The ARNP in OB Triage Wanda Jeavons, MSN, PNNP Shady Grove Adventist Hospital Rockville, MD wjeavons@ahm.com Objectives Discuss the laws which govern OB triage Discuss why an ARNP is of benefit to OB triage what are their assets List ways an ARNP will lead to RN retention Discuss ways quality of care will improve i.e. case managers List skills of an ARNP which are most impt Discuss cost vs benefits of an ARNP in OB triage Historical Review of ARNP use Earliest papers written about programs which began in 1964 Many types of advanced practice nurses have been used in OB programs Family Nurse Practitioners Perinatal Nurse Practitioners Women s Health Nurse Practitioners Certified Nurse Midwives Clinical Nurse Specialists 1
ARNP use in facilities Emergency rooms Private practice- either solo or with MDs Health clinics Nursing Homes Hospital units cardiology/ pulmonary Education OB Triage One of the busiest areas in the hospital Probably only surpassed by the main Emergency Room All governing bodies review it with the same eyes that they review the main ER EMTALA is a strong governing law Logs and disposition must be carefully documented References suggest arriving patients should be triaged within 15 minutes of arrival EMTALA Flow of patients is tightly prescribed L&D nurse initiates OB triage classifications which categorizes pregnant women by their conditions, prioritizes need for medical attention and helps determine what type clinician will perform MSE If stable, registered at this time If questionable, MSE must be performed first Woman must be considered to be in true labor until certified that she is not 2
Record keeping for EMTALA Must include evidence of all the following Name Time client arrives Chief complaint Acuity designation (must be done by an RN or ARNP)(ENA states must be done within 2-5 minutes) May be registered now Care provider Time they are moved to an assessment area Time of MSE Disposition Time of discharge or admission Follow-up Purposes for triage Provide urgent care for pregnant women Improve OB services Expeditiously assess pts Remove pregnant women from ER waits Prevent unnecessary admissions Decrease pt wait time Avoid tying up limited labor beds Gate keeper to monitor room utilization & prioritization Decrease workload in L&D Save time, money, & improve patient flow Primary purpose Improve services to incoming patients by providing a continuous, uninterrupted disposition while decreasing waiting times. Angelini 3
ARNPs = Unit Asset Strengths of an ARNP Advanced clinical knowledge Able to monitor outcomes Able to assist in improving processes of nursing care Have expertise in area of work Benefits to the unit Cost effective Increased productivity Able to improve throughput High pt satisfaction, despite significantly lower LOS Impact on utilization of services More reasons for use of ARNP Provides leadership which has been proven to lead to increased recruitment & retention of RNs Supports, values & recognizes achievements of individual nurses Promotes care excellence Much time spent communicating with vital parties, supports physician s primary care role and enhances families satisfaction with care More reasons for use of ARNP Promotes collaboration between NPs and residents As of 2003, MDs may be on-call at more than one hospital at the same time and may perform elective surgery while on call. Shorter length of stay Shorter waiting times Actively involved in setting and evaluating treatment goals Undertakes clinical decision making with greater analysis & synthesis of data and sophistication of skills 4
Unit improvements Advanced communication & problem-solving skills Experience working in variety of settings, know how to navigate them Gained respect of nurses & MDs, allowing them to change practice patterns by teaching at teachable moments and facilitate change across the continuum Capacity to understand cost-efficiency & weigh implications of cost cutting on care quality Quality of Care ARNPs provide care that is at least equivalent to care provided by physicians with studies to back up the information Able to recognize & react to emergent situations which present themselves Quality of care Positive outcomes in key indicators of care and reduction in costs to the healthcare systems have been attributed to NP practice. Cost effectiveness and improved quality was attributed to reduced transfers, fewer hospitalizations, & improvement in functional status. One study showed improved practice efficiency, more comprehensive documentation, enhanced problem identification, & reduced costs when using APNs Rapp 5
The big picture after adding an ARNP ARNPs could help alleviate the shortage of primary care physicians Establish relationships with return patients Highly visible program in the community promoting increased market share It has been demonstrated that the presence of an APN on a continual basis results in better mentoring plus education for the RNs. Also improved processes of nursing care in institutions. Why do L&D units like ARNPs? Ease of working with staff Provides RNs with consulting person at hand Usually easier to ask questions and process information Nurses do not have to wait for phone calls Why we love having an ARNP Available in emergencies on unit If CNM, can participate in precipitous deliveries Determine urgency of need and proper place for providing care 6
ARNPs Their clinical decision making has greater analysis & synthesis of data; and has a more advanced sophistication of skills. Provides expert, comprehensive patient care. Has an autonomous practice grounded in an expanded knowledge base & greater skills in managing & organizing health systems. ARNPs and MDs Physician satisfier providing an extension of their services Able to teach physician about care issues Helps shape practice patterns to reflect the needs of the patients With collaborative agreements, physicians more able to concentrate on the tasks at hand ARNPs Promotes clinical excellence Supports, values, & recognizes achievements of individual nurses Provides leadership in addressing factors & designing comprehensive & innovative strategies directed at recruitment & retention of RNs in acute & critical care settings 7
Case managers for in-patients Skill set complements that of physician by providing expertise in functional care issues & psychosocial needs. Stands back and views big picture Actively involved in setting & evaluating treatment goals in all settings & phases of care Plays large role in teaching physicians about care issues and shapes practice patterns Case Management and ARNP Article by Howard Larkin, (2003) discusses programs throughout the US which utilize ARNPs such as one which transferred primary responsibility for managing CV surgical pts from residents to NPs. They were asked to constantly monitor pt s conditions, and to adjust care to keep them progressing toward discharge. Also primary contact for patients families & follow-up. Results: mortality dropped from 3% to 0.9%-in 2001 has lowest mortality rate among 50 participants involved in this study. Other recognized programs Neuroscience program implemented NP case management Critical care unit length of stay decreased Heart failure pts and general medical pts ARNPs can be highly effective when used to coordinate & implement complex evidence based care programs 8
Setting up a program in your hospital Protocols or guidelines developed ahead of time in collaboration with physicians, midwives, and practitioners Agreement on treatment for private patients with different disease processes Notification of patient visits to provider Discharges patients home Provide referral for NPC patients Some facilities have an MFM as acting director Should not be so strict that they take away criticalthinking & clinical judgment, but offer a wide margin of safety Essential skills for your ARNP Assessing clients, synthesizing& analyzing data, & understanding and applying nursing principles at an advanced practice level Skills and abilities essential for the ARNP Providing expert guidance & teaching Working effectively with clients, families, & other members of the health care team Utilizing research skills Able to react to emergencies with immediacy Hagedorn, 1999 9
Needs when an ARNP is working in triage Consultation, collaboration & co-management with MDs needs to be readily available to ensure success of a triage facility Angelini-Menihan Multi-competencies must be skilled in more than one area (i.e. high risk for CNM) Performing diagnosis & prescribing therapeutic measures consistent with area of practice Skills and abilities essential for the ARNP Analyzing multiple sources of data, identifying alternative possibilities as to the nature of a health care problem & selecting appropriate treatment Recognizing limits of knowledge & experience, planning for situations beyond expertise, & consulting with or referring clients to other health care providers as appropriate Hagedorn, 1999 Skills and abilities essential for the ARNP Managing clients physical & psycho-social health-illness status Making independent decisions in solving complex client care problems Hagedorn, 1999 10
More practical skills necessary Prescriptive power Able to perform limited ultrasounds-afi/bpp Evaluate lab work for high risk patients and make preliminary diagnosis Cost of an ARNP 1987 Omnibus Budget Reconciliation Act allowed APNs to receive reimbursement from Medicare 1997 Balanced Budget Act allowed APNs to bill Medicare independently for their services & expanded sites of service Medicare will reimburse APNs for services at 85% of physicians allowable fee. Hiring an APN as a clinical house office is potentially a financially viable option that can have significant positive functional & clinical benefits for patients. Rapp. Billing for an ARNP CMS/Medicaid has made it easy to bill for exams by an ARNP-even those employed by the hospital Must determine the codes, also codes for each procedure Payment of submitted bills depends on whether the diagnosis is covered in the global fee or not Many hospitals absorb the Nurse Practitioner s salary as a cost of doing business 11
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