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Acute Care Nurse Practitioners: Creating and Implementing a Model of Care for an Inpatient General Medical Service

	Abstract

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
Changes in medical education and healthcare reimbursement are recent threats to most academic medical centers’ dual mission of patient care and education. Financial pressures stem from reduced insurance reimbursement, capitation, and changes in public funding for medical residency education. Pressures for innovation result from increasing numbers of patients, higher acuity of patients, an aging population of patients with complex problems, and restrictions on residency workloads. A framework for addressing the need for innovation in the medical service at a large academic medical center is presented. The framework enables acute care nurse practitioners to provide inpatient medical management in collaboration with a hospitalist. The model’s development, acceptance, successes, pitfalls, and evaluation are described. The literature describing the use of nurse practitioners in acute care settings is reviewed.

The evolution in healthcare has created opportunities for advanced practice nurses. An evolving type of nurse practitioner is the acute care nurse practitioner (ACNP). Whereas traditional nurse practitioners focus on promotion of health and management of chronic illness, ACNPs focus on the care of acutely ill patients. More than 75 graduate programs are training ACNPs today.³

Another important change in academic health centers has been the development and use of hospitalists.⁴ Hospitalists are defined as physicians who care for hospitalized patients but then refer the patients to the care of primary physician upon hospital discharge.⁴ The University of California, San Francisco, Medical Center, an academic facility used this time of turmoil in healthcare to incorporate creative models of care in the medical service. One creative model included the use of hospitalists and ACNPs primarily to expand the medical service’s capacity, but also to improve the efficiency and quality of patients’ care. We describe the processes that led to the creation of an ACNP-hospitalist framework of care and describe the framework’s development, acceptance, successes, barriers to implementation, and evaluation.

	ACNPs: Literature Review

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
Nurse practitioners can provide many services for patients to improve the overall course of care in the hospital. Nurse practitioners provide high-quality, cost-effective care for patients in a variety of outpatient settings^5–7; however, data on the role of the practitioners in hospitals are limited (see Table). Much of the research substantiating the effectiveness of inpatient nurse practitioners relative to quality of care, satisfaction of patients and patients’ family members, and length of stay has been done in pediatric settings.^8,17,18 For example, Schultz et al⁸ found that the care provided by neonatal nurse practitioners was not only comparable to the care provided by house staff but was more cost-effective because the patients’ length of stay was shorter. The study was limited by a design that used a historical comparison from 2 consecutive years, so factors other than the practice of the nurse practitioners may have influenced care. Another limitation of the study was the absence of data on satisfaction among parents, house staff, and hospital staff.

Effectiveness of nurse practitioners in the emergency department has also been researched.^10,19 In these studies, nurse practitioners often provided care to patients in a "fast-track" or urgent care area created to manage less emergent cases. Buchanan and Powers⁹ described a minor emergency or fast-track area staffed by nurse practitioners. The fast-track area was opened to reduce the number of nonurgent visits to the emergency department and was staffed by nurse practitioners. Use of the nurse practitioners led to improved access to care, less costly care, and shorter visits to the emergency department. Complaints from patients were rare. Buchanan and Powers also hypothesized that more efficient care might attract more patients. Rhee and Dermeyer¹⁰ did a telephone survey to assess satisfaction levels among patients seen by a nurse practitioner in a university emergency service and reported that the patients were satisfied with the care provided. The limitation of this survey was that only 1 nurse practitioner was evaluated, so the results may not be representative of most nurse practitioners.

Several researchers have studied nurse practitioners in surgical and trauma service settings. Hylka and Beschle¹¹ described hiring nurse practitioners to provide services in a more cost-effective manner. The nurse practitioners obtained patients’ medical histories and did physical examinations preoperatively, ordered laboratory tests, and taught patients about what to expect. When nurse practitioners did the preoperative workups, laboratory costs and surgical delays were decreased. The nurse practitioners followed up with the patients during the hospital stay and at outpatient follow-up appointments. Additional cost savings resulted from the development of guidelines to individualize patients’ care. The nurse practitioners were familiar with the patients throughout the continuum of care, and they could tailor the care and education to meet each patient’s needs. Hylka and Beschle did not report the impact of the use of nurse practitioners on staff or on patients’ outcomes of care. They did cite specific examples of how nurse practitioners intervened to improve care.

In a study¹² on a surgical service, nurse practitioners were hired to work in the trauma surgery service because of a dramatic increase in the number of inpatients due to consolidation of regional trauma services without subsequent increases in house staff. The addition of nurse practitioners was associated with a decreased length of stay for seriously injured patients, improved documentation in medical records, decreased waiting time in the outpatient clinic, and fewer complaints from patients. The researchers¹² reported time savings for house staff but did not report on the quality of care that nurse practitioners provided or how these nurses influenced patients’ outcomes or satisfaction.

Few published reports^13,14,20,21 describe nurse practitioners in an inpatient medical service. Reductions in the number of house staff have affected surgical and some specialty programs rather than internal medicine services. The reluctance to assimilate nurse practitioners into acute internal medicine services may be related to the extensive differential diagnoses required for these patients, who often have numerous comorbid conditions. Genet et al¹³ described an inpatient medical service that was designed for delivering patient care without medical residents. The nurse practitioner had the primary responsibility for facilitating the plan of care for all the patients admitted until they were discharged. Genet et al stated that collaboration between physicians and the nurse practitioner was the key component of the care delivery model. Benefits of this model included decreased fragmentation of care, increased interaction between physicians and nurses, and enhanced roles of nurses in clinical evaluation and decision making. Genet et al also stated that use of nurse practitioners in inpatient services allows teaching hospitals and schools of medicine and nursing to focus on what is best for postgraduate learning rather than what is necessary for service needs.

Goksel et al¹⁴ wrote a brief description of an inpatient service that used nurse practitioners to manage medically stable hospitalized patients. The patients were admitted by house staff and then transferred to the nurse practitioner service after being in the hospital more than 48 hours. The service was designed to reduce the burden on house staff in the internal medicine service by transferring patients who were expected to have a long stay over to the nurse practitioners. The nurse practitioners effectively cared for internal medicine patients and received favorable ratings from house staff. Satisfaction among patients and staff was not evaluated.

Rudy et al¹⁵ did a comprehensive and informative study comparing a large group of ACNPs, physician assistants, and residents at 2 large academic medical centers. The participants in the study described their care activities through diaries, and data on patients’ outcomes were collected. The researchers examined the number and type of procedures that nurse practitioners and physician assistants performed in comparison to house staff. They found that the patients treated by the house staff were sicker and older than the patients treated by the nurse practitioners and physician assistants. However, outcomes were similar in both groups. Rudy et al did not describe how patients were assigned to the nurse practitioners, physician assistants, and residents, nor did they discuss potential bias in the assignment of patients or the need for residents to learn. The older, sicker patients may have been assigned to the resident teams in order to meet the residents’ need for learning rather than because of any reason related to the ability of the nurse practitioners and physician assistants to provide care. The researchers also stated that nurse practitioners and physician assistants did not routinely perform invasive procedures. Again, this situation may have reflected the need for residents to learn. Rudy et al concluded that the nurse practitioners and physician assistants followed the routines and expectations of medical practice and that their success was their ability to collaborate with all members of the staff and demonstrate good clinical decision-making skills. The investigators did not measure patients’ outcomes or satisfaction levels among staff or patients.

Stetler et al¹⁶ evaluated the role of the ACNP. They described role expectations, influence on targeted aspects of care, retention of focus on nursing, and factors facilitating or hindering the effectiveness of ACNPs. They concluded that the ACNPs improved patients’ care, retained a visible nursing component in their role, and were accepted as providers by patients and patients’ families. They did not evaluate patients’ outcomes in that study.

Although this summary of published literature offers little insight into the function and value of nurse practitioners in inpatient medical services, it does highlight the potential value of nurse practitioners in acute care settings. In a supportive environment, the assimilation of nurse practitioners into an inpatient medical service can create a successful patient management team. To explore this assimilation further, we examine the experience at a single institution.

	Motivation for Creation of an ACNP Medical Service

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
The University of California, San Francisco, Medical Center is a large 476-bed hospital that employs nurse practitioners in the acute clinical areas of oncology/hematology, neonatal intensive care, nurse midwifery, and preoperative evaluation. The medicine service was divided into 4 teams with patients’ assignment to 1 of the 4 teams determined by the admission activity on the call day (the particular day a team is on call). The medicine service also provides consultation to other specialty services. Each team included an attending physician, residents, medical students, a pharmacist, and pharmacy students. An attending faculty member and a second- or third-year resident did the medical consultations.

Because of an increase in medical patients, restrictive admission caps for house staff, and workload reduction, the department of medicine considered using nurse practitioners to provide acute care services for inpatients. The school of nursing had recently developed an ACNP program. In early 1998, members of the departments of nursing and medicine began discussing the use of ACNPs in the inpatient medical service. Hospital administrators were an integral part of the negotiation and were asked to provide financial support for the concept in an effort to meet the accreditation requirements and patient care activities of the medicine service.

Initial discussions between the departments involved detailing ACNP practice; the education, abilities, and contributions of ACNPs; and the limitations of their practice. Four areas of initial concern were continuity of care among ACNPs, continuing education, use of the hospital formulary, and preserving opportunities for medical residents to learn procedures.

A job description based on the needs of the medical service, the role of the ACNPs, the licensing regulations of the California Board of Registered Nurses, and other institutions’ experience with ACNPs was developed (see Appendix). The job description was presented to the interdisciplinary practice committee and was refined, creating a functional framework that described patients’ care, patients’ admissions, lines of communication, and interactions with consultative and interdisciplinary services. The ACNPs collectively developed a standardized practice protocol, which also required approval from the interdisciplinary practice committee. Roles and responsibilities were explicitly defined, and ultimate approval was received after several months of revisions.

In October 1998, 3 nurse practitioners were hired to create an additional medical management group—or team—along with a resident and an attending physician. With the supervision and collaboration of the attending faculty member, the new team provided care for patients who did not require a stay in the intensive care unit. The residents continued to do the medical consultations, but they also assisted with management of patients, especially as the ACNPs were establishing their role and knowledge base.

	The Role of the ACNP Team

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
The ACNP team admitted and managed patients from a general medical population of patients who had a lower probability than other patients of acute cardiac decompensation or need for treatment in the intensive care unit. The team did not provide care for patients who required transfer to the intensive care unit; however, they provided care for the patients when the patients were transferred back to a general or step-down unit.

The sources of patients included the emergency department, transfers from other teams, and direct or planned admissions. Examples include planned admissions of patients undergoing chemotherapy for solid tumors, patients with cystic fibrosis who required antibiotics and respiratory therapy, patients in whom low-probability myocardial infarction needed to be ruled out, and patients with a multitude of acute exacerbations of chronic illnesses. The ACNPs’ admission cap was 3 to 5 new patients per day, and the entire service’s cap was 10 patients per day. The ACNPs provided care 7 days per week during daytime hours, and they did not admit patients on weekends or have "on-call" responsibilities. Care of the ACNPs’ patients at night was provided by the existing on-call team, consisting of house staff who received a report on all medicine service patients before the residents or ACNPs left the hospital for the day.

Each day, an ACNP pre-rounded on all patients on the team and presented the new patients to the attending physician and/or resident. Management plans were formulated by the ACNP and were reviewed with the attending physician and throughout the day as necessary. The ACNPs initiated contact with each patient’s primary care provider if possible and integrated outpatient care needs with the inpatient management of the patient. The ACNPs dictated discharge summaries for all patients on the day of discharge in an effort to enhance timely insurance reimbursement and to communicate about follow-up with primary care providers.

ACNPs employed on this medical service provide a continuity of care that is difficult to compare with traditional resident models. The ACNPs are generally more familiar with hospital and community resources and policies than are residents. Because the ACNPs are nurses with inpatient experience, they are familiar with issues specific to patients and patients’ families that may influence recovery. This expanded focus provides an additional dimension beyond medical diagnosis and management.

The primary goal of the ACNPs is to provide excellent care that focuses on the needs of patients without the distractions of academic learning requirements. Residents rotate monthly and may not be able to use the resources or hospital system as effectively as the service-based ACNPs can. The primary goal of residents is to learn, which may add to inefficient use of resources and services as they order diagnostic tests for academic inquiry.

Our framework of using ACNPs may create the ideal team situation, taking advantage of the strengths of all members on a medical service. The ACNPs provide the continuity and collaboration of resources, and the residents share the residents’ training and medical expertise.

	Standardized Practice Protocols

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
Part of establishing the role of the ACNPs included writing standardized protocols and receiving approval from the hospital’s interdisciplinary practice committee, with subsequent acceptance by the medical executive board. The state of California requires that all nurse practitioners develop standardized procedures or protocols to reflect their practice. This document for our ACNPs describes their role, setting, and functions. This document was reviewed, revised, and accepted by committee members in a series of meetings. Getting all committee members to accept the document was challenging because of legal concerns about the authority to write prescriptions, practice limitations, and historical reluctance. Physicians on the committee were concerned about the complexity of providing care to medical inpatients because they were thought to lack a predictable pattern of recovery. Openness to this new role of ACNPs evolved by citing resources and other similar models of care. The successful acceptance of the ACNP-hospitalist model was intimately tied to the support of both the departments of medicine and nursing.

Inpatient medication orders and therefore access to the hospital’s formulary were the most important barriers to approval. The ACNP-hospitalist team decided to review this issue at a later meeting of the interdisciplinary practice committee. This delay would allow time to evaluate the team’s practice and provide anecdotal validation of the team’s successes.

A second issue was the procedural interventions proposed by the ACNP team. Procedural interventions such as paracentesis, lumbar puncture, thoracentesis, and placement of central venous catheters were thought to be important learning opportunities for medical students and residents. The most frequent procedures needed for the patients of the ACNP team included obtaining blood for arterial blood gas analysis and other laboratory tests and, infrequently, paracentesis or lumbar puncture. The patients of the nurse practitioner team did not require frequent procedures so medical students and residents would not miss learning opportunities. The ACNPs established a protocol for procedural proctoring that permitted independent practice of procedures after the ACNP had done 4 procedures under the supervision of a third-year medical resident or attending physician.

	Continuing Education

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
A concern about the extent of the ACNPs’ knowledge of disease pathophysiology and management of complex and simultaneous disease processes was voiced by members of the medical service. The ACNPs were not educated as ACNPs, but as family nurse practitioners and adult nurse practitioners. Each nurse practitioner had a unique and extensive background in management of medical patients that provided a foundation for practice in the new role, but knowledge deficits were identified.

The residents and attending physicians on the service provided lectures and learning opportunities through didactic interaction and case review to meet the knowledge deficits of each nurse practitioner. The medical center has many mechanisms in place to assist in case review. The university has daily medical conferences at noon, weekly medical grand rounds, multiple conferences throughout the year, and financial support available for travel to conferences.

	Initiating the Role

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
An important step in the beginning was to discuss the role of the ACNPs with the staff nurses and administrative nurses. The staff were given information about the ACNPs’ role, and opportunity for clarification was provided at nursing staff meetings and administrative nursing meetings. We also discussed the role with the pharmacists and solicited their support. Active solicitation of support and education helped establish good communication patterns. Eliciting feedback from these groups further improved and streamlined delivery of care. Monthly meetings with the director of nursing to discuss issues and report on the evolving role of the ACNPs and frequent contact with nurse managers and staff established good communication.

The director of the medical consultation service took a survey of residents’ perceptions of the ACNPs’ practice. The survey used 7 parameters to evaluate their practice. Overall, residents ranked the ACNPs as either competent or superior in the categories of responsibility, continuity of care, interaction with patients, interaction with team members, and record keeping. The ACNPs were ranked competent in clinical judgment and fund of knowledge. These findings were somewhat surprising to the residents and attending physicians because the role of managing inpatients on the medicine service was a new one for the nurses. Perhaps the ACNPs’ previous experience negated the initial concerns, resulting in positive findings on the evaluation. We think that the ACNPs’ positive attitudes, desire for success, and enthusiasm contributed to the findings.

	Lessons Learned

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
Despite extensive communication of the new role and responsibilities of the ACNPs, it took time for all allied health professionals, house staff, and nurses to understand the role. A prudent approach would be to explain the new role at its initiation to all allied health professionals, including nurses, residents, pharmacists, respiratory therapists, dietitians, home care workers, case managers, and social workers. This communication could be accomplished by having all providers attend staff meetings rather than focusing only on the nursing staff. Such communication would have eased the lack of clarity for clinical personnel.

Another important factor that ensured success was the creation of a good communication system among the ACNPs. Cards describing patients’ care were created to "hand off " patients to the next ACNP after a patient was admitted or to the nighttime resident (Figures 1 and 2). Reporting clinical information about the patients in a consistent and structured manner was initially a problem. The initial structure required the ACNP who was going off duty to communicate with the ACNP who was coming on duty. With the frequent changes in the ACNPs’ schedules, the time required for such communication was significant. Eventually the sign-out process was streamlined by using a voice-mail system and improved sign-out cards.

View larger version (23K): [in this window] [in a new window]   Figure 1 Patient admission card used by the acute care nurse practitioner team. The card is printed out on a 20 x 28-cm piece of paper and is folded twice.

View larger version (12K): [in this window] [in a new window]   Figure 2 Card used by acute care nurse practitioners to "hand off" patients to nighttime residents.

	The Future

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 
Anecdotally, the general opinion of the residents and allied health professionals was that the team was undeniably a success. The nurses found that the ACNPs were responsive to the nurses’ suggestions for patients’ care, very approachable, and willing to explain a patient’s disease in detail. In addition, they found that the ACNPs were willing to take extra time with patients’ families. The ACNPs were available throughout the day to interact with the nursing staff and were not distracted by academic demands. The continuity of the ACNP-hospitalist team was valuable for the patients who were repeatedly admitted because of acute exacerbations of chronic illness. As the ACNPs developed a relationship with these patients and the patients’ primary care providers, transitions between home and hospital became smoother.

No study has fully evaluated nurse practitioners in inpatient settings. Most researchers have focused on methods to relieve workload for the house staff and reduce cost. Although these aspects are important, it would be useful to study patients’ outcomes and the clinical decision-making skills associated with patients managed by nurse practitioners. Although past studies focused on either the level of quality that nurse practitioners can provide or how they can replace or reduce the workload of residents, the studies did not focus on what value nurse practitioners can add. Future studies on ACNPs should focus on patient outcomes and clinical decision-making skills associated with patients managed by nurse practitioners. More nurse practitioners should describe their practice so that others can create workable frameworks. These descriptions would also enable nurse practitioners to describe and study methods to improve efficiency and outcomes.

Nurse practitioners should not replace all functions of medical residents; they are not trained as residents. With advanced practice training, nurse practitioners can provide high-quality, cost-effective care; use resources effectively for excellent care of patients; and create consistent relationships with attending faculty, staff nurses, patients, allied healthcare workers, and primary care physicians while providing high levels of satisfaction throughout the healthcare system.

ACNPs have continued to grow in their roles and expand into new areas. With implementation of a practice framework, ACNPs at our institution were able to expand their role and enhance collaboration between physicians and nurses. The establishment and implementation of the ACNP medical service was an exciting opportunity to create and shape the direction of an innovative model of care. Nurse practitioners practice in primary care, specialty clinics, nursing homes, and subacute, acute, and critical care settings. Nurse practitioners must continue to document and communicate methods to improve patients’ care in cost-effective and innovative ways across the continuum of care. This goal must be achieved through evidence-based research. Through research and direct observation of lower cost, high-quality management, additional indicators will show the value-added benefits of inpatient ACNP services.

	Appendix*

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 

ACNP Role Description and Responsibilities Department of Medicine, UCSF, Moffitt-Long Hospital Inpatient Nurse Practitioner, Medical Service Position Description General Responsibilities
Working under the supervision of Medicine faculty and receiving general direction from the Vice President, Nursing and Patient Care Services, the inpatient nurse practitioner (NP) will provide clinical care to medicine, cardiology, and solid tumor patients. The NP will utilize advanced clinical skills and knowledge to assess patients and manage all aspects of care, including invasive diagnostic and therapeutic procedures. He/she will communicate clinical issues to the attending/resident physician on the team, write orders according to standardized procedures/protocols, coordinate and schedule diagnostic and therapeutic procedures, and facilitate arrangements for discharge. Continuity of care will be maintained from admission to discharge except with patients requiring transfer to intensive care management. The NP will interact with key ancillary departments such as pharmacy, radiology, and clinical laboratory to coordinate and schedule services. The NP will work collaboratively with all members of the medicine service to ensure that continuity of care is maintained between inpatient care and referring physicians. The NP will support/educate clinical nursing staff regarding protocol goals and treatment strategies.

Specific Responsibilities

1. Participate in daily clinical rounds, management rounds, team meetings, other appropriate patient care meetings and conferences, and communicate pertinent clinical history.
   
2. Maintain current knowledge of the clinical status of all assigned patients, including current diagnoses and treatment plans.
   
3. Perform pertinent physical exams and clinical evaluations of assigned patients and document findings in the medical record.
   
4. Monitor solid tumor patients for side effects/toxicities of standardized chemotherapeutic regimens.
   
5. Sign out patients daily to the day’s on-call team per current protocol. Each AM, receive report for assigned patients and overnight admissions per established schedule.
   
6. Assess and manage all medication therapies according to established protocols, practice guidelines, standards or algorithms as warranted by patient’s diagnosis or changing medical condition.
   
7. Perform procedures such as (but not limited to) venipuncture, paracentesis, thoracentesis, blood cultures, arterial blood gases, and lumbar puncture as required for diagnostic and/or therapeutic purposes.
   
8. Order and review laboratory test results. Notify the attending/resident physician of any problems that may require immediate attention or intervention and coordinate any required nursing interventions.
   
9. Using guidelines and standardized procedures, write daily TPN orders and monitor for abnormal blood chemistries, weight changes, and related problems.
   
10. Using protocol guidelines and standardized procedures, write transfusion orders.
    
11. Order and review diagnostic studies such as CT and MRI scans, radiographic and ultrasound procedures, endoscopies, and biopsies as required.
    
12. Arrange for the placement of central lines and communicate pertinent clinical history.
    
13. Provide support and educational in-services to clinical nursing staff on medical floors regarding clinical management issues.
    
14. Manage clinical care according to supportive care management guidelines/protocols such as in the care of dying or palliative care patients. Participate in planned efforts to improve such services.
    
15. Participate in short- and long-range planning of patient care and clinical research activities as identified on the medicine service.
    
16. Coordinate patient care with members of the multidisciplinary team to include physicians, nurses, pharmacy, social work, physical therapy, home care, case management, and appropriate supports.
    
17. Coordinate transition to outpatient care, including appointments with PMDs, appropriate providers in clinics, and orders for required outpatient management.
    
18. Interface with inpatient nursing staff, ancillary departments, and consultative services to promote and maintain effective communication and cooperative working relationships.
    
19. Demonstrate adherence to Medical Center Telephone and Service Excellence standards in all interactions and follow through in all areas of responsibility.
    
20. In collaboration with the faculty, develop and maintain protocols and associated standardized procedures for overlapping practice. Participate in standardized procedure revision and amend as needed or at least every three years.
    
21. Communicate/consult immediately with medicine consult attending/resident as evidence of patient decompensation evolves.
    
22. Develop annual plan of personal educational and growth needs to meet continued certification and licensure requirements.
    
23. Complete annual self-evaluation of job performance with written feedback from the Chief of the Medical Service, Medicine Consult Attending(s), medicine service registered nurses, and another interdisciplinary staff member.
    

Qualifications
  Required   Master’s degree in Nursing with at least 3 years of acute inpatient Medicine experience.

Current California NP licensure.

Current certification from the American Nurse’s Credentialing Center.

Current Board of Registered Nurses Certificate (proof of NP status)

National Certification as a Nurse Practitioner.

Current Nurse Practitioner Furnishing License.

Verification of Experience to Furnish (must have experience furnishing for at least one year under MD supervision and must have a physician attest to the fact that such supervision took place).

Current CPR certification.

Current ACLS certification.

  Preferred   One year experience as an NP in an inpatient, emergency department, or outpatient adult medical setting.

^* ACLS indicates Advanced Cardiac Life Support; ACNP, acute care nurse practitioner; AM, morning; CPR, cardiopulmonary resuscitation; CT, computed tomography; MD, physician; MRI, magnetic resonance imaging; PMD, primary care physician; TPN, total parenteral nutrition.

	REFERENCES

Top Abstract ACNPs: Literature Review Motivation for Creation of... The Role of the... Standardized Practice Protocols Continuing Education Initiating the Role Lessons Learned The Future Appendix* References

 

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				L. A. Hoffman, F. J. Tasota, T. G. Zullo, C. Scharfenberg, and M. P. Donahoe Outcomes of Care Managed by an Acute Care Nurse Practitioner/Attending Physician Team in a Subacute Medical Intensive Care Unit Am. J. Crit. Care., March 1, 2005; 14(2): 121 - 130. [Abstract] [Full Text] [PDF]

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