Vol. 17 • Issue 2 • Page 37
For more than 40 years, nurse practitioners have provided high-quality, cost-effective health care.1,2 Traditionally, NPs have focused on health promotion and management of chronic illness in outpatient settings. The evolving role of the acute care nurse practitioner is one of the newest ways that NPs are making a mark on health care.
Acute care nurse practitioners provide and coordinate health care for acutely ill patients who are hospitalized. In the 2007 National Salary and Workplace Survey of Nurse Practitioners, 6% of nurse practitioners reported being certified in acute care.3
Background
Academic medical centers were the first to hire acute care NPs to reduce costs and improve the quality of inpatient care. Starting in the 1990s, many university hospitals employed NPs to provide care otherwise provided by resident house staff.4As hospitals continued to struggle for alternative approaches to improve the quality of care and to reduce expenditures, a variety of models evolved. Most had one thing in common: pairing acute care NPs with attending physicians, hospitalists, interdisciplinary teams or physicians in training.
The quality of care provided by acute care NPs has been examined in studies that used clinical outcomes measured by compliance with evidence-based practice protocols, patient satisfaction and discharge care management. The cost of care was measured by length of hospital stay.
This article reviews published research related to the hypothesis that overall clinical quality care outcomes improve and hospital costs decrease when acutely ill patients receive medical management from an acute care NP-physician team rather than the attending physician or resident staff alone.
Literature Review
Because patients are admitted to hospitals with complex medical problems, several physicians typically become involved in each patient's care. Managed care policies have placed pressure on physicians to minimize lengths of stay. Meanwhile, hospital administrators have struggled to adhere to professional national evidence-based quality care guidelines as well as federal and state credentialing regulations. Hospitals added acute care NPs to incorporate creative models of care into the medical service in order to meet these patient care goals. Although the expansion of NP practice in acute care is widespread, few published studies have examined nurse practitioner practice in an inpatient hospital. This reflects a hesitation by some institutions to embrace this model.
Any reluctance to bring NPs into acute internal medicine services may be related to the extensive differential diagnoses required due to the many comorbidities in this population.5One relevant study focused on hospitals that did not have residents or physicians in training and hired acute care NPs to meet this need.6The acute care NPs had the primary responsibility of facilitating patient care plans from admission to discharge. The researchers found that collaboration between the physicians and acute care NPs was the key element of success for the care delivery model. The researchers reported that the quality of patient care improved with the acute care NP model due to decreased fragmentation of care, increased interaction between physicians and nurse practitioners, and enhanced roles of nurse practitioners in clinical evaluation and decision making.6
The work environment and functions of an acute care NP vary. A literature review compared the acute care NP role with the resident house staff role within hospitals. In emergency departments, acute care NPs are often used in fast-track units to provide minor emergency care.5Surgical services use acute care NPs for preoperative histories and physicals, to educate patients and to coordinate postoperative home care. In the inpatient medical service, acute care NPs perform invasive procedures, manage the unit with physicians and coordinate hospital and discharge care follow-up.
A summary of clinical outcomes for acute care NPs in one hospital system showed improved documentation of completed care related to protocol compliance, decreased complaints by patients, minimized surgical delays and improved continuity with discharge planning goals when compared with house resident staff.5
Technical skills were comparable between acute care NPs and the house staff. Hospital staff nurses described acute care NPs as more approachable and responsive to suggestions about patient care. Acute care NPs spent more time at the bedside interacting with patients and families. The acute care NPs were more skilled at developing relationships with patients and the patients' physicians, which facilitated a smoother transition from hospital to home.5Another study showed that acute care NP-MD teams safely managed subgroups of ICU patients in a manner comparable to house residents.4No significant difference was noted in quality of care or length of stay.4Acute care NPs had a constant presence on the hospital unit and provided more proactive care than physicians or residents who had additional off-unit responsibilities. When frequent changes in shift rotation personnel occurred (nurses and physicians), gaps were evident in the provider's knowledge of the patient's history and interventions. Acute care NPs provided a steady consistency of care, with a single practitioner comanaging patients.
An important consideration in interpreting study findings was related to the amount of oversight provided by the physician member of the acute care NP-MD team. The acute care NP practiced in collaboration with one attending physician who was always available for consultation. Supervision and consultation with the physician depended on years of nursing service, special training and expertise. The study also emphasized that results were based on workload and cost constraints that allowed a single acute care NP to be assigned to one unit Monday through Friday. Continuity of care improved quality of care.4
The available research shows that the success of the acute care NP-MD model is dependent on significant support from medical and nursing personnel. An important early step is to clarify the role of the acute care nurse practitioner with staff nurses and administrative staff before the program starts. Active solicitation of support from nurses, pharmacists, respiratory therapists and nursing assistants promotes good communication patterns.5
For the acute care NP-MD model to be successful, evidence-based performance measures should be implemented, monitored and measured before bringing the NP on board.5Establishing the role of the acute care NP ina hospital should include the development of written, standardized evidence-based practice protocols and formal approval from the hospital's interdisciplinary practice committee and medical executive board. These protocols describe the role, setting and functions of the acute care NP. In the typical setting, supervision or collaboration is provided by one attending physician.
Ongoing educational sessions for acute care NPs are typically provided through didactic sessions with various attending physicians. In the typical setting, acute care NPs report clinical patient information in a standardized, structured manner that provides professional consistency when communicating with various physicians.5
Financial Considerations
Cost containment is a primary goal at all hospitals. The emergence of new technologies, better medications and managed care have allowed patients to be discharged to an outpatient setting quickly, leaving only the seriously ill to be cared for in the hospital.
Researchers studied the use of the acute care NP model for patients admitted with community-acquired pneumonia (CAP) and chronic obstructive pulmonary disease (COPD) at an urban hospital. The goal was to reduce length of stay and increase cost savings.7Compliance with CAP performance measures dramatically improved with NP care, from a range of 67.9% to 87.2% to a range of 97% to 100%. After a 6-month implementation phase, the mean length of stay was reduced from 7.17 days to 5.83 days (decrease of 1.34 days).
This drop in length of stay generated 965 additional bed days, of which 75% would likely be filled due to high census with Medicare patients (paid per case rather than per diem). This newly improved flow through the system allowed for an estimated 124 new Medicare admissions. The calculated increased revenues from the NP intervention in the CAP program were $319,424.7For the COPD cases, the average actual direct costs did not change significantly.7
Other Considerations
Acute care NPs acting as care managers are typically paid by the hospital or contracted agency. In many states, acute care NPs are required to have collaborative agreements with physicians.8Other states allow NPs to function in hospital settings without collaborative agreements.9 Informed consent is obtained upon admission to the hospital and applies to all health care providers, including acute care NPs.
Another consideration is whether other health care providers respect and trust acute care NPs to work collaboratively in an acute care setting. The health care culture may be affected by perceptions about the acute care NPs' competence, accessibility, knowledge, care coordination and communication skills.
Researchers who investigated this aspect of the role concluded that acute care NPs were viewed as experts in providing routine daily management of patients and in meeting the needs of patients and patients' families - especially with regard to so-called "long stay" patients.10
Acute care NPs were valued for their commitment to quality care and patient safety and for their advanced communication skills. When asked to cite examples, respondents pointed to the NPs' ability to provide staff education and to involve patients and families in quality teaching. The conclusion of this study identified physician and staff perceptions of acute care NPs as medically oriented but with themes that were clearly nursing focused.10
Putting It Into Practice
In the hospitals that employ them, acute care NPs have become agents of change. Research shows that where acute care NPs play an important role, physicians, nurses and hospital staff members function in a more collaborative culture with a strong focus on patient care and safety.
Compared with medical residents, acute care NPs spend more time interacting with patients and their families and collaborating with other members of the health care team.11Because acute care NPs typically do not have other responsibilities off the unit, they devote themselves to the details of patient care.11The NPs' comanagement of medical care, combined with their strong social assessment and discharge planning skills, help decrease length of stay.8
Acute care NPs spend more time than residents reviewing chart notes, interacting with patients and family members, documenting, and interacting with other health care providers.12Patient satisfaction scores for acute care NPs are significantly higher than those for medical residents.12
Overall, the research published thus far supports the hypothesis that clinical quality-of-care outcomes improve and costs are reduced when acutely ill patients receive medical management from an acute care NP-MD team rather than the attending physician and resident staff alone. These outcomes are dependent on well functioning teams with appropriate specialized training, effective communication skills and successful collaboration with other health care providers.
References
1. Buppert C. Justifying nurse practitioner existence: hard facts to hard figures. Nurse Pract. 1995;20(8):43-48.
2. Kleinpell R. Evolving role descriptions of the acute care nurse practitioner. Crit Care Nurs Q. 1999;21(4):9-15.
3. Rollet J, Lebo S. The 2007 National Salary and Workplace Survey of Nurse Practitioners. A decade of growth. Salaries increase as profession matures. ADVANCE for Nurse Practitioners. 2008;16(1):29-35.
4. Hoffman L, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130.
5. Howie J, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. Am J Crit Care. 2002;11(5):448-458.
6. Genet C, et al. Nurse practitioners in a teaching hospital. Nurse Pract. 1995;20(9):47-52.
7. Gross P, et al. Extending the nurse practitioner concurrent intervention model to community acquired pneumonia and chronic obstructive pulmonary disease. Jt Comm J Qual Saf. 2004;30(7):377-386.
8. Larkin H. The case for nurse practitioners. Used correctly, they can improve outcomes, lower costs and make up for reduced residents' hours. Hosp Health Netw. 2003;77(8):54-58.
9. Nursing and Advanced Practicing Nursing Act. Illinois Division of Professional Regulation. Available at: http://ilga.gov/. Accessed Nov. 14, 2008.
10. Hoffman L, et al. Perceptions of physicians, nurses, and respiratory therapists about the role of acute care nurse practitioners. Am J Crit Care. 2004;13(6):480-488.
11. Hoffman L, et al. Management of patients in the intensive care unit: comparison via work sampling analysis of an acute care nurse practitioner and physicians in training. Am J Crit Care. 2003;12(5):436-443.
12. Sidani S, et al. Outcomes of nurse practitioners in acute care: an exploration. Internet Journal of Advanced Nursing Practice. 2006;8(1). Available at: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijanp/vol8n1/outcome.xml. Accessed Oct. 30, 2008.
Mary VanOyen Force is an adult nurse practitioner at Suburban Pulmonary and Sleep Associates in Geneva, Ill.
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