Objectives. So, what are we doing here? Pediatric Nurse Practitioners as Hospitalists. History of APNs. Disclosures. SLCH.

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1 Pediatric Nurse Practitioners as Hospitalists NAPNAP 2015 Cheryl Grave, RN, CPNP APN Practice Lead Hospitalist PNP - Manager So, what are we doing here? Objectives Discuss the history of nurse practitioners that set the foundation for future advancements; Identify the opportunities and challenges for model development, talent acquisition and pilot implementation; Identify methods to ensure program implementation success. Pay homage to my favorite children s author Disclosures History of APNs No financial disclosures 1965 first program started at the University of Colorado to train Pediatric Nurse Practitioners Increased demand for primary care Nursing s potential to meet the needs Shortage of primary care physicians, particularly in rural areas Knew they must combine the best of nursing with new assessment and diagnostic skills first Family Nurse Practitioner program started at the University of Kentucky History of APNs 1972 first Neonatal Nurse Practitioners began at University of Utah First role to include critical care assessment and interventions 1973 NAPNAP is established 1980 s Nearly all NP programs were master's degree or post-master's degree programs 1994 NEJM published "Advanced Practice Nursing Good Medicine for Physicians" Today, about 26% of Nurse Practitioners practice in hospital-based locations ED started in 1985 NICU started in 1993 SLCH PICU started in 2001 Oncology started in 1990; current model started in 1996 Inpatient general medical floor teams August

2 PNPs as Hospitalist Pilot: Talent Acquisition Anticipated new ACGME guidelines Effective July 2011 Limited residents work hours to only 16 hours consecutively Limited resident availability for the floor teams Answer the IOM call to nursing Nurses should practice to the full extent of their education and training Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. Education and formal preparation Interest in inpatient care Willingness to work nights, weekends, and holidays Experience with in-patient medicine experience Comfortable with abiguity Character of candidates as important is as clinical skills Nursing Trust Responsibilities Pilot: Barriers Physicians Interns Learning opportunities Supervising Residents Supervision vs collaboration Attendings Billing NICU Asthma Sub-speciality Pilot: Orientation Pilot: Implementation Shadow: Interns/Residents Hospitalists Inpatient pharmacists Staff RNs Other NPs (NICU, PICU, Hem/Onc, Asthma) Intern & Nursing Orientation Floor Attending Sickle Cell Clinic Floor Intern Floor Nurse Shadow Experiences Floor Senior PICU APNs Floor Pharmacist NICU APNs Integrated the APN s as part of the whole 8E team at St. Louis Children s Hospital (SLCH) Busy inpatient unit (N=5,600 patient days per year; 1,830 admissions) Patient populations = general medicine, sickle cell disease, rheumatology, infectious disease, and genetics 2

3 Pilot: Team Composition A Day in the Life 3 APN s (2.2 FTE) were hired to function in the traditional intern role Day Team Attending (2 week rotation) Day Senior Resident (PL 3) (4 week rotation) 3 Interns (PL 1) (4 week rotation) Sub-interns 1 APN (Sunday Friday days) Night Team Night float Senior Resident (PL 2 or 3) (2 week rotation) Intern or NP APN on Sunday and Wednesday nights Termed fourth Intern Maintain a service of patients Participate in family centered rounds Provide continuity to patient populations and staff Admit patients Provide inpatient management Provide discharge teaching Coordinate care between admitting and consulting/cocovering services Participate in patient-centered rounds Participate in unit-based education and QI projects Complete pre-round data collection Review Vital Signs Review I/O Review laboratory and radiology data Overnight events Daily Physical Exams Daily Progress Notes Present patient data and plan of care on family-centered rounds Coordinate discharge planning Show me the DATA 8E Winter Volume Pilot Year NP Intern A Intern B Intern C Intern D Sub I Nov Dec Jan Feb Totals Show me the DATA Life Lessons APN s interns APN s bring a different approach to solving problems APN s bring more holistic approach to patient care Service volume analysis Different education and training background Generally more experienced than the interns 3

4 Life Lessons Foundational Findings Successful integration Nursing Physician Patient/family Identified problems and solutions Develop tracking tools for role Established monthly meetings with Chief Residents Incorporated APN s into unitbased joint practice teams HPNP 2.0 Piloting Success Model adjustment prior to hospital-wide program implementation (July 2011): APN provide Sunday overnight shift only APN compose Day Team Monday through Saturday APNs introduced to Medicine Teams on 8W and 12 with adjusted schedule 3 APNs (2.6 FTE) for each unit Who s in charge? General Medicine HPNP 3.0 Increase staffing to total 8.0 fte Space out weekend/holiday requirements Every 4 th weekend = Friday, Saturday, & Sunday overnight Develop on call rotation/schedule Monday Saturday Sunday nights HPNP 3.1 Inpatient Neurology 3.0 total FTE Monday-Saturday Role definition Preadmission no show rate Rehab Barriers Billing Impact to Physicians Optimize APNs and Resident relations and communication APNs attend new intern orientation luncheon Joint simulation center exercises Chief Residents meetings Attend to the Attendings Hospitalist core curriculum Unit Orientation 4

5 Impact to Nursing Consistency Create a stable foundation for medical/nursing teams Ease transitions to new Residents and Interns Familiar face to the patients and families Facilitate collaboration The Urge to Surge! Analyzing traditional provider staffing models AND do something about it! Provider schedules have never been adjusted to account for inpatient volume Provider schedules inversely disproportional to work volume Encourage the bedside nurse to take an active roll in rounds Encourage bedside to nurse to advocate for patients and families Contribute to more cohesive family-centered rounds Present a complete picture of patient care Surge staffing Provide designated provider for off-unit medical patients Dun, dun, dun Surge Planning and Provider Staffing Patient Placement Short Stay Unit/Models of Care Complex Care Team To Infinity and Senior leadership support Attending physician support APNs are not resident replacements Proactive resident and physician relations Be realistic about regulatory constraints to collaborative practice Pearls of Wisdom Additional relief staff needed Get the right body, not somebody Avoid reliance on resident jeopardy system PRN pool Non-clinical time is essential Personal/professional growth Retention Job satisfaction Process/quality improvement projects Gen Peds Natalie Bayton Robin Foster Patti Fredrick Joanne G Sell Kristine Moore Becky Phelps Elise Schaller Ashley Sunshine Role the Credits Thank you, for making me look good! Neuro Mitzie Graeler Tiffany Hammerschmidt Madeleine Ortman Ortho Beth Schickler Marie Turner Palliative Care Carol Massman PRN Sarah Burrus Aundrea Schubbe Donelle Sherman Jen Oldham Thank you for your support and guidance. Judy Johnston, Susan Hibbits, Peggy Gordin, Sesh Cole, Mike Turmelle, Chrissy Hrach Points of Reference Anchorman: The Legend of Ron Burgundy (2004); Adam McKay (director); Judd Apatow (producer) For a list of her works, go to Advanced-Practice Nursing -- Good Medicine for Physicians? - Mary O. Mundinger, Dr.P.H. - N Engl J Med 1994; 330: January 20, of- Nursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf 5