Suhong Tong, MS

The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P < 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P < 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.

The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P < 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P < 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.

The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P < 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P < 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.