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
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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