Effect of an Outcomes-Managed Approach to Care of Neuroscience Patients by Acute Care Nurse Practitioners

Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care

AIMS

To describe the actual clinical activities undertaken by a critical care nurse consultant in an eight-bedded adult surgical high dependency unit within a large NHS Teaching Hospitals NHS Trust.

BACKGROUND

In the United Kingdom, the first critical care nurse consultants were approved in 2000 following the Department of Health's (1999) revised career structure for nurses. Expert practice is a core function of the role although the nature of expert practice in the context of critical care is unclear. Expert practice is often deemed to be a feature of advanced practice and although a number of studies have investigated this in context of critical care, there is little insight into the nature of advanced practitioners' clinical practice and how it might influence patient outcome.

DESIGN METHODS

A diary was used by a critical care nurse consultant to record activity during scheduled clinical sessions. Data were collected for four months: 39 sessions were evaluated. Qualitative data were content analysed and coded into categories. Clinical activities were coded, categorized and analysed using SPSS 11.0 for windows (SPSS Inc., Chicago, IL, USA).

FINDINGS

Clinical activities included direct care activities, clinical leadership, education and training. Two main themes emerged from the qualitative data and were categorized as clinical reasoning and clinical instruction. Clinical activities arising from clinical reasoning and clinical instruction were aimed at minimizing risk and the provision of quality care. In doing this, one of the outcomes was the detection and resolution of untoward clinical occurrences.

CONCLUSION

The level of achievement--or end point--of clinical activities was that the patient was established in 'a state free from risk or harm that optimises rehabilitation'. 'A state free from risk or harm that optimizes rehabilitation' might be one outcome reflecting the needs of individual critically ill patients that is sensitive to individual nursing contribution.

RELEVANCE TO CLINICAL PRACTICE

There is increasing pressure on health-care professionals to identify and measure their individual impact on the outcome of patients. This study adds further insight into the complexities associated with evaluating the influence of individual contribution on patient outcome, especially when it is characterized by complex processes involving clinical judgement and decision-making.

Integrating midlevel practitioners into a teaching service

Meeting the educational needs and requirements of surgical resident physicians while achieving optimal patient care is a challenge for program directors. Midlevel practitioners (MLPs) were employed by a large community teaching hospital to augment the surgical teaching service, to improve continuity of patient care, and to provide resident physicians with greater flexibility to participate in classroom, operative, and clinical educational experiences. The MLPs were carefully integrated into the surgical program by creating the necessary buy-in, developing positive relationships, decreasing resistance, and reinforcing acceptance when demonstrated. MLPs function at the level of junior resident physicians and are active participants in the teaching and evaluation process. Structurally, MLPs receive their assignments from and report to the chief resident physician, but are ultimately responsible to the program director. Instituting the program required providing financial justification to administration and flexibility in meeting the diverse needs of the four teams. As a result, surgical resident physicians have been sufficiently freed from service activities to be able to capitalize on learning activities that range from surgeries to conferences. MLPs can be integrated into a surgical teaching program and become a positive force in the education of resident physicians.

Strategies for success in the acute care nurse practitioner role

This article reviews issues related to development of the role of the acute care nurse practitioner (ACNP). Strategies for ensuring success in the role are outlined, including the importance of communication about the role, maintaining competency, forming collaborative relationships, and the value of networking. The ACNP represents an innovative role in advanced practice nursing. Demonstrating the outcomes of ACNP practice ensures recognition of the impact and value of this unique role.

Tandem practice model: A model for physician-nurse practitioner collaboration in a specialty practice, neurosurgery

PURPOSE

To describe the benefits of a physician-nurse practitioner (NP) collaborative practice model, specifically that of a tandem practice model, using a neurosurgeon and a primary care NP in the clinic and inpatient setting.

DATA SOURCES

Selected journal articles from Medline and CINAHL, and anecdotal clinical experience.

CONCLUSIONS

This collaborative practice model, in which the physician and NP deliver patient care in tandem, is beneficial to patients and their families because they receive comprehensive care that is patient oriented and holistic. Further, the model benefits multiple disciplines across the healthcare continuum by providing efficient communication of patient needs, accessibility of the specialty team, and timely implementation of patient interventions. The collaboration of the physician specialist and primary care NP provides a holistic approach to the care of diverse and challenging patient populations.

IMPLICATIONS FOR PRACTICE

Patients seen in a specialty practice, particularly that of neurosurgery, often have little understanding of their problem and may be frightened or confused because of their perceptions of the unknown. Providing care to such specialized patient populations in a constantly changing healthcare environment may prove demanding to the specialist. The introduction of a primary care NP into such specialty settings offers patients, their families, consultants, and staff members an additional resource for evaluation, intervention, education, and communication, improving the continuity and comprehensiveness of care to challenging patient populations. This model is an option for physician specialists interested in augmenting their practice and provides further resources for meeting the holistic needs of selected patient populations regardless of the setting.

Acute Care Nurse Practitioner Practice: Results of a 5-Year Longitudinal Study

The role of acute care nurse practitioners (ACNPs) has developed in capacity. More than 3500 advanced practice nurses have been certified as ACNPs, and the number of practice settings where these professionals work is continually expanding. Beginning in 1996, a series of surveys were conducted of nurse practitioners seeking national certification as ACNPs. What started as an attempt to gather information on the role of ACNPs evolved into a national 5-year longitudinal survey of ACNP practice. The cumulative results of the project are reported, and how the role of the ACNP was established in advanced practice nursing is discussed.

Outcomes of Care Managed by an Acute Care Nurse Practitioner/Attending Physician Team in a Subacute Medical Intensive Care Unit

• Background Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff.

• Objective To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows.

• Methods During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes.

• Results Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02).

• Conclusions In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

Assessing Outcomes in Advanced Practice Nursing Practice

Advanced practice nurses (APNs) impact both patient care and healthcare systems on a daily basis. Tracking and documenting the outcomes of APN practice have become essential, due partly to the emphasis on outcomes that has become a component of the majority of healthcare initiatives. This article outlines important aspects related to assessing outcomes and discusses the use of quality indicators to demonstrate outcomes of APN practice. Examples from clinical practice are provided in order to demonstrate that assessing the outcomes of APN practice can be incorporated into daily practice as part of ongoing initiatives. In delineating the outcomes of APN care, the value of APNs can be formally acknowledged.

Perceptions of Physicians, Nurses, and Respiratory Therapists About the Role of Acute Care Nurse Practitioners

• Background Information about the contributions of acute care nurse practitioners to medical management teams in critical care settings is limited.

• Objective To examine contributions of acute care nurse practitioners to medical management of critically ill patients from the perspectives of 3 disciplines: medicine, respiratory care, and nursing.

• Methods Attending physicians, respiratory therapists, and nurses in 2 intensive care units were asked to list 3 advantages and 3 disadvantages of collaborative care provided by acute care nurse practitioners. Qualitative methods (coding/constant comparative analysis) were used to identify common themes and subthemes. Overall response rate was 35% (from 69% for attending physicians to 26% for nurses).

• Results Responses were grouped into 4 main themes: accessibility, competence/knowledge, care coordination/communication, and system issues. Acute care nurse practitioners were valued for their accessibility, expertise in routine daily management of patients, and ability to meet patient/family needs, especially for “long-stay” patients. Also, they were respected for their commitment to providing quality care and for their communication skills, exemplified through teaching of nursing staff, patient/family involvement, and fluency in weaning protocols. Physicians valued acute care nurse practitioners’ continuity of care, patient/family focus, and commitment. Nurses valued their accessibility, commitment, and patient/family focus. Respiratory therapists valued their accessibility, commitment, and consistency in implementing weaning protocols.

• Conclusion Responses reflected unique advantages of acute care nurse practitioners as members of medical management teams in critical care settings. Despite perceptions of the acute care nurse practitioner’s role as medically oriented, the themes reflect a clear nursing focus.

Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: One-year outcomes and lessons learned*

OBJECTIVE

To determine the effect of an institutional approach to the care of patients requiring mechanical ventilation for longer than three consecutive days in five adult intensive care units (ICU) on clinical and financial outcomes.

DESIGN

A multidisciplinary team was selected from five adult ICUs to design the approach. Planning occurred from August 1999 to September 2000. The process was called outcomes management (OM) and included an evidence-based clinical pathway, protocols for weaning and sedation use, and the selection of four advanced practice nurses (called outcomes managers) to manage and monitor the program.

SETTING

The project was completed in a 550-bed mid-Atlantic academic medical center. The ICUs included the following: coronary care, medical ICU, neuroscience ICU, surgical trauma ICU, and thoracic cardiovascular ICU.

PATIENTS

The sample included 595 pre-OM patients and 510 post-OM patients mechanically ventilated for greater than three consecutive days.

INTERVENTIONS

Full implementation of the OM approach occurred in March 2001. Retrospective baseline (18 months pre-OM) and prospective (12 months OM) clinical and financial data were compared.

MEASUREMENTS AND MAIN RESULTS

Statistically significant differences in clinical outcomes were demonstrated in the managed patients compared with those managed before the institutional approach. Outcomes include ventilator duration (median days declined from ten to nine; p =.0001), ICU length of stay (median days declined from 15 to 12; p =.0008), hospital length of stay (median days declined from 22 to 20; p =.0001), and mortality rate (declined from 38% to 31%, p =.02). More than 3,000,000 US dollars cost savings were realized in the OM group.

CONCLUSIONS

This institutional approach to the care of patients ventilated >3 days improved all clinical and financial outcomes of interest. To date, few similar initiatives have demonstrated similar results. The approach and lessons learned in this process improvement project may be helpful to other institutions attempting to improve outcomes in this vulnerable population.

Educating advanced practice nurses for practice reality

The complexity of the current health care environment ethically mandates advanced practice nursing (APN) educators to prepare graduates with a clear understanding of APN roles and professional and regulatory issues for them to make a reasonable transition to the marketplace. Integrating both clinical content needed for APN practice and APN role issues can be a difficult balance. This article describes critical role content needed in APN programs and offers a variety of teaching strategies. Recommendations regarding the timing and placement of role content in the graduate curriculum also are offered. Although there is no one right way to build APN role content into graduate coursework, some approaches are preferable to others.

Management of Patients in the Intensive Care Unit: Comparison Via Work Sampling Analysis of an Acute Care Nurse Practitioner and Physicians in Training

• Background Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients’ outcomes.

• Objective To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients’ care in a step-down medical intensive care unit.

• Methods Work sampling techniques were used to collect data when the nurse practitioner had 6 months’ or less experience in the role (T1), after the nurse practitioner had 12 months’ experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities.

• Results Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001).

• Conclusion The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients’ families and collaborating with health team members.