Julie Stanik-Hutt PhD, ACNP/GNP, CCNS Johns Hopkins University

GWAC AACN Advanced Practice

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

Quality

45th Infant mortality

24th Life expectancy

37th for Health Care Performance

98,000 die from preventable errors

Correct diagnosis 55 % of time

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

International Comparison of Spending on Health, 1980–2004

0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Data: OECD Health Data 2005 and 2006.

0

2

4

6

8

10

12

14

16

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

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

Health disparities

HTN / DM / ESRD / CVA

5 year difference in survival

• Access, prevention & experiences

• Distribution & number of providers

• Poverty

Emphasize wellness & health promotion

Use patient-centered, community based care

coordination models

Expand use of APRNs

Adopt meaningful use Health Info systems

Apply quality improvement processes and best evidence to improve practice

Expand use of APRNs

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

Expand use of APRNs

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

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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)

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

Primary care

Pediatric 9 %

Family 49 %

Women’s Hlth 9 %

Adult 18%

Gerontologic 3 %

Psychiatric 3 %

Acute Care

Neonatal 2 %

Pediatric <1%

Adult 5%*

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

Multiple transitions

Frailty

Disability

Multiple providers

Comorbidity

Complexity

Acute illness

Multiple providers

Iatrogenesis

Adverse drug events

Functional decline

Geriatric syndromes

Acute Hospitalization:

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

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

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

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)

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)

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

< 20 % need certification for job

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

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

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

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 %

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

Primary care

Pediatric 9 %

Family 49 %

Women’s Hlth 9 %

Adult 18%

Gerontologic 3 %

Psychiatric 3 %

Acute Care

Neonatal 2 %

Pediatric <1%

Adult 5%*

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)

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

Newhouse, Stanik-Hutt, White, Johantgen, Bass, Zangaro, Wilson, Fountain, Steinwachs, Heindel & Weiner

Nursing Economics; Journal for Nurse Practitioners

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

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

Blood pressure**

Glucose**

Symptom management*

Satisfaction*

Health status

Functional status

ED use

Hospitalizations

Length of stay** Similar or better* Better**

Systematically review & summarize

Patient outcomes

Quality, Safety & Effectiveness

Care provided by US APNs

1990 - 2009

Clear question

Systematic, explicit methods to identify, select, & critically appraise

Collect & analyze data from multiple studies

Quality =

degree or grade of excellence

Safety =

prevent injury or loss

Effectiveness =

complies with guidelines and/or produces desired result

Ways to assess Quality

Structures

Processes

Outcomes

Patient outcomes the ultimate measure

Incorporate both structures & processes

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

Exhaustive literature search

Two independent reviewers

Titles -> Abstracts -> Articles

Critique each study quality – Jadad

Aggregate & rate quality of data – GRADE

Draw conclusions

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

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)

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)

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)

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)

High level of evidence:

Mortality 8 (1 RCT)

Moderate level of evidence

CNS / NP led team interventions reduced readmission/hospitalization 4 (2 RCT)

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 $

Legislation in Maryland and several other states

Federal Trade Commission

Veterans Administration ‘full practice authority”

Physicians taking on their colleagues

Impact on nurses, nursing care & nurse retention

Impact on system outcomes & costs

Direct care outcomes

Symptom management, prescribing

Primary care models

Rural & underserved areas

“Let the NPs be NPs”

Explain “How did NPs do that?”

Compare to established benchmarks

Everyday practitioners

Alternative care models

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

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”