Vol. 17 • Issue 5 • Page 31
Nurse practitioners who practice in acute care settings have demonstrated successful outcomes in continuity of patient care, decreased length of stay and enhanced multidisciplinary collaboration.1-6 n the area of cardiovascular disease specifically, NPs have become valuable members of the healthcare team because they promote early discharge and decrease hospital readmissions for heart failure and acute myocardial infarction. When NPs are teamed with physicians, patient hospital stays and patient care costs are reduced.1,2,5-7 Tertiary hospitals have been the traditional sites of acute care practice by nurse practitioners.3,8 he literature demonstrates the effectiveness of NP practice in the tertiary referral center, and community-based hospitals now are seizing on this trend to improve quality of service and patient outcomes.
A Vital Link
NPs who practice in the acute care setting are the link across the patient continuum to improve continuity. The literature confirms that nurse practitioners can decrease average length of stay by up to 1 day.2,9 y reducing the average hospital stay after the first 4 days (the days that are the most profitable), profits increase by $1,591 per day for each patient.2Through multidisciplinary collaboration, nurse practitioners can decrease hospital readmission rates - particularly among patients with heart failure.3
Why is this so? Nurse practitioners spend more time listening to patients and providing patient and family education during their rounds, actions that improve patient satisfaction. NPs help improve patient-provider relationships. And physicians generally are happy for the help - especially when the nurse practitioner is paid by the hospital.
History of a Program
HCA Kingwood Medical Center is a 197-bed, community-based hospital outside Houston Metropolitan Texas Medical Center. HCA is a hospital corporation that is a visionary in implementing programs designed to meet patient needs. HCA Kingwood Medical Center became an accredited chest pain center in 2005 when it established an interventional cardiology program serving a 120-mile stretch of the U.S. Highway 59 corridor in rural east Texas.
Along with the expansion of the cardiology program, the hospital administration initiated a cardiovascular NP program to assist with continuity of patient care and quality outcomes. In a research-based, quality-driven healthcare market, community-based hospitals are in a unique position to save lives and offer valuable healthcare services.
HCA Kingwood Medical Center created two full-time NP positions to provide Monday through Friday coverage of 12-hour shifts for the intermediate care and intensive care units. Four days a week, a single nurse practitioner is responsible for approximately 20 patients. The exception is Thursday, when the two NPs share a day and are then able to work together on educational projects after rounding. These projects are in addition to responding to changes in patient conditions.
The Nuts and Bolts
When developing a nurse practitioner program in a community-based hospital, administrative support is paramount. Many of the attending cardiologists at HCA Kingwood Medical Center had worked with NPs at their tertiary practice sites and were familiar with the benefits of nurse practitioner involvement. They persuaded the hospital administration to create an NP program.
In Texas, nurse practitioners have delegated diagnostic and prescriptive authority through collaborative practice agreements.10Use of nurse practitioner services at HCA Kingwood is voluntary, and physicians must sign the collaborative practice agreement if they want the NPs to participate in the care of their patients. The nurse practitioners report directly to the chief nursing officer. At other facilities, NPs may report to a director of the service line or a nurse manager.
Nurse practitioners who start or work in an NP hospital-based practice should consider the reporting structure of the position to ensure understanding of the NP role and to acquire full administrative support. For example, it may not be appropriate for an NP to report to a nursing director who does not hold an advanced nursing degree or to a non-nursing director who may not appreciate the NP role.
In Texas, nurse practitioners in a hospital setting must have a medical director. This medical director serves as the delegating physician for medical aspects of care.10A cardiologist from our largest cardiovascular group agreed to serve as our medical director.
We obtained a sample job description from another hospital within the HCA system and modified it to meet the needs of the local hospital. The hospital developed a competitive compensation package that reflected the knowledge that it is sometimes difficult to recruit to a community-based facility.
Stages of Development
We identified stages in the development and implementation of our nurse practitioner practice: initiation, inauguration and independence (see table). During the initiation phase, we received credentialing through the medical staff services. Because this was a new program, the medical director requested that each participating cardiologist sign the collaborative agreement. Fifteen of the 19 cardiologists at HCA Kingwood Medical Center signed on to our services.
In the inauguration phase, we began with daily rounds to get to know the cardiologists and to allow them to get to know us. We established collegial relationships and over time coordinated care practices such as the preferred cardiac medication for certain conditions, anticoagulation decisions, treatment for electrolyte imbalance, and so on. After the initial few months, we began our autonomous practice.
We now round prior to the cardiologist and write our own daily progress notes. This allows any additional practice questions to be addressed while the cardiologist is on the unit. The cardiologists value the fact that we are their eyes and ears on the unit. We are first on the scene when a patient's status changes, and we begin the work-up before the cardiologist even arrives. We assess patients for discharge, prepare prescriptions and dictate discharge summaries.
The hospital values our attention to the Centers for Medicaid and Medicare services (CMS) core measures for acute myocardial infarction and heart failure. Prior to the establishment of our NP program, compliance rates for aspirin and beta-blocker prescriptions atdischarge for acute myocardial infarction were occasionally in the 90thpercentile range. After we had been on the unit for 1 year, compliance was 100%. CMS requires specific discharge instructions for heart failure (HF) patients.11Our greatest results have been demonstrated in HF core measures. Hospital compliance improved from 83% to 100% after 1 year of NP presence.
The CMS core measures recommend an angiotensin-converting enzyme inhibitor or angiotension receptor blocker for left ventricular ejection fraction of less than 40%.11Scores prior to NP involvement were 92% and improved to 100% with NP involvement. This has placed our hospital in the top of its market in the Houston metropolitan area.
In addition to addressing CMS core measures, we assisted with documentation to capture optimal codes for reimbursement and with meeting documentation requirements of JCAHO.
As with any new program, we had to overcome certain barriers. We had to educate our physicians and allied health colleagues about the nurse practitioner role. Our health information department initially thought all NP orders and notes had to be cosigned by physicians. This is not true in Texas, and this requirement has been removed.12
An additional barrier to nurse practitioner practice is the clear delineation of responsibilities. For example, our medical director has asked us not to do initial cardiology consults. In a community-based hospital, some physicians may consider it improper to delegate the initial consult to a nurse practitioner. We are still working to overcome this barrier. If the cardiologist is the admitting physician, we may perform the history and physical examination and assist in getting the documentation on the chart per hospital requirement.
Acceptance by physicians and allied health professionals continues to evolve. Patience is necessary to educate and re-educate colleagues about the role. Some physicians viewed the inability to receive reimbursement for our notes and dictation as a barrier. Initially, staff nurses "tested" the nurse practitioners by calling the physicians after taking an order from the NP. This practice has resolved with time.
We have facilitated professional development with the introduction of a monthly journal club and quarterly nursing grand rounds. Staff nurses have been inspired to further their education with advanced degrees and to obtain specialty certification. We have also served as preceptors for both graduate and undergraduate nursing students.
Putting It Into Practice
Our community-based NP program is still in its infancy, but it already has demonstrated improvements in continuity of care and the quality of patient outcomes. Our presence in the cardiac intermediate care unit and intensive care unit has decreased the number of rapid response team calls and cardiopulmonary arrests. Since the initiation of the program, overall patient length of stay has decreased 0.34 days. CMS core measure data have improved. Physicians are satisfied with NP performance and assistance with patient care. Nursing is appreciative of the clinical expertise available on the units. Administration is satisfied with the overall outcomes of patient satisfaction and is recruiting more nurse practitioners for additional service lines. Nurse practitioners can have a valuable impact in community-based hospitals.
1. Potera C. In the news. NPs prove their value in the inpatient setting: teaming NPs with physicians reduces hospital stays and costs. Am J Nurs. 2006;106(12):19.
2. Cowan MJ, et al. The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs. J Nurs Adm. 2006;36(2):79-85.
3. McCauley KM, et al. Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Dis Manag. 2006;9(5):302-310.
4. Hoffman LA, 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):121-132.
5. Hoffman LA, 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.
6. Miller M, et al. Forces of change. Nurse practitioners: current status and future challenges. Clin Excellence Nurse Pract. 2005;9(3):162-169.
7. Howie JN, 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.
8. Kleinpell R. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care. 2005;14(3):211-221.
9. Meyer SC, Miers LJ. Cardiovascular surgeon and acute care nurse practitioner: collaboration on postoperative outcomes. AACN Clin Issues. 2005;16(2):149-158.
10. Texas Board of Nursing. Rules and regulations relating to nursing education, licensure and practice. Available at: http://www.bon.state.tx.us/about/pdfs/bon-rr-0808.pdf. Accessed Feb. 16, 2009.
11. U.S. Department of Health and Human Services. Hospital Quality Initiatives Overview. Available at: http://www.cms.hhs.gov/HospitalQualityInits/.
Accessed Feb. 16, 2009.
12. Texas Board of Nursing. Nurses carrying out orders from advanced practice nurses. Available at: http://www.bon.state.tx.us/practice/position.html#15.18. Accessed Feb. 16, 2009.
Cindy Weston is a family nurse practitioner and a critical care clinical nurse specialist in the cardiovascular service line at HCA Kingwood Medical Center in Kingwood, Texas. Christina Bennett is an acute care nurse practitioner in the cardiovascular service line at HCA Kingwood Medical Center.