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

Abstract

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.

Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals

“…The spectrum of activities performed by APPs in the VHA is similar to those reported in these inpatient medicine studies, although their scope of practice appears to be much broader than in these few small single academic center studies. 10,22,[29][30][31][32][33][34][35][36] For example, only 11% of hospitalist PAs did procedures in a 2006 Society of Hospital Medicine survey, whereas 50% did in our study. 36 Interestingly, we found that VHA NPs and PAs perform very similar tasks with similar caseloads despite differences in their background, training, regulation, reimbursement, and the longstanding observation that "nurse practitioners are not physician assistants."…”

“…27,28 In spite of these concerns, we found widespread use of APPs with almost half of the VHA inpatient medicine services reporting use, which stands in contrast to prior research. 9,10,22,[29][30][31][32][33][34][35] APPs practice in a variety of acute and subacute inpatient medicine settings including academic, community, rural, and urban settings without many discernable differences. The spectrum of activities performed by APPs in the VHA is similar to those reported in these inpatient medicine studies, although their scope of practice appears to be much broader than in these few small single academic center studies.…”

“…Second, we did not measure other outcomes of care that may be affected by the use of APPs, such as clinical outcomes, process of care measures, or cost-effectiveness, some of which have been shown in small studies to be impacted by APPs in inpatient medicine. 10,22,[29][30][31][32][33][34][35] Third, we are unable to attribute causality to our findings and may not have accounted for all the differences between services. Ideally, a randomized controlled trial of APPs in inpatient medicine would be helpful to address these concerns, but no such trials have been conducted.…”

Patient Outcomes in a Pediatric Hospital Medicine Service Staffed With Physicians and Advanced Practice Providers

“…Over the last 2 decades, the role of advanced practice providers (APPs), specifically nurse practitioners (NPs) and physician assistants (PAs), has expanded from primary care to inpatient settings. [1][2][3][4][5][6][7][8][9] The impetus for increasing the presence of APPs in hospitals is multifactorial and attributed to the need to build strong health systems that promote optimal patient outcomes in the face of workforce shortages and rising health care costs. 10 One major driver has been graduate medical education reform, which reduced the number of residents in subspecialty training programs, limited resident exposure to ICUs, and restricted total resident duty hours.…”

“…[19][20][21][22][23][24] Historically, hospital-based APP service models have been implemented in medical and surgical subspecialty units and ambulatory clinics for which their scope of practice is limited to a narrow patient population. 1,6,9,25 Care delivery models in which APPs have been incorporated on a resident service or where the APP service works independently of residents have been studied on surgical trauma services. 7,26,27 By incorporating APPs, Christmas et al 27 demonstrated improved patient throughput and reduced length of stay (LOS) while decreasing resident service hours without affecting mortality or increasing the cost per patient.…”