Constructing a Team in 2012 What I’ve been telling the other doctors…

Joshua Koch, MD

Assistant Professor of Pediatrics

Medical Director, CICU

Outline

• ACGME regulations and work hours

• Increasing medical complexity and “hybrid” models of care

• Training and educational needs for APNs and PAs

• Care and feeding of a growing program

• Tracking quality and efficiency

• Financial implications (now and in the future)

Alphabet Soup

• APN = Advanced Practice Nurse

• PA = Physician Assistant

• APP = Advanced Practice Practitioner = APNs + PAs

• DEEP CRAP = What we’re going to be in if we don’t figure out how to care for patients safely, effectively, and efficiently in the very near future

Reduced Resident/Fellow Work Hours

Nuckols and Escarce, JGIM, 2011

Reduced Resident/Fellow Work Hours

Baldwin et al, JGME, 2010

Expanding Patient Populations

• Increasing complexity leads to increased subspecialty care• Technology and expertise are increasing

– Command over “new knowledge” is limited to subspecialists– Specialty care can be targeted with focused education

• Traditional Models (Attending/Fellow/Resident) are becoming outdated

• Leads to “hybrid models of care”– Attending + Resident + APP– Attending + Fellow + APP– Attending + Fellow + APP + Hospitalist– Attending + APP

What is a hybrid and why should I care?

Is it possible that we will all drive electric cars in the future?

A Hybrid Model of Care

Traditional Model

• Attending physician

• Fellow

• Senior Resident

• 2 interns

Hybrid Model

• Attending physician

• Resident x 2

• APP x 2

What is the ideal patient for an APP?

Traditional (clinic setting)

Low acuity

Low Intensity

High Complexity / Specialty Unit

NICU

Newer ModelsPICUCICUOncology Inpatient

Newer ModelsERStem Cell Transplant

Newer ModelsGI InpatientCardiology Inpatient

Where are they now?

• Over 13,000 PNPs practice currently in the United States*– 59% work in primary care

– 64% do not provide care in inpatient settings

• Established settings are not “set”– For every newly graduated NNP, there are up to

80 open positions**

*Freed et al, Pediatrics, 2010**Freed et al, Pediatrics, 2010

What are physicians planning?

• Survey of 498 pediatric generalists and 1696 subspecialists

Freed et al, Pediatrics, 2011

43% of subspecialists plan to increase thenumber of NPs they use in the next 5 years

What is the supply?

Freed et al, Journal of Pediatrics, 2010

How are NPs and PAs trained?

Nurse Practitioners**

• Undergraduate degree (4)

• Clinical time as an RN (?)– Critical thinking

– Targeted experience

• NP Training (2)*– Primary vs. Acute Care

– Practicum times spent in selected specialty

Physician Assistants**

• PA School (2)*– Broad education

– Adult and OR experience

– Limited pediatrics• 6 weeks with primary care

pediatrician

• 4 weeks elective/selective

*Program X ≠ Program Yand

**Graduate X ≠ Graduate Y

The Ocean of Experience

NP

PA

How should we educate APPs?

• Role Transition Program– Workshop #1: Laying the Foundation– Workshop #2: Launching– Workshop #3: Meeting the Challenge– Workshop #4: Broadening the Perspective

• Acknowledge that teaching model is different– Probing for knowledge gaps not the norm– Reluctance to ask for help may be even greater than

residents/fellows • Set clear expectations

• Understand your learner’s limitations– Depth and breadth are different– Don’t lose faith in competence

NP

PA

How should we educate APPs?

• Involve them in research

• Involve them in journal club

• Involve them in the lecture series (give them a turn)

• Involve them…

Show that you want to be involvedWhen an opportunity presents itself,

grab the bull by the horns!

How do we educate APPs and housestaff?

We may want electric cars, but a model of patient care is probably best as a hybrid…This is a new concept for many physicians you are working with!

The Ocean of Experience

NP

PA

PGY-2

PGY-1

PGY-3

PGY-6PGY-5PGY-4

Teamwork – where can we go wrong?

• Attending – APP • Fellow – APP• Resident – APP• Primary Goal = Quality Patient Care

– Avoid Us vs. Them– Encourage ownership– Build Trust

• Ok to acknowledge that there are different backgrounds and frames of reference

Leadership and Communication

• Medical leadership is needed– Keep the ship on target towards ultimate goal

– Right the ship when needed

– Keep people from jumping ship

• Communication is essential– Goals will change, new hurdles arise

– Growth is expected and expectations will change

Reach out to your medical leadership, be specific in your needs, don’t be discouarged by initial hiccups

What are we doing in the CICU?

• Teamwork

• Communication

• Leadership

• Focus on Education and Career

CICU Clinical Discussion

• Weekly meeting

• Includes attendings, fellows, and NPs

• Led by attendings going off service– Who were the most challenging patients?

– What did we learn?

– What can we do differently next time?

– Should we be doing this differently as a group…

If they don’t want to organize this, do it yourself! Learn from each other. It’s less painful to learn from other people’s mistakes.

CVICU Research Group

• Meets monthly• Goals

– Discuss ideas for research– Develop consensus for protocols– Engage in public humiliation model for

non-production (Alan Nugent, lead protagonist)

• Open to ideas, participation, guests• Engage the community in research

– Fellows, Residents, RNs, NPs, PAs, RTs

This is a great opportunity to make inroads with your physician group and build relationships

Augmenting education

• Each APP has a faculty mentor– Resource for challenging situations– Educational liaison – Career guidance

• APPs lead journal club– Monthly, occurs outside of work (+ morale)– Mentorship by faculty member

• APPs lead simulation sessions– Critical events– Critical thinking

Don’t forget about nursing!

• Development of consistent front-line safety net

• Education focused on specialty population– Quarterly education sessions led by medical and

nursing leadership

– Multidisciplinary simulation sessions

• Development of talent– Education, quality, and leadership

Demonstrate how to “bridge the gap”

2008 2009 2010 2011

Unplanned Extubations

# Ex

tub

atio

ns

/ 10

0 ve

nt

day

s

2007 2008 2009 2010 2011 2007 2008 2009 2010 2011

Blood Stream InfectionsCardiopulmonary Arrests

# In

fect

ion

s /

1000

CL

day

s

# C

od

es /

100

pat

ien

t d

ays

What are the next steps?

• Diagnosis Related Groups (DRG)– Classification system developed to replace “cost

based reimbursement”

– Used in the U.S. since 1982 for Medicare payments

• All Patient Refined DRG (APR-DRG)– Designed to encompass severity as well as

components of pediatric patient (birth weight, specific pediatric mortality distinctions)

Hospitals are going to start caring a lot about efficient care (LOS, etc.)

Clinical Pathways: Effects on Professional Practice, Patient Outcomes, Length of Stay, and Hospital Costs

▶ A structured multidisciplinary plan of care.

▶ Used to channel the translation of guidelines or evidence into local structures.

▶ Detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other "inventory of actions".

▶ Possess time-frames or criteria-based progression (ie. steps were taken if designated criteria were met).

▶ Aimed to standardize care for a specific clinical problem, procedure or episode of care.

Rotter et al, Cochrane Database Syst Rev, 2010

How does a clinical pathway help?• Defines a pathway in a chaotic environment• Improves clinical efficiency and communication• Identifies outliers to the clinical team

– Why is this patient different?– Differences must be documented!

• A well-designed protocol does not constrain decision-making

• Protocol-driven care does not replace clinical judgment

• Continual appraisal can be used to modify protocols and adapt new strategies

This may help NPs everywhere to stay sane!Get involved with design and implementation!

Summary

• There will be continued need for hybrid models of care as resident and fellows hours are restricted

• Training and educational needs are different amongst APNs, PAs, residents, and fellows

• Leadership and communication are essential to retention and satisfaction

• Importance of tracking quality cannot be overstated– Patient Care– Financial Implications

Acknowledgements

Joshua Wolovits

Joe Don Cavender

Lisa Milonovich

Jean Storey

Jeff McKinney