issues and updates for aprns - gwac
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Issues and Updates for APRNsTRANSCRIPT
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Julie Stanik-Hutt PhD, ACNP/GNP, CCNS Johns Hopkins University
GWAC AACN Advanced Practice
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Explain rationale for adding geriatric competencies and content to graduate prep for APRNs in Acute and Critical Care
Determine how implementation of Consensus Model , esp. APRN education, certification & licensure, might impact you personally and your practice.
Describe results of recent systematic review of research on outcomes of APRN care & how they might be used to support policy change
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Quality
45th Infant mortality
24th Life expectancy
37th for Health Care Performance
98,000 die from preventable errors
Correct diagnosis 55 % of time
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Health care expenditures > $ 2 trillion # 2 for expenditures in the world
16 % of GDP
Threaten businesses
50 % of personal bankruptcies
Where does all the $$ go?
Chronic disease = 75 % of spending
Hospitalization = 30 % of costs
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International Comparison of Spending on Health, 1980–2004
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United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Data: OECD Health Data 2005 and 2006.
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Average spending on health
per capita ($US PPP)
Total expenditures on health
as percent of GDP
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
EFFICIENCY
6
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Health disparities
HTN / DM / ESRD / CVA
5 year difference in survival
• Access, prevention & experiences
• Distribution & number of providers
• Poverty
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Emphasize wellness & health promotion
Use patient-centered, community based care
coordination models
Expand use of APRNs
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Adopt meaningful use Health Info systems
Apply quality improvement processes and best evidence to improve practice
Expand use of APRNs
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Use biobehavioral, holistic approach
Patient in context of family and life
Health focus rather than illness focus
Inter professional communication
Care coordination
Fix systems to deliver better patient focused care
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Expand use of APRNs
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Nurse
Anesthetist
Nurse
Midwife
Clinical
Nurse
Specialist
Nurse
Practitioner
Adult-
Gero*
Women’s
Health
Family
lifespan
Neonatal Pediatrics* Mental
Health
Lic
en
su
re a
t le
ve
ls o
f ro
le
an
d p
op
ula
tio
n f
oc
i
POPULATION FOCI
APRN ROLE
APRN Specialties
Focus of Practice beyond broad population focus
e.g.: Oncology, Older Adults, Orthopedics,
Nephrology, Palliative care,
Primary OR
Acute Care
APRN Consensus Work Group & NCSBN (2008)
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Sheer numbers: Patients vs providers
Baby Boomers are 27 % of population –
50 % inpatients
The “Old old” - 3 million in 1994
19 million in 2050
GNP programs under enrolled /closing
High density, High risk:
Hospital admission produces functional decline & geriatric syndromes
Back to basics plus enhanced expertise
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Primary care
Pediatric 9 %
Family 49 %
Women’s Hlth 9 %
Adult 18%
Gerontologic 3 %
Psychiatric 3 %
Acute Care
Neonatal 2 %
Pediatric <1%
Adult 5%*
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Sensory changes (vision, hearing)
Pain – Pressure ulcers
Immobility -Incontinence
Confusion (delirium) - Constipation
Eating /drinking -Evidence of falls
Sleep Impaired responses
Less reserves
Volume of distribution
Polypharmacy
Comorbidities
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Multiple transitions
Frailty
Disability
Multiple providers
Comorbidity
Complexity
Acute illness
Multiple providers
Iatrogenesis
Adverse drug events
Functional decline
Geriatric syndromes
Acute Hospitalization:
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Provide desired care - choices
Maintain functional capacity
Avoid geriatric syndromes
Decrease complications – reduce length of stay
Return to previous residence
Provide safe transition
Prevent readmissions
Reduce costs
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Adult -> Adult / Geriatrics
Pediatrics no population change
ACNPs:
Refocus clinicals & add clinical experiences
CNSs must have:
3 Ps
Span wellness to illness
Health promotion Disease prevention
Diagnose & prescribe / Clinical Judgment
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ANCC
AG – ACNP & AGCNS exams available (?)
Accept last application for ACNP exam Dec 2014
AACN
ACNPC-AG exam 2013, ACCNS – AG now
Retire ACNPC & CCNS Dec 2014
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APRN Core
APRN Role
Specialty
Competencies
Specialty
Certification
Licensure:
based
on education
& certification
Identified by Professional
Organizations
(e.g. oncology, palliative
care, CV)
Measures of competencies
CNP, CRNA, CNM, CNS
& Population foci
APRN Core:
Patho/phys,Pharm. &
physical/health assess
Population
Relationship between Educational
Competencies, Licensure and Certification
APRN Consensus Work Group & NCSBN (2008)
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Nurse
Anesthetist
Nurse
Midwife
Clinical
Nurse
Specialist
Nurse
Practitioner
Adult-
Gero*
Women’s
Health
Family
lifespan
Neonatal Pediatrics* Mental
Health
Lic
en
su
re a
t le
ve
ls o
f ro
le
an
d p
op
ula
tio
n f
oc
i
POPULATION FOCI
APRN ROLE
APRN Specialties
Focus of Practice beyond broad population focus
e.g.: Oncology, Older Adults, Orthopedics,
Nephrology, Palliative care,
Primary OR
Acute Care
APRN Consensus Work Group & NCSBN (2008)
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Change from multiple ‘specialties’ to a ‘population’
Populations (Required certification & licensure):
Adult/Geriatric or Pediatric or Neonatal
Specialties (Optional - post certification):
Cardiovascular
Oncology
Orthopedics
Palliative care
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< 20 % need certification for job
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Arkansas
California
Colorado
District of Columbia
Hawaii
Idaho
Iowa
Maine
Maryland
Montana
Nebraska
New Mexico
North Dakota
Oklahoma
Oregon
Rhode Island
Utah
Vermont
West Virginia
Wisconsin
Wyoming
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Three Spheres
Patient – nurse - system
Role Components
Direct care – consultation – systems leadership – collaboration – research – ethical decision making & advocacy
Who will be fixing the system?
Which is bigger? $ 50 vs $ 50,000
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Seize the opportunities in enabling environment
Grow the practice (nursing’s role)
Partner – educate – integrate - coordinate
Anchor safety and quality with eye on cost
Drive innovation
Quantify – measure - compare
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59,242 CNSs
84 % are employed in Nursing
50 % hospitals 13 % ambulatory care
16 % universities ? Health industry
Job titles
CNS = 19 %
Educator = 21 % (service & academia)
Manager / administrator = 18 %
Staff RN = 16 %
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59,242 CNSs (2008)
18 % decline from 2004
Others substituted for CNS
About 40 % are certified < 20 % certification required for job
Need certification for title protection
CNSs older than other APRNs
64 % are > 50 y/o
Only 10 % are < 40 y/o
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Primary care
Pediatric 9 %
Family 49 %
Women’s Hlth 9 %
Adult 18%
Gerontologic 3 %
Psychiatric 3 %
Acute Care
Neonatal 2 %
Pediatric <1%
Adult 5%*
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Nurse
Anesthetist
Nurse
Midwife
Clinical
Nurse
Specialist
Nurse
Practitioner
Adult-
Gero*
Women’s
Health
Family
lifespan
Neonatal Pediatrics* Mental
Health
Lic
en
su
re a
t le
ve
ls o
f ro
le
an
d p
op
ula
tio
n f
oc
i
POPULATION FOCI
APRN ROLE
APRN Specialties
Focus of Practice beyond broad population focus
e.g.: Oncology, Older Adults, Orthopedics,
Nephrology, Palliative care,
Primary OR
Acute Care
APRN Consensus Work Group & NCSBN (2008)
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Physiologically unstable, technologically dependent, requiring frequent monitoring and intervention, highly vulnerable for complications
Complexity, patient safety & care quality
Hospitalist & intensivist
Medical malpractice
Graduate education Certification
Scope of Practice Credentialing
Opportunties to expand need to be provided
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Newhouse, Stanik-Hutt, White, Johantgen, Bass, Zangaro, Wilson, Fountain, Steinwachs, Heindel & Weiner
Nursing Economics; Journal for Nurse Practitioners
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CNS
Fulton & Baldwin 2004
NPs
Edmunds 1978
Sox 1979
OTA 1981 & 1986
LaRochelle 1987
Ventura et al 1991
Brown & Grimes 1995
Horrocks et al 2002
Laurant et al 2005
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reduce hospital costs
reduce lengths of stay
reduce frequency of emergency room visits,
improve pain management practices,
increase patient satisfaction with nursing care
fewer complications in hospitalized patients
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Blood pressure**
Glucose**
Symptom management*
Satisfaction*
Health status
Functional status
ED use
Hospitalizations
Length of stay** Similar or better* Better**
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Systematically review & summarize
Patient outcomes
Quality, Safety & Effectiveness
Care provided by US APNs
1990 - 2009
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Clear question
Systematic, explicit methods to identify, select, & critically appraise
Collect & analyze data from multiple studies
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Quality =
degree or grade of excellence
Safety =
prevent injury or loss
Effectiveness =
complies with guidelines and/or produces desired result
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Ways to assess Quality
Structures
Processes
Outcomes
Patient outcomes the ultimate measure
Incorporate both structures & processes
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RCT or Observational Comparative
Two provider types
US Studies
1990 - 2009
Out of US
Non-English
Descriptive, correlation, qualitative
No quantitative data
Outcomes not affected by APN
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Exhaustive literature search
Two independent reviewers
Titles -> Abstracts -> Articles
Critique each study quality – Jadad
Aggregate & rate quality of data – GRADE
Draw conclusions
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Variety of databases (e.g., MEDLINE, Proquest, CINAHL).
Systematic reviews (e.g., Cochrane Database, Joanna Briggs Institute, Institute of Medicine/National Research Council Reports).
Government reports (i.e. AHRQ or HRSA). Prior published literature reviews Peer reviewed non- profit organization reports Doctoral dissertations & HRSA grants Hand searching
References of key review articles and articles included in review.
Footnote chasing Query of experts about literature in their personal files. Professional organizations affiliated with APNs
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Titles = 27,993
Abstracts = 7113
Articles = 1673
Articles included = 82 NP (49); CNS (24);
CNS and NP combined (9)
Articles with aggregated outcomes = 54 NP (37); CNS (13);
CNS and NP combined (4)
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High level of evidence: Do not affect Satisfaction 3 (1 RCT) Reduce LOS* 7 ( 2 RCT) Decrease cost * 4 (2 RCT)
Moderate level of evidence:
Lower complications 5 (1 RCT) Low level of evidence:
Affects quality of life 4 (1 RCT)
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High level of evidence:
Satisfaction 6 (4 RCT)
Perceived health 7 (5 RCT)
Functional status 10 (6 RCT)
Une x pected ED or
Urgent care visit 5 (3 RCT)
Hospitalization 11 (3 RCT)
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High level of evidence: Glucose 5 (5 RCT) Blood pressure 4 (4 RCT) Lipid* 3 (3 RCT)
Moderate level of evidence: Length of stay 16 (2 RCT)
Low level of evidence: Duration of ventilation 3 (0 RCT)
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High level of evidence:
Mortality 8 (1 RCT)
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Moderate level of evidence
CNS / NP led team interventions reduced readmission/hospitalization 4 (2 RCT)
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Addition depth of data (previous reviews)
Support MSN prepared CNS & NP
Trigger conversations, target research $
Make optimum use of providers – work distribution, models of care
Policy applications – rescind barriers, support any willing provider,
educational $
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Legislation in Maryland and several other states
Federal Trade Commission
Veterans Administration ‘full practice authority”
Physicians taking on their colleagues
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Impact on nurses, nursing care & nurse retention
Impact on system outcomes & costs
Direct care outcomes
Symptom management, prescribing
Primary care models
Rural & underserved areas
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“Let the NPs be NPs”
Explain “How did NPs do that?”
Compare to established benchmarks
Everyday practitioners
Alternative care models
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Nursing is responding to Grey Tsunami
Don’t let your certification lapse
Expand your skills
CNSs need to take action
decide our core business
get certified to protect the title
Preparation needs to match practice
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Health care reform still up in air
Huge opportunities for NPs but also for CNSs
Take on Populations, Systems & Policy
“Timid women need not apply”
Know the outcomes, know YOUR outcomes
“In God we trust. All others must bring data”
Carpe diem! “Well behaved women rarely make history”