April N. Kapu

Quality and Financial Impact of Adding Nurse Practitioners to Inpatient Care Teams

OBJECTIVE The purpose of this project was to examine the financial impact of adding nurse practitioners (NPs) to inpatient care teams at Vanderbilt University Hospital. BACKGROUND National initiatives targeting quality, safe, and cost-effective healthcare have created the optimal environment for NPs to showcase their abilities and contributions. Identifying outcomes that are directly affected by NPs and quantifying data in terms of dollars can be affirmation for the contribution of the NP practice. Value can be garnered in terms of revenue generation and cost-effectiveness of hiring NP providers; however, a considerable financial impact can be in cost avoidance and cost savings through NP-associated outcomes of care. METHODS This was a retrospective, secondary analysis of return on investment after adding NPs to 5 teams. Software was used to abstract billing, acuity, and length of stay (LOS) data and NP-associated quality metrics. Billing data, LOS, and risk-adjusted LOS data for designated years before and after adding NPs were compared. RESULTS Gross collections compared with expenses for 4 NP-led teams for 2 year time periods were 62%, 36%, and 47%, and +32%. Average risk-adjusted LOS for the 5 time periods after adding NPs decreased and charges decreased, thus demonstrating less resource use. Most clinical outcomes improved beyond preproject baselines. CONCLUSION This project demonstrated the value of adding NPs to inpatient care teams by means of generated revenue, reduction in LOS, and standardization of quality care.

Developing nurse practitioner associated metrics for outcomes assessment

As nurse practitioners (NPs) assume an increasing role in providing care to hospitalized patients, measuring the impact of their care on patient outcomes and quality of care measures becomes a necessary component of performance evaluation. Developing metrics that relate to quality of care measures as well as patient outcomes based on the specific practices of an NP can help to specifically identify the impact of NP care in hospital and ambulatory care settings. New opportunities have arisen for highlighting NP outcomes that can be used to structure NP-associated metrics including the Hospital Value-Based Purchasing Program and the Joint Commissions practice evaluation standards. This manuscript discusses the use of NP-associated metrics for assessing the outcomes of NP care on patient care as well as on quality of care measures.

Addition of Acute Care Nurse Practitioners to Medical and Surgical Rapid Response Teams: A Pilot Project

Background Vanderbilt University Hospitals original rapid response team included a critical care charge nurse and a respiratory therapist. A frequently identified barrier to care was the time delay between arrival of the rapid response team and arrival of the primary health care team. Objective To assess the impact of adding an acute care nurse practitioner to the rapid response team. Methods Acute care nurse practitioners were added to surgical and medical rapid response teams in January 2011 to diagnose and order treatments on rapid response calls. Results In 2011, the new teams responded to 898 calls, averaging 31.8 minutes per call. The most frequent diagnoses were respiratory distress (18%), postoperative pain (13%), hypotension (12%), and tachyarrhythmia (10%). The teams facilitated 360 transfers to intensive care and provided 3056 diagnostic and therapeutic interventions. Communication with the primary team was documented on 97% of the calls. Opportunities for process improvement were identified on 18% of the calls. After implementation, charge nurses were surveyed, with 96% expressing high satisfaction associated with enhanced service and quality. Conclusions Teams led by nurse practitioners provide diagnostic expertise and treatment, facilitation of transfers, team communication, and education.

Benchmarking the Use of a Rapid Response Team by Surgical Services at a Tertiary Care Hospital

BACKGROUND Rapid response teams (RRT) are used to prevent adverse events in patients with acute clinical deterioration, and to save costs of unnecessary transfer in patients with lower-acuity problems. However, determining the optimal use of RRT services is challenging. One method of benchmarking performance is to determine whether a departments event rate is commensurate with its volume and acuity. STUDY DESIGN Using admissions between 2009 and 2011 to 18 distinct surgical services at a tertiary care center, we developed logistic regression models to predict RRT activation, accounting for days at-risk for RRT and patient acuity, using claims modifiers for risk of mortality (ROM) and severity of illness (SOI). The model was used to compute observed-to-expected (O/E) RRT use by service. RESULTS Of 45,651 admissions, 728 (1.6%, or 3.2 per 1,000 inpatient days) resulted in 1 or more RRT activations. Use varied widely across services (0.4% to 6.2% of admissions; 1.39 to 8.73 per 1,000 inpatient days, unadjusted). In the multivariable model, the greatest contributors to the likelihood of RRT were days at risk, SOI, and ROM. The O/E RRT use ranged from 0.32 to 2.82 across services, with 8 services having an observed value that was significantly higher or lower than predicted by the model. CONCLUSIONS We developed a tool for identifying outlying use of an important institutional medical resource. The O/E computation provides a starting point for further investigation into the reasons for variability among services, and a benchmark for quality and process improvement efforts in patient safety.

Advanced Practice Providers' Perceptions of Patient Workload: Results of a Multi-Institutional Survey.

OBJECTIVE: This study examines data collected from a survey of advanced practice providers’ (APPs’) perceptions of reasonable versus actual APP-to-patient ratios and other factors that affect workload burden in both inpatient and outpatient clinical settings. BACKGROUND: Advanced practice providers provide accessible, cost-effective, and quality care in a growing number of specialty practices across multiple patient care settings. They are caring for higher volumes of patients and assuming more responsibilities while continuing to navigate highly complex healthcare systems. Limited evidence or benchmark data exist that would assist in determining optimal workload and staffing models that include APPs. METHODS: A group of advanced practice leaders developed and distributed a 43-question survey of workload factors to a highly diverse APP workforce. RESULTS: There were 1466 APPs across 37 areas of practice who responded to the survey distributed in 14 separate organizations. The perceived reasonable workload was lower than the actual workload for 22 specialty practice areas. The analysis included years of experience as an APP, work hours, on-call commitment, nonclinical responsibilities, and time spent in documentation, direct patient care, and performing procedures. CONCLUSIONS: There is a consensus among APPs, within their practice area, about what constitutes a reasonable patient assignment, despite the variability in APP experience, organizational culture, processes, and patient acuity.

Quality measures for nurse practitioner practice evaluation

BACKGROUND AND PURPOSE Evaluating the impact of nurse practitioner (NP) practice has become a priority area of focus for demonstrating outcomes. A number of quality measures are available to enable practice-specific evaluation of NP roles and initiatives. This article reviews sources of quality measures that can be used to facilitate quantifying the outcomes of NP practice as part of an overall evaluation agenda. METHODS National resources and published literature on NP quality measures were reviewed. CONCLUSIONS Various resources and toolkits exist to assist NPs in identifying outcomes of practice using quality measures. IMPLICATIONS FOR PRACTICE The need to demonstrate outcomes of NP practice remains an ongoing priority area regardless of the clinical practice setting. A variety of sources of quality measures exist that can be used to showcase the effect of NP care. The use of quality measures can be effectively integrated into evaluation of NP role and NP-directed initiatives to demonstrate impact, and enhance the conduct of an NP outcomes assessment. The use of organizational, NP-specific, and national-related quality measures can help to showcase how NP care improves the quality, safety, and costs of health care.Background and purpose Evaluating the impact of nurse practitioner (NP) practice has become a priority area of focus for demonstrating outcomes. A number of quality measures are available to enable practice-specific evaluation of NP roles and initiatives. This article reviews sources of quality measures that can be used to facilitate quantifying the outcomes of NP practice as part of an overall evaluation agenda. Methods National resources and published literature on NP quality measures were reviewed. Conclusions Various resources and toolkits exist to assist NPs in identifying outcomes of practice using quality measures. Implications for practice The need to demonstrate outcomes of NP practice remains an ongoing priority area regardless of the clinical practice setting. A variety of sources of quality measures exist that can be used to showcase the effect of NP care. The use of quality measures can be effectively integrated into evaluation of NP role and NP-directed initiatives to demonstrate impact, and enhance the conduct of an NP outcomes assessment. The use of organizational, NP-specific, and national-related quality measures can help to showcase how NP care improves the quality, safety, and costs of health care.

407: IMPLEMENTATION OF A CRITICAL CARE ULTRASONOGRAPHY WORKSHOP FOR ADVANCED PRACTICE PROVIDERS.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) surrogates. Approximately 20 % of deaths in United States occur in Intensive Care Unit (ICU), mostly preceded by withdrawal of life support. Emphasis on assessment, teaching and feedback at all levels of training is essential to foster attitudes and abilities to continuously improve communication skills. Methods: We conducted a prospective study to assess and teach communication skills around breaking bad news and discussing end of life issues to the training fellows in Pulmonary and Critical Care Medicine (PCCM) and Critical Care Medicine (CCM).The study was done in three phases. The first phase involved utilization of high fidelity mannequins and standardized patients (SPs) in a hybrid fashion to assess baseline skills of fellows in breaking bad news and discussing goals of care with the simulated patient and SP families. Fellows were then randomized to intervention and control groups. The intervention group underwent four hour training session consisting of didactic, simulated scenarios with feedback from SPs and facilitator using SPIKE and SILVER tool, self-assessment and discussion with the peers. In the final phase, currently all the fellows are being assessed during family discussions in ICU by two co-investigators, who are blinded to physician invention group to evaluate the effect of training. Results: Wilcoxon signed-rank test and Mann-Whitney test are being used to estimate the score differences from baseline to post-education intervention within groups and between groups with 95% confidence intervals. A preliminary data is showing improvement in scoring on SPIKE and SILVER tools by approximately 20% in third year fellows who underwent training. Conclusions: Learners can attain proficiency in communication by training with hybrid simulation scenarios. Effective communication will not only assist in implementing best patient care practices but will also have organizational impact if applied towards multidisciplinary team framework.