Ruth M. Kleinpell PhD APRN-BC

Rush University College of Nursing Chicago, Illinois USA

Outcomes of APN Roles on

Patients and Cost Effectiveness

Objectives

Discuss key considerations related to

APN role

Describe process of measuring APN

outcomes

Highlight practical application to

individual APN roles

Advanced Practice Nursing

4 Traditional Roles

◊ Certified Registered Nurse

◊ Certified Nurse Midwife

◊ Clinical Nurse Specialist

◊ Nurse Practitioner (NP)

NP

CNS

CNM

CRNA

National Profile of APNs

American Nurses Association: www.nursingworld.org/readroom/fsadvprc.htm, 2015

Developing APN Role

Essential Considerations

Educational Standards

Scope of Practice

Regulatory Legislative Framework

APN licensure

APN certification

Developing APN Role

Essential Considerations

APN Role What is health care context –

priorities, goals, unmet needs

What will the APN role be?

Function

Education

Number required

Career pathway

Assessing Outcomes of APN

Practice

Overview

•Measurement of outcomes:

◊ No longer an option

◊ A mandated component of providing

healthcare

Expectations of today:

▪ High quality health care

▪ Cost effective

▪ Good outcomes

Nursing Outcomes

● Over 150 years ago Florence Nightingale

conducted the first nursing outcomes

research, documenting unsanitary and

unsafe conditions in hospitals

● Nightingale introduced basic measures for

improving sanitation and hygiene

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856593/

Nursing Outcomes

● The effect on mortality rates was dramatic.

Within six months the death rate at the

military hospital in Scutari, Turkey fell from

43% to 2%

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856593/

Why Measure APN Outcomes?

◊ Identify role of APN

◊ Demonstrate impact on:

▪ Clients

▪ Health care

▪ Costs of care

▪ Other measures

True or False?

● An APN should be in practice for many

years before attempting to measure

outcomes

● In order to be able to measure outcomes,

an APN has to conduct research

● The best outcomes to measure are the

traditional medical outcomes – eg. length

of stay, costs

True or False?

● As APN care is often “invisible” it is best

not to try and measure outcomes of APN

care

● Outcomes should only be measured

with instruments

● An outcomes project takes years to

develop & complete

My Interest in Outcomes

Outcomes after Critical Illness

Outcomes of APN Practice

5 year study of 437 NPs certified in acute care

working in ICU and acute care settings

American Journal of Critical Care 2005;14;3

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Percent

Patient care

management

Teaching Quality

Assurance

Dept Projects Program

Development

Administrative

ACNP Role Components

Kleinpell Am J Crit Care. 2005;14:211-219.

90

80

70

60

50

40

30

20

10

0

Costs of Care

Rehospitalization

Access

Resource Use

Length of Stay

Complications

Satisfaction

Education

Care Continuity

Best Practice Care

How Are You Impacting Outcomes?

0

10

20

30

40

50

60

70

80

90

100

Percent of APNs Who Reported Measuring Outcomes

0102030405060708090

100

Percent of APNs Who Reported Measuring Outcomes

WHY Should An APN Measure

Outcomes Related To Their Role?

Other Reasons

Demonstrate value of role

Identify impact on patient care, quality of

care, patient experience of care, etc.

It is an APN’s professional responsibility

Job security

Provide rationale for why APN roles

should be expanded in a

setting/organization

What Outcomes Should an

APN Measure Related to their

Role?

How Does the APN Impact

Outcomes?

Comparison of time to treatment for acute ischemic stroke patients utilizing

an NP led acute stroke team in Taiwan

Results: Median time to CT scan decreased from 29 to 20 minutes (p<.001)

Time to neurology evaluation decreased from 61 to 43 minutes (p<.001)

Door to needle time for thrombolytics decreased from 68 to 58 minutes (p<.05)

226 women receiving care by nurse midwife were compared to 226 receiving usual care

Vaginal birth rate was 87.6% compared with 58.8% in usual care;

Apgar scores were similar;

Rates of amniotomy ↓(17.2% vs 89.9%); Episiotomy rates ↓ (77.9% vs 94.2%)

97% were mobilized vs standard care unit where bedrest was maintained after delivery

RCT trial of NP and MD care for 160 patients < age 16 with childhood eczema

Results were similar with respect to eczema severity and quality of life

Satisfaction ratings were higher for NP care, and costs of care were less

● Retrospective (n=402) and 6 month prospective (n=122)

evaluation of impact of ACNP care in Neuroscience ICU

●Focused on evidence based care for respiratory care,

nutrition, pain management

American Journal of Critical Care July 2002 Volume 11 No 4:353-364

0

1

2

3

4

5

6

7

Urinary Tract Infection

Skin B

reakdown

Pneum

onia

Complication

Pati

en

ts w

ith

co

mp

licati

on

s ,

%

Without ACNP

With ACNP

Russell D et al. Am J Crit Care 2002;11:353-364.

*p<.05 *p<.05

What Outcomes Relate to the APN

Role?

● Access: Time to appointment; clinic wait

time

● Chronic disease management: HbA1C

● Lab test use; costs of care

● Rehospitalization rates

● ED visits for asthma exacerbation

● Patient experience of care

Factors to Consider

• What are role components of the APN

that may impact outcomes?

• How easily can the outcome be

measured?

• Can a relationship be established

between APN care and the outcome?

Identifying APN Outcomes

● What are important quality indicators

currently being monitored?

● Have there been situations/sentinel events

that indicate new areas to target?

● What are best practices that can be

incorporated?

640 bed University Medical Center

APNs in Medical Center: 140

Nurse Practitioners, Clinical Nurse Specialists,

Certified Nurse Midwives, Certified

Registered Nurse Anesthetists

APN programs in College of Nursing

Service based & Unit based APN roles

Purpose

● To implement and evaluate the efficacy of a

multidisciplinary initiative to reduce CAUTIs in a

Medical ICU by decreasing urinary catheter

device use

During 6 month period, reinforced

assessment of appropriate use of

urinary catheters and monitored

catheter device days and

rates of CA-UTI’s compared to

prior 11 month timeline

HOW Does an APN Measure

Outcomes Related To Their Role?

Reflect on APN role

to identify specific

areas of focus

Measuring APN

OutcomesIdentify outcomes

that are impacted by

the role

Select plan/method for

evaluating impact on outcome Assess options for

gathering data

Collect, analyze &

evaluate data

Disseminate to relevant

stakeholders and via

publication &

presentation