APCs in Hospital Settings
Mary Ruth Pugh, MSN, FNP-BC
Trauma Nurse Practitioner, Program Director of Trauma and Critical Care APC Postgraduate Residency, Intermountain Medical Center,
Intermountain Healthcare Objectives: • Describe the current status of APC’s roles in a hospital setting, citing
national trends • Summarize current literature review of APC’s role in trauma
critical care • Describe IMC Trauma Service use of APCs, citing staffing to patient
ratio research
Mary Ruth Pugh, MSN, FNP –BCIntermountain HealthCare Trauma Service IMED
Objectives Background Literature Review Methods Results Conclusions
APCs in Hospitals1) National NP Trends
• After private physician practices, the main practice setting of an NP is a HOSPITAL.
• 44.8% of NPs hold HOSPITAL privileges.• (aanp.org)
2) Utah PA Trends• After private physician practices, the main practice setting of a PA in Utah is a HOSPITAL 26.8%.
• (aapa.org)
Intermountain APCsJuly 2013
December 2003
Increase
Physicians 1,199 721 66.3%
Adv Practice Clinicians 544 209 160.3%
Medical Group
Clinic Visits (Millions) 2.89 1.52 91%
Select Health
Medical Members 630,906 478,433 31.9%
Dental Members 109,225 N/A
Source: Laura Kaiser, Exec VP, COO
Intermountain UCR APCs Trauma 11 Neurosurgery 5 Ortho 2 Neurology 7 Abdominal Transplant 7 Cardiology (heart failure, transplant, EPS) 26 Hyperbaric 4 RICU 4 Med/surg ICU 5
APCs in Trauma Critical Care EAST
EAST Advanced Pracitioners Ad Hoc Committee.
ANCC Adult‐Gerontology Acute Care NP
Emergency NP
NCCPA CAQs (Certifications of Added Qualifications Hospital Medicine
Literature Review Most literature to date focuses on the integration/collaboration/and or comparison to medical resident staffed trauma teams. (Livesley, Christmas, Reines, Terry, Tye, Furlong, Ballard, Bray, Henrich, Nyberg, Sherwood, et.al.)
Some literature focuses on outcomes of APCs utilized in trauma centers. (Nyberg, Fanta, Oswanski, Gillard, Mikhail, Haan, et.al.).
Literature Review What are the outcomes of the studies?
Adding CRNP staff led to improvements with discharge rounds compared to house staff (Haan, et.al.)
PNPs vs residents provided decreased LOS and higher patient satisfaction scores (Fanta, teal.)
Trauma patients satsified with MLPs care (Nyberg, et.al.)
PAs vs. residents provided decreased LOS on floor (Oswanski, et.al.)
MLPs provide effective and efficient care on a trauma service (Mikhail, et.al.)
Trauma Team
Background APC =Advanced Practice Clinician
Fully staffed Trauma Team with APCs and core surgeons
EM residents Moved to American College of Surgeons’‐verified Level One Trauma Center in 2007
Background Kept track of daily patient census and APC staffing since 2007
Developed safe rounding practice/limits 2 inpatient teams
Trauma ICU Floor/ED trauma activations and consults
Trauma Clinic
Trauma APC
Background APC Postgraduate Residency Trauma and Critical Care Research Director Two additional trauma surgeons Trauma service manages all critical care trauma patients
Trauma service keeps all patients on the service until discharge
How do we round? ICU Team and Floor Team:
APC pre‐rounds with EM residents, APC residents, and students.
Bedside rounds with trauma attending and multi‐disciplinary team: pharmacy, nurse, case management, nutrition, etc.
APC or resident presents patient. MD directs/supervises rounds.
Resuscitations APC, EM resident, or APC resident acts as team leader MD directs/supervises
Full Staff ModelAPC Rounding Census APC Coverage ICU = up to 10 patients/day
per APC Floor = up to 15 patients/day
per APC Call when need help
In‐house 24 hours a day 365 days a year.
1 APC in the ICU 24 hours a day 1 APC covering the floor and ED
(trauma consults and activations) 24 hours a day
1 APC float covering floor rounds, clinic calls during daylight hours every day
1 APC covering outpatient clinic once a week
Methods We compared EARLY to FULL staff time periods.
Basic demographics as well as ISS, LOS, ICU LOC, hospital DC disposition, and common complications were recorded for all patients
Data collected from trauma registry
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Slide 16
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Results Complications, readmissions, and mortality rates were the same. Early complication rates were 14 % vs. fully staffed rates were 13% (ns).
Readmissions for early staff 3.29 % vs full staff 3.28 % (ns).
Mortality rates for early staff 4.00% vs. 3.37% for full staff p=0.14 trended to sig.
Conclusions Adding APC staff to our trauma service based on safe rounding limits and care coordination is associated with: Decreased LOS for hospital days, ICU days, and LOS for those discharged to SNF
No significant change in complications, readmissions, or mortality (despite increased age and increased ISS)
Conclusions Adding a residency was not accounted for in the staff census.
Tracking cost data would be beneficial.
We continue to track our staff vs patient census to optimize our team.
Take Home… COUNT SOMETHING
Collaborate Converse
APC geared education Collaborative practice education for all providers
Documentation and Billing Education
APC model for each ACS level
… your ideas?
Thank you
The most pathetic person in the world is the person who has sight but no vision.
Helen Keller
Questions?
References