Abstract & Commentary
Administrative observations that financial data for 2 units (neuroscience ICU, neurosurgical ward) in a university-affiliated hospital were less than optimal compared with similar units in other hospitals in the health system led to the decision to add an acute care nurse practitioner (ACNP) to the management team of each unit. To determine the effect of this change, Russell and colleagues compared outcomes in 402 consecutive patients who were admitted to the 2 units in the first 6 months after this change with a random sample of 122 patients admitted to the same units during the year prior to the change. Patients in the random sample were selected to match the most common diagnostic codes (laminectomy, hydrocephalus, intracerebral hemorrhage, subarachnoid hemorrhage, brain tumor, spinal cord injury, head injury, and tracheostomy) of patients in the prospective sample.
No differences were found in age, gender, or race between the ACNP and retrospective sample. ACNP-managed patients had a shorter hospital length of stay (mean, 8 days) compared to the retrospective sample (mean, 11 days) (P = 0.03) and a shorter mean ICU length of stay (P < 0.001). The ACNP-managed group also experienced a lower rate of urinary tract infection and skin breakdown, a shorter time (days) to removal of urinary catheters, and a shorter time to mobilization (out of bed) (P < 0.05). No significant differences were found in the number of days on mechanical ventilation, time to tracheostomy decannulation, or days to placement after a written order for discharge.
In the first year of implementation, Russell et al estimated that patients managed in collaboration with the ACNP were hospitalized 2306 fewer days than the historical group. There was no difference in the 1-month readmission rate between groups (Russell D, et al. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners. Am J Crit Care. 2002;11:353-364).
Comment by Leslie A. Hoffman, RN, PhD
Findings of this study suggest that introduction of a unit-based ACNP improved several key outcomes (time out of bed, time to urinary catheter removal, urinary tract infection, and skin breakdown), which can act to delay patient recovery and, in turn, increase hospital stay. Management by the ACNPs consisted of: 1) daily rounds on all patients, including review of laboratory and diagnostic tests; 2) morning rounds with the primary and consulting physician; 3) daily attendance on interdisciplinary rounds; 4) close monitoring of the patients’ clinical status; and 5) collaboration with the house staff and attending physicians for changes in the management plan.
Russell et al attributed the improved outcomes seen in this study to closer patient monitoring and more rapid titration of the management plan due to greater availability of the ACNP. Previously, changes were likely to be delayed until after the surgical day, rounds, or teaching sessions. This care delivery model takes advantage of the same efficiency that is possible when daily weaning protocols are implemented by the respiratory therapist or the bedside nurse. Because ACNPs are unit-based and do not have the added responsibilities of academic training, they have more time to provide consultation to patients, families, nursing staff, and other health team members. They can more closely monitor patients for changes in condition and change therapy based on the results of lab and diagnostic tests immediately after they are received.
During a 12-month period, Russell et al reported that patients in the ACNP-managed group were hospitalized 2306 fewer days than patients in the historical comparison group. While this change was likely in part due to earlier discharge, it is too large a change to be due solely to this factor. It is interesting to note that seemingly small things, such as earlier mobilization, quicker removal of a Foley catheter, lower rates of urinary tract infection, and more efficient attention to changes in the management plan, might be able to produce a major decrement in hospital stay.
Dr. Hoffman is Professor Medical-Surgical Nursing Chair, Department of Acute/Tertiary Care University of Pittsburgh School of Nursing.