Discharge Facilitation: An Innovative PNP Role

Acute Care Pediatric Nurse Practitioner: The 2018 Practice Analysis

INTRODUCTION

Practice research serves as the certification framework for validating advanced practice roles and updating national qualifying examinations. This national study informed an update of the Certified Pediatric Nurse Practitioner - Acute Care (CPNP-AC) examination content outline.

METHOD

A descriptive analysis of a survey completed in 2018 by 373 pediatric nurse practitioners (PNP) practicing as an acute care role (AC).

RESULTS

Respondents were primarily females aged 25 to 34 years (35.4%) and formally educated as AC PNPs (84.2%) and held the CPNP-AC credential (98.9%). Most respondents (83.6%) practiced in urban areas and spent 84% of their time in direct patient care with 74% working in inpatient settings. The majority (87%) worked in subspecialty practice such as critical care (18.5%) and cardiac intensive care (12.3%).

DISCUSSION

This is the fourth practice analysis of the AC PNP role that demonstrates continuous evolution in clinical practice, educational preparation, and subspecialty practice distribution.

Comparing subspecialty and intensive care providers perspectives on pediatric complex chronic patients: A survey study

Introduction

Pediatric complex chronic care patients present unique challenges regarding healthcare provision: complex medical regimes, complicated family/provider dynamics, and multiple healthcare teams that can result in inconsistent care. This study examined subspecialty providers’ perspectives regarding pediatric complex chronic care patients and compared them with acute care providers while exploring opportunities to better facilitate care provided to pediatric complex chronic care patients.

Methods

This survey study occurring within a Canadian tertiary care pediatric center, utilized REDCap to deploy surveys involving Likert Scale and short answer questions. The Kruskal–Wallis test compared subspecialty provider perspectives when providing care to pediatric complex chronic care patients versus non-pediatric complex chronic care patients; and perspectives between subspecialty and acute care providers.

Results

Survey response rate was 24/46 (52.2%). Eight overarching themes emerged from Likert scale questions. Short answer questions revealed factors that may facilitate care provided to pediatric complex chronic care patients: access to funding; discharge planning; communication methods between specialists; and healthcare provider continuity. Several differences were identified when working with pediatric complex chronic care patients, compared to non-pediatric complex chronic care patients: increased time/resource burden; managing expectations of patients/families; navigating discrepancies in goals of care; complexity of coordination between services; increased efforts in coordinating discharge from hospital and working with medicalized patients/families.

Discussion

Exploring pediatric subspecialty provider perspectives of pediatric complex chronic care patients revealed opportunities to enhance care provided: increased resources to ease the strain of care provision for parents, implementation of a discharge coordinator, complex care clinics with a pediatrician to “quarterback” care, and co-management between the complex care pediatrician and acute care physician when admitted to an acute care service. Implementation of these initiatives may improve the care provided to pediatric complex chronic care patients.

The "hard, relentless, never-ending" work of focusing on discharge: a qualitative study of managers' perspectives

PURPOSE

Interventions to hasten patient discharge continue to proliferate despite evidence that they may be achieving diminishing returns. To better understand what such interventions can be expected to accomplish, the authors aim to critically examine their underlying program theory.

DESIGN/METHODOLOGY/APPROACH

Within a broader study on patient flow, spanning 10 jurisdictions across Western Canada, the authors conducted in-depth interviews with 300 senior, middle and frontline managers; 174 discussed discharge initiatives. Using thematic analysis informed by a Realistic Evaluation lens, the authors identified the mechanisms by which discharge activities were believed to produce their impacts and the strategies and context factors necessary to trigger the intended mechanisms.

FINDINGS

Managers' accounts suggested a common program theory that applied to a wide variety of discharge initiatives. The chief mechanism was inculcation of a sharp focus on discharge; reinforcing mechanisms included development of shared understanding and a sense of accountability. Participants reported that these mechanisms were difficult to produce and sustain, requiring continual active management and repeated (re)introduction of interventions. This reflected a context in which providers, already overwhelmed with competing demands, were unlikely to be able (or perhaps even willing) to sustain a focus on this particular aspect of care.

ORIGINALITY/VALUE

The finding that "discharge focus" emerged as the core mechanism of discharge interventions helps to explain why such initiatives may be achieving limited benefit. There is a need for interventions that promote timely discharge without relying on this highly problematic mechanism.

Improving Discharge Outcomes by Using a Standardized Risk Assessment and Intervention Tool Facilitated by Advanced Pediatric Providers

OBJECTIVES

Pediatric discharge from the inpatient setting is a complex, error-prone process. In this study, we evaluated the outcomes of using a standardized process for hospital discharge of pediatric patients.

METHODS

A 1-year pre- and postintervention pilot study was designed to improve discharge transition of care. The bundle intervention, facilitated by advanced practice providers, included risk identification and intervention. Process and outcome metrics included patient satisfaction measures on the discharge domain (overall discharge, speed of discharge process, whether they felt ready for discharge), use of handouts, scheduling of follow-up appointments, and postdischarge phone call.

RESULTS

Significant improvements were found in all aspects of patient satisfaction, including speed of the discharge process and instructions for discharge, discharge readiness, and the overall discharge process. Length of stay decreased significantly after intervention. The checklist identified ∼4% of discharges without a correct primary care physician. Significant differences were found for scheduled primary care appointment before discharge and patients receiving handouts. The bundle identified risks that may complicate transition of care in approximately half of the patients. Phone communication occurred with almost half of the patients after discharge.

CONCLUSIONS

Integration of an evidence-based discharge checklist can improve processes, increase delivery of patient education, and improve patient and family perceptions of the discharge process. Involvement of key stakeholders, use of evidence-based interventions with local adaptation, and use of a consistent provider responsible for implementation can improve transitions of care.

Effect of Facilitated Discharge in Pediatric Orthopedic Patients at an Academic Medical Facility

INTRODUCTION

Because health care reimbursement is being linked to discharge quality and patient satisfaction, this quality improvement initiative reviewed the outcomes of embedding a pediatric nurse practitioner within the resident team at an academic medical facility.

METHODS

The project was completed at a pediatric orthopedic unit at a large Southeastern U.S. academic medical facility. During the intervention, the pediatric nurse practitioner student completed daily rounds, communicated with the resident team, assessed readiness for discharge, provided patient education, and ensured that comprehensive discharge materials were completed.

RESULTS

Analyses were completed for 219 patients (pre-intervention, n = 116; post-intervention, n = 103). Patient satisfaction was measured for provider communication and discharge. All areas experienced improvement, with provider communication benchmarks obtained. Ambulatory call volume decreased from 97 to 45 calls/100 patients.

DISCUSSION

This study shows that embedding a pediatric nurse practitioner into the resident team helped improve patient satisfaction and reduce ambulatory workload by decreasing call volume.

Contemporary issues relating to transitional care in bladder exstrophy

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The Case for the Use of Nurse Practitioners in the Care of Children with Medical Complexity

Although children with medically complex illness represent less than one percent of the total pediatric population, their health care expenditures and health care system utilization far exceed the numbers of other pediatric patients. Nurse practitioners, with their educational background focused on health care promotion and education, are uniquely qualified to reduce this inequity with cost effective care. Currently, nurse practitioners are used in a variety of health care settings and can provide acute and chronic care. Incorporating nurse practitioners at each step in the care of children with medical complexity can improve the quality of life for these children and their families, increase family satisfaction and decrease costs.