Traditionally, hospitalists have been hospital-based physicians who make decisions about the care of inpatients and refer them to primary care physicians after they are discharged from the hospital. Approximately 20,000 hospitalist physicians are in practice in the United States today.¹In recent years, hospitals have struggled with growing numbers of inpatients, dwindling numbers of physicians and reduced physician and resident workloads. A primary solution has been the addition of nurse practitioners to their hospitalist teams. This role evolution has met with much success, yet awareness and understanding of the hospitalist role continue to be spotty.

Most hospitalist NPs are certified as acute care nurse practitioners, a specialty that emerged in the 1990s.²The American Academy of Nurse Practitioners reports that acute care NPs make up 5.6% of all NPs. Nearly 80 programs are training acute care nurse practitioners and pediatric acute care NPs across the country. But what exactly do NPs do as hospitalists?

The Hospitalist Role
Hospitalist nurse practitioners provide services to inpatients who have no primary care physician or patients whose primary care physician cannot visit the patient in the hospital. They admit, care for and discharge patients in the hospital, and they perform procedures based on hospital privileges they have earned. Some NP hospitalists manage the patient load of other NPs, PAs and residents in the hospital.

Hospitalist responsibilities include rounding, participating in team meetings, being aware of all patients' treatment plans, documenting findings in patient charts, assigning patients to on-call staff, assessing and managing medications, ordering and reviewing lab tests or other diagnostic tests, coordinating patient transitions, and providing inservice education to nurses.¹

ospitalist NPs can also perform special functions, according to Maggie McLain, an NP in the hospitalist service at St. Alphonsus Regional Medical Center in Boise, Idaho.

"We act as the lone providers in a presurgical screening clinic," providing complete perioperative risk evaluation, McLain says. "This has even been helpful for patients who have primary care physicians, because it is often difficult for patients to get a visit scheduled with their primary care provider within the time frame necessary to avoid postponing their scheduled surgery."

Role History
During the 1990s, many hospitals recognized a need for changes in hospital care. For example, in 1995 the University of Rochester Medical Center (URMC) hired its first nurse practitioners as hospitalists. The concept for the program came about because the hospital recognized that inpatients being managed by primary care physicians were not getting the care they needed.

"A lot of these patients were cared for by primary care physicians who either didn't have the time or the expertise to manage acute illness," says Mike Ackermann, NP, director of the Margaret D. Sovie Center of Advanced Practice at URMC. "The idea was [that] we could probably form a service, and we could take care of these patients for primary care physicians and some subspecialties like gastroenterology or nephrology, where they're admitted for different problems but they're still under the care of a nephrologist or gastroenterologist."

Initially, Ackermann says, NPs saw fairly uncomplicated cases such as urinary tract infections or cellulitis - patients whose typical length of stay was less than 3 days. The service began with a handful of physicians and NPs caring for about 10 patients. Over time, the concept grew, and response was positive. "Now we have a waiting list of primary care physicians who want to use the service," he notes.

In 2005, Ackermann developed a cluster system in which one lead NP is responsible for the cluster's evaluations, ongoing communication and meetings with program leadership. Today, the hospital employs 375 NPs; 26.5 full-time positions are designated for the lead NP hospitalist role.

Education and Certification
The most logical certification for a hospitalist NP would be certification as an acute care nurse practitioner, Ackermann says. "You illegitimize the certification and the educational process if you don't differentiate who can practice where: If it didn't matter whether you're acute or family, why do we even have these programs?"

But because the supply of acute care NPs falls short of filling all hospitalist positions, adult and family nurse practitioners are commonly hired by hospitals for hospitalist teams. And, Ackermann says, an NP's ability isn't necessarily defined by credentials: Related experience trumps certification.

"We look more at the person than what his or her credentialing is." It is, however, difficult to employ gerontologic NPs, because they can't treat patients younger than 55. This restricts their ability to work in the hospital setting.

Ackermann says that since URMC began preferentially hiring acute care NPs as hospitalists, enrollment in the acute care NP program at the University of Rochester has risen. "It used to be that if you want to be more marketable, go into family practice, because then you can do anything. Well I've put a stop to that rumor and said, no, if you want an acute care job, go into acute care."

A Day in the Life
A typical day for a hospitalist NP consists of a 10-hour shift. At URMC, hospitalist NPs start the morning by meeting with overnight staff, discussing admissions, and assigning patients to different teams based on acuity and educational opportunities.

"The hospitalist is the leader of the team, so ideally the hospitalist delegates and then spends the day seeing patients and discharging," Ackermann explains. The rest of theday is spent prioritizing based on when patients will be discharged. "NPs see patients between 8 a.m. and 1 p.m., also answering pages and putting out fires and seeing other patients they haven't seen yet, and doing admissions." When the evening shift starts, the NPs take care of anything that has carried over. They admit and cross-cover patients and take call.

"During the day shift, it's more systematic: We make sure we see the patients, write a note, do orders, follow up on x-rays and labs, do whatever needs to be done" and work on coordinating discharge, Ackermann says. "If they get a chance they can go to the bathroom, or eat, or go to a conference," he jokes. "Some days are really quite manageable, and others are just crazy." Ackermann says he tries to keep each NP's patient load under 10.

In states where NPs are supervised byphysicians, all hospital patients who require a diagnosis must be seen daily by a physician. If a hospitalist NP is the provider designated to see a patient, an internist often sees the patient briefly afterward and writes a short note indicating concurrence or adding a comment.

NPs manage conditions such as diabetes, hypertension, venous thromboembolism and many others. Hospitalists may or may not perform procedures such as central line placement or thoracentesis, depending on the hospital and its hospitalist program. If a specific treatment question arises, NPs typically consult with internists on the team or specialists from other departments.