Experienced nurse practitioners are at least as good as junior doctors in treating minor injuries
- Iliffe, Dr Steve
BACKGROUND
Accident and emergency departments in the United Kingdom have experienced an increase in workload and reduction in the number of doctors. Alternative methods of care need to be compared in well designed trials.
OBJECTIVE
To compare care and outcomes for people with minor injuries managed by a nurse practitioner or a junior doctor.
SETTING
Accident and emergency department, Northern General Hospital, Sheffield, United Kingdom.
METHOD
Semi-single-blind randomized controlled trial.
LITERATURE REVIEW
No explicit strategy; ten references.
PARTICIPANTS
Consecutive patients with recent minor injuries, over 16-years old, and self referred.
INTERVENTION
People were randomized to care by a nurse practitioner (n = 704) or a junior doctor (n = 749). Patients were then assessed by an experienced accident and emergency physician as a gold standard to determine adequacy of care. A follow-up questionnaire was provided 28 days later.
MAIN OUTCOME MEASURES
Adequacy of care: including patient history and examination; interpretation of radiographs; treatment decision; advice; follow-up.
MAIN RESULTS
Compared with the gold standard, nurse practitioners made important errors in 65/704 patients (9.2%) compared with 80/749 (10.7%) by junior doctors (the difference was not significant). The nurse practitioners recorded an accurate medical history in 76% of patients compared with 56% for junior doctors. Most of these omissions were judged not to be clinically important. Nurse practitioners adhered to treatment guidelines more regularly than junior doctors did, but the difference was not significant. Junior doctors made fewer errors in their examination than nurse practitioners, but the difference was not significant. Significantly more people treated by a junior doctor scored their courtesy as poor or very poor (8/415 versus 1/392, P = 0.04). There were no significant differences in requests for radiography, although both groups differed substantially from the gold standard generally requesting more than were necessary. At 28 day follow-up fewer people treated by a nurse had returned to work or activity, but the difference was small and not significant (17.5 versus 15.6%). There were significantly more unplanned follow-ups for people treated by junior doctors than by nurse practitioners (13.1 versus 8.6%, P = 0.03).
AUTHORS' CONCLUSIONS
Care provided by well trained, experienced nurse practitioners is at least as good as that provided by junior doctors. Patient satisfaction may have been lower with junior doctors because they had other types of patients to see and delegated some tasks to departmental nurses. However, this reflects the real practice in an accident and emergency department.