Used correctly, they can improve outcomes, lower costs and make up for reduced residents' hours
In 1998, executives at Loyola University Health System, Maywood, Ill., were dissatisfied with the medical center's cardiovascular surgery program. While clinical outcomes and costs were nothing to be ashamed of--Loyola stood mid-pack compared with other programs both regionally and nationally--they weren't quite what leaders wanted at an institution that prides itself on its reputation for pioneering advanced cardiovascular services and transplants.
Loyola set out to redesign CV surgery care. Under the direction of surgeon Jeffrey Schwartz, M.D., the hospital developed and implemented detailed admitting, case evaluation, monitoring, ventilator weaning and rehabilitation protocols. Post-op bypass and valve patients were grouped together in a dedicated recovery area, where they were attended by surgeons and anesthesiologists dedicated to the CV service rather than by their primary care physicians.
To keep everything on track, primary responsibility for managing CV surgery patient care in the ICU and on the floor was transferred from cardiology residents to three specially trained nurse practitioners. Their job: to ensure that the advanced protocols were followed by constantly monitoring patients' conditions, and adjusting their care to keep them progressing toward discharge. They also served as primary contacts for patients' families and took charge of discharge and follow-up care.
The results were dramatic, especially for coronary artery bypass procedures. From 1998 to 2001, risk-adjusted operative mortality, as measured by the Society of Thoracic Surgeons database, steadily drop-ped from 3 percent to 0.9 percent, a decline in the ratio of observed to expected mortality from about 1.0 to 0.33. In the second half of 2001, the program achieved the lowest mortality rate among 50 academic cardiovascular programs participating in a University HealthSystems Consortium benchmarking project.
Costs also fell. Between the 12 months ending in the third quarter of 2000 and the second half of 2001, cost per case declined more than 9 percent, from just over $27,000 to about $24,500, resulting in an annualized direct savings of about $1 million.
Schwartz emphasizes that these gains resulted from a complete redesign of cardiovascular surgery care, but he believes that having highly skilled nurse practitioners dedicated to patient management, and coordinating all aspects of a highly complex care process, has been essential to the program's success.
"Unlike residents, the nurse practitioners have no other responsibilities. It allows them to immerse themselves completely in the details of patient care," he says. "It's less likely that something will be overlooked because they are totally focused on getting the patient to recover."
The intimate knowledge the nurse practitioners gain of individual patients' clinical issues helps them spot early signs of trouble that might be missed by physicians who see inpatients for only a few minutes a day and in follow-up clinics, Schwartz says. "I am certain they have saved numerous lives because of their familiarity with patients' conditions."
Loyola is not unique in its experience with nurse practitioners in acute care. A growing body of evidence shows that nurse practitioners and other advanced practice nurses can be highly effective when used to coordinate and implement complex evidence-based care programs.
"We're seeing it more now in areas of critical care and ICU," says Pamela Thompson, R.N., chief executive officer of the American Organization of Nurse Executives. "But it's worthwhile to note that we've been using advance practice nurses in neonatal intensive care for 20 years."
Systems such as the VA have historically made more use of nurse practitioners, says Lucy N. Marion, Ph.D., R.N., professor and associate dean of academic nursing at the University of Illinois at Chicago school of nursing. Extending nurse practitioners to other settings has met resistance, but that's declining.
"As we see more studies published documenting the positive impact of using nurse practitioners, we'll see them in more places," Marion says.
Nurse practitioners are typically better qualified to manage complex cases than general nurses because they have additional training in pathophysiology, pharmacology and diagnostic techniques. Many also have advanced training in research and evidence-based protocols, and can interpret monitoring data to know when a change in care must be made. They are trained at the master's degree level and may prescribe drugs and write orders, though their scope of practice varies by state. In most cases, they are required to work in a collaborative arrangement with a physician, though they typically have enough authority to work within a protocol in a hospital setting.
Limits on resident work hours are also pushing increased use of nurse practitioners. A recent survey of 42 teaching hospitals by University HealthSystems Consortium found that more than half have added or plan to add nurse practitioners or physician's assistants to alleviate resident shortages.
"If we didn't already have this [nurse practitioner] model in place, we'd be having coverage problems," Schwartz says.
The financial case in favor of nurse practitioners is often compelling. At the University of Virginia Health System, for example, a nurse practitioner model introduced in the neurosciences area in 1999 has cut about 2,000 inpatient days on a similar volume and case mix of patients, resulting in a $2.4 million savings the first year, says Dale Shaw, R.N. This on an investment of about $150,000 in salaries and benefits--a return on investment of about 1,600 percent.
The results surpassed all expectations. "When we first calculated the savings, everyone wanted to go over them again," Shaw says. "They were reworked by administration and medical management and they all got the same result." Neurosciences administrator Rebecca A. Lewis, R.N., estimates the program has saved the University of Virginia about $8 million since its inception.
A study by Shaw and her colleagues showed that average length of stay for patients who were overseen by nurse practitioners was three days fewer than for patients who were not managed by nurse practitioners, a reduction of 27 percent. Complication rates for urinary tract infections, skin lesions and pneumonia also dropped significantly.
Nurse practitioners' social assessment and discharge planning skills also help cut lengths of stay. Shaw credits an aggressive push to identify early those patients who will need extra support at discharge so arrangements can be made without having to hold them an extra day or two simply because there's no place for them to go.
Virginia's neuro program was modeled on a successful nurse practitioners program in the adult medical intensive care unit. Aggressive implementation of ventilator weaning protocols cut an estimated $3,341 per case for DRGs 475 and 483 (tracheostomy without head and neck surgery), says Suzy Burns, R.N., who heads the MICU program.
Hospital officials estimate the program has reduced ventilator days by 2,000 annually, for a savings of $1.2 million. A nurse management model also cut lengths of stay 37 percent and cost per case 15 percent for parathyroidectomy, making a marginal or money-losing service profitable.
Virginia also uses nurse practitioners as care managers in cardiac cath labs, heart failure clinics and a chest pain clinic.
At the University Hospitals Health System, Cleveland, nurse practitioners not only serve as dedicated care managers in high-intensity service areas, including heart failure, they also admit and supervise general medical patients, says Robin J. Rowell-Leinweber, R.N., manager of the nurse practitioner service.
Any physician can admit a patient who meets specific guidelines through the nurse practitioner service, which is overseen by a physician hospitalist. Nurse practitioners oversee care, filling many of the functions of a resident or hospitalist.
About 15 percent of medical patients are admitted to the nurse practitioner service, Rowell-Leinweber estimates. "The hospital is definitely looking to expand the program," she says.
As much as nurse practitioners have to contribute, they are not a panacea, notes William M. Barron, M.D., executive medical director of Loyola's Center for Clinical Effectiveness, which oversees quality improvement initiatives for the system. They are most effective when integrated into a team implementing evidence-based medicine. "Nurse practitioners are good glue and good communicators," Barron says. "They can hold a complex protocol together, but the protocol has to be put in place, and that requires changes at every level of the institution."
That kind of change can be difficult, Thompson points out. "You need significant support from the medical staff and from the nursing staff because these are nurses working in a medical model. They're not just an extra nurse on the unit."
Reimbursement is another issue. Many insurers limit or deny payment for professional services for nurse practitioners. NPs acting as care managers are typically paid by the hospital or service line for which they work, making it important to monitor their impact on costs.
Yet even the American Medical Association supports greater use of advanced practice nurses in acute care, says Edward Hill, M.D., a full-time faculty family physician at the North Mississippi Medical Center, Tupelo, and immediate past chair of the AMA board. "The AMA is very much in favor of the team approach to care," Hill says. "Most of the errors made in care today are system errors and we need all the help we can to avoid them." Subspecialists in particular are increasingly training and trusting advanced practice nurses to carry out orders at the bedside that might otherwise be overlooked.
However, Hill emphasizes the need to keep physicians in charge to ensure quality of care and because physicians are ultimately held accountable for mistakes. "It's important how you define the collaborative and supervisory relationship, and the organized medical staff needs to be involved in that," he says. "In most of the cases, I've seen the medical staff is involved, though we've heard of a few situations where the administration or the board has unilaterally attempted to define the role of nurse practitioners. We have a real problem with that."
Others raise concerns about the impact on resident training, though many physicians say the presence of highly trained nurse practitioners benefits residents as a resource on evidence-based protocols and relieves them of mundane chores that distract from learning opportunities. "The outcomes manager takes on necessary tasks that don't seem to interest the residents," says Thomas P. Bleck, M.D., the University of Virginia's chair of critical care and director of the neurosciences intensive care unit.
The growing literature documenting improved outcomes will only expand the role of nurse practitioners in acute care, Marion believes. Bringing the combination of diagnostic and coordination skills and the authority to prescribe to the bedside only makes sense for keeping critically ill patients cared for in real time. "From the day I saw the word 'hospitalist,' I knew the next thing we would see is nurse practitioner hospitalists," she says. "They have the skills we need to make evidence-based changes in care. These are system changes that will really improve care."
Howard Larkin is a Chicago-based freelance writer.
Data indicate that, when part of a well-designed and comprehensive process, use of nurse practitioners can improve outcomes and lower costs in certain areas of care.
Mortality and cost per case results for Loyola University Health System, coronary artery bypass graft procedures
|4Q 1999--3Q 2000||3Q 2001--4Q 2001|
|Cost per case||$27,037||1.02||$24,511||0.84|
Mortality results for Loyola University Health System, coronary artery bypass procedures:
Complication rates and length of stay for patients in the neurosciences intensive care unit at University of Virginia Health System, with and without management by nurse practitioners
|Urinary tract infection||2%||6%|
|ALOS||8 days||11 days|
Total one-year cost savings: $2,467,328 due to a reduction of 2,000 ICU days. Average length of stay decreased in 13 of 17 DRGs managed by nurse practitioners.
Source: University of Virginia Health System, 2002
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This article first appeared in the August 2003 issue of H&HN magazine.
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