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Perez R, Yarrington ME, Deri CR, Smith MJ, Hayes J, Wrenn RH, Moehring RW. Teams in Transition: Increasing Role of Advanced Practice Providers in Antimicrobial Use and Infectious Diseases Consultation. Open Forum Infect Dis 2024; 11:ofae141. [PMID: 38577030 PMCID: PMC10993059 DOI: 10.1093/ofid/ofae141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
Background Advanced practice providers (APPs) have taken on increasing responsibilities as primary team members in acute care hospitals, but the impact of this practice shift on antimicrobial prescribing and infectious diseases (ID) consultation requests is unknown. Here we describe longitudinal trends in antimicrobial days of therapy (DOT) and ID consultation by attributed provider type in 3 hospitals. Methods We performed a retrospective time series analysis of antimicrobial use and ID consultation from July 2015 to June 2022 at a major university hospital and 2 community hospitals. We evaluated antimicrobial DOT and ID consultation over time and assessed attribution to 3 groups of providers: attending physicians, trainees, and APPs. We used multinomial logistic regression to measure changes in percentage of DOT and ID consultation across the clinician groups over time using physicians as the referent. Results Baseline distribution of antimicrobial DOT and ID consultation varied by practice setting, but all subgroups showed increases in the proportion attributable to APPs. Large increases were seen in the rate of ID consultation, increasing by >30% during the study period. At our university hospital, by study end >40% of new ID consults and restricted antimicrobial days were attributed to APPs. Conclusions Hospitals had differing baseline patterns of DOT attributed to provider groups, but all experienced increases in DOT attributed to APPs. Similar increases were seen in changes to ID consultation. APPs have increasing involvement in antimicrobial use decisions in the inpatient setting and should be engaged in future antimicrobial stewardship initiatives.
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Affiliation(s)
- Reinaldo Perez
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
| | - Michael E Yarrington
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael J Smith
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Jillian Hayes
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah W Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
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Hooker RS, Christian RL. The changing employment of physicians, nurse practitioners, and physician associates/assistants. J Am Assoc Nurse Pract 2023; 35:487-493. [PMID: 37523244 DOI: 10.1097/jxx.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Indexed: 08/02/2023]
Abstract
ABSTRACT Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 nurse practitioners (NPs), and 139,100 physician associates/assistants (PAs). These three health care professionals accounted for approximately 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is "office of a physician" (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.
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Hooker RS, Christian RL. The changing employment of physicians, NPs, and PAs. JAAPA 2023; Published Ahead of Print:01720610-990000000-00066. [PMID: 37399472 DOI: 10.1097/01.jaa.0000944616.43802.f6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
ABSTRACT Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics (BLS) employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 NPs, and 139,100 physician associates/assistants (PAs). These three healthcare professionals accounted for about 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is "office of a physician" (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than that of physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.
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Affiliation(s)
- Roderick S Hooker
- Roderick S. Hooker is a retired health policy analyst. Robert L. Christian is an independent data visual contractor in Portland, Ore. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Simulation-based Mastery Learning Improves Critical Care Skills of Advanced Practice Providers. ATS Sch 2023; 4:48-60. [PMID: 37089675 PMCID: PMC10117416 DOI: 10.34197/ats-scholar.2022-0065oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/28/2022] [Indexed: 01/25/2023] Open
Abstract
Background Advanced practice providers (APPs) are essential members of intensive care unit (ICU) interprofessional teams and are expected to be competent in performing procedures. There are no published criteria for establishing when APPs can independently perform procedures. Simulation-based mastery learning (SBML) is an effective strategy for improving critical care skills but has not been applied to practicing ICU APPs. Objective The purpose of this study was to evaluate if an SBML curriculum could improve the critical care skills and procedural self-confidence of ICU APPs. Methods We performed a pretest-posttest study of central venous catheter (CVC) insertion, thoracentesis, and mechanical ventilation (MV) management skills among ICU APPs who participated in an SBML course at an academic hospital. For each skill, APPs underwent baseline skills assessments (pretests) on a simulator using previously published checklists, followed by didactic sessions and deliberate practice with individualized feedback. Within 2 weeks, participants were required to meet or exceed previously established minimum passing standards (MPS) on simulated skills assessments (posttests) using the same checklists. Further deliberate practice was provided for those unable to meet the MPS until they retested and met this standard. We compared pretest to posttest skills checklist scores and procedural confidence. Results All 12 eligible ICU APPs participated in internal jugular CVC, subclavian CVC, and MV training. Five APPs participated in thoracentesis training. At baseline, no APPs met the MPS on all skills. At training completion, all APPs achieved the mastery standard. Internal jugular CVC pretest performance improved from a mean of 67.2% (standard deviation [SD], 28.8%) items correct to 97.1% (SD, 3.8%) at posttest (P = 0.005). Subclavian CVC pretest performance improved from 29.2% (SD, 32.7%) items correct to 93.1% (SD 3.9%) at posttest (P < 0.001). Thoracentesis pretest skill improved from 63.9% (SD, 30.6%) items correct to 99.2% (SD, 1.7%) at posttest (P = 0.054). Pretest MV skills improved from 54.8% (SD, 19.7%) items correct to 92.3% (SD, 5.0%) at posttest (P < 0.001). APP procedural confidence improved for each skill from pre to posttest. Conclusion SBML is effective for training APPs to perform ICU skills. Relying on traditional educational methods does not reliably ensure that APPs are adequately prepared to perform skills such as CVC insertion, thoracentesis, and MV management.
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Felix HM, Cowdell JC, Paulson MR, Maita KC, Dugani SB, Avila FR, Torres-Guzman RA, Forte AJ, Matcha GV, Maniaci MJ. Impact of an Acquisition Advanced Practice Provider on Home Hospital Patient Volumes and Length of Stay. Healthcare (Basel) 2023; 11:healthcare11030282. [PMID: 36766857 PMCID: PMC9914253 DOI: 10.3390/healthcare11030282] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
In July 2020, Mayo Clinic introduced a hospital-at-home program, known as Advanced Care at Home (ACH) as an alternate option for clinically stable medical patients requiring hospital-level care. This retrospective cohort study evaluates the impact of the addition of a dedicated ACH patient acquisition Advanced Practice Provider (APP) on average length of stay (ALOS) and the number of patients admitted into the program between in Florida and Wisconsin between 6 July 2020 and 31 January 2022. Patient volumes and ALOS of 755 patients were analyzed between the two sites both before and after a dedicated acquisition APP was added to the Florida site on 1 June 2021. The addition of a dedicated acquisition APP did not affect the length of time a patient was in the emergency department or hospital ward prior to ACH transition (2.91 days [Florida] vs. 2.59 days [Wisconsin], p = 0.22), the transition time between initiation of the ACH consult to patient transfer home (0.85 days [Florida] vs. 1.16 days [Wisconsin], p = 0.28), or the total ALOS (6.63 days [Florida] vs. 6.34 days [Wisconsin], p = 0.47). The average number of patients acquired monthly was significantly increased in Florida (38.3 patients per month) compared with Wisconsin (21.6 patients per month) (p < 0.01). The addition of a dedicated patient acquisition APP resulted in significantly higher patient volumes but did not affect transition time or ALOS. Other hospital-at-home programs may consider the addition of an acquisition APP to maximize patient volumes.
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Affiliation(s)
- Heidi M. Felix
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Jed C. Cowdell
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Margaret R. Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, 1221 Whipple St, Eau Claire, WI 54701, USA
| | - Karla C. Maita
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Sagar B. Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Francisco R. Avila
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | | | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Gautam V. Matcha
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Michael J. Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Correspondence: ; Tel.: +904-956-0081; Fax: +904-953-2848
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Nargiso S, Tristan V, Ramos L, Muriel JA, Sachs RE. The evolving role of advanced practice providers in transplantation: a literature review. Curr Opin Organ Transplant 2021; 26:482-487. [PMID: 34369400 DOI: 10.1097/mot.0000000000000905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Solid organ transplantation is a life-saving procedure, often performed in critically ill patients, and advanced practice providers (APPs) have increasingly been incorporated into the multidisciplinary transplant team. A literature review was performed and reinforces the value of transplant APPs, details their evolving roles and responsibilities, and highlights innovative solutions created to address complex problems. RECENT FINDINGS The literature review revealed a deficit of quality quantitative data supporting the utilization of APPs in transplantation. Thus, data regarding the value of APPs in critical care was also analyzed. SUMMARY The limited data despite decades long integration of transplant APPs into the multidisciplinary team, suggests there are likely positive outcomes and innovations that go undocumented. Thus, there are missed opportunities for learning and improvement. Transplant programs investing time and mentorship to support APP research will identify strengths and weaknesses within our existing care models, discover cost saving innovations, and continue to optimize the role of APPs in delivering high quality care that is efficient and evidence based.
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Affiliation(s)
| | | | | | - Jaira A Muriel
- Department of Hepatobiliary and Abdominal Transplant Surgery
| | - Robert E Sachs
- Department of Cardiothoracic Surgery, Keck Hospital of USC, Los Angeles, California, USA
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Workload in the Cardiac ICU: You Down With APPs? Pediatr Crit Care Med 2021; 22:753-755. [PMID: 34397990 DOI: 10.1097/pcc.0000000000002771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics. J Vasc Surg 2021; 74:2055-2062. [PMID: 34186163 DOI: 10.1016/j.jvs.2021.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/06/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics. METHODS A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year. RESULTS One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period. CONCLUSIONS Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.
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Johnson SA, Ciarkowski CE, Lappe KL, Kendrick DR, Smith A, Reddy SP. Comparison of Resident, Advanced Practice Clinician, and Hospitalist Teams in an Academic Medical Center: Association With Clinical Outcomes and Resource Utilization. J Hosp Med 2020; 15:709-715. [PMID: 33231541 DOI: 10.12788/jhm.3475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Academic medical centers have expanded their inpatient medicine services with advanced practice clinicians (APCs) or nonteaching hospitalists in response to patient volumes, residency work hour restrictions, and recently, COVID-19. Reports of clinical outcomes, cost, and resource utilization differ among inpatient team structures. OBJECTIVE Directly compare outcomes among resident, APC, and solo hospitalist inpatient general medicine teams. DESIGN Retrospective cohort study using multivariable analysis adjusted for time of admission, interhospital transfer, and comorbidities that compares clinical outcomes, cost, and resource utilization. SUBJECTS Patients 18 years or older discharged from an inpatient medicine service between July 2015 and July 2018 (N = 12,716). MAIN MEASURES Length of stay (LOS), 30-day readmission, inpatient mortality, normalized total direct cost, discharge time, and consultation utilization. KEY RESULTS Resident teams admitted fewer patients at night (32.0%; P < .001) than did APC (49.5%) and hospitalist (48.6%) teams. APCs received nearly 4% more outside transfer patients (P = .015). Hospitalists discharged patients 26 minutes earlier than did residents (mean hours after midnight [95% CI], 14.58 [14.44-14.72] vs 15.02 [14.97-15.08]). Adjusted consult utilization was 15% higher for APCs (adjusted mean consults per admission [95% CI], 1.00 [0.96-1.03]) and 8% higher for residents (0.93 [0.90-0.95]) than it was for hospitalists (0.85 [0.80-0.90]). No differences in LOS, readmission, mortality, or cost were observed between the teams. CONCLUSION We observed similar costs, LOS, 30-day readmission, and mortality among hospitalist, APC, and resident teams. Our results suggest clinical outcomes are not significantly affected by team structure. The addition of APC or hospitalist teams represent safe and effective alternatives to traditional inpatient resident teams.
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Affiliation(s)
- Stacy A Johnson
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Claire E Ciarkowski
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Katie L Lappe
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
- Division of General Internal Medicine, Department of Internal Medicine, George E. Wahlen VA Hospital, Salt Lake City, Utah
| | - David R Kendrick
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Adrienne Smith
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Santosh P Reddy
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
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LeBar K, Murawski S, Umayam S, Quinn V. The Role of Advanced Practice Providers and Telemedicine in Reinventing Care: The Transition of a CAR T-Cell Transplantation Program to the Outpatient Setting. J Adv Pract Oncol 2020; 11:757-763. [PMID: 33575070 PMCID: PMC7646631 DOI: 10.6004/jadpro.2020.11.7.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As the health-care industry continues to be pushed to find new, innovative ways to deliver quality care with an emphasis on enhancing quality of life, the use of advanced practice providers and telemedicine technology are two promising developments at the forefront of this new era. Advanced practice providers have been shown to provide highly effective, quality patient care. They often deliver this care at a decreased cost to the patient and healthcare system. Telemedicine technology allows providers to access patients through new, patient-centered avenues, thus enhancing their healthcare experience. Advanced practice providers are well equipped to apply telemedicine technology to expand access to care and innovate new care delivery models. This article describes the design and implementation of a novel telemedicine care model within a malignant hematologic team.
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Atkinson S, Crutcher TD, King JE. Improving efficiency within a trauma nurse practitioner team. J Am Assoc Nurse Pract 2020; 33:239-245. [PMID: 32453087 DOI: 10.1097/jxx.0000000000000425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/21/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinicians, including nurse practitioners (NPs), face a number of challenges in delivering high-quality care including frequent interruptions that can potentially compromise patient safety and job satisfaction. LOCAL PROBLEM Trauma NPs voiced frustration with their efforts to provide efficient, high-quality care with frequent interruptions, most commonly pager alerts. The purpose of this quality improvement (QI) initiative was to increase trauma NPs' perceptions of patient safety and improve NPs' job satisfaction by reducing workflow interruptions. METHODS The Model for Improvement guided this initiative. INTERVENTIONS The aims of this initiative were to reduce the percentage of nonurgent workflow interruptions via pager alerts by 20% and to increase the utilization of a standardized trauma NP patient rounding process from 0% to 50%. RESULTS Use of the standardized rounding process improved from 0% to 87%. Interruptions via pager alerts decreased by 36.2%. All nine (100%) trauma NP survey responses revealed an improvement in NP perception of patient safety and job satisfaction. CONCLUSION The QI initiative found that increasing communication during rounds by using a standardized rounding process involving the bedside registered nurse can minimize interruptions and improve the efficiency of a trauma NP team. The key to the success of the QI initiative was the implementation of a standardized rounding process.
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Affiliation(s)
| | | | - Joan E King
- Vanderbilt University School of Nursing, Nashville, Tennessee
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Abstract
OBJECTIVES This article aims to identify the steps necessary to evaluate the clinical need for innovative coverage models within the oncology setting to help prevent hospital readmissions. DATA SOURCES Multiple published studies suggest alternative methods for patient care delivery that are safe and cost effective. CONCLUSION Improving care transitions for the oncology patient is necessary to be able to provide low-cost, high-quality, and patient-centered care. Many of the review studies in this article suggest that emergency room visits and subsequent readmission could be decreased with the use of innovative care models. IMPLICATIONS FOR NURSING PRACTICE Nurses are critical to the care of medically fragile patients. Nurse-led activities such as telephone triage, post discharge phone calls, or telehealth visits can reduce patient emergency department utilization and readmissions through early recognition of symptoms and oncologic emergencies by prompting timely referrals/consultations and quick interventions.
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Affiliation(s)
- Kiersten LeBar
- Vice President, Advanced Practice Providers Jefferson Health, Philadelphia, PA.
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Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018. Crit Care Med 2020; 47:1442-1449. [PMID: 31414993 PMCID: PMC6750122 DOI: 10.1097/ccm.0000000000003925] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings. DATA SOURCES Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018. STUDY SELECTION Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting. DATA EXTRACTION Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice. DATA SYNTHESIS Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes. CONCLUSIONS Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.
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Horne MP, Estes KR. Implementation of a new cardiology hospital service leveraging nurse practitioners to improve patient access and outcomes. J Am Assoc Nurse Pract 2020; 33:231-238. [PMID: 32384362 DOI: 10.1097/jxx.0000000000000421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 02/24/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Delays in patient access due to excessive wait times for clinic consult appointments impair timely diagnosis and treatment, resulting in worse outcomes. LOCAL PROBLEM Average days wait (ADW) for clinic consult appointments for the cardiology group of a regional managed care organization was too long. A quality improvement project (QIP) was undertaken to improve efficiency/efficacy of patient coverage and reduce ADW by implementing a new cardiology hospital service with expanded roles for nurse practitioners (NPs). METHODS AND INTERVENTION The QIP used the Institute for Healthcare Improvement's Model for Improvement. The new cardiology hospital service deployed a group of 11 cardiologists and three cardiology NPs who rotated between hospital and clinic service. Two cardiologists and one NP covered all cardiology inpatients, alleviating the need for clinic-assigned cardiologists to also see hospitalized patients, thus improving capacity. The primary measure was ADW, whereas secondary measures included patient satisfaction with access, hospital readmissions, clinic cancellations, and provider job satisfaction. RESULTS All measures were assessed on pre/post 6-month averages. Average days wait reduced from 28 to 14; patient satisfaction improved from 39% to 52%; readmissions reduced from 13.2% to 9.7%, and provider job satisfaction with the intervention was 91% positive. There were no significant changes in potential confounding factors and no identified negative consequences. CONCLUSIONS Implementation of a cardiology hospital service leveraging NPs was feasible, increased capacity to improve patient access and associated outcomes, and did not manifest any known adverse impacts.
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Affiliation(s)
| | - Krista R Estes
- University of Colorado College of Nursing, Aurora, Colorado
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Schirle L, Dietrich MS. Advanced practice registered nurses' work environment perceptions in hospitals: A cross-sectional survey. J Nurs Manag 2020; 28:919-926. [PMID: 32249469 DOI: 10.1111/jonm.13020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/24/2020] [Accepted: 03/20/2020] [Indexed: 11/30/2022]
Abstract
AIM To examine work environment differences between hospital certified nurse practitioners (CNPs) and certified registered nurse anaesthetists (CRNAs). BACKGROUND Nurse work environments impact patient and nurse outcomes. How differing advanced practice nurse (APRN) roles influence work environments is unknown. METHODS Multi-level cross-sectional survey design. APRNs (n = 490) completed the APRN Organizational Climate Questionnaire and Psychological Ownership Questionnaire. Nurse executives (N = 24) reported on Scope of Practice and Institutional Voice. Descriptive, t test, chi-square and linear and mixed-effects regression statistical analyses were employed. RESULTS CNPs reported better organisational climate and job ownership than CRNAs. The largest effects involved relationships with physicians, control over practice and independent practice. Among CNPs, a significant positive relationship was observed between relations with physicians and work engagement. In CRNAs, a similar positive relationship between physician relations and work engagement was only observed for those working in higher scope of practice settings, not for those working in more restrictive settings. CONCLUSIONS Significant differences exist in the perceived work environments between CNPs and CRNAs that may be related to differences in job design and historical relations with physician colleagues. IMPLICATIONS FOR NURSING MANAGEMENT Efforts to improve APRN work environments in hospital settings should consider differing CRNA and CNP perspectives.
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Affiliation(s)
- Lori Schirle
- Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Mary S Dietrich
- Vanderbilt University School of Nursing, Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
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Scanlon A, Murphy M, Smolowitz J, Lewis V. National Nursing Association and Regulatory Authority Websites of Low-Income and Lower-Middle–Income Countries. JOURNAL OF NURSING REGULATION 2020. [DOI: 10.1016/s2155-8256(20)30061-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kapu AN, Borg Card E, Jackson H, Kleinpell R, Kendall J, Lupear BK, LeBar K, Dietrich MS, Araya WA, Delle J, Payne K, Ford J, Dubree M. Assessing and addressing practitioner burnout: Results from an advanced practice registered nurse health and well-being study. J Am Assoc Nurse Pract 2019; 33:38-48. [PMID: 31702604 DOI: 10.1097/jxx.0000000000000324] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/08/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous nursing and physician studies have reported the effects of workload, environment, and life circumstances contributing to burnout. Effects may include job dissatisfaction, poor quality of life, and associated negative patient outcomes. Although assessing clinician burnout to determine effective interventions has become a topic of great importance, there are minimal studies specific to advanced practice registered nurses (APRNs). PURPOSE This single-center study was conducted to assess the prevalence and impact of APRN burnout and to recommend targeted interventions toward improvement of overall health and well-being. METHODS A cross-sectional, mixed methods design was used. The voluntary, anonymous survey examined perceptions of wellness, inclusion, social support, personal coping mechanisms, and status of burnout. RESULTS The 78-question survey was sent to 1,014 APRNs (94%) and PAs (6%), with a 43.6% response rate (n = 433); 76.4% were nurse practitioners. Participants were identified as currently experiencing burnout, formerly burned out, or never having experienced burnout. Profiles were developed, and similarities and differences between each group were compared. Of 433 respondents, 40.4% (n = 175) reported having never experienced burnout, 33.3% (n = 144) reported they had formerly experienced burnout, and 26.3% (n = 114) reported they were currently experiencing burnout. IMPLICATIONS FOR PRACTICE The results of the study identified that some APRNs report experiencing burnout at different times in their careers. Recommendations by participants to mitigate burnout included self-care, organizational promotion of health and well-being, career development, and leadership support. This study is one of the first to report on burnout among APRNs and potential interventions to build resilience; however, additional research is warranted.
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Affiliation(s)
- April N Kapu
- Advanced Practice, Vanderbilt University Medical Center and Professor of Clinical Nursing, Vanderbilt University School of Nursing, Nashville, Tennessee
| | | | - Heather Jackson
- Outpatient Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ruth Kleinpell
- Vanderbilt University School of Nursing, Nashville, Tennessee
| | - Jim Kendall
- Work/Life Connections-EAP, Vanderbilt University School of Nursing, Nashville, Tennessee
| | - Buffy Krauser Lupear
- Office of Advanced Practice, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kiersten LeBar
- Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary S Dietrich
- Vanderbilt University Schools of Medicine and Nursing, Nashville, Tennessee
| | - Wendy A Araya
- Neonatal Intensive Care Practitioners, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Janelle Delle
- Trauma Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kate Payne
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jaquelyn Ford
- Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marilyn Dubree
- Vanderbilt University Medical Center, Nashville, Tennessee
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Scanlon A, Murphy M, Smolowitz J, Lewis V. Low- and lower middle-income countries advanced practice nurses: an integrative review. Int Nurs Rev 2019; 67:19-34. [PMID: 31364775 DOI: 10.1111/inr.12536] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
AIM To review published literature descriptions of advanced practice nurses' roles in low- and lower middle-income countries. BACKGROUND Advanced practice nurse roles have the potential to address insufficient healthcare resources in low- and lower middle-income countries. INTRODUCTION This integrative review highlights advanced practice nurses' roles in the delivery of healthcare services in low- and lower middle-income countries. METHODS Three electronic databases PubMed, CINAHL complete and ProQuest Health & Medicine were searched. No limits by year or language were set. The names for low- and lower middle-income countries and combinations 'related to advanced practice nurses' titles were used to identify papers. In addition, a review of publication type was performed. Themes found within the publications were assessed against the advanced practice nurses' International Council of Nurses' characteristics. An integrative review facilitated an appraisal of the papers identified. RESULTS The initial search identified 5778 publications in 16 languages. This number was reduced to 23, from 18 low- and lower middle-income once exclusion criteria were applied. Six publications were from 1977 to 1999, and six between 2000 and 2010, with the remaining 11 from 2011 to 2018. Zambia had the most publications. Notably, 63 countries were not represented. Of those meeting inclusion criteria, the majority addressed education with a lesser extent focusing on practice and regulation of advanced practice nurse's roles. The majority were published during the last decade. DISCUSSION This review of the published literature identified advanced practice nurses' roles and function within some healthcare systems. However, not all components were reported. Examination of the grey literature could provide additional information about the actual and potential benefits of advanced practice nurses' in low- and lower middle-income countries. CONCLUSION The published literature that referred to advanced practice nurses' identified their contribution to positive impacts on health care over the last 40 years. However, with only 11 publications identified in the last 7 years, further review is required to understand the advanced practice nurses' roles in these countries. IMPLICATIONS FOR NURSING AND/OR HEALTH POLICY Further development of advanced practice nurses' in low- and lower middle-income countries is supported by the lack of published literature.
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Affiliation(s)
- A Scanlon
- School of Nursing and Midwifery, La Trobe University, Bundoora, Vic., Australia.,School of Nursing, Montclair State University, Montclair, NJ, USA
| | - M Murphy
- School of Nursing and Midwifery, La Trobe University, Bundoora, Vic., Australia
| | - J Smolowitz
- School of Nursing, Montclair State University, Montclair, NJ, USA
| | - V Lewis
- Australian Institute for Primary Care & Ageing, Bundoora, Vic., Australia
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Pastores SM, Kvetan V, Coopersmith CM, Farmer JC, Sessler C, Christman JW, D'Agostino R, Diaz-Gomez J, Gregg SR, Khan RA, Kapu AN, Masur H, Mehta G, Moore J, Oropello JM, Price K. Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review. Crit Care Med 2019; 47:550-557. [PMID: 30688716 DOI: 10.1097/ccm.0000000000003637] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess-by literature review and expert consensus-workforce, workload, and burnout considerations among intensivists and advanced practice providers. DESIGN Data were synthesized from monthly expert consensus and literature review. SETTING Workforce and Workload section workgroup of the Academic Leaders in Critical Care Medicine Task Force. MEASUREMENTS AND MAIN RESULTS Multidisciplinary care teams led by intensivists are an essential component of critical care delivery. Advanced practice providers (nurse practitioners and physician assistants) are progressively being integrated into ICU practice models. The ever-increasing number of patients with complex, life-threatening diseases, concentration of ICU beds in few centralized hospitals, expansion of specialty ICU services, and desire for 24/7 availability have contributed to growing intensivist staffing concerns. Such staffing challenges may negatively impact practitioner wellness, team perception of care quality, time available for teaching, and length of stay when the patient to intensivist ratio is greater than or equal to 15. Enhanced team communication and reduction of practice variation are important factors for improved patient outcomes. A diverse workforce adds value and enrichment to the overall work environment. Formal succession planning for ICU leaders is crucial to the success of critical care organizations. Implementation of a continuous 24/7 ICU coverage care model in high-acuity, high-volume centers should be based on patient-centered outcomes. High levels of burnout syndrome are common among intensivists. Prospective analyses of interventions to decrease burnout within the ICU setting are limited. However, organizational interventions are felt to be more effective than those directed at individuals. CONCLUSIONS Critical care workforce and staffing models are myriad and based on several factors including local culture and resources, ICU organization, and strategies to reduce burden on the ICU provider workforce. Prospective studies to assess and avoid the burnout syndrome among intensivists and advanced practice providers are needed.
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Affiliation(s)
- Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Craig M Coopersmith
- Department of Surgery, Emory Critical Care Center, Emory University, Atlanta, GA
| | | | - Curtis Sessler
- Division of Pulmonary Diseases and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - John W Christman
- Division of Pulmonary, Allergy, Critical Care and Sleep, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Rhonda D'Agostino
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jose Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Sara R Gregg
- Department of Surgery, Emory Critical Care Center, Emory University, Atlanta, GA
| | - Roozehra A Khan
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - April N Kapu
- Vanderbilt University School of Nursing, Vanderbilt University Medical Center, Nashville, TN
| | - Henry Masur
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
| | - Gargi Mehta
- Jay B. Langner Critical Care System, Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY
| | - Jason Moore
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John M Oropello
- Division of Critical Care Medicine, Department of Surgery, Mount Sinai Medical Center, New York, NY
| | - Kristen Price
- Department of Critical Care Medicine, MD Anderson Cancer Center, Houston, TX
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A scoping review of nurse practitioner workforce data: Part two of a four-part series on critical topics identified by the 2015 Research Agenda Roundtable. J Am Assoc Nurse Pract 2018; 30:685-695. [DOI: 10.1097/jxx.0000000000000069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Customizing Functionality in an Electronic Health Record to Capture Value of Provider-Specific Services. Comput Inform Nurs 2018; 36:417-421. [DOI: 10.1097/cin.0000000000000479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bovero M, Giacomo C, Ansari M, Roulin MJ. Role of advanced nurse practitioners in the care pathway for children diagnosed with leukemia. Eur J Oncol Nurs 2018; 36:68-74. [PMID: 30322512 DOI: 10.1016/j.ejon.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 08/05/2018] [Accepted: 08/16/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE The development of advanced nursing practices (ANP) can meet challenges presented by evolving needs of health care. We aimed at describing the approach taken to implement ANP in a pediatric oncology-hematology unit. METHOD The Participatory, Evidence-informed, Patient-centered Process for Advanced practice was considered as a conceptual framework for the development, implementation and evaluation of the nursing role. Successive steps were taken for identifying patients and family needs, defining the health care priorities, and establishing a new health care model. RESULTS The seven steps of the PEPPA framework were carried out over a year and contributed to the identification of the tasks and the role of the advanced nurse practitioner in the patient care pathway. The implementation of ANP was gradually achieved with the development of new evidenced-based health care procedures. The subsequent approval of a contract specification for advanced nurse practitioners facilitated the onset of a specific consultation, which facilitated a holistic approach. CONCLUSION The impact of the implementation can be appreciated at different levels: i) the patient and his or her family, with improvement of communication and continuity of care; ii) the interdisciplinary team, with development of a dynamic and greater motivation of the health care providers; and iii) the profession, with a greater recognition of the competencies and conceptualization of the new role. An assessment of the process, the structure and the results should be carried out to validate the role of the advanced nurse practitioner throughout the long journey of a child with leukemia.
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Affiliation(s)
- Maryline Bovero
- Pediatric Oncology and Hematology Unit, Department of Pediatrics, Geneva Children's Hospital, University Hospitals of Geneva, Rue Willy Donzé, 6, Geneva, Switzerland.
| | - Cristiano Giacomo
- Pediatric Oncology and Hematology Unit, Department of Pediatrics, Geneva Children's Hospital, University Hospitals of Geneva, Rue Willy Donzé, 6, Geneva, Switzerland
| | - Marc Ansari
- Pediatric Oncology and Hematology Unit, Department of Pediatrics, Geneva Children's Hospital, University Hospitals of Geneva, Rue Willy Donzé, 6, Geneva, Switzerland
| | - Marie-José Roulin
- Directorate of Nursing and Allied Health Professions, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil, 4, 1205, Geneva, Switzerland
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Wannemacher J, Tschannen D, Biery K, Arslanian-Engoren C. Advanced Practice Registered Nurses on Therapeutic Hypothermia Response Teams. AACN Adv Crit Care 2018; 28:332-341. [PMID: 29212639 DOI: 10.4037/aacnacc2017708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Therapeutic hypothermia can improve neurological recovery after cardiac arrest when implemented quickly. OBJECTIVE To determine whether outcomes are improved among patients undergoing therapeutic hypothermia by adding advanced practice registered nurses to a therapeutic hypothermia response team. METHODS A pilot quality improvement project was conducted in a Midwest community teaching hospital using a retrospective chart review of all adult patients undergoing therapeutic hypothermia before and after the addition of advanced practice registered nurses to the therapeutic hypothermia response team. Outcomes evaluated included time to target core body temperature, therapeutic hypothermia protocol initiation, discharge status, and hospital length of stay. RESULTS A total of 14 adult patients (preintervention n = 8, postintervention n = 6) comprised the sample. Length of stay decreased in the postintervention group (median 2.5 vs 6 days for the preintervention group; P = .05), but other outcomes did not differ. CONCLUSIONS This quality improvement project provides foundational data to evaluate advanced practice registered nurses specific metrics and to compare with future data using a larger longitudinal sample.
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Affiliation(s)
- Jason Wannemacher
- Jason Wannemacher is Pulmonary/Critical Care Nurse Practitioner in Dayton, Ohio, and at University of Michigan School of Nursing, 7056 Corporate Way, Centerville, OH 45459 . Dana Tschannen is Clinical Associate Professor, Director of Post Master's DNP, Vice Chair of Academic Affairs-Systems, Populations & Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan. Kim Biery is Director of Quality Innovation, Miami Valley Hospital, Dayton, Ohio. Cynthia Arslanian-Engoren is Associate Dean, Faculty Affairs and Faculty Development, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Dana Tschannen
- Jason Wannemacher is Pulmonary/Critical Care Nurse Practitioner in Dayton, Ohio, and at University of Michigan School of Nursing, 7056 Corporate Way, Centerville, OH 45459 . Dana Tschannen is Clinical Associate Professor, Director of Post Master's DNP, Vice Chair of Academic Affairs-Systems, Populations & Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan. Kim Biery is Director of Quality Innovation, Miami Valley Hospital, Dayton, Ohio. Cynthia Arslanian-Engoren is Associate Dean, Faculty Affairs and Faculty Development, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Kim Biery
- Jason Wannemacher is Pulmonary/Critical Care Nurse Practitioner in Dayton, Ohio, and at University of Michigan School of Nursing, 7056 Corporate Way, Centerville, OH 45459 . Dana Tschannen is Clinical Associate Professor, Director of Post Master's DNP, Vice Chair of Academic Affairs-Systems, Populations & Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan. Kim Biery is Director of Quality Innovation, Miami Valley Hospital, Dayton, Ohio. Cynthia Arslanian-Engoren is Associate Dean, Faculty Affairs and Faculty Development, University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Cynthia Arslanian-Engoren
- Jason Wannemacher is Pulmonary/Critical Care Nurse Practitioner in Dayton, Ohio, and at University of Michigan School of Nursing, 7056 Corporate Way, Centerville, OH 45459 . Dana Tschannen is Clinical Associate Professor, Director of Post Master's DNP, Vice Chair of Academic Affairs-Systems, Populations & Leadership, University of Michigan School of Nursing, Ann Arbor, Michigan. Kim Biery is Director of Quality Innovation, Miami Valley Hospital, Dayton, Ohio. Cynthia Arslanian-Engoren is Associate Dean, Faculty Affairs and Faculty Development, University of Michigan School of Nursing, Ann Arbor, Michigan
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Lee B, D'Souza M, Singman EL, Wang J, Woreta FA, Boland MV, Srikumaran D. Integration of a Physician Assistant Into an Ophthalmology Consult Service in an Academic Setting. Am J Ophthalmol 2018; 190:125-133. [PMID: 29604282 DOI: 10.1016/j.ajo.2018.03.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/19/2018] [Accepted: 03/21/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE To describe the impact of a physician assistant (PA) in an academic ophthalmology consult service. DESIGN Evaluation research. METHODS A PA was integrated into our ophthalmology consult service to enhance resident education. First-year resident annual surgical logs before and after the introduction of the PA were reviewed. Residents were anonymously surveyed for their perceptions regarding the impact of the PA integration on their residency experience. Consult wait time was compared for residents and the PA. Internal financial metrics for the PA were reviewed for a cost scenario analysis using 2016 national salary data for PAs. RESULTS The PA made approximately 28 days per year for each first-year resident available for alternative clinical assignments, which resulted in a 75% increase in total first-year resident annual surgical volume. The majority of residents (93%) strongly agreed that having a PA improved both their ophthalmic education (by enabling them to spend time on other clinical assignments) and their service-to-education balance on the consult rotation. Adjusted median consult wait time for residents was 28 minutes longer (P < .001) than for the PA. A PA would likely need to see an average of 8-12 patients per day to be cost neutral to a consult service. CONCLUSIONS Integrating a PA into an ophthalmology consult service can optimize the resident clinical service-to-education balance, reduce consult wait time, and be financially feasible. PAs trained in ophthalmology present a unique opportunity for all institutions that require clinical ophthalmology expertise.
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Affiliation(s)
- Benjamin Lee
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark D'Souza
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eric L Singman
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jiangxia Wang
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael V Boland
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Divya Srikumaran
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Simone S, McComiskey CA, Andersen B. Integrating Nurse Practitioners Into Intensive Care Units. Crit Care Nurse 2018; 36:59-69. [PMID: 27908947 DOI: 10.4037/ccn2016360] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
As demand for nurse practitioners in all types of intensive care units continues to increase, ensuring successful integration of these nurses into adult and pediatric general and specialty intensive care units poses several challenges. Adding nurse practitioners requires strategic planning to define critical aspects of the care delivery model before the practitioners are hired, develop a comprehensive program for integrating and training these nurses, and create a plan for implementing the program. Key strategies to ensure successful integration include defining and implementing the role of nurse practitioners, providing options for orientation, and supporting and training novice nurse practitioners. Understanding the importance of appropriate role utilization, the depth of knowledge and skill expected of nurse practitioners working in intensive care units, the need for a comprehensive training program, and a commitment to continued professional development beyond orientation are necessary to fully realize the contributions of these nurses in critical care.
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Affiliation(s)
- Shari Simone
- Shari Simone is a senior nurse practitioner clinical program manager, Women and Children's Services, a pediatric critical care nurse practitioner, University of Maryland Medical Center, Baltimore, Maryland, and an assistant professor, University of Maryland School of Nursing, Baltimore, Maryland. .,Carmel A. McComiskey is the director of nurse practitioners and physician assistants, University of Maryland Medical Center, and an assistant professor, University of Maryland School of Nursing. .,Brooke Andersen is a nurse practitioner clinical program manager, R. Adams Cowley Shock Trauma Center critical care units, and an adult acute care nurse practitioner, University of Maryland Medical Center.
| | - Carmel A McComiskey
- Shari Simone is a senior nurse practitioner clinical program manager, Women and Children's Services, a pediatric critical care nurse practitioner, University of Maryland Medical Center, Baltimore, Maryland, and an assistant professor, University of Maryland School of Nursing, Baltimore, Maryland.,Carmel A. McComiskey is the director of nurse practitioners and physician assistants, University of Maryland Medical Center, and an assistant professor, University of Maryland School of Nursing.,Brooke Andersen is a nurse practitioner clinical program manager, R. Adams Cowley Shock Trauma Center critical care units, and an adult acute care nurse practitioner, University of Maryland Medical Center
| | - Brooke Andersen
- Shari Simone is a senior nurse practitioner clinical program manager, Women and Children's Services, a pediatric critical care nurse practitioner, University of Maryland Medical Center, Baltimore, Maryland, and an assistant professor, University of Maryland School of Nursing, Baltimore, Maryland.,Carmel A. McComiskey is the director of nurse practitioners and physician assistants, University of Maryland Medical Center, and an assistant professor, University of Maryland School of Nursing.,Brooke Andersen is a nurse practitioner clinical program manager, R. Adams Cowley Shock Trauma Center critical care units, and an adult acute care nurse practitioner, University of Maryland Medical Center
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Schirle L, McCabe BE, Mitrani V. The Relationship Between Practice Environment and Psychological Ownership in Advanced Practice Nurses. West J Nurs Res 2018; 41:6-24. [PMID: 29357756 DOI: 10.1177/0193945918754496] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Barriers in advanced practice nurses' work environment impede effective use in acute care settings, reduce job satisfaction, and increase intent to leave. Fostering psychological ownership for work through improved work design has increased satisfaction, motivation, and productivity, and lowered turnover in other fields, and may have similar effects for advanced practice nurses. This multilevel cross-sectional survey study examined the relationship between advanced practice nurse work environment and psychological ownership using data from a survey of advanced practice nurses and nurse executives in Florida hospitals. Barriers in scope of practice and exclusion from hospital governance were common. Advanced practice nurses reported good relations with physicians and moderate organizational climate but poor relations with administrators and limited control over work. Organizational climate had a strong positive relationship with psychological ownership. Fostering advanced practice nurse psychological ownership could improve job satisfaction and decrease turnover leading to increased effectiveness in acute care settings.
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Dolan CM. Understanding employment contracts: What to know before you sign. Nurse Pract 2017; 42:44-49. [PMID: 29040178 DOI: 10.1097/01.npr.0000521996.45934.ba] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
NPs are conscientious providers, but when it comes to their own careers, they may not be as careful to apply the same prevention strategies, monitoring, and hypervigilance that they use with their patients to avoid poor outcomes. This article identifies potential risks in employment contracts and offers suggestions for avoiding disputes.
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Affiliation(s)
- Carolyn M Dolan
- Carolyn M. Dolan is a professor at the University of South Alabama, Fairhope, Ala
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Eastern Association for the Surgery of Trauma and Society of Trauma Nurses advanced practitioner position paper: Optimizing the integration of advanced practitioners in trauma and critical care. J Trauma Acute Care Surg 2017; 83:190-196. [PMID: 28328684 DOI: 10.1097/ta.0000000000001455] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nurse practitioners and physician assistants, collectively known as advanced practitioners (APs), enhance the provision of care for the acutely injured patient. Despite their prevalence, institutions employ, train, and utilize these providers with significant variability. The Eastern Association for the Surgery of Trauma, the Society of Trauma Nurses, and the American Association of Surgical Physician Assistants acknowledge the value of APs and support their utilization in the management of injured and critically ill patients. This position paper offers insight into the history of, scope of practice for, and opportunities for optimal utilization of APs in trauma, critical care, and acute care surgery services.
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Kvarnström S, Jangland E, Dahlgren MA. Introducing the nurse practitioner into the surgical ward: an ethnographic study of interprofessional teamwork practice. Scand J Caring Sci 2017; 32:765-771. [DOI: 10.1111/scs.12507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 06/19/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Susanne Kvarnström
- Region Östergötland; Linköping Sweden
- Department of Medicine and Health Sciences; Linköping University; Linköping Sweden
- Jönköping Academy for Improvement of Health and Welfare; Jönköping University; Jönköping Sweden
| | - Eva Jangland
- Department of Surgical Sciences; Uppsala University; Uppsala Sweden
- Department of Surgery; Uppsala University Hospital; Uppsala Sweden
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Preparation and Evolving Role of the Acute Care Nurse Practitioner. Chest 2017; 152:1339-1345. [PMID: 28823758 DOI: 10.1016/j.chest.2017.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/26/2017] [Accepted: 08/07/2017] [Indexed: 11/21/2022] Open
Abstract
Acute care nurse practitioners (ACNPs) are increasingly being employed as members of critical care teams, an outcome driven by increasing demand for intensive care services, a mandated reduction in house officer hours, and evidence supporting the ability of ACNPs to provide high-quality care as collaborative members of critical care teams. Integration of adult ACNPs into critical care teams is most likely to be successful when practitioners have appropriate training, supervision, and mentoring to facilitate their ability to practice efficiently and effectively. Accomplishing this goal requires understanding the educational preparation and skill set potential hires bring to the position as well as the development of an orientation program designed to integrate the practitioner into the critical care team. Pediatric ACNPs are also commonly employed in critical care settings; however, this commentary focuses on the adult ACNP role.
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Kleinpell R, Kapu AN. Quality measures for nurse practitioner practice evaluation. J Am Assoc Nurse Pract 2017. [DOI: 10.1002/2327-6924.12474] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Implementation of the Affordable Care Act (2010) enabled more than 30 million people to have new access to primary care services. On the basis of current utilization patterns, demand for primary care providers is expected to grow more rapidly than physician supply. This imbalance is expected to worsen, as the aging population requires more health care resources. In addition, more patients are requiring critical care services and physician numbers are not keeping with this growing need. Restrictions on resident physician practice hours have impacted inpatient care as well. Revisiting outdated state practice laws, and considering Full Practice Authority (FPA) for nurse practitioners (NP), is needed for improving access to care while creating greater flexibility for development of patient-centered health care homes and other emerging models of care delivery. Currently, 21 states and the District of Columbia have adopted FPA for NPs, with 15 more states planning legislation in 2016. Allowing FPA and Prescriptive Authority (PA) enables NPs to become more efficient and effective patient care team members. However, physician resistance to FPA and PA presents barriers to implementation.
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Affiliation(s)
- Deborah Dillon
- University of Virginia School of Nursing, Charlottesville (Dr Dillon); and Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio (Dr Gary)
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Tsai PI. Commentary on: Impact of Advanced Practice Providers (Nurse Practitioners and Physician Assistants) on Surgical Residents' Critical Care Experience. J Surg Res 2015; 199:13-4. [PMID: 26456354 DOI: 10.1016/j.jss.2015.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 08/17/2015] [Accepted: 08/19/2015] [Indexed: 11/20/2022]
Affiliation(s)
- Peter I Tsai
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
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Russell KW, Mone MC, Serpico VJ, Ward C, Lynch J, Neumayer LA, Nelson EW. Optimal utilization of a breast care advanced practice clinician. Am J Surg 2014; 208:1054-9; discussion 1058-9. [DOI: 10.1016/j.amjsurg.2014.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 11/29/2022]
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Kulkarni N, Cardin T. Hospital medicine workforce: the impact of nurse practitioner and physician assistant providers. J Hosp Med 2014; 9:678-9. [PMID: 25224751 DOI: 10.1002/jhm.2254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 08/17/2014] [Accepted: 08/19/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Nita Kulkarni
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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