- Email: [email protected]
Evaluation of In-patient Interventional Cardiology
Crit Care Nurs Clin N Am 18 (2006) 523–529
Evaluation of In-patient Interventional Cardiology Juanita Reigle, RN, MSN, ACNPa,*, Helen-Marie Molnar, RN, MSN, ACNPa, Christine Howell, RN, MSN, ACNPb, Cheryl Dumont, RN, PhDc a
University of Virginia Health System, Charlottesville, VA, USA Cardiology Associates of Fredericksburg, Fredericksburg, VA, USA c University of Virginia School of Nursing, Charlottesville, VA, USA
b
The role of the acute care nurse practitioner (ACNP) has expanded and evolved since national certification was first offered in 1995. Initially the ACNP role was configured as a hospital-based role, but many ACNPs are moving from the traditional tertiary care setting to physician practices [1]. At the same time, academic institutions are facing reductions in the number of physician residents and strict regulatory requirements that limit resident duty hours [2]. These changes in the health care environment challenge health care delivery systems to provide high-quality patient care services in an efficient and cost-effective manner. To reach this goal, it often is necessary to reconfigure traditional approaches to patient care management. In 2002 more than 6.3 million individuals were discharged from hospitals in the United States with a diagnosis of heart disease, and more than 1.4 million diagnostic cardiac catheterizations were performed [3]. As the population ages, and the incidence of obesity and type 2 diabetes continues to rise, chronic disease, including coronary artery disease, will continue to increase [4]. Based on these projections and the regulatory requirements related to resident workload, the authors designed an ACNP service to manage
a population of patients transferred to their institution for cardiac catheterization or percutaneous coronary intervention (PCI). The ACNP service was designed to address a complex system issue. Many patients are referred to the University of Virginia Health System for cardiac catheterization and other interventional procedures. Frequently patients were transferred to the institution late in the afternoon because there were no available in-patient beds earlier in the day. This delay in transfer started a cascade of issues, including delayed catheterization, increased length of stay (LOS), and increased cost. The ACNP service was established to manage patients referred for cardiac catheterization or PCI from outlying institutions. Patients admitted to the ACNP service met specific admission criteria and were managed within a defined scope of care in collaboration with the attending cardiologist and interventional cardiology fellow (Box 1). The housestaff were not responsible for patients on the ACNP service except to cross-cover after 6 PM. The interventional cardiology fellow was available after 6 PM to manage any issues identified by the housestaff.
Objective
* Corresponding author. Box 800782, McLeod Hall, University of Virginia, Charlottesville, VA 22908. E-mail address: [email protected] (J. Reigle).
This retrospective study compares patient care outcomes between the traditional housestaff service and the ACNP service. The ACNP interventional cardiology service included three ACNPs,
0899-5885/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2006.09.002
ccnursing.theclinics.com
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et al
Box 1. Admission and exclusion criteria for nurse practitioner inpatient interventional service Admission criteria for ACNP inpatient interventional service Medically stable patients of an interventional service attending who are transferred from a referral hospital, interventional cardiology clinic, or admissions office for the primary purpose of cardiac catheterization or PCI who do not meet any of the exclusion criteria are eligible for admission. Exclusion criteria 1. Angina at rest accompanied by hypotension or relative hypotension not related to nitrates. 2. New ST-segment elevation on EKG of 1 mm or more in two or more contiguous leads of ischemic origin consistent with ST-elevation myocardial infarction within the past 24 hours 3. Malignant hypertension or sustained hypotension 4. Atrial fibrillation with sustained heart rate higher than 120 beats/min, ventricular tachycardia, second-degree type II atrioventricular block, complete heart block, or any dysrhythmia with hemodynamic instability 5. Syncope within the previous 48 hours of undetermined origin or resulting in significant hemodynamic compromise 6. Suspected or confirmed endocarditis 7. Intravenous administration of inotropes for hemodynamic support 8. Intravenous administration of nitroglycerin 9. Severe or refractory pulmonary edema 10. Heart failure requiring active diuresis and close monitoring of volume status 11. Severe complications after catherization/PCI (ie, acute renal failure requiring dialysis, cerebrovascular accident, major vascular or bleeding complications) that are not controlled or continue to progress 12. Any coexisting medical or nonmedical condition that makes admission to the inpatient Interventional nurse practitioner service inappropriate as determined by the nurse practitioner, cardiology fellow, or interventional attending physician 13. Anticipated prolonged length of stay Criteria for transfer If the patient’s condition necessitates management beyond the scope of the nurse practitioner service, the patient is transferred to the appropriate housestaff service. This determination is made by the nurse practitioner, cardiology fellow, or interventional attending physician.
an interventional cardiology fellow, and an attending cardiologist.
Methods Definition of terms Housestaff service The housestaff service was comprised of adult patients transferred from outlying hospitals to the cardiology service for cardiac catheterization or PCI between January and June 2001. Housestaff patients were admitted and discharged from acute cardiology units, were managed by the traditional
resident and attending cardiologist team configuration, and did not require admission to the coronary care unit. The all-patient refined diagnostic-related group numbers for this population were 112 percutaneous cardiovascular procedures, 116 percutaneous transluminal coronary angioplasties with coronary stent implantation, 124 circulatory disorders other than acute myocardial infarction with cardiac catheterization, and 125 circulatory disorders other than acute myocardial infarction, with cardiac catheterization, without complex diagnosis. The patients were selected from a list of consecutive admissions from the acute cardiology units. To
EVALUATION OF IN-PATIENT INTERVENTIONAL CARDIOLOGY
assure that the patients on the housestaff service were comparable to those on the ACNP service, all discharge summaries for patients meeting the diagnostic-related group criteria were reviewed on-line to establish that they met the ACNP service admission and exclusion criteria (see Box 1) before data were extracted for the study. Acute care nurse practitioners service Patients on the ACNP service were adults admitted to the ACNP service between January and June 2002. All ACNP service patients met the admission criteria established for this service. Patients who underwent coronary artery bypass grafting or were transferred off the ACNP service during the hospitalization were excluded from the sample. Time to admission Time to admission (TOA) was measured in hours as the time between initial request from the referral hospital to transfer a patient for an interventional cardiac procedure and the actual time of admission to the authors’ institution. Time to catheterization Time to catheterization (TOC) was measured in hours as the time between admission to the authors’ institution and the time the patient arrived in the cardiac catheterization laboratory. Length of stay LOS was measured in hours from the day of admission to the day of discharge from the institution. Timeliness to care Timeliness to care (TTC) was measured in hours and percent hours of TOA, TOC, and LOS. Comorbid conditions Comorbid conditions were medical conditions documented on the medical record as preexisting. These conditions included a history of myocardial infarction, diabetes mellitus, hypertension, dyslipidemia, valvular heart disease, peripheral vascular disease, cerebrovascular disease, prior coronary artery bypass grafting, PCI, heart failure, dysrhythmias, and chronic renal insufficiency. Patient education Patient education was defined as documented education for cardiac risk factors including dyslipidemia, tobacco use, hypertension, diabetes, and lack of exercise. In this study, education occurred if it was documented in the nurse practitioner’s notes, the physician’s notes, or progress notes,
525
nurses’ notes, patient education plan, or discharge summary. Discharge medications Adherence to best-practice guidelines for discharge medications was defined by documentation in the medical record of appropriate discharge medications as delineated by the American College of Cardiology and American Heart Association. Appropriate discharge medications included beta-blockers for patients who had suffered a myocardial infarction; angiotensin-converting enzyme (ACE) inhibitors for patients who had left ventricular systolic dysfunction; aspirin for patients who had coronary artery disease, myocardial infarction, or PCI; clopidogrel for patients after a coronary stent placement or for those who had an indication for but were allergic to aspirin; and lipid-lowering agents for patients if they had coronary artery disease with a low-density lipoprotein level greater than 100. Data collection and analysis Internal review board approval was granted, and data were collected retrospectively by chart review on a convenience sample of 278 patients. Of these patients 124 were on the ACNP service, and 153 were managed by the housestaff service. The demographic information collected included the primary diagnosis-related group, age, gender, race, and comorbid conditions The data collectors did not draw conclusions from available chart data (eg, laboratory results, blood pressure reading) and thus recorded a comorbid condition only if it was documented in the medical record. Data also were collected regarding documentation of the patient’s left ventricular ejection fraction, referral to cardiac rehabilitation for post–myocardial infarction patients, and whether a follow-up appointment with the primary care provider or cardiology service was made for the patient before discharge. Data were analyzed using the Statistical Package for Social Sciences 11.5. Descriptive statistics (SPSS Inc., Chicago, IL) and t-tests were performed on demographic and comorbidity data to ensure that the patients in the two provider groups were not significantly different (Table 1). Pearson c2 was used to compare frequencies of categorical data between the ACNP and physician-provider groups. These data included documentation of education for risk factors, follow-up referrals, and provision of appropriate discharge medication prescriptions.
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Table 1 Patient demographics*
et al
Results
Patient characteristic
Physician service
ACNP service
Sample size Mean age in years (SD) Mean number comorbidities (SD) Gender (%) Male Female Race (%) White Black Other
N ¼ 153 64.4 (11.5)
N ¼ 124 62 (12.9)
3.8 (1.8)
3.5 (1.6)
60.8 39.2
57.4 42.6
94.8 4.6 0.7
96.6 2.5 0.8
Abbreviation: ACNP, acute care nurse practitioners. * There were no statistically significant differences between the two groups (P ¼ .05).
The multivariate analysis of covariance (MANCOVA) was used to determine differences in mean TTC between the two provider groups. This analysis provided protection of the alpha (0.05) by comparing all three measures of TTC (TOA, TOC, LOS) in one test. TTC data were calculated for 126 patients, 75 patients from the ACNP service and 51 from the housestaff service. The smaller sample size was a result of a large number of patients with missing data and outliers that were deleted because of excessive times related to issues that were not under the control of the provider. Most of the outliers deleted were from the physician-service group (102 versus 49 from the ACNP service).
A total of 278 patients’ charts were reviewed for this study. The patients’ ages, gender, race, and number of comorbid conditions were not significantly different between the housestaff and ACNP services (see Table 1). Education and counseling for risk factors for dyslipidemia, exercise, and diabetes mellitus was documented more frequently for the patients on the ACNP service (P ! .01). The frequency of documentation of education and counseling for hypertension and smoking were equivalent between the two services (Table 2). Other benchmarks of quality care also were analyzed. The frequency of documentation of left ventricular ejection fraction was found to be equivalent, but the ACNP service made followup appointments for its patients more often than the physician service (P ! .01). The only benchmark of care found to be better for the physician service was the frequency of referral to cardiac rehabilitation (P O .01). On the physician service 69.2% of patients were referred for cardiac rehabilitation, compared with 40.2% of patients on the ACNP service. Appropriate prescription of medications on discharge was assessed for the prescription of beta-blockers, aspirin, ACE inhibitors, lipid-lowering agents, and the platelet antagonist clopidogrel. The ACNP service provided appropriate discharge medication prescriptions for betablockers, aspirin, ACE inhibitors, and lipid-lowering agents more often than the physician service. Appropriate discharge prescriptions for clopidogrel were equivalent in the two groups (Table 3). The
Table 2 Education for risk factors % Frequency by provider service Prevention education
Pearson Chi-square
P (two-sided)
Physician
ACNP
Dyslipidemia
8.770
.003
Exercise
6.953
.008
Diabetes mellitus
6.004
.014
Smoking
NS
NS
Hypertension
NS
NS
Yes: 67.6 No: 32.4 Yes: 62.3 No: 37.7 Yes: 64.3 No: 35.7 Yes: 90.6 No: 9.4 Yes: 56.7 No: 43.3
Yes: 83.6 No: 16.4 Yes: 77.2 No: 22.8 Yes: 85.4 No: 14.6 Yes: 88.9 No: 11.1 Yes: 54.1 No: 45.9
Abbreviations: ACNP, acute care nurse practitioners; NS, nonsignificant at P ! .05.
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EVALUATION OF IN-PATIENT INTERVENTIONAL CARDIOLOGY
Table 3 Discharge medications % Frequency by provider service P-value (two-sided)
Physician
ACNP
Beta-blockers
Medication
Pearson Chi-square 6.831
.009
Aspirin
5.896
.015
ACE inhibitors
85.755
.000
Lipid-lowering agents
10.646
.001
Clopidogrel
NS
NS
Yes: 49.7 No: 50.3 Yes: 93.5 No: 6.5 Yes: 25.5 No: 74.5 Yes: 88.2 No: 11.8 Yes: 95.4 No: 4.6
Yes: 65.3 No: 34.7 Yes: 99.2 No: 0.8 Yes: 81.8 No: 18.2 Yes: 98.4 No: 1.6 Yes: 99.2 No: 0.8
Abbreviations: ACE, angiotensin-converting enzyme; ACNP, acute care nurse practitioners; NS, nonsignificant.
discharge prescription was considered appropriate only if the medication was indicated for the patient and was prescribed. Medications prescribed that were not indicated and medications not prescribed when indicated were rated as not appropriate. The final analysis for TTC included 126 patients. Despite the smaller sample size the overall MANCOVA using Pillai’s trace criteria was significant and demonstrated good power (Table 4; Fig. 1). Patients managed by the ACNP service had significantly shorter TOA, TOC, and LOS than those on the housestaff service. Discussion Many institutions are faced with the responsibility to provide cost-effective, quality patient care services while reducing the number of physician residents and limiting duty hours for resident physicians. The use of ACNPs in the hospital setting to manage chronically critically ill patients has been shown to be an effective alternative to traditional physician teams [5–8]. The present study expanded this work to managing patients undergoing cardiac catheterization or PCI. Often the care of this patient population is not well matched with the goals of academic teaching
programs, because most housestaff do not manage patients in this setting after completing the residency program. Thus, an academic institution may choose to entrust the care of select patient populations to ACNPs to offset the workload and refine the educational activities of resident physicians. This decision must be made with confidence that patient care outcomes will remain at least congruent when the provider changes. This study indicated that in many areas of care the ACNP service provided more efficient and thorough care. Patients managed by the housestaff service waited at the referral hospitals longer before transfer to the authors’ institution. Because patients arrived later in the day, the availability of the catheterization laboratory diminished, and the patients’ waiting period from admission to catheterization increased. All elements in the TTC were significantly reduced for patients on the ACNP service. The implications for these TTC elements are many. Referring institutions expect institutions to accept and admit patients once the request for transfer is made. A delay in transfer to the accepting institution can affect the ability of the referring institution to admit patients into their own institution. Moreover, patients and families
Table 4 Mean hours of timeliness to care* Timeliness to Care
Physician (N ¼ 51)
ANCP (N ¼ 75)
F Statistic
Power
Time to admission Time to catherization Length of stay
11.8 h (SD 11.3) 15 h (SD 7.2) 39.3 h (SD 9.8)
7.0 h (SD 7.5) 5.7 h (SD 7.3) 27.6 h (SD 10.3)
7.98 50.276 45.08
0.8 1.0 1.0
Abbreviation: ACNP, acute care nurse practitioners. * P ! .01 for all values.
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50 TOA
Mean hours to care
40
TOC LOS
30
20
10
0 ACNP
Physician
Provider Fig. 1. Timeliness of care by physician housestaff versus acute care nurse practitioners service. ANCP, acute care nurse practitioners; LOS, length of stay; TOA, time to admission; TOC, time to catheterization.
are anxious to proceed to the accepting institution and, once there, expect the cardiac procedure to be performed promptly. Delays in factors affecting the TTC elements may reduce patient and family satisfaction and may alter the referral pattern of institutions. In this study, the ACNP service coordinated timely transfers of patients to its institution, performed the necessary precatheterization history and physical examination, reported to the attending cardiologist, and negotiated transfer to the cardiac catheterization laboratory in a competent and efficient manner. The shortened length of stay of nearly 12 hours for the ACNP service has significant implications for the authors’ institution. Even a small reduction in the LOS increases the availability of acute hospital beds. The increased availability may reduce waiting times for patients admitted from the emergency room or decrease the time to transfer for patients at referral institutions. This study also shows that the ACNP service provides evidence-based care. Many institutions are judged by their compliance with the Joint Commission on Accreditation of Health care Organizations recommendations, which include documentation of patient education and appropriate discharge medications for this patient population. Patients on the ACNP service were more likely to be prescribed appropriate medications and provided follow-up appointments upon discharge. The ACNPs also were more likely to provide education regarding the risk factors of
et al
diabetes, hypertension, and dyslipidemia than those on the housestaff service. The increased documentation of patient education and appropriate discharge medications of the ACNP service help the institution meet the benchmarks that are indicators of quality patient care. The results of this study help justify the role of ACNPs in interventional cardiac practice settings. ACNPs are skilled in assessment, diagnostic reasoning, patient education, and in ensuring quality patient care. In an academic teaching institution, delegation of this patient population to an ACNP service may help the institution meet the Accreditation Council for Graduate Medical Education requirements for resident workload. More importantly, it is clear from this study that patients managed by the ACNP service are more likely to receive care that reflects national quality care standards.
Summary The ACNP service in this study decreased the TA, TC, and LOS for patients transferred from outlying hospitals for cardiac catheterization or PCI. Patients on the ACNP service were provided prescriptions for appropriate discharge medications including beta-blockers, aspirin, ACE inhibitors, and lipid-lowering agents more often than patients on the housestaff service. Other aspects of care, including follow-up appointments and elements of patient education, were documented more often for patients on the ACNP service. Future studies should examine the cost effectiveness of an ACNP interventional cardiac service and expand the role of ACNPs into other areas of acute-care cardiology practice.
References [1] Kleinpell RM. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care 2005;14:211–9. [2] Accreditation Council for Graduate Medical Education website. Available at: http://www.acgme.org/ acWebsite/home/home.asp. Accessed 10/24/04. [3] American Heart Association. Heart disease and stroke statisticsd2005 update. Dallas (TX): American Heart Association; 2005. [4] Cannon CP. Evidence-based risk stratification to target therapies in acute coronary syndromes. Circulation 2002;106:1588–91.
EVALUATION OF IN-PATIENT INTERVENTIONAL CARDIOLOGY
[5] Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med 2003;31:2752–63. [6] Russell D, VorderBruegge M, Burns SM. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners. Am J Crit Care 2002;11:353–64.
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[7] Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care 2005;14: 121–30. [8] Meyer SC, Miers LJ. Cardiovascular surgeon and acute care nurse practitioner: collaboration on postoperative outcomes. AACN Clin Issues 2005;16: 149–58.
Evaluation of In-patient Interventional Cardiology Juanita Reigle, RN, MSN, ACNPa,*, Helen-Marie Molnar, RN, MSN, ACNPa, Christine Howell, RN, MSN, ACNPb, Cheryl Dumont, RN, PhDc a
University of Virginia Health System, Charlottesville, VA, USA Cardiology Associates of Fredericksburg, Fredericksburg, VA, USA c University of Virginia School of Nursing, Charlottesville, VA, USA
b
The role of the acute care nurse practitioner (ACNP) has expanded and evolved since national certification was first offered in 1995. Initially the ACNP role was configured as a hospital-based role, but many ACNPs are moving from the traditional tertiary care setting to physician practices [1]. At the same time, academic institutions are facing reductions in the number of physician residents and strict regulatory requirements that limit resident duty hours [2]. These changes in the health care environment challenge health care delivery systems to provide high-quality patient care services in an efficient and cost-effective manner. To reach this goal, it often is necessary to reconfigure traditional approaches to patient care management. In 2002 more than 6.3 million individuals were discharged from hospitals in the United States with a diagnosis of heart disease, and more than 1.4 million diagnostic cardiac catheterizations were performed [3]. As the population ages, and the incidence of obesity and type 2 diabetes continues to rise, chronic disease, including coronary artery disease, will continue to increase [4]. Based on these projections and the regulatory requirements related to resident workload, the authors designed an ACNP service to manage
a population of patients transferred to their institution for cardiac catheterization or percutaneous coronary intervention (PCI). The ACNP service was designed to address a complex system issue. Many patients are referred to the University of Virginia Health System for cardiac catheterization and other interventional procedures. Frequently patients were transferred to the institution late in the afternoon because there were no available in-patient beds earlier in the day. This delay in transfer started a cascade of issues, including delayed catheterization, increased length of stay (LOS), and increased cost. The ACNP service was established to manage patients referred for cardiac catheterization or PCI from outlying institutions. Patients admitted to the ACNP service met specific admission criteria and were managed within a defined scope of care in collaboration with the attending cardiologist and interventional cardiology fellow (Box 1). The housestaff were not responsible for patients on the ACNP service except to cross-cover after 6 PM. The interventional cardiology fellow was available after 6 PM to manage any issues identified by the housestaff.
Objective
* Corresponding author. Box 800782, McLeod Hall, University of Virginia, Charlottesville, VA 22908. E-mail address: [email protected] (J. Reigle).
This retrospective study compares patient care outcomes between the traditional housestaff service and the ACNP service. The ACNP interventional cardiology service included three ACNPs,
0899-5885/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2006.09.002
ccnursing.theclinics.com
524
REIGLE
et al
Box 1. Admission and exclusion criteria for nurse practitioner inpatient interventional service Admission criteria for ACNP inpatient interventional service Medically stable patients of an interventional service attending who are transferred from a referral hospital, interventional cardiology clinic, or admissions office for the primary purpose of cardiac catheterization or PCI who do not meet any of the exclusion criteria are eligible for admission. Exclusion criteria 1. Angina at rest accompanied by hypotension or relative hypotension not related to nitrates. 2. New ST-segment elevation on EKG of 1 mm or more in two or more contiguous leads of ischemic origin consistent with ST-elevation myocardial infarction within the past 24 hours 3. Malignant hypertension or sustained hypotension 4. Atrial fibrillation with sustained heart rate higher than 120 beats/min, ventricular tachycardia, second-degree type II atrioventricular block, complete heart block, or any dysrhythmia with hemodynamic instability 5. Syncope within the previous 48 hours of undetermined origin or resulting in significant hemodynamic compromise 6. Suspected or confirmed endocarditis 7. Intravenous administration of inotropes for hemodynamic support 8. Intravenous administration of nitroglycerin 9. Severe or refractory pulmonary edema 10. Heart failure requiring active diuresis and close monitoring of volume status 11. Severe complications after catherization/PCI (ie, acute renal failure requiring dialysis, cerebrovascular accident, major vascular or bleeding complications) that are not controlled or continue to progress 12. Any coexisting medical or nonmedical condition that makes admission to the inpatient Interventional nurse practitioner service inappropriate as determined by the nurse practitioner, cardiology fellow, or interventional attending physician 13. Anticipated prolonged length of stay Criteria for transfer If the patient’s condition necessitates management beyond the scope of the nurse practitioner service, the patient is transferred to the appropriate housestaff service. This determination is made by the nurse practitioner, cardiology fellow, or interventional attending physician.
an interventional cardiology fellow, and an attending cardiologist.
Methods Definition of terms Housestaff service The housestaff service was comprised of adult patients transferred from outlying hospitals to the cardiology service for cardiac catheterization or PCI between January and June 2001. Housestaff patients were admitted and discharged from acute cardiology units, were managed by the traditional
resident and attending cardiologist team configuration, and did not require admission to the coronary care unit. The all-patient refined diagnostic-related group numbers for this population were 112 percutaneous cardiovascular procedures, 116 percutaneous transluminal coronary angioplasties with coronary stent implantation, 124 circulatory disorders other than acute myocardial infarction with cardiac catheterization, and 125 circulatory disorders other than acute myocardial infarction, with cardiac catheterization, without complex diagnosis. The patients were selected from a list of consecutive admissions from the acute cardiology units. To
EVALUATION OF IN-PATIENT INTERVENTIONAL CARDIOLOGY
assure that the patients on the housestaff service were comparable to those on the ACNP service, all discharge summaries for patients meeting the diagnostic-related group criteria were reviewed on-line to establish that they met the ACNP service admission and exclusion criteria (see Box 1) before data were extracted for the study. Acute care nurse practitioners service Patients on the ACNP service were adults admitted to the ACNP service between January and June 2002. All ACNP service patients met the admission criteria established for this service. Patients who underwent coronary artery bypass grafting or were transferred off the ACNP service during the hospitalization were excluded from the sample. Time to admission Time to admission (TOA) was measured in hours as the time between initial request from the referral hospital to transfer a patient for an interventional cardiac procedure and the actual time of admission to the authors’ institution. Time to catheterization Time to catheterization (TOC) was measured in hours as the time between admission to the authors’ institution and the time the patient arrived in the cardiac catheterization laboratory. Length of stay LOS was measured in hours from the day of admission to the day of discharge from the institution. Timeliness to care Timeliness to care (TTC) was measured in hours and percent hours of TOA, TOC, and LOS. Comorbid conditions Comorbid conditions were medical conditions documented on the medical record as preexisting. These conditions included a history of myocardial infarction, diabetes mellitus, hypertension, dyslipidemia, valvular heart disease, peripheral vascular disease, cerebrovascular disease, prior coronary artery bypass grafting, PCI, heart failure, dysrhythmias, and chronic renal insufficiency. Patient education Patient education was defined as documented education for cardiac risk factors including dyslipidemia, tobacco use, hypertension, diabetes, and lack of exercise. In this study, education occurred if it was documented in the nurse practitioner’s notes, the physician’s notes, or progress notes,
525
nurses’ notes, patient education plan, or discharge summary. Discharge medications Adherence to best-practice guidelines for discharge medications was defined by documentation in the medical record of appropriate discharge medications as delineated by the American College of Cardiology and American Heart Association. Appropriate discharge medications included beta-blockers for patients who had suffered a myocardial infarction; angiotensin-converting enzyme (ACE) inhibitors for patients who had left ventricular systolic dysfunction; aspirin for patients who had coronary artery disease, myocardial infarction, or PCI; clopidogrel for patients after a coronary stent placement or for those who had an indication for but were allergic to aspirin; and lipid-lowering agents for patients if they had coronary artery disease with a low-density lipoprotein level greater than 100. Data collection and analysis Internal review board approval was granted, and data were collected retrospectively by chart review on a convenience sample of 278 patients. Of these patients 124 were on the ACNP service, and 153 were managed by the housestaff service. The demographic information collected included the primary diagnosis-related group, age, gender, race, and comorbid conditions The data collectors did not draw conclusions from available chart data (eg, laboratory results, blood pressure reading) and thus recorded a comorbid condition only if it was documented in the medical record. Data also were collected regarding documentation of the patient’s left ventricular ejection fraction, referral to cardiac rehabilitation for post–myocardial infarction patients, and whether a follow-up appointment with the primary care provider or cardiology service was made for the patient before discharge. Data were analyzed using the Statistical Package for Social Sciences 11.5. Descriptive statistics (SPSS Inc., Chicago, IL) and t-tests were performed on demographic and comorbidity data to ensure that the patients in the two provider groups were not significantly different (Table 1). Pearson c2 was used to compare frequencies of categorical data between the ACNP and physician-provider groups. These data included documentation of education for risk factors, follow-up referrals, and provision of appropriate discharge medication prescriptions.
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REIGLE
Table 1 Patient demographics*
et al
Results
Patient characteristic
Physician service
ACNP service
Sample size Mean age in years (SD) Mean number comorbidities (SD) Gender (%) Male Female Race (%) White Black Other
N ¼ 153 64.4 (11.5)
N ¼ 124 62 (12.9)
3.8 (1.8)
3.5 (1.6)
60.8 39.2
57.4 42.6
94.8 4.6 0.7
96.6 2.5 0.8
Abbreviation: ACNP, acute care nurse practitioners. * There were no statistically significant differences between the two groups (P ¼ .05).
The multivariate analysis of covariance (MANCOVA) was used to determine differences in mean TTC between the two provider groups. This analysis provided protection of the alpha (0.05) by comparing all three measures of TTC (TOA, TOC, LOS) in one test. TTC data were calculated for 126 patients, 75 patients from the ACNP service and 51 from the housestaff service. The smaller sample size was a result of a large number of patients with missing data and outliers that were deleted because of excessive times related to issues that were not under the control of the provider. Most of the outliers deleted were from the physician-service group (102 versus 49 from the ACNP service).
A total of 278 patients’ charts were reviewed for this study. The patients’ ages, gender, race, and number of comorbid conditions were not significantly different between the housestaff and ACNP services (see Table 1). Education and counseling for risk factors for dyslipidemia, exercise, and diabetes mellitus was documented more frequently for the patients on the ACNP service (P ! .01). The frequency of documentation of education and counseling for hypertension and smoking were equivalent between the two services (Table 2). Other benchmarks of quality care also were analyzed. The frequency of documentation of left ventricular ejection fraction was found to be equivalent, but the ACNP service made followup appointments for its patients more often than the physician service (P ! .01). The only benchmark of care found to be better for the physician service was the frequency of referral to cardiac rehabilitation (P O .01). On the physician service 69.2% of patients were referred for cardiac rehabilitation, compared with 40.2% of patients on the ACNP service. Appropriate prescription of medications on discharge was assessed for the prescription of beta-blockers, aspirin, ACE inhibitors, lipid-lowering agents, and the platelet antagonist clopidogrel. The ACNP service provided appropriate discharge medication prescriptions for betablockers, aspirin, ACE inhibitors, and lipid-lowering agents more often than the physician service. Appropriate discharge prescriptions for clopidogrel were equivalent in the two groups (Table 3). The
Table 2 Education for risk factors % Frequency by provider service Prevention education
Pearson Chi-square
P (two-sided)
Physician
ACNP
Dyslipidemia
8.770
.003
Exercise
6.953
.008
Diabetes mellitus
6.004
.014
Smoking
NS
NS
Hypertension
NS
NS
Yes: 67.6 No: 32.4 Yes: 62.3 No: 37.7 Yes: 64.3 No: 35.7 Yes: 90.6 No: 9.4 Yes: 56.7 No: 43.3
Yes: 83.6 No: 16.4 Yes: 77.2 No: 22.8 Yes: 85.4 No: 14.6 Yes: 88.9 No: 11.1 Yes: 54.1 No: 45.9
Abbreviations: ACNP, acute care nurse practitioners; NS, nonsignificant at P ! .05.
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EVALUATION OF IN-PATIENT INTERVENTIONAL CARDIOLOGY
Table 3 Discharge medications % Frequency by provider service P-value (two-sided)
Physician
ACNP
Beta-blockers
Medication
Pearson Chi-square 6.831
.009
Aspirin
5.896
.015
ACE inhibitors
85.755
.000
Lipid-lowering agents
10.646
.001
Clopidogrel
NS
NS
Yes: 49.7 No: 50.3 Yes: 93.5 No: 6.5 Yes: 25.5 No: 74.5 Yes: 88.2 No: 11.8 Yes: 95.4 No: 4.6
Yes: 65.3 No: 34.7 Yes: 99.2 No: 0.8 Yes: 81.8 No: 18.2 Yes: 98.4 No: 1.6 Yes: 99.2 No: 0.8
Abbreviations: ACE, angiotensin-converting enzyme; ACNP, acute care nurse practitioners; NS, nonsignificant.
discharge prescription was considered appropriate only if the medication was indicated for the patient and was prescribed. Medications prescribed that were not indicated and medications not prescribed when indicated were rated as not appropriate. The final analysis for TTC included 126 patients. Despite the smaller sample size the overall MANCOVA using Pillai’s trace criteria was significant and demonstrated good power (Table 4; Fig. 1). Patients managed by the ACNP service had significantly shorter TOA, TOC, and LOS than those on the housestaff service. Discussion Many institutions are faced with the responsibility to provide cost-effective, quality patient care services while reducing the number of physician residents and limiting duty hours for resident physicians. The use of ACNPs in the hospital setting to manage chronically critically ill patients has been shown to be an effective alternative to traditional physician teams [5–8]. The present study expanded this work to managing patients undergoing cardiac catheterization or PCI. Often the care of this patient population is not well matched with the goals of academic teaching
programs, because most housestaff do not manage patients in this setting after completing the residency program. Thus, an academic institution may choose to entrust the care of select patient populations to ACNPs to offset the workload and refine the educational activities of resident physicians. This decision must be made with confidence that patient care outcomes will remain at least congruent when the provider changes. This study indicated that in many areas of care the ACNP service provided more efficient and thorough care. Patients managed by the housestaff service waited at the referral hospitals longer before transfer to the authors’ institution. Because patients arrived later in the day, the availability of the catheterization laboratory diminished, and the patients’ waiting period from admission to catheterization increased. All elements in the TTC were significantly reduced for patients on the ACNP service. The implications for these TTC elements are many. Referring institutions expect institutions to accept and admit patients once the request for transfer is made. A delay in transfer to the accepting institution can affect the ability of the referring institution to admit patients into their own institution. Moreover, patients and families
Table 4 Mean hours of timeliness to care* Timeliness to Care
Physician (N ¼ 51)
ANCP (N ¼ 75)
F Statistic
Power
Time to admission Time to catherization Length of stay
11.8 h (SD 11.3) 15 h (SD 7.2) 39.3 h (SD 9.8)
7.0 h (SD 7.5) 5.7 h (SD 7.3) 27.6 h (SD 10.3)
7.98 50.276 45.08
0.8 1.0 1.0
Abbreviation: ACNP, acute care nurse practitioners. * P ! .01 for all values.
528
REIGLE
50 TOA
Mean hours to care
40
TOC LOS
30
20
10
0 ACNP
Physician
Provider Fig. 1. Timeliness of care by physician housestaff versus acute care nurse practitioners service. ANCP, acute care nurse practitioners; LOS, length of stay; TOA, time to admission; TOC, time to catheterization.
are anxious to proceed to the accepting institution and, once there, expect the cardiac procedure to be performed promptly. Delays in factors affecting the TTC elements may reduce patient and family satisfaction and may alter the referral pattern of institutions. In this study, the ACNP service coordinated timely transfers of patients to its institution, performed the necessary precatheterization history and physical examination, reported to the attending cardiologist, and negotiated transfer to the cardiac catheterization laboratory in a competent and efficient manner. The shortened length of stay of nearly 12 hours for the ACNP service has significant implications for the authors’ institution. Even a small reduction in the LOS increases the availability of acute hospital beds. The increased availability may reduce waiting times for patients admitted from the emergency room or decrease the time to transfer for patients at referral institutions. This study also shows that the ACNP service provides evidence-based care. Many institutions are judged by their compliance with the Joint Commission on Accreditation of Health care Organizations recommendations, which include documentation of patient education and appropriate discharge medications for this patient population. Patients on the ACNP service were more likely to be prescribed appropriate medications and provided follow-up appointments upon discharge. The ACNPs also were more likely to provide education regarding the risk factors of
et al
diabetes, hypertension, and dyslipidemia than those on the housestaff service. The increased documentation of patient education and appropriate discharge medications of the ACNP service help the institution meet the benchmarks that are indicators of quality patient care. The results of this study help justify the role of ACNPs in interventional cardiac practice settings. ACNPs are skilled in assessment, diagnostic reasoning, patient education, and in ensuring quality patient care. In an academic teaching institution, delegation of this patient population to an ACNP service may help the institution meet the Accreditation Council for Graduate Medical Education requirements for resident workload. More importantly, it is clear from this study that patients managed by the ACNP service are more likely to receive care that reflects national quality care standards.
Summary The ACNP service in this study decreased the TA, TC, and LOS for patients transferred from outlying hospitals for cardiac catheterization or PCI. Patients on the ACNP service were provided prescriptions for appropriate discharge medications including beta-blockers, aspirin, ACE inhibitors, and lipid-lowering agents more often than patients on the housestaff service. Other aspects of care, including follow-up appointments and elements of patient education, were documented more often for patients on the ACNP service. Future studies should examine the cost effectiveness of an ACNP interventional cardiac service and expand the role of ACNPs into other areas of acute-care cardiology practice.
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EVALUATION OF IN-PATIENT INTERVENTIONAL CARDIOLOGY
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