Twilight emergency nurse practitioner - winter pressures case study

Dr Richard Burridge and Dr Michelle Jacobs from Watford General Hospital discuss the introduction of a ‘twilight’ emergency nurse practitioner shift as one part of a range of measures to manage long waits in the children’s emergency department.

What was the challenge?

As our Children's Emergency Department (CED) does not have its own dedicated medical staff rota, and adults and children are seen by the ED team in time order, the long waits seen overnight in ED are replicated in CED, with children who arrive after 22:00 often waiting in excess of four hours to be seen.

Our regular paediatric emergency nurse practitioner (ENP) shift is 10:00 - 22:30 and after they leave, the wait time in CED tends to increase rapidly. This issue is reflected in the CED performance against the four-hour ED target which is often poor over winter months and normally relates mainly to long ED waits overnight.

What did you do?

We recognised that the ENP in CED provides a valuable resource in impacting on the ED four-hour target seeing a large range of the walk -in presentations in CED.

We created an additional ENP shift from 19:00 - 02:00. This was based on the peak in attendances and long waits in CED. We put this out as a daily bank shift, in addition to the regular 10:00 - 22:30 shift.

What impact did this have? 

The shift fill for these shifts was very variable and gaining good data on impact proved a challenge. Crude performance data suggests a reduction in the number of children waiting a long time to be seen during these busy hours compared to shifts when the ENP was not available.

What did it cost to set this up? 

The cost of this investment went into a wider business case for winter pressures and was agreed at a rate of £35 per hour for a daily seven-hour shift over a five-month 'winter' period.

We opted to only make the shift available to internal ENPs from the existing paediatric ENP group; this was felt to provide the biggest benefit of the additional staff as these staff know the departmental processes. Time costs were with the setting up of the additional shifts on the NHSP system and managing the shift fill, which was undertaken by the lead consultant for the department.

What advice can you share?

Make sure that when the trust is discussing 'winter pressures' plans that children are included, and try and put any measures required through as part of a wider case.

This increases the power of the whole winter pressures case and is a good opportunity for cross working with other divisions within the Trust and ensuring the needs of the paediatric population are addresses and prioritised.

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Disclaimer: RCPCH have been notified that the above is a good examples in managing winter pressures in emergency departments and will be reviewed on a regular basis. Sharing examples does not equate to formal RCPCH endorsement.