1. Bridging the Gap Advanced Nurse Practitioners in the Emergency Department Consultant Georgina Robertson ANP Janet Oliver Trainee Advanced Physiotherapist Stuart Barker

2. East Lancashire Hospitals NHS Trust  180,000 patients per year  3 sites  7 Consultants  4 fulltime Speciality Doctors  3 part time Speciality Doctors  3 higher trainees in Emergency Medicine  Full compliment of junior doctors

3. Three sites  Accrington Minor Injuries Unit  Operates 08:00-20:00  Nurse led by Emergency Nurse Practitioners  Supervision provided by Consultants at Royal Blackburn Hospital

4.  Urgent Care Centre at Burnley General Hospital  24 hour service  Consultant led 09:00-17:00  Emergency Nurse Practitioners 08:00-23:00  Middle Grades and junior doctors  GP 19:00-23:00 mon-fri 11:00-23:00 sat & sun

5.  Emergency Department and Urgent Care Centre at Royal Blackburn Hospital  Consultant led service from 08:00-00:00  Junior and Middle Grade doctors  Emergency Nurse Practitioners 08:00-23:00  GP 19:00-23:00 mon-fri 11:00-23:00 sat & sun

6. Service Developments  Advanced Nurse Practitioners  First contact physiotherapists  Advanced Physiotherapy practitioner  Consolidation of ENP skills  Enhanced skills of Clinical Support Workers  Clinical Fellow rotation and middle grade secondments  Departmental GPs

7. Advanced Nurse Practitioners  Two fully qualified  Three more in training  Assess and manage majors patients in a holistic manner refer to all specialities  Senior, experienced members of staff  Career progression clinically for nursing staff  Development projects within the department  Teaching and clinical support of nursing staff within the department

8. First contact Physiotherapist  Paid for a physio service which provided mobility assessments and aids  Now have 1-2 physios assessing and managing MSK patients in both UCC 08:00-18:00  At UCC at RBH physio 14:00-18:00 sat & sun  Physio run MSK clinic three times per week  Can refer to fracture clinic and speciality orthopaedic clinics  Teaching within the department

9. Advanced Physiotherapy Practitioner  Assesses and manages patients with MSK problems  Development of pathways within the Department in conjunction with orthopaedics – Ankle Injury Pathway  Teaching of medical and nursing staff  Increased through put in the MSK clinic reducing unnecessary referrals to fracture clinic  Will have an extended scope of practice once qualified e.g. head injuries, chest injuries, burns.  Currently independently request and interpret x-rays.

10.  Physio’s see 200 patients per month on average  Offer real time clinical support to doctors and nurses for MSK conditions and discharge planning  Provide direct referral to outpatient physio without the need for patients to be sent back to the GP  Aiding with the development of links with orthopaedics  The Physio team has recently won extra funding for additional staff. 3 wte to 5 wte. Impact of Physiotherapy

11. Consolidation of ENP skills  Enhanced teaching programme to include minor illness  Peer review  All moved to UCC at BGH with rotation to MIU at Accrington

12. Clinical support workers  Departmental training days focused on the six ‘c’s  ECG recording, taking and recording of observations  IV cannulation and blood taking

13. Clinical Fellow Rotation  Six clinical fellows  Rotate between ICU/Anaesthetics, MAU and EM over a two year period  Encouraged to take MCEM, paid for ALS,ATLS & APLS  Four hours per week of study time  Progression to Middle Grade job  Permanent Middle Grades given three month secondments to other specialities (ICU/Anaesthetics/Paeds/MAU)

14. Departmental GPs  GPs given sessional contracts to work in UCC at RBH at weekends and to cover GP teaching

15. Streaming Pilot  6 month period  UCC patients at RBH  Computer programme to stream back to GP  Majority of patients unwilling to go back to the GP once in the department  Triage took too long  Service not continued

16.  Facilitation of appropriate prescribing activities  Tetanus  Oxygen  Implementation of an innovative approach to pain management in # Femoral Neck  Audit  Staff development  Middle-grade teaching  Nurse and health care support worker development ANP Service Improvement

17.  Care Bundles  Diabetic Keto-Acidosis  Referral Pathways and Patient Information  Deep Vein Thrombosis  Implementation of national guidance via decision- making tools  Chest Pain of Recent Onset (NICE CG95, 2010) ANP Service Improvement

18. Patient Experience Snapshot Survey 100%