outcomes of adding acute care nurse practitioners to a level i...

Outcomes of adding acute care nurse practitioners to a Level Itrauma service with the goal of decreased length of stay and

improved physician and nursing satisfaction

Nina Collins, MSN, RN, ACNP-BC, Richard Miller, MD, April Kapu, DNP, RN, ACNP-BC,Rita Martin, MSN, RN, ACNP-BC, Melissa Morton, MSN, RN, ACNP-BC,

Mary Forrester, MSN, RN, ACNP-BC, Shelley Atkinson, MSN, RN, ACNP-BC, ANP-BC,Bethany Evans, MSN, RN, ACNP-BC, and Linda Wilkinson, MSN, RN, ACNP-BC, Nashville, Tennessee

BACKGROUND: The trauma service experienced preventable delays caused by an Accreditation Council for Graduate Medical Education workrestrictions and a 16% increase in patient census. Furthermore, nurses needed a consistently accessible provider for thecoordination of care. We hypothesized that using experienced acute care nurse practitioners (ACNPs) on the stepdown unitwould improve throughput and decrease length of stay (LOS) and hospital charges. Moreover, we hypothesized that addingACNPs would improve staff satisfaction. On December 1, 2011, the Vanderbilt University Medical Center Division of Traumareassigned ACNPs to the stepdown area 5 days a week for a pilot program.

METHODS: LOS data from December 1, 2011 through December 1, 2012 was compared with data from the same months from theprevious two years and estimated hospital charges and patient days were extrapolated. Physician and nursing surveys wereperformed. Data from 2010 (n = 2,559) and 2011 (n= 2,671) were averaged and the mean LOS for the entire trauma servicewas 7.2 days. After adding an experienced ACNP, the average LOS decreased to 6.4 days, a 0.8 day reduction. Per patient,there was a $ 9,111.50 savings in hospital charges, for a reduction of $27.8 million dollars in hospital charges over the12 month pilot program.

RESULTS: A confidential survey administered to attending physicians showed that 100% agreed that a nurse practitioner in thestepdown area was beneficial and helped throughput. Dayshift nurses were surveyed, and 100% agreed or strongly agreedthat the ACNPs were knowledgeable about the patient’s plan of care, experienced in the care of trauma patients, andimproved patient care overall.

CONCLUSION: The addition of experienced ACNPs resulted in the decrease of overall trauma service LOS, saving almost $9 million inhospital charges. (J Trauma Acute Care Surg. 2014;76: 353Y357. Copyright * 2014 by Lippincott Williams & Wilkins)

LEVEL OF EVIDENCE: Economic/decision study, level III.KEY WORDS: Acute care nurse practitioner; ACNP; nurse practitioner; throughput; length of stay.

The acute care nurse practitioner (ACNP) has become anintegral part of many busy trauma surgery services as theconcept of the multidisciplinary team has become accepted asbest practice. In particular, having an ACNP with experience inthe specialized field of trauma is economical and practical incoordinating care and assisting with throughput of patients asthey recuperate and approach discharge. Nurse practitioners(NPs) have been shown to improve the use of resources andreduce unnecessary emergency department visits.1

The day-to-day workload of the Vanderbilt UniversityMedical Center (VUMC) Trauma Stepdown area was resident

house staff driven before the initiation of the pilot program.Despite changes to the Accreditation Council for GraduateMedical Education work hour restrictions, there was a 16%increase in patient census during the study period.2 Intensivecare unit (ICU) rounds, procedures, operative cases, emergencydepartment consultations, educational programs, outpatientclinic, and Level I trauma alerts all compete for residents’ at-tention. Trauma stepdown patients were not dependably man-aged with regard to normalization and discharge planning ortransitioned off the unit as efficiently as possible given the manydemands on residents’ time. Nurses expressed the need to have aconsistently accessible provider available for consultation andmanagement of patient care.

The trauma ACNPs were very successful in the role asa coordinator of care for patients throughout their hospitali-zation in other areas of the trauma service. The ACNPs havealso been involved in resident education since the inceptionof the trauma service in 1998. Therefore, we hypothesizedthat using experienced ACNPs on the stepdown area wouldimprove throughput and decrease length of stay (LOS). Inaddition, we hypothesized that adding ACNPs would improvestaff satisfaction.

WTA 2013 PLENARY PAPER

J Trauma Acute Care SurgVolume 76, Number 2 353

Submitted: February 18, 2013, Revised: October 18, 2013, Accepted: October 18, 2013.Published online: January 6, 2014.

From the Division of Trauma and Surgical Critical Care (N.C., R.Mi., R.Ma., M.M.,M.F., S.A., B.E., L.W.), and Advanced Practice Nursing (A.K.), Division ofCritical Care, Vanderbilt University School of Medicine, Nashville, Tennessee.

This study was presented at the 43rd Annual Meeting of the Western Trauma As-sociation, March 3Y8, 2013, in Snowmass, Colorado.

Address for reprints: Nina Collins MSN, RN, ACNP-BC, Division of Trauma andSurgical Critical Care, Vanderbilt University School of Medicine, MCNAA1218,1161 21ST Avenue South, Nashville, TN 37232-2102; email: [email protected].

DOI: 10.1097/TA.0000000000000097

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

mailto:[email protected]:[email protected]

PATIENTS AND METHODS

This study was a single-center, retrospective report of therole of the ACNP on cost-effectiveness at a large academicLevel I trauma center. Variables analyzed included Injury Se-verity Score (ISS), LOS, and associated patient costs during a12-month pilot program. Nurse and attending physician sat-isfaction surveys were performed.

The trauma service is loosely divided into three manage-ment areas (Fig. 1). Trauma ICU (T1) is a 14-bed trauma ICUand is primarily managed by an attending physician and housestaff. Trauma stepdown (T2) is a 17-bed area consisting of cardiacmonitored/pulse oximetry beds staffed by ICU nurses. This areawas primarily managed by an attending physician and housestaff before the initiation of the pilot program andwas the focus ofthe study. The third arm of the trauma surgery service is thetrauma NP satellite service (T3), which manages the care of thetrauma patients who are in other areas of the hospital. This servicecarries an average census of approximately 15 to 25 patients perday. The T3 service has been staffed with an attending physicianand one to two ACNPs for approximately 10 years.

The pilot program was initiated in December 2011, andan ACNP was transferred from the T3 service to the stepdownservice to join the multidisciplinary team. Five ACNPs wereselected, each with an experience level ranging from 4 years to20 years in the daily management of posttraumatic and post-surgical care. These ACNPs were well acclimated to the traumaservice and the discharge process and were rotated through thestepdown area fromMondays to Fridays 6:00 AM to 6:00 PM. Noadditional ACNPswere hired to cover the stepdown area duringthe first year of the pilot program. Therefore, the ACNPs wereeither reallocated from regular T3 service duties or worked perdiem shifts to cover the additional workload.

The T2 ACNP participated in morning multidisciplinaryteam rounds consisting of the attending trauma surgeon, residentphysicians, and nursing staff. After rounds were complete, amorning teaching conference reviewed all admissions to thetrauma service and all ICUpatients.After themorning conference,

the ACNP concentrated on the stepdown area, while residentsfocused on other duties as previously described.

Most importantly, the ACNP was the point of first contactfor all patients, families, and nurses in the stepdown area. TheACNP coordinated patient care with various members of theteam including consulting services, ancillary services, and casemanagement. TheACNP focused on barriers to normalization ordischarge and coordinated the flow of information. The ACNPattended the daily ‘‘discharge huddle,’’ a team meeting that en-compasses T2 and T3 NPs, case managers, social worker, liai-sons to rehabilitation and nursing home facilities, and homehealth agency staff to facilitate communication and the dischargeprocess. This meeting allows cohesive management of the dis-charge process and group discussion of any potential barriers tosuccessful discharge.

The ACNP updated clinical information in the electronicmedical record and entered orders in real time via iPad or laptop.The NP reviewed each patient’s chart, entered orders, updatedthe team communication tool, contacted any consulting or an-cillary services, and communicated with patients and family.Furthermore, the ACNP also was able to perform clinical dutiessuch as complex wound care, removal of chest tubes or tra-cheostomies, and review and interpretation of laboratory andradiographic data in a timely manner. Patient normalization wasfacilitated in a very efficient manner given the ACNPs level oftrauma experience.

For example, while morning ICU rounds were still inprogress, the ACNP could access the final radiology in-terpretations of upright films in an orthotic, contact the spinespecialist for mobilization recommendations, enter physicaltherapy orders immediately, and communicate this informationwith the physical therapist via text paging over iPad technology.Before an NP staffing the stepdown area, many of these taskswould have not been accomplished until the afternoon afterresident procedures were complete.

Another key role of the ACNPwas triage coordinator. TheACNPworked closely with the charge nurse to triage patients offof the trauma floor. The ACNP communicated directly with theT3NPor other accepting services to coordinate care andmanageresources. This initiative prevented unnecessary or inappropriatetransfers that resulted in wasted resources or in bounce-backs tothe trauma unit.

Discharge data were collected from the institution’s Medi-pac software, which is used for admissions, discharges, andtransfers in the hospital, chart abstraction, and billing. AverageLOS (ALOS) data were compared for trauma patients admittedand discharged between December 1, 2011, and June 30, 2012, totheprevious2years for the sameperiod.Thecasemix index (CMI)was extracted from billing data and compared per patient withISS data from the trauma registry during the same period. Allpatients admitted and discharged to the trauma service betweenDecember 1, 2011, and June 30, 2012,were included and definedas cases. The average hospital charge per case was drawn fromhospital financial records of average surgical case charges perMedicare Severity Diagnosis Related Groups (MSDRG). Phy-sician and provider billing data were excluded. Statistical anal-ysis was performed using StataSE 9 Stata, College Station,Texas. The difference between the years was analyzed usingt tests. ALOSdatawere represented in 24-hour days. A pG 0.05

Figure 1. Trauma patient hierarchy and flow among T1, T2,and T3. Description of how a trauma patient is admitted andthe possible paths of transfer between trauma services. T1,trauma intensive care unit. T2, trauma stepdown unit. T3,trauma satellite service.

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was considered significant. Physician and ACNP dischargesfrom T2 directly to home or outside facility (versus transferto floor bed) for each period were averaged. Discharge tooutside facility or home from T2 data was extracted from theinstitution’s Medipac software.

During the first 3 months of the study, physician andnurse satisfaction surveys were conducted using REDCapelectronic data capture (Research Electronic Data Capture,Vanderbilt University, Nashville, Tennessee), which is a se-cure, Web-based application designed to support data cap-ture for research studies. REDCap was developed by a grantthrough the institution’s clinical and translations researchsupport (UL1TR000011 from NCATS/NIH).3 The answerswere based on a four-point Likert scale of strongly agree,agree, disagree, strongly disagree. Twenty-two nurses and13 trauma surgeons who had circulated through the T2 areaand had interacted with the ACNPs were surveyed.

At the end of Year 1 (December 1, 2011, to November 30,2012), discharge and hospital charge data were pulled andcompared with the data 2 years before. ISS data and CMIcomparisons were available for the first 6 months of the study.

RESULTS

Comparing the first 6 months of data from December 1 toJune 30, the ALOS in the stepdown area in 2010 (n = 972;average CMI, 4.03; average ISS, 20.1, with an SD of 11.9) was2.8 and was 2.5 days in 2011 (n = 999; average CMI, 3.69;average ISS, 19.7, with an SD of 11.5). After the addition of anexperienced ACNP, the ALOS decreased to 2.3 days (n = 972;average CMI, 3.29; average ISS, 20.3 with an SD of 11.5)resulting in a 0.35-day reduction overall (p = 0.0033) (Fig. 2).Although the CMI decreased during the 3-year period, the3 years of ISS were statistically the same.

During the first 6 months of the study, the LOS was alsoevaluated for the service as a whole. The ALOS for the overalltrauma service, including ICU, stepdown, and floor patients whohad circulated through the trauma stepdown at some point

during their hospitalization in 2012 (n = 1,667; ALOS, 6.4 days)was compared with the average in 2010 (n = 1,358; ALOS,6.6 days) and 2011 (n = 1,412; ALOS, 7.3 days), resulting in anoverall reduction in ALOS by 0.55 days (p = 0.0239) (Fig. 3).Per case, there was a $5,326 difference in hospital charges,resulting in a reduction of $8,878,000 in hospital charges over6 months (Fig. 3).

December 1 to June 30, 2010, and 2011 discharges fromthe trauma stepdown area directly to home or outpatient facilitywere examined. A total of 727 patients were discharged by anACNP, and 572 patients were discharged by a resident physi-cian, a difference of 155 patients. For the same period in2012, the ACNPs discharged 1,222 patients directly from thestepdown, whereas a physician discharged 340 patients, a dif-ference of 882 patients.

For the 1-year comparison data, when examiningDecember 1to November 30, the ALOS in the stepdown area in 2010(n = 1,827) was 2.6 days and was 2.5 days in 2011 (n = 1,875).After the addition of experienced ACNPs, the ALOS decreasedto 2.2 days (n = 2,202), resulting in a 0.35-day reduction (Fig. 4).

Figure 2. Comparison of December 1 to November 30 of ALOSof overall trauma service over 3 years. Comparison of average LOSon the T2 service. This figure presents 3 years; the first 2 years waswithout an ACNP, and the third shows improvements in thereduction of ALOS with an ACNP on T2.

Figure 3. Comparison of December 1 to November 30 ofaverage hospital charges per case over 3 years. Comparison ofaverage of hospital charges per case on the T2 service. Thisfigure presents 3 years; the first 2 years was without an ACNP,and the third shows improvements in the reduction of chargeswith an ACNP on T2.

Figure 4. Attending physician satisfaction survey results ofassessing ACNP on T2. Results of a Likert scale survey taken bythe trauma attending physician. This figure demonstratessatisfaction scores of six aspects of the ACNP on T2.

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At this year mark, the ALOS for the entire service wasexamined. The ALOS for overall trauma service, includingICU, stepdown, and floor patients who had circulated throughthe trauma stepdown at some point during their hospitalizationin 2012 (n = 3,053) was compared with the average in 2010(n = 2,559) and 2011 (n = 2,671), resulting in a reduction inALOS by 0.8 days (Fig. 4). The number of cases increased by16% from Year 1 to Year 3. Per case, there was a $9,111.50difference in hospital charges, resulting in a reduction of$27.8 million in hospital charges (Fig. 4).

A confidential survey was administered to the trauma at-tending surgeons to evaluate staff satisfaction and demonstratedthat 100% agreed that an NP on the stepdown service wasbeneficial. Likewise, 100% of attending physicians stronglyagreed that adding NPs to the multidisciplinary team helpedthroughput.Among attending physicians, 76.9% strongly agreedthat the ACNPs helped their workflow, and 83% strongly agreedthat patient care was improved (Fig. 5).

The dayshift trauma nurses were also surveyed, and 100%agreed or strongly agreed that the ACNPs were knowledgeableabout the patient’s plan of care, experienced in the care of traumapatients, and improved patient care overall. Of the nurses, 100%felt that normalization of the patient was improved and that painwas better controlled. Of the nurses, 96% felt that patients andfamilies were better informed of the plan of care (Fig. 6).

DISCUSSION

NPs have becomemore commonplace in academicmedicalcenters for varying reasons. Many academic health centers addedor increased the number of midlevel providers in response toAccreditation Council for Graduate Medical Education residentduty hour restrictions.4 Other motivating factors also includedimproved patient access, increased patient safety or quality ofcare, reduced LOS, continuity of care, and improved throughput.Other studies have examined the role of trauma NPs. Morriset al.5 demonstrated that there was no statistical difference be-tween NPs and resident staff when looking at many quality ofcare markers including LOS, pneumonia, uncontrolled pain, and

readmission rates. Sise et al.6 showed that the incorporation ofACNPs to a Level I trauma center team decreased ICU LOS andreduced direct patient care costs. Spisso et al.7 documenteddecreased LOS and improved documentation with the use ofNPs. Christmas et al.8 demonstrated statistically significant re-duction in LOS with the addition of NPs.

The stepdown area of the trauma service at VUMC expe-rienced preventable delays in throughput and in overal dischargesfor numerous reasons including the reduction in resident workhours and an increasing patient census. House staff accessibilityhad long been a problem owing to their many responsibilitiesincluding thegeneral care andmanagement of critically ill patients,new consultations in the emergency department, responding toLevel I trauma alerts, outpatient clinic staffing,mandatory residenteducational programs, and surgical procedures.

Following the addition of an experienced ACNP, manystatistical and subjective positive results were noted. Thischange resulted in a servicewide 0.8-day reduction in LOS,which caused an estimated $27.8 million dollar reduction inhospital charges. Direct discharges from the stepdown areawere also increased by 21%.

Several other positive advantages were noted that im-proved patient and staff satisfaction in addition to the reductionin LOS and estimated hospital charges. The staffing of anACNP allowed residents to focus on new admissions andprocedures off the trauma unit while ensuring that stepdownpatients continued to progress toward discharge. Since theACNP is consistently accessible to staff, patients, and familiesto discuss the plan of care, the entire multidisciplinary team canmove forward together to achieve patient care goals.

Detailed patient and family education and discharge in-structions on complex traumatic injurieswere some of the benefitsprovided by having an NP in the stepdown area. The ACNP alsowas able to expedite the discharge process in a timely manner,which not only helped improve LOS but also added to patientsatisfaction. Time was spent following up on plans of care fromthe multidisciplinary team.Moreover, having a dedicated ACNPfacilitated relationships between consulting services, ancillarystaff, and other members of the team.

Furthermore, trauma-specific experience was cultivatedsince the ACNP did not rotate through other services. The

Figure 5. Registered Nurse satisfaction survey results ofassessing ACNP on T2. Results of a Likert scale survey taken bythe trauma nurses. This figure demonstrates satisfaction scoresof 10 aspects of the ACNP on T2.

Figure 6. Outcomes of adding experience trauma NPs toVanderbilt’s T2 service over 3 years. Overview of outcomes ofreduction in ALOS and charges per case after adding an ACNP toT2 and the previous 2 years.

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ACNP has played an integral role in the education of residentstaff and in the development of service practice protocols andguidelines. Consistent, evidence-based care was a priority inthe stepdown area, given this extensive knowledge of practiceguidelines.

Given the success of this program, the division of traumadetermined that additional ACNPs were a cost-effective mea-sure to improve patient care and throughput and decided tocontinue to staff the stepdown area with ACNPs. The studymodel was not sustainable in the long term owing to the busynature of the service; therefore, two additional ACNPs werehired. Although, adding a new NP directly to an area wouldinvolve expense related to recruitment, credentialing andprivileging, orientation and training, the benefit of decreasedLOS outweighed the cost of hiring additional NPs.

Nyberg et al.9 surveyed physicians and staff and found ahigh level of satisfaction with the care of NPs and that the use ofNPs had increased efficiency. VUMC physician and nurse sat-isfaction surveys also demonstrated the advantages of having adedicated ACNPon the floor. They felt that patients and familieswere better informed, workflow and communication were im-proved, and patients were discharged more efficiently and wereknowledgeable about their injuries. Both groups surveyed alsofelt that the ACNP had a skill set sufficient to dealwith a numberof the nonsurgical medical problems that might arise duringa shift. Overall, the survey results were decidedly positive. Theaddition of the ACNP demonstrated many opportunities forfuture improvement, which may include staffing the stepdownarea 7 days a week and possibly expanding coverage to includethe trauma ICU.

A limitation of this study is that it did not evaluate directhospital costs and reimbursements including the associatedcost of hiring additional NPs to staff the stepdown area on along-term basis. Given the real-time review of the data, theresults of the study were drafted before being able to extractactual costs and reimbursement for each case. Future studiescan incorporate a retrospective review of the expense to hireand train an ACNP, direct cost-savings and reimbursement,and professional billing.

CONCLUSION

In conclusion, 1 year after the addition of experiencedtrauma ACNPs to the multidisciplinary team, both the traumastepdown and overall trauma service ALOS decreased. Significantly,

this resulted in a reduction of approximately $27.8million in hospitalcharges. Trauma surgeons and nurses all indicated a high degree ofsatisfaction with this new role.

AUTHORSHIP

N.C., M.M., and M.F. conducted the literature search. R.M. and A.K.designed the study. A.D. performed data collection and analysis. M.C.,R.Mi., A.K., and R.Ma. contributed to data interpretation. N.C., R.Mi.,and R.Ma. wrote the manuscript, which all authors crticially revised.

ACKNOWLEDGMENT

We thank statistician Byron Lee, BS, MBA, and the Vanderbilt UniversityHospital Trauma Faculty and Staff.

DISCLOSURE

This study was supported by the Vanderbilt Institute for Clinical andTranslational Research grant support (UL1TR000011 fromNCATS/NIH).

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* 2014 Lippincott Williams & Wilkins 357


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