American Journal of Critical Care. 2002;11: 353-362
Effect of an Outcomes-Managed Approach to Care of Neuroscience Patients by Acute Care Nurse Practitioners
By
Dale Russell, RN, MSN, ACNP-CS,
Mary VorderBruegge, RN, MSN, ACNP-CS
and
Suzanne M. Burns, RN, MSN, RRT, ACNP-CS, CCRN.
From the Neuroscience Service Center (DR, MV) and the School of Nursing (SMB), University of Virginia Health System, Charlottesville, Va.
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Abstract
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• Objective To improve clinical and financial outcomes for neuroscience patients by using an "outcomes-managed" model of care delivery and 2 acute care nurse practitioners as outcomes managers.
• Methods Baseline data from the year before implementation of the care model were compared with data from the first 6 months of implementation. A random list of 122 adult patients admitted to the neuroscience intensive care unit or the acute care neurosurgery unit of a university teaching hospital between January and December 1998 was generated to provide the baseline data. The prospective sample included 402 patients admitted to either unit during the first 6 months of the project (January through June 1999). The acute care nurse practitioners used an evidence-based multidisciplinary plan of care to manage all patients.
• Results No differences were found in age, sex, or ethnicity between groups. Patients managed by acute care nurse practitioners had significantly shorter overall length of stay (P = .03), shorter mean length of stay in the intensive care unit (P<.001), lower rates of urinary tract infection and skin breakdown (P<.05), and shorter time to discontinuation of the Foley catheter and mobilization (P < .05). The outcomes-managed group was hospitalized 2306 fewer days than the baseline group, at a total cost savings of $2 467 328.
• Conclusions Clinical and financial outcomes are improved significantly by identifying patients at risk, monitoring for complications, and having acute care nurse practitioners manage the patients.
Managing clinical and financial outcomes of complex cases has become the focus of many system initiatives in hospitals across the United States. To that end, numerous models of care have been developed in an attempt to determine the most effective methods. Unfortunately, few of the models have been widely tested despite claims of effectiveness. In this article, we describe the design, implementation, and results of a model of care called "outcomes management" in which acute care nurse practitioners (ACNPs) managed patients in a neuroscience service center at an academic university hospital.
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Background
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The administrative and clinical leaders of the neuroscience intensive care unit (ICU) and a neurosurgical ward at the University of Virginia Health System, Charlottesville, VA, noted that financial data for the 2 units (as compared with other hospitals contributing to the University Hospital Consortium’s database) were less than optimal. They thought that considerable cost savings might be realized if care delivery could be managed more effectively. In collaboration with the office of medical management and the school of nursing, a plan for the design and implementation of an "outcomes management" model of care delivery in which 2 experienced nurses were selected to act as outcomes managers for the project was negotiated. The 2 clinicians selected for the role were experienced nurses from the 2 units who were completing the academic requirements for ACNP certification.
Outcomes management is described as a care model that uses an advanced practice nurse to manage and monitor patients assigned to a multidisciplinary plan of care.1 The model had been used previously in the medical ICU of the hospital2,3 and served as a blueprint for implementation of the project in the neuroscience units.
Advanced clinicians with ACNP training were considered especially desirable for the role of outcomes manager because the combination of advanced assessment and care management skills inherent in their training was considered optimal for acceptance of the project by the physicians and staff. In addition, many of the ACNP roles in the institution had been designed to be "blended roles." This term is used in the institution to describe ACNP job descriptions that are inclusive of elements of the traditional clinical nurse specialist role such as system change, research, consultation, and teaching. Although these components are part of many ACNP roles as described by Kleinpell,4,5 the term is used at our institution to differentiate roles that include the combination of advanced practice components from those that focus solely on the management of a certain number of patients.
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Review of the Literature
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Information on care initiatives designed for neuroscience patients is limited. The majority of projects were designed for patients with acute stroke (including ischemic and hemorrhagic infarcts).6–10 Other care initiatives used for neuroscience patients focused on multiple sclerosis,11 patients undergoing transsphenoidal resection of a pituitary adenoma,12 and acoustic tumor management.13 Although the implementation of clinical pathways improved selected outcomes and shortened hospital lengths of stay in these subsets of neuroscience patients, none of the studies addressed the use of a comprehensive model of care such as case or outcomes management to improve quality and cost outcomes in a varied (more inclusive) population of neurosurgical patients.
Studies in other populations of patients describe more comprehensive approaches. Outcomes of chronically critically ill patients assigned to a special care unit and a case management approach were compared with outcomes of patients cared for in an intensive care unit.14–17 A small percentage of these patients were neuroscience patients. Although the outcomes for the patients in the special care unit did not differ significantly from those of patients cared for in the ICU, the results for all the study variables were more favorable in the patients from the special care unit. Further, significant cost savings were attributed to the methodical attention to all aspects of care and the decreased use of laboratory and diagnostic testing. The authors14–17 concluded that similar systematic, comprehensive approaches used with other populations of patients might result in cost-effective, high-quality care.
Finally, in a prospective study by Burns et al,2 an approach to the care of patients who require prolonged mechanical ventilation in a medical ICU in which an outcomes manager, a clinical pathway, a weaning protocol, and a weaning assessment tool were used was compared with a non-outcomes–managed approach. Although the results of the study did not indicate a statistically significant effect on the variables of interest, a positive trend was noted in all outcomes, and significant cost savings were associated with the model. This trend has continued since the study’s end, and the outcomes-managed approach continues to be used in the medical ICU and is being implemented in the other ICUs within the institution.
Studies on outcomes associated with the use of nurse practitioners in acute care settings are limited but do suggest the effectiveness of the approach. In a study by Mitchell-DiCenso et al,18 neonatal infants were randomly assigned to neonatal nurse practitioners or to house-staff physicians with no difference in clinical outcomes, satisfaction, or follow-up measures. Spisso et al19 noted that care provided by trauma nurse practitioners in a tertiary care setting resulted in decreased cost, improved care, a decrease in patients’ complaints, and improved communication among members of the healthcare team. In a multisite study by Rudy et al,20 the care activities and outcomes associated with ACNPs and physician assistants were compared with those of resident physicians. Outcomes were similar for both groups, although residents cared for a greater number of patients, worked longer hours, and performed more invasive procedures than did the ACNPs or physician assistants. The results did suggest that ACNPs and physician assistants were more likely to discuss patients with nurses and to interact with patients’ families. Finally, a retrospective evaluation of care provided by nonphysician providers (an ACNP and a physician assistant) caring for trauma patients after transfer from an ICU suggests that the care was both efficient and effective.21 The providers made new diagnoses in 53% of the patients, and all patients were discharged from the hospital.
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Purpose
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The purpose of this quality improvement project was to determine the clinical and financial impact of an outcomes-managed model on 2 neurosurgical units. The clinicians, administrators, and physicians involved in this project thought that the intervention would decrease system variation. Thus, the goal was to improve clinical outcomes for all patients in the 2 units and to monitor the financial impact of the intervention. We thought that the clinical and financial outcomes of patients cared for by the ACNPs using the outcomes-managed model of care delivery would be better than the outcomes of patients cared for in the year preceding implementation of the model. In order to evaluate the effect of the model over time, key clinical indicators that affect outcomes of neuroscience patients were determined. These served as a clinical prompt for the ACNPs’ daily care management and were also used in the retrospective chart review of patients for benchmarking purposes in order to make comparisons.
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Sample
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Approval and authorization for investigation of human subjects were obtained to review and evaluate existing data for this project. The project was given exempt status.
The retrospective benchmark population was identified by using the following procedures and/or diagnostic codes from the International Classification of Diseases, Ninth Revision: laminectomy, tracheostomy, intracerebral hemorrhage, subarachnoid hemorrhage, hydrocephalus, and craniotomy for brain tumor. A random list of 122 adult patients (18 years and older) admitted to a 29-bed neuroscience ward or the 14-bed neuroscience ICU from January 1998 through December 1998 was generated by using a random number table to obtain a total of 20 patients per category. These codes were used because they were representative of the 6 most common diagnoses seen in the neuroscience units. We used this sampling technique for expediency and because the selected patients accurately reflected the makeup of the patients to be followed up prospectively.
The prospective sample of 402 patients consisted of a consecutive convenience sample of neuroscience patients admitted to either unit for 6 months (from January 1999 through June 1999). The patients in the prospective group were grouped by the following diagnostic codes: laminectomy, hydrocephalus, intra-cerebral hemorrhage, subarachnoid hemorrhage, craniotomy for brain tumor, spinal cord injury, head injury, and tracheostomy. The prospective sample also included patients with spinal cord injuries (the retrospective random sample did not include any patients in this category). Although data collection continued after this interval (as is consistent with the monitoring necessary for such process-improvement projects), we wished to determine the outcomes of the model so we could revise it as necessary to continue to refine and improve care. Thus, analysis of clinical outcomes was done on data collected during the first 6 months of use of the care model. Cost analysis, however, was calculated for the entire first year of the model because doing so was consistent with the reporting mechanisms for all the institution’s quality improvement projects.
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Materials and Methods
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We obtained more than 100 clinical pathways for the specific neurosurgery categories identified by codes from the International Classification of Diseases, Ninth Revision by using the University Hospital Consortium’s query mechanism. The pathway elements were compared with evidence-based practice guidelines (when available) for care elements for patients with neuroscience conditions. A literature search was conducted to assist in establishing best practice. Finally, a list of essential care elements was developed for monitoring and care management by the ACNPs. Although a clinical pathway was not developed, all aspects of a pathway were integrated into the monitoring tool used by the clinicians. The tool served as both a clinical prompt and a data collection instrument for the ACNPs (see Table
).
One element of particular interest to the ACNPs was the need to identify patients who evidenced neurological deficits such as altered mental status and/or any motor weakness and who had no family support or who lived alone. The term used to identify the patients for analysis was "patients at risk." The hypothesis of the 2 clinicians was that these categories of patients were likely to stay in the hospital for longer periods and would be harder to place in rehabilitation centers than those who were not at risk. The ACNPs thought that by evaluating patients early in the hospitalization and aggressively pursuing appropriate placement options, they could ensure timely placement options and shorten hospital length of stay.
Data elements compared between the retrospective and prospective samples included only those elements that could be directly linked to the daily "management" and interventions of the 2 ACNPs. We also selected elements that were reliably present in the charts of the patients in the retrospective group: complications (urinary tract infection, skin breakdown, pneumonia, falls, seizures, ileus, and deep vein thrombosis), timing of interventions (wait to placement after hospitalization, removal of Foley catheters, days until a tracheostomy tube was placed, total ventilator days, time until out of bed, time in an ICU, and days tracheostomy tube in place). Patients at risk (those with a neurological deficit who did not have family support or who lived alone) were a specific category of interest. For these patients, discharge disposition (skilled nursing facility, rehabilitation center, or home) was determined in addition to the hospital length of stay. Finally, cost savings were calculated by using "total costs," that is, both the direct costs of patients’ care and the indirect costs associated with delivering that care. An "average cost per patient day" was calculated. "Savings" were estimated by multiplying reduction in length of stay by the cost per patient day.
Daily "management" by the ACNPs consisted of the following elements: (1) daily rounds on all patients, including history and physical examination, laboratory tests, and radiological and other diagnostic evaluations; (2) attendance on morning rounds and discussion with both the primary and consulting teams about the patient’s plan of care; (3) daily attendance on interdisciplinary rounds; and (4) throughout the day, close monitoring of the patients’ clinical status, with interventions as necessary and collaborations with the physicians to implement orders (generally verbal orders) for therapies, consultations, medications, and discharge planning.
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Analysis
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Descriptive statistics were used for retrospective, prospective, and combined populations of patients. Continuous variables were compared between groups by means of t tests. Chi-square analysis was used to compare the proportions of patients in the prospective and retrospective groups who had at least 1 ICU day. One-way analysis of variance with post hoc testing was used to determine differences in length of ICU stay for different disease categories.
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Results
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A total of 524 patients were studied: 122 without ACNP management and 402 with ACNP management. The retrospective and prospective groups did not differ significantly with respect to age, sex, or ethnicity. The mean age for both groups was 55 years; 47% were women, and 53% were men. Eighty-eight percent of both samples were white, and 12% were African American. Mortality rates for the ACNP-managed group (2.63%) and the nonmanaged group (2.06%) were not significantly different.
Figure 1 shows the distribution of diagnostic categories by percentage for the prospective study sample. Outcomes of ACNP management (prospective sample) versus non-ACNP managed care (retrospective sample) were compared.
Figures 2 and 3 illustrate the hospital discharge disposition to a skilled nursing facility, rehabilitation center, or home by percentages of patients, for patients at risk (those who live alone and those with no family support). Figure 4 shows the significant effect (P = .04) of ACNP management compared with no ACNP management on length of stay (in days) for patients at risk.
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Figure 3 Discharge disposition of patients who have no family support vs patients who have family support.
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Figure 4 Significant effect of outcome management by an acute care nurse practitioner (ACNP) on length of stay in the hospital for patients at risk. All differences were significant at P=.04.
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Mean length of stay in days in the neuroscience ICU was significantly shorter in patients managed by an ACNP (P <.001, Figure 5). Figure 6 shows the percentages of patients in the 2 management groups who had complications: urinary tract infection, skin breakdown, and pneumonia. Rates for urinary tract infection and skin breakdown were significantly better (P<.05) in the ACNP-managed group than in the other group. The complication rate for pneumonia did not differ significantly between groups.
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Figure 5 Mean length of stay in the neuroscience intensive care unit by diagnostic category for patients managed by an acute care nurse practitioner (ACNP) and patients not managed by an ACNP.
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Figure 6 Significant effects of outcomes management by an acute care nurse practitioner (ACNP) on complication rates.
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Figure 7 represents the days to treatment (essentially when the intervention occurred) with and without ACNP-managed care. Significant differences (P<.05) were found in timing (days) related to the discontinuation of Foley catheters and time to mobilization (out of bed). No significant differences were found in the number of days to placement once the order was written for discharge (referred to as wait), days until a tracheostomy tube was placed, duration of mechanical ventilation, length of stay in the ICU (out of ICU to the ward when ordered), and time until tracheostomy decannulation occurred.
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Figure 7 Comparison of timing of interventions between patients managed by an acute care nurse practitioner (ACNP) and patients not managed by an ACNP.
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Overall length of stay for patients in the study was significantly (P = .03) shorter in the ACNP-managed group (8 days) than in the non-ACNP–managed group (11 days).
Financial results were calculated as described earlier for the 2 study periods. The project resulted in a total 1-year savings of $2 467 328 (direct costs, $1 668 904). Length of stay was decreased in 13 of 17 managed diagnosis-related groups, with no difference in 1-month readmission rate between the intervals.
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Discussion
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Significantly improved outcomes occurred in the patients managed by the ACNPs. Of the monitored clinical outcomes, urinary tract infections and skin breakdown were notable and were associated with interventions such as early removal of the Foley catheter and mobility. These earlier interventions most likely resulted in a shortened length of stay. Other complications that were monitored and managed by the ACNPs included pneumonia, ventilator dependence, falls, seizures, ileus, and deep vein thrombosis. The rate of pneumonia was lower in the patients managed by ACNPs than in the others, but the difference was not statistically significant. The other complication rates were too low for comparison.
Although the ACNPs were managing numerous elements of care and intervening as appropriate, their effect on these elements was difficult to document in the daily data collection. For example, management by the ACNPs included adjustments of anticonvulsant medications to achieve or maintain therapeutic levels, and the results of daily laboratory and diagnostic studies often required intervention. The interventions all occurred more rapidly than if the surgical house staff were to respond (an event that most likely would have occurred after the surgical day, and after rounds or teaching sessions). Differences between groups in care elements such as days to placement of a tracheostomy tube and days to decannulation, although not statistically significant, did increase patients’ comfort, a result that was noted anecdotally via reports from patients and their families. Finally, pain management was a key quality goal, yet data collection would have required a more scientific approach than the project was designed to ensure. Documentation of the pain level by nurses on the units was not consistent.
As noted previously, the 2 ACNPs hypothesized that patients with neurological deficits who had no family support and/or who lived alone would have longer stays than would the other patients. The ACNPs thought that this expectation was likely because of the reluctance of rehabilitation centers to accept patients who could not be placed after a reimbursed "rehab" interval. The ACNPs identified patients considered at risk early, usually on the day of admission. At that point, they initiated interventions, including contacting family members and friends of patients who might be able to provide supervision or assistance at discharge and making referrals to social services, home health, and physical medicine and rehabilitation when appropriate. By educating physicians, nurses, and the physicians’ nurse coordinators about the risk of patients without resources, earlier identification and intervention, sometimes before admission to the hospital for elective procedures, was accomplished.
Patients’ satisfaction was not studied during the project interval; however, anecdotal reports from patients, patients’ families, nurses, and house staff were positive. Patients and their families reported satisfaction at having a specific consistent caregiver who provided information and guidance. Administrators at the neuroscience service center noted an increase in favorable letters from and comments made by patients and patients’ families.
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Limitations
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Our study has a number of limitations. First, it was not a randomized controlled trial. Although this quality intervention was designed with some rigor in order to determine the effect of the model on outcomes, a prospective control group was not used. The beneficial outcomes reported, as compared with retrospective data from the year before implementation of the model, may have been the result of system forces that were not recognized. No change in physician, nurse, or utilization review nurse practices occurred during this interval, making this possible explanation unlikely. However, the possibility must be considered. Because of the interest of the hospital in designing the care model to improve the care of all neuroscience patients in the 2 units of interest, a true experimental design was not possible. The focus was on ensuring quality care and monitoring outcomes. It is unlikely that many institutions involved in similar system initiatives will consider randomized controlled trials because such trials are difficult to accomplish (require informed consent), take time to complete, and are costly. Further, it has been shown repeatedly that when variation is decreased, outcomes improve. Institutions across the United States are struggling to find quality solutions, such as the one described here, that are also cost-effective.
A second limitation is that many care elements of interest could not be monitored in such a way as to establish the effect of the ACNP interventions (noted earlier in examples such as their attention and interventions designed to ensure appropriate drug levels, pain management, satisfaction, etc). Last, the use of an ACNP was not compared with other advanced practice nurse models to determine if the same effect might be realized with other models. In fact, in the outcomes-managed reports described earlier for patients receiving mechanical ventilation in this same institution, the outcomes managers were not trained at the ACNP level although they were advanced practice nurses. Regardless, we think that the background of ACNPs fits the model extremely well. The ACNPs’ credibility with all members of the multidisciplinary team, especially the physicians, was critical to the clinicians’ ability to make accurate and timely decisions and interventions.
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Conclusions and Summary
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The goal of this study was to improve clinical outcomes in neuroscience patients by using an outcomes-managed approach to care in which ACNPs were used as outcomes managers. Inherent in the model is the understanding that by decreasing system variation, more efficient and effective care may be delivered and financial outcomes improved. In the ACNP-managed patients, total patient days were reduced by 2306 (without an increase in 1-month readmissions).
Although many elements of a clinical pathway were included in this model, the model relied more on the 2 ACNPs’ assertive clinical acumen, system savvy, and communication skills to ensure that best practice be accomplished for the patients. As noted by others, pathways may be considered useful tools to chart multidisciplinary care of complex patients; however, the essential component in the management of these patients is a knowledgeable and skilled outcomes manager.22,23 In this instance, the care managers were ACNPs. This relatively new category of nurse practitioner may be especially effective in roles such as the one described in this model. As acute care institutions struggle to make care more effective and efficient, similar models in which ACNPs are used should be considered.
This study indicates that clinical and cost outcomes are improved by identifying patients at risk, closely monitoring for complications, and having a consistent advanced practice nurse to guide and manage the care of specified groups of patients. The model may be an effective one for use in a wide variety of patients.
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ACKNOWLEDGMENTS
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We thank the following people who supported, believed in, and encouraged our project. Without them, the project could not have been done. They are Becky Lewis, RN, MSN, patient care services administrator; Deb Baker, RN, MSN, manager of the neuroscience intensive care unit; Susan Prather, RN, MSN, manager of the neurosurgical ward; Tom Bleck, MD; John Jane, MD; all the neuroscience attending physicians and house staff physicians; and the many clinicians who worked on both of the units. We also appreciate the support of the office of the chief of staff, Tom Massaro, MD, and the "Medical Management Team," and analyst Dave Barton, RRT, PhD. Most importantly, we dedicate this manuscript to our beloved friend and colleague, Mary VorderBruegge, who loved being an ACNP and was thrilled to have affected patients’ care so positively in her role as an outcomes manager. We will always be proud of her many accomplishments; she was a star!
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
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Abstract
Background
