Peter Munk Cardiac Centre, University Health Network. Allied Health Personnel Symposium American Association of Thoracic Surgery April 26, 2014

Transcription

1 The Expanding Role of the Nurse Practitioner and Physician Assistant Across the Continuum of Care for the CTS Patient: Preoperative, Postoperative, and After Discharge Jane MacIver RN NP PhD Peter Munk Cardiac Centre, University Health Network Allied Health Personnel Symposium American Association of Thoracic Surgery April 26, 2014

2 Definition Background Nurse Practitioners Masters prepared RNs Advanced training in a clinical specialty Can diagnose, order tests, prescribe meds and perform specific procedures Physician Assistants Licenced health care professionals Advanced training in a clinical specialty Can diagnose, order tests, prescribe meds, perform procedures Autonomy Autonomous Delegated function model Model/Education Nursing Medicine Legislation Province/State Province/State Role Implementation Critical and acute care Inpt and outpt settings Critical and acute care Inpt and outpt settings

3 Background Non physician provider roles were a response to: Changes in resident availability hours Decreased hospital length of stay Increased acuity of patients Need to expand services, enhance revenue and fill service gaps Nature of the patient population guideline based care with predictable complications and high annual volumes provided an opportunity for PA/NP to develop skill and expertise

4 Common Components of Both Roles Direct patient management ACNPs spend 85 88% of time in direct patient care 1 Patient and family education Coordination and communication of care Administrative functions Surgical assist in OR 1. Kleinpell et al (2005)

5 Limited Utilization of Roles 1. Full utilization of role Heavy clinical responsibilities Expectations of MDs and program administration Limited non clinical contributions Expectations of MDs and program administration Seldom achieve full scope of practice Prescribing authority Admission privileges Referrals to other specialists 1. Kleinpell et al (2005)

6 Documented Effectiveness in Acute Care No difference in outcomes of care compared to MDs (readmission rates, LOS, mortality) NP/PA spend more time discussing patients With RNs, MDs, patient/family NP/PA spend more time coordinating care Some evidence that NP/PA have lower LOS, infection rates Patients cared for by NP/PA have better adherence to lipid, diabetes, BP guidelines Kleinpell et al 2008; Goldie et al 2012

7 Utilization in the ORs As a member of the OR team NP/PA s: 1. Harvest veins/arteries for ACB 2. First or Second Assist experience meeting the needs of staff surgeon Trained in idiosyncrasies 3. Support increasing patient volumes: Without increasing trainee positions Allow existing trainees greater opportunities in the OR.

8 Utilization in Critical Care Skinner et al 2013 Pre/Post evaluation of a change in first line coverage in a cardiac ICU in UK 7 NPs trained in advanced assessment, management, ACLS & chest re opening First line care providers with resident back up No significant change in mortality after implementation Majority of calls were for airway/breathing, low blood pressure, low urine output 4 cardiac arrests 3 successful; 1 expected

9 Utilization in Critical Care Skinner et al 2013 Safe and sustainable model Time and money needed to train NPs Evaluation of staff satisfaction needed Applicable to both NP and PA practice Advantageous for medical trainees more OR time, less on call time BUT may lose exposure to ICU situations Impact on non teaching hospitals? Time spent waiting for on call surgeon for surgical emergencies

10 Utilization in Critical Care Evaluation of coding practices before/after implementing documentation templates completed by NP/PA in ICU Daily progress note Critical care event note Increased revenues by 40% Significant improvement in charges submitted and revenues collected Positive benefits of role for program management

11 Utilization in the Outpatient Setting NPs/PAs across the US Between 2001 and 2009, the proportion of outpatient visits seen by an NP/PA have increased More common in: non teaching hospitals Smaller hospitals Rural areas

12 Utilization in the Outpatient Setting Cardiac Surgery (Nabagiez et al, 2013) Pre/Post evaluation of a PA home visiting program for post op CV surgery patients PAs conducted home visits on day 2 & 5 physical exam, medication review, exam of surgical wounds 122 interventions documented during housecalls 25% reduction in readmission rates (NS) Majority of interventions were for med changes 19% of patients refused visits

13 Utilization in the Outpatient Setting Cardiac Surgery (Nabagiez et al, 2013) Reduced readmissions beneficial for patient flow Better outcomes for patients: Patient education Early identification and management of post op complications Early follow up provides reassurance for patients and families

14 Heart and Lung Transplantation and MCS Increasing number of patients needing and surviving heart & lung Tx and MCS MCS as destination therapy Episodic management of non Tx/MCS related conditions across the institution As volumes increase, need for more staff to provide pre and post, inpatient and outpatient care. Guideline based care well suited for NP/PA practice

15 The Changing Role of Patient Care More complex patients, fewer staff, tighter budgets Evaluation of NP/PA roles Need to develop non clinical aspects of role that support program management and development The impending silver tsunami Anticipation of additional costs associated with care Consumerism Will make it harder for us to do our work

16 Evaluation of the use of smartphone images for assessment of wounds (Quinn et al 2013) High agreement between direct wound assessment and assessment using a digital image upload success rates only 37% (needed 1 + attempt) Facilitates the direct access to specialist expertise BUT.difficulty getting timely feedback on images Other issues: App development needs to be easy to use across different platforms and depends on pt having Wi Fi Where and how to store images raises Privacy & confidentiality concerns

17 The Changing Role of Patient Care Smartphone revolution Electronic retrieval of results Telemedicine/Telemonitoring Patient education Remote monitoring of wounds Either from primary care teams of patients Will require creative ways of managing care 24/7 availability is a blessing and a curse Personalization of patient education Use of technology to manage situations

18 Educating New Care Providers Increasing demand for non physician care providers Current applicants have less clinical and life experience which impacts: Orientation strategies Implementation strategies Retention strategies

19 In Summary Patients cared for by NP/PA s have comparable acute care outcomes to patients cared for by MDs. NP/PA may have better outcomes in some indicators Diffusion of NP/PA roles to other areas is safe and effective The outpatient setting provides opportunities for NP/PA s to expand practice and provide innovative patient care programs. New practitioners may challenge existing orientation, care delivery and retention programs

20 References 1. Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: An evidence based review. Crit Care Med. 2008;36(10): Goldie C, Prodan Bhalla N, Mackay M. Nurse practitioners in post operative cardiac surgery: Are they effective? Canadian Journal of Cardiovascular Nursing. 2012; 22(4): Skinner H, Skoyles J, Redfearn S, Jutley R, Mitchell I, Richens D. Advanced care nurse practitioners can safely provide sole resident cover for level three patients: Impact on outcomes, cost and work patterns in a cardiac surgery programme. European Journal of Cardio Thoracic Surgery. 2013; 43(1): Nabagiez JP, Shariff MA, Khan MA, Molloy WJ, McGinn JT. Physician assistant home visit program to reduce hospital readmissions. J Thorac Cardiovasc Surg. 2013; 145(1): Quinn EM, Corrigan MA, O'Mullane J, et al. Clinical unity and community empowerment: The use if smartphone technology to empower community management of chronic venous ulcers through the support or a tertiary unit.. PLOS. 2013; 8(11):e78786.