Advanced nurse practitioners (ANPs) deliver specialised acute care in the emergency department (ED) of North Dublin's largest public teaching hospital. The service specialises in the stabilisation of critically ill patients presenting to the ED with a range of cardiology conditions, including cardiac arrest, acute coronary syndrome, arrhythmias, heart failure and syncope. The service also operates a general cardiology clinic.
In January 2023, the ANP service became the first to be accepted by a private hospital as referrers for CT coronary angiograms (CTCA). Before this, referrals for CTCA were only accepted after a discussion with specialist consultants or doctors working within cardiology consultant services. This initiative was driven by the absence of a suitable CT scanner in public hospitals for patients presenting to the ED with low to intermediate risk and potentially ischaemic symptoms, requiring the exclusion of atherosclerotic coronary disease as a potential cause. After discussions with the hospital's business manager about the costs associated with referrals, a cost code was assigned to each patient referred by the service, ensuring that the patient does not incur any financial burden. In countries where relevant legislation and regulations support nurse referrals for ionising radiation, this pathway presents a valuable opportunity for ANPs who face similar challenges because of equipment limitations in other public hospitals, both nationally and internationally.
Advanced practice: an Irish context
The evolution of advanced practice nursing in Ireland is a testament to progressive legislation and stakeholder collaboration (Government of Ireland, 1998; National Council for the Professional Development of Nursing and Midwifery, 2001). The Nurses and Midwives Act 2011 established a regulatory framework under the Nursing and Midwifery Board of Ireland (NMBI), marking a significant shift in ANP responsibilities (NMBI, 2017). Educational pathways, as recommended by the International Council of Nurses (ICN), are integral to this development, aligning with global standards for advanced practice nursing (ICN, 2020).
Nurse referral for radiological procedures
Ireland's journey in nurse referral for ionising radiation began with Statutory Instrument (SI) 303 in 2007, which was initially limited to projection radiology (Government of Ireland, SI No 303/2007). This legislation marked the first step toward formalising the role of nurses in referring patients for diagnostic imaging involving ionising radiation. The scope was later expanded with SI 256, which aligned with broader European Union directives on medical ionising radiation, notably Council Directive 2013/59/Euratom. This progression reflects international trends in expanding nursing roles within diagnostic procedures, enabling nurses to take on more responsibility in patient care and diagnostics, thereby improving service delivery and patient outcomes.
Challenges and solutions
Despite legislative advancements, the ANP service encountered barriers and challenges in implementing pathways for high-dose radiology referrals (Drennan et al, 2014). The main barrier to implementation, which was eventually overcome, was the team's lack of educational preparedness to make referrals for high-dose ionising radiation. While the NMBI (2020) and the Office of the Nursing and Midwifery Services Director (2021) guidelines are comprehensive, they do not explicitly outline additional training competencies specific to high-dose radiologic modalities such as CTCA. To address this gap, the service integrated recommendations from Radiation Protection (RP) 175 (6), which outlines competencies aligned with accepted European Union standards. The author believes that this approach should be considered by all ANPs working on developing pathways for high-dose radiation modalities within jurisdiction.
Medicolegal indemnity, corporate governance and clinical governance
The governance structure at the author's institution, which includes the nurse referral committee and the local implementation group, played a crucial role in effectively managing nurse-led radiological referrals, as outlined by the Health Service Executive (2021). These entities are vital in ensuring the quality and safety of healthcare services, reflecting a global emphasis on strong healthcare governance. In Ireland, clinical indemnity for healthcare professionals, including ANPs, is managed by the State Claims Agency through the clinical indemnity scheme. ANP practice, regulated by the NMBI, is grounded in the policy, procedure, protocols and guidelines outlined by the NMBI (2017). Within their scope of practice, ANPs are empowered to autonomously assess, diagnose, treat, evaluate, admit, refer and discharge patients while maintaining a medicolegal connection to a named specialist consultant.
This medicolegal framework mandates that patients are explicitly linked to a specialist consultant, ensuring both patient safety and legal protection. ANPs are encouraged to adopt a collaborative team approach in referrals, designating a registered specialist consultant as the lead practitioner for all radiologic referrals. The integration of electronic systems in Ireland, such as the national integrated medical imaging system and picture archiving and communication system, facilitates seamless communication between the ANPs and the consultant lead, enhancing the efficiency of reporting and urgent result transmission.
As part of the radiologic referral pathways for CTCA, the author advises that all documentation should clearly identify the specialist consultant (practitioner), the referring ANP and the ANP's NMBI personal identification number. Referral documentation must include adequate information to justify the test.
ANPs also have a crucial responsibility in promptly reviewing imaging reports to mitigate medical risks. They must be proficient in interpreting these reports to facilitate effective communication with patients.
Furthermore, ANPs play a key role in informing patients about the purpose and process of the proposed imaging and the method used for the communication of results. It is also essential for ANP services to establish pathways for subsequent radiologic procedures, anticipating common scenarios where follow-up diagnostics may be required, thereby ensuring continuity of care.
Pathway outcomes January–July 2023
A total of 223 patients had a clinical indication for CTCA and an acceptable 9% required further functional diagnostics, such as cardiac magnetic resonance imaging or catheter angiogram.
Global perspective and conclusions
The initial experience of ANP-led referral for CTCA in Ireland demonstrated that it is safe and effective when supported by robust clinical and corporate governance structures, highlighting the pivotal role ANPs play in enhancing patient care in this emerging area of practice. The author's experience in bridging gaps amidst resource constraints and the growing demand for innovative healthcare solutions provides valuable insights globally.
While this initiative improves service efficiency and patient outcomes, it also exemplifies the significant impact of nursing professionals in driving healthcare reform and advancing quality standards worldwide. By integrating multidisciplinary teamwork and strong governance frameworks, the author's team has established a model that can inspire similar advancements in other healthcare systems, showcasing the potential of ANPs to lead transformative changes in global healthcare delivery.