% vasopressors.

The ACNP was responsible for the evaluation and management of patients. Responsibilities included conducting admissions, transfers, discharges, obtaining and interpreting diagnostic tests, and performing critical care procedures with supervision of critical care fellows and attending physicians.

90-day survival; ICU LOS; hospital LOS; ICU mortality; hospital mortality; longer term mortality

Moran et al. (2016), USA [39]

Medium

To evaluate if the introduction of 24/7, on-site coverage with a neurocritical ACNP as first responders for acute “stroke code” would shorten time to treatment and improve compliance with acute stroke time targets

Stroke center of a tertiary hospital

Retrospective cohort study

Adult patients with the principal diagnosis of acute ischemic stroke (n = 168)

Intervention (n = 122):

On-call neurovascular physician and 24/7 ACNP first responder coverage for the hospital stroke code team.

Median age 73; 49% male; 48% Asian; 77% hypertension.

Comparator (n = 44):

On-call vascular neurologist or neurointensivist had a 30-min window for arrival to the bedside after the stroke code team was activated.

Median age 68; 54% male; 48% Asian; 77% hypertension.

The ACNP took initial history, obtained the National Institutes of Health Stroke Scale (NIHSS) score, obtain and review imaging, review the indications and contraindications for tissue plasminogen activator (tPA), and discussed tPAeligibility with the on-call vascular neurologist by telephone. For patients who were ineligible for tPA, the ACNP documented the clinical encounter. For patients who were eligible for tPA, the on-call vascular neurologist directly evaluated the patient and made the final decision regarding tPA administration.

Onset-to-needle time; imaging-to-needle time; door-to-needle time; hospital mortality

Morris et al. (2012), USA [40]

High

To determine if there were differences between the care provided by unit-base NP (UBNP) and residents

Level 1 trauma center

Retrospective cohort study

Adult patients requiring trauma service (n = 3 859)

Intervention (n = 2 759):

UBNP care of trauma patients led by trauma attending physicians.

Mean age 42.4; 72% male; 52% African American.

Comparator (n = 1 100):

Resident care of trauma patients led by trauma attending physicians.

Mean age 42.6; 70% male; 54% African American.

A group of NPs provided direct daily care, supervised by the trauma attending physician. Resident involvement with the patients admitted to the UBNP floor is limited to invasive procedures and overnight cross-coverage.

ICU admission; LOS; complications; readmissions

Roche et al. (2017), Australia [42]

Medium

To examine the safety and quality of ENP service in the provision of care and the effectiveness of ENP service for adults with chest pain

EDs of 3 rural hospitals

Prospective cohort study

Patients ≥ 18 years presenting with chest pain that was not a result of an acute injury (n = 61)

Intervention (n = 23):

ENP model.

Mean age 59.9; 30% male.

Comparator (n = 38):

Standard care model (care delivered and coordinated by medical officer).

Mean age 61.7; 50% male.

The ENP managed the patient presenting with undifferentiated chest pain. The ENP delivered and coordinated care in diagnosis, investigation, therapeutic treatment, and referral.

Adherence to guidelines; diagnostic accuracy of ECG interpretation; waiting times; LOS; LWOT; diagnostic accuracy as measured by unplanned representation rates; patient satisfaction; quality-of-life; functional status

Scherzer et al. (2016), USA [41]

Medium

To compare usage patterns and outcomes of a NP-staffed MICU and a resident-staffed physician MICU

MICU of a large urban university hospital

Retrospective cohort study

Patients admitted to the adult MICU (n = 1 157)

Intervention (n = 221):

NP-staffed MICU.

Mean age 62.3; 53.8% male; 64.3% White; 39.4% respiratory failure.

Comparator (n = 936):

Resident-staffed MICU.

Mean age 59.2; 55.8% male; 56.1% White; 32.8% respiratory failure.

Daytime staffing consisted for 2 internal medicine residents and two NPs, supervised by an attending critical care physician. Nighttime coverage consisted of 1 NP with 1 critical care fellow.

MICU mortality; hospital mortality; MICU readmission; MICU LOS; hospital LOS; post-MICU discharge LOS; charges observed

Skinner et al. (2013), UK [34]

Medium

To assess the feasibility and safety of NPs providing first-line care on an ICU with all doctors becoming non-resident at night

Cardiac ICU of a tertiary hospital

Retrospective cohort study

Patients admitted to an adult cardiac ICU (n = 1 380)

Intervention (n = 678):

NP providing first-line care.

Comparator (n = 702):

Junior resident doctors providing first-line care.

Model of care included NPs in the team and resident NP providing first-line care after evening rounds. Non-resident doctors remain within 15 min of the hospital.

ICU mortality; annual staffing cost

Steiner et al. (2009), Canada [32]

Medium

To determine if the addition of a broad-scope NP would improve wait times, ED LOS and left-without-treatment (LWOT) rates

Urban community ED

Prospective cohort study

Patients requiring ED services (n = 3 238)

Intervention (n = 1 924):

NP collaborative visits or NP autonomous visits.

Comparator (n = 1 314):

Emergency physician (EP) visits.

The NP collaborative model was like that of residents, with the EP retaining the ultimate decision-making authority. The NP also provided health promotion and counseling. EP delegated specific discretionary tasks such as direct patient care, discharge planning and follow-up arrangements to an NP. In the NP autonomous scope of practice, it was limited to patients in categories 4 and 5 of the Canadian ED Triage and Acuity Scale (CTAS).

Wait times; ED LOS; LWOT