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Nurse practitioners employ a holistic and interpersonal approach to health care. Outcomes of care indicate high patient satisfaction, increased health benefits and decreased costs to patient, family and community.^1,2,3 NPs in the emergency department provide health care that increases patient choices, reduces waiting times, improves patient access and relieves pressure on medical staff .⁴

The most commonly employed NPs in the ED are family nurse practitioners, acute care nurse practitioners and emergency nurse practitioners.

ED Care in the United States
Emergency departments are in a national crisis as a result of patient overuse, overcrowding, boarding of patients, scarcity of inpatient beds, a shortage of ED physicians and RNs, and hospital closings. In addition, increased patient acuity, rising medical costs, decreased medical coverage and lack of access to medical care increase the numbers of patients seeking care in the ED, resulting in overextended emergency departments across the country.

Emergency department visits have increased from 84 million to 100 million within a 5-year span. The ED is the "safety net of health care."⁵ Crowding in the ED affects the hospital's ability to provide safe, timely patient care and may result in dangerous delays, inconvenience and dissatisfaction among patients and families.

The majority of the nation's EDs report that they are operating at or over critical capacity. The American College of Emergency Physicians (ACEP) reports an increase of ED visits of 23% from 1992 to 2002, to 110 million a year.⁶ According to the Centers for Disease Control and Prevention, "ED visits jumped, the number of ED's nationwide decreased from 4,176 in 1995 to 3,795 in 2005, driving up the average of patient visits per ED from 20,388 to 23,119 during that time frame and exacerbating overcrowding at many of the nations' hospitals."⁷

Overcrowding can be traced to population growth, increased number of visits per person and a 15% increase in visits for injuries to patients under 25 years old.⁸ The highest number of  per capita ED visits was by infants under 12 months old, estimated at 3.8 million visits per year. Baby boomers contributed to the increases in the number of geriatric patients with chronic diseases who seek medical treatment in the ED.^7,8

History of NPs in the ED
Physicians often provided the first courses in advanced nursing practice in the ED, realizing that there was a national physician shortage and that nurses were often the first health care professional to render assistance. The American College of Surgeons Chicago Trauma Committee sponsored postgraduate courses in for nurses in 1966. By 1970, the pattern of physicians teaching ED nurses was well established.

Other short-term continuing education programs, some devoid of academic and didactic standards came into being. Since they were first developed in 1965, nurse practitioner programs have evolved from a certificate-based pediatric program to a master's degree with multiple clinical specialties.⁸ By 2007, there were more than 325 universities offering graduate nurse practitioner programs with more than 6,000 NP graduates each year.

Prior to 1960, advanced degree nurses were prepared primarily as educators and administrators, except for clinical specialists in psychiatry. In the 1960s, physicians began leaving the primary care setting to specialize in medicine, leaving a gap in health care. Patients without a primary care physician or who were unable to access care increasingly sought treatment in the ED. In response, the Surgeon General asked for a 194% increase (3,000) in master's degree nurse clinicians by 1970, in order to help alleviate the physician shortage.

In 1971, the U.S. government urged national certification for NPs. A model nurse practice law was developed that could be applied throughout the nation. In 1974, reacting to the request for assistance, the American Nurses Association (ANA) published educational standards, describing the NP role and the expanded scope of nursing practice. The ANA endorsed the authority of NPs to diagnose, treat and prescribe.⁸

The use of NPs in the ED began in the late 1970s in the United States.⁹ In 1970, ED visits increased as much as 175%, with 50% nonurgent cases. The role of the ED nurse practitioner was introduced to alleviate the physician shortage by providing safe, effective primary and acute care in an expanded role in the ED setting.

The first program to educate NPs in the ED specialty was introduced in 1994, at the University of Texas. This program specializes in emergency medicine, ensuring efficiency in emergent, primary and acute clinical skills including life-threatening situations. In 2001, Loyola University in Chicago introduced an NP program with an ED specialty focus. There are now five NP programs specializing in emergency care. These programs educate NPs in providing overlapping direct medical and nursing care to less-acute patients presenting to the ED. After completion of these programs, students take the family nurse practitioner or acute care nurse practitioner national certification examination.

The Emergency Nurses Association (ENA), founded in 1970, represents emergency nursing as a specialty. ENA developed the national scope of practice for NPs in 1999 to reflect the unique environment of unpredictability in the emergency department.⁸ Emergency NPs are educated to develop and apply theory, conduct research, educate health care providers and develop standards of care that enhance patient outcomes.⁸ Criteria for practice also include high-quality and cost-effective care for nonurgent, urgent or emergent conditions in a multitude of ED settings in individuals and families.¹⁰