Using VPS to Assess Impact of Advance Practice Staffing

ChangesEmilie Henry, MD, FAAPAmy Harrell, RN, BSN

Pediatric Critical CareThe Children’s Hospital at OU Medical Center

Speaker DisclosureNo financial disclosures or affiliations to disclose

About usPICU at Children’s Hospital at the University of

Oklahoma in OKC

25 beds

~1600 admissions per year

Developing CTS programNew surgeon January 2014~300 cases 2014

About usStaff

7 full time attendings1 part time2 on service during day, 1 on service at night

Advance Practice Team7 full time2 part time3 Physician Assistants6 Acute Care Nurse Practitioners12 hour shifts

Vision of the APPProvide

exceptional patient care with emphasis on continuityeducation and research

DilemmaWith busier cardiac unit and only one physician

on at night, how staff APP team most effectively?

Meet vision of excellent patient care and continuity

Asked AP team recommended a swing shiftLooked at VPS data

Extracting Data from MyReports

• View Report• ICU Summary – Here we looked at

the which days and time of day the PICU had the most admissions.• 1300-0100 Swing Shift recommended by APP.

APP “Swing Shift”Started August 1, 2014

From 1pm to 1am, Tues-Thurs

One APP

Predominantly to assist with new admissions and evening coverage in CVICU

APP team loved this additional coverage

But was it truly helpful with providing excellent patient care?

Study ObjectiveDetermine if the addition of the APPs for a

“swing shift” three nights per week led to

1. Decreased length of stay (LOS) for pediatric post-operative cardiac patients admitted to the PICU and

2. Decrease in mortality, length of intubation, duration of chest tubes, arterial lines, or central venous lines.

Study DesignRetrospective chart review

all pediatric post-operative cardiac patients

March 1-July 31, 2014 - before “swing shift” (Group 1)

August 1-December 31, 2014 - after “swing shift” (Grop 2)

Data from our Virtual PICU Systems database and

Meditech

Using MyReports, a query was built using a population of:

• Admission dates from March 1, 2014-July 31, 2014 (before swing shift) and

• Admission dates from August 1, 2014-December 31, 2014 (after swing shift).

• Had a cardiac procedure = yes

Variables included:• Age• Gender• LOS• PIM2 ROM score• PRISM3 score• Disposition • Outcome

Extraction of procedure duration for:• Endotracheal tubes• Chest tubes• Arterial Catheters• Percutaneous Central Venous Catheters• STS procedures • divided into Single Ventricle

physiology vs not.

StatisticsThe two groups were compared using:

Descriptive statistics (Table 1)Fisher’s exact for categorical variables (Table 2)Wilcoxon-Mann-Whitney for non-normal continuous

variables (Tables 2&3)

A multiple regression model comparing the “swing shift” with LOS as the dependent variable

DemographicsGroup 1N=103 Freq.

Group 2N=94 Freq.

Male 52 50.5% 52 55.3%

Female 51 49.5% 42 44.7%

Single Ventricle Physiology 16 15.5% 13 13.8%

Mortality 5 4.9% 3 3.2%

Age at ICU Admit (mo)* 10 (3, 141)

-5

(2, 67)-

Patient Characteristics

* Non-normally distributed variables reported as median (25th, 75th percentile)

Length of StayGroup 1 Median

(IQR) n=103

Group 1 mean (SD)

N=103

Group 2 Median (IQR)

n=94

Group 2 Mean (SD)

n=94P-

value

2.80 (1.33, 5.89)* 6.20 (10.7) 3.00 (2.01, 5.26) 4.96 (5.69) 0.5423

Multiple regression model comparing Group 2 with LOS Lower CI Upper CI

P-value

Estimate of change in LOS 0.87 days 0.74 1.02 0.0759

* Non-normally distributed variables reported as median (25th, 75th percentile)

Secondary OutcomesDuration of Continuous

VariablesGroup 1

NGroup 1Median

Group 2N

Group 2Median

P-value

Arterial Line * 1011.13 (0.89, 3.00)

931.14

(0.80, 2.86)

0.3054

Central Line* 922.75 (1.82, 5.84)

782.15

(1.78, 4.66)

0.2413

Chest Tube* 911.49 (0.96, 2.50)

881.53

(1.26, 3.42)

0.175

4

Endotracheal Tube* 860.68 (0.13, 2.97)

880.72

(0.23, 2.92)

0.2915

* Non-normally distributed variables reported as median (25th, 75th percentile)

Results Group 1 (before “swing shift”) similar to Group 2 (after “swing shift” ) Groups not normally distributed No statistically significant change in LOS after addition of APP “swing

shift” (p=0.5423) However, multiple regression analysis revealed trend toward shorter

LOS Estimated change in LOS when “swing shift” was available was 0.87 days,

or 21 hours Accounted for factors such as patient disposition, PIM 2, age at ICU

admission, mortality, single ventricle physiology No significant difference between groups regarding secondary

outcomes

Conclusions

Trend toward shorter LOS has positive impact Financially (average cost of one PICU day $8,200) PICU resources Families emotionally and psychologicallyLack of significance may be related to Small sample size “Swing shift” only 3/7 nights Some patients are transferred back to NICU prior to

lines and tubes being removed

Future StudiesAs the APP team expands, night coverage will increase

Just recently expanded to include Monday night swingTeam will eventually have full coverage of nights

Inotropes

Patient satisfaction

ThanksKathryn Rougraff, PA-C

Summer Frank, MPH

Michael Anderson, PhD

Questions?