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work in the hospital


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work in the hospital

  1. 1. FROM OUR PRINT ARCHIVES – ADVANCE FOR NURSE PRACTITIONERS Vol. 17 • Issue 2 • Page 43 (2/2/2009) NP Hospitalists - A New Niche for NPs Jennifer Ford Traditionally, hospitalists have been hospital-based physicians who make decisions about the care of inpatients and refer them to primary care physicians after they are discharged from the hospital. Approximately 20,000 hospitalist 1 physicians are in practice in the United States today. In recent years, hospitals have struggled with growing numbers of inpatients, dwindling numbers of physicians and reduced physician and resident workloads. A primary solution has been the addition of nurse practitioners to their hospitalist teams. This role evolution has met with much success, yet awareness and understanding of the hospitalist role continue to be spotty. 2 Most hospitalist NPs are certified as acute care nurse practitioners, a specialty that emerged in the 1990s. The American Academy of Nurse Practitioners reports that acute care NPs make up 5.6% of all NPs. Nearly 80 programs are training acute care nurse practitioners and pediatric acute care NPs across the country. But what exactly do NPs do as hospitalists? The Hospitalist Role Hospitalist nurse practitioners provide services to inpatients who have no primary care physician or patients whose primary care physician cannot visit the patient in the hospital. They admit, care for and discharge patients in the hospital, and they perform procedures based on hospital privileges they have earned. Some NP hospitalists manage the patient load of other NPs, PAs and residents in the hospital. Hospitalist responsibilities include rounding, participating in team meetings, being aware of all patients' treatment plans, documenting findings in patient charts, assigning patients to on-call staff, assessing and managing medications, ordering and reviewing lab tests or other diagnostic tests, coordinating patient transitions, and providing 1 inservice education to nurses. Hospitalist NPs can also perform special functions, according to Maggie McLain, an NP in the hospitalist service at St. Alphonsus Regional Medical Center in Boise, Idaho. "We act as the lone providers in a presurgical screening clinic," providing complete perioperative risk evaluation, McLain says. "This has even been helpful for patients who have primary care physicians, because it is often difficult for patients to get a visit scheduled with their primary care provider within the time frame necessary to avoid postponing their scheduled surgery." Role History During the 1990s, many hospitals recognized a need for changes in hospital care. For example, in 1995 the University of Rochester Medical Center (URMC) hired its first nurse practitioners as hospitalists. The concept for the program came about because the hospital recognized that inpatients being managed by primary care physicians were not getting the care they needed. "A lot of these patients were cared for by primary care physicians who either didn't have the time or the expertise to manage acute illness," says Mike Ackermann, NP, director of the Margaret D. Sovie Center of Advanced Practice at URMC. "The idea was [that] we could probably form a service, and we could take care of these patients for primary care physicians and some subspecialties like gastroenterology or nephrology, where they're admitted for different problems but they're still under the care of a nephrologist or gastroenterologist." Initially, Ackermann says, NPs saw fairly uncomplicated cases such as urinary tract infections or cellulitis - patients whose typical length of stay was less than 3 days. The service began with a handful of physicians and NPs caring for about 10 patients. Over time, the concept grew, and response was positive. "Now we have a waiting list of primary 1
  2. 2. care physicians who want to use the service," he notes. In 2005, Ackermann developed a cluster system in which one lead NP is responsible for the cluster's evaluations, ongoing communication and meetings with program leadership. Today, the hospital employs 375 NPs; 26.5 full-time positions are designated for the lead NP hospitalist role. Education and Certification The most logical certification for a hospitalist NP would be certification as an acute care nurse practitioner, Ackermann says. "You illegitimize the certification and the educational process if you don't differentiate who can practice where: If it didn't matter whether you're acute or family, why do we even have these programs?" But because the supply of acute care NPs falls short of filling all hospitalist positions, adult and family nurse practitioners are commonly hired by hospitals for hospitalist teams. And, Ackermann says, an NP's ability isn't necessarily defined by credentials: Related experience trumps certification. "We look more at the person than what his or her credentialing is." It is, however, difficult to employ gerontologic NPs, because they can't treat patients younger than 55. This restricts their ability to work in the hospital setting. Ackermann says that since URMC began preferentially hiring acute care NPs as hospitalists, enrollment in the acute care NP program at the University of Rochester has risen. "It used to be that if you want to be more marketable, go into family practice, because then you can do anything. Well I've put a stop to that rumor and said, no, if you want an acute care job, go into acute care." A Day in the Life A typical day for a hospitalist NP consists of a 10-hour shift. At URMC, hospitalist NPs start the morning by meeting with overnight staff, discussing admissions, and assigning patients to different teams based on acuity and educational opportunities. "The hospitalist is the leader of the team, so ideally the hospitalist delegates and then spends the day seeing patients and discharging," Ackermann explains. The rest of the day is spent prioritizing based on when patients will be discharged. "NPs see patients between 8 a.m. and 1 p.m., also answering pages and putting out fires and seeing other patients they haven't seen yet, and doing admissions." When the evening shift starts, the NPs take care of anything that has carried over. They admit and cross-cover patients and take call. "During the day shift, it's more systematic: We make sure we see the patients, write a note, do orders, follow up on x- rays and labs, do whatever needs to be done" and work on coordinating discharge, Ackermann says. "If they get a chance they can go to the bathroom, or eat, or go to a conference," he jokes. "Some days are really quite manageable, and others are just crazy." Ackermann says he tries to keep each NP's patient load under 10. In states where NPs are supervised byphysicians, all hospital patients who require a diagnosis must be seen daily by a physician. If a hospitalist NP is the provider designated to see a patient, an internist often sees the patient briefly afterward and writes a short note indicating concurrence or adding a comment. NPs manage conditions such as diabetes, hypertension, venous thromboembolism and many others. Hospitalists may or may not perform procedures such as central line placement or thoracentesis, depending on the hospital and its hospitalist program. If a specific treatment question arises, NPs typically consult with internists on the team or specialists from other departments. NPs Improve Hospital Care Studies have measured NP performance in various hospital settings, and the results have shown that NPs provide equal if not superior care to patients, when compared with resident physicians. The University of California Medical Center in San Francisco created an acute care NP hospitalist service in 1998, and a subsequent study about care provided by those NPs revealed positive results. This occurred in large part, the authors hypothesize, because NPs are more experienced with the hospital's resources than residents, and because their experience with patient care and family interaction enables them to influence recovery. "This expanded focus provides an additional dimension 2
  3. 3. 3 beyond medical diagnosis and management," the authors wrote. In an article describing the NP hospitalist program at Loyola University Health System in Maywood, Ill., surgeon Jeffrey Schwartz noted that after NPs were integrated into the cardiology unit, mortality rates dropped from 3% to 0.9% and saved the hospital about $1 million yearly. He said that NPs' intimate knowledge of patients' conditions helps them identify problems sooner. "I am certain they have saved numerous lives because of their familiarity with 4 patients' conditions."? NP Adoption of the Role Acute care NPs who work in the hospital setting are truly putting their education to work and pursuing the career path they chose, so it makes sense that they are happy with the role. "They like the patients, they like the autonomy, they like the complexity, they like the challenge . these patients are sick, and you don't get in the hospital anymore unless you're really sick, so it's really a challenge," Ackermann says. "Another benefit is the relative freedom we are allowed in this setting," McLain notes. "When rounding on patients, we choose the order in which we see them. We also have the leeway to create our own schedule throughout the day, going to a meeting or having lunch when it works best." Challenges NPs face a few difficulties with this role, including stigmatization of hospital medicine. "It's not recognized as a subspecialty yet because it's so new," Ackermann says. Relationships with family physicians can become strained, McLain points out. "This is one aspect of our role within the hospital that will continue to take time to change." Also, hospitals sometimes hire hospitalist physicians straight out of school. "I'm not so sure that's a good thing - you get somebody who June 30 is a third-year resident and July 1 is an attending in a hospitalist service taking care of the sickest patients in the hospital," McLain says. The Future of the NP Hospitalist Hospitals now know the value of the nurse practitioner in a hospitalist role and are starting to expand programs. "I never thought we'd be able to say we were fully hired, but we're fully hired," Ackermann says. He has worked to create incentives for NPs in his service. "I'm advocating for them, I'm at the table, and they don't just have things shoved down their throats." The future holds the promise of expansion for these programs as well as changes in the way they're run, such as improvements in billing structures. According to Ackermann, few hospitals are billing NP professional fees through the hospital. He is seeking to enable NP billing as well as to improve NPs' autonomy and the hospitalist model. "I want them to become more involved professionally, and I want to see more productivity besides just taking care of patients," Ackerman says. "So we're really trying to develop a professional practice model that's not just taking exceptionally good care of patients, but contributing to the literature and everything else." To that end, Ackerman coordinated an acute care summit to address the future of acute care and hospitalists. About 65 attendees came from across the country to participate, which took place which took place at URMC in November 2008. The speakers discussed topics such as reimbursement for NPs in acute care, organizational models for hospitalist programs, educational needs and measuring outcomes. The summit was such a success that Duke University agreed to host next year's meeting. "We really wanted to get the attention of some of the professional organizations, and I think we did. The groups need to meet the needs of NPs in acute care. That's why there was overwhelming support to do this again," Ackerman said. "[Attendees] were there because they really wanted to be. It wasn't a clinical meeting, it was more a leadership and management meeting, and the feedback was excellent." References 3
  4. 4. 1. Li JMW. Society of Hospital Medicine (SHM) 2007-2008 productivity and compensation survey. Highlights From Hospital Medicine 2008: Society of Hospital Medicine Annual Update. San Diego: Society of Hospital Medicine. Available online at Accessed Sept. 15, 2008. 2. Kleinpell RM, et al. Hospitalist services: an evolving opportunity. Nurs Pract. 2008;33(5):9-10. 3. Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medicine service. Am J Crit Care. 2002;11(5):448-458. 4. Larkin H. The case for nurse practitioners. Hospital & Health Networks. 2003;77:54-58. Jennifer Ford is the associate editor. Reach her at 2 Quick Facts: NP Responsibilities as Hospitalists Diagnose Prescribe medications and interventions Order and interpret laboratory and diagnostic tests, such as electrocardiograms, x-rays, ultrasounds, stress tests, cultures and sensitivities Manage the care of patients hospitalized with complex acute health problems, such as trauma, coronary artery disease, cancer, diabetes and heart failure Coordinate the interdisciplinary health care team Plan and coordinate patients' discharge, rehabilitation, home health care and follow-up Other Hospital Roles for the NP Many NPs work in hospitals not as hospitalists, but as part of specialty and subspecialty teams. Karen Kilian, a pediatric NP in the emergency medical services department at Seattle Children's Hospital, works on a pediatric inpatient team to provide daily management of pediatric patients. It is typical for NPs to be part of a specialty care team, she says. "There are more children with complex care issues being hospitalized, and there simply weren't enough residents to care for them. Thus, the role of the inpatient NP was born." Kilian says that physicians and surgeons at her facility truly value the presence of NPs on their teams because they provide the continuity of care the residents couldn't - simply because of their training needs. Similar to hospitalists, NPs on these specialty teams lead morning rounds, determine the plan of care for the day, and assist with discharge needs. This scenario is not in place everywhere, however. "I don't know of any NP at Children's Hospital of Philadelphia that is called a 'hospitalist,'" says Judy Verger, NP, program director of pediatric critical care and neonatal programs at the University of Pennsylvania School of Nursing in Philadelphia. "This is likely more common with NPs who work with adults. Children's Hospital of Philadelphia employs more than 200 NPs from primary care settings to specialty practices to the intensive care unit." At Henry Ford Health System (HFHS) in Detroit, NPs lead care in the division of nephrology and hypertension. Results of a study conducted there showed that nurse practitioners provided care at least equal to that provided by nephrologists in reducing hypertension in chronic kidney disease (CKD) patients. "Our patients are initially seen by a nephrologist, and, once their CKD diagnosis is established, they are referred to a nurse practitioner. . The nurse practitioner was still able to lower their blood pressure by 6%," said Naima Ogletree, NP and comanager of the CKD Clinic at HFHS, in an interview with MedPage Today. When administrators at Seattle Children's Hospital noted that a certain set of children tended to come to the hospital often for complex issues and therefore needed continuity of care, they developed a new care team called the medically complex care (MCC) team. NPs were hired as providers on this team, to help provide continuity of care in the setting of a teaching hospital. The NPs on the MCC team function in a teaching role to interns rotating onto the 4
  5. 5. team, see consults within the hospital (including the ED), and provide daily care and management to their patients. "Our physician colleagues tend to refer to the inpatient NPs as functioning at a senior resident or even fellow level. Some NPs may be upset by that reference, but I tend to think it's quite the compliment to our training and the care that is being provided," Kilian says. "We aren't doctors, but we can provide excellent care, know when to obtain consults and ask questions, and have families who enjoy seeing the same care provider when their child has a problem." Both pediatric and family NPs work at Seattle Children's. The hospital also staffs a family NP on the cardiology service who has a specialized role in managing adolescents and young adults with congenital heart defects, transitioning them to an adult setting. Kilian foresees growth for the NP role in the hospital, partly because of decreases in residents' hours and due to increased demand for the communication expertise of nurse practitioners. "I can see NPs having roles in every specialty setting including the PICU, the ED and more specialty services." "It's a fun job to have, and it's actually quite enjoyable to work with the residents. They teach me, I teach them, and we all work together for a common goal," Kilian says. 5