Original Article
Continuity of care by cardiothoracic nurse practitioners: Impact on outcome
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(8) 944–947 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314523630 aan.sagepub.com
Dawn Southey1, Pankaj Kumar Mishra2, Alan Nevill3, Dincer Aktuerk2 and Heyman Luckraz2
Abstract Objectives: There have been recent reports on increased mortality in British National Health Service hospitals during weekends. This study aimed to assess the impact on patient care following the introduction of nurse practitioner cover for the cardiothoracic ward, including weekends. Methods: Prospectively collected and validated data of patients operated on from January 2005 to October 2011 were analyzed. The patients were grouped according to era: before (n ¼ 2385) and after (n ¼ 3910) the introduction of nurse practitioners in October 2007. Results: There were no significant differences in preoperative patient characteristics such as age, logistic EuroSCORE, sex, smoking, and extracardiac vascular problems. There were more patients from an Asian background (p < 0.01), more with noninsulin-dependent diabetes (p < 0.01), and more requiring urgent cardiac surgery (p < 0.01) in the later era. Following the introduction of nurse practitioner grade, there was a decrease in the rate of cardiac intensive care unit readmission from 2.6% to 1.9% (p ¼ 0.05) and length of hospital stay from 10 to 8 days (p < 0.01). There was a significant improvement in overall survival after cardiac surgery from 96.5% to 98.0% (p < 0.01). Logistic regression analysis confirmed that the presence of nurse practitioners on the ward was the strongest predictor of survival with an odds ratio of 1.9 (95% confidence interval: 1.23–3.01). Conclusion: The introduction of the nurse practitioner grade to provide continuity in patient care including at weekends has been confirmed to improve patient outcomes including survival after cardiac surgery.
Keywords Advanced practice nursing, health services needs and demand, nurse practitioners, personnel staffing and scheduling, thoracic surgery
Introduction A recent report from the Dr Foster Intelligence group suggested that outcomes for hospital patients were worse over the weekend, possibly reflecting the lack of consultants’ presence within the hospital during that period.1 Consequently, the British National Health Service (NHS) Medical Director, Sir Bruce Keogh, through the British Medical Journal, called for the NHS to work in a similar fashion during the weekend as during a week day.2 The context of nursing practice is varied, dynamic, and complex.3 Yet healthcare professionals have faced extraordinary changes in recent years, due to major developments in clinical practice and reorganization within the work place.4 The development of advanced nursing practice has become a global trend in the last decade.5 Advanced
nursing practice has been used as an umbrella term to describe nursing at a higher level than traditional nurses. Schober and Affara6 stated that the role of the nurse practitioner (NP) is characterized by autonomous extended practice requiring advanced clinical knowledge and skills in stable, variable, and complicated conditions. In our practice, pressure on junior doctors’ 1
Heart & Lung Centre, Wolverhampton, UK Cardiothoracic Unit, Heart & Lung Centre, Wolverhampton, UK 3 Research Institute of Healthcare Sciences, University of Wolverhampton, UK 2
Corresponding author: Pankaj Kumar Mishra, MD, MCh (CTh), MRCS, FRCS (CTh), Cardiothoracic Unit, Heart & Lung Centre, Wolverhampton WV10 0QP, UK. Email: [email protected]
Downloaded from aan.sagepub.com at Bobst Library, New York University on May 31, 2015
Southey et al.
945
hours (European Working Time Directive) and training as well as continuity of care have highlighted the need for specialist ward-based nurse practitioners. Four NP took responsibility for the ward management of adult cardiothoracic patients in our unit from October 2007, under the guidance of 7 consultants, including weekend cover, following discontinuation of the senior house officer posts, with only a cardiothoracic registrar available during the week, with limited hours because the cardiothoracic registrars currently spend the majority of their time in theatres, intensive care units, and outpatient clinics, allowing NP to manage the ward with consultant supervision when needed. This means that the consultant cardiothoracic surgeons were available to discuss their patients’ care, at least over the telephone, on a 24/7 basis. Most consultants conduct daily rounds during weekdays and even over the weekend if patients under their care are poorly, irrespective of being on-call. The NP roles include history taking and clinical examinations, admitting patients, daily ward rounds, chasing results, note documentations as well as advanced roles consisting of independent prescribing and advanced wound management. NP as a team also develop policies and protocols, and undertake audits to highlight improvements in practice. The aim of this study was to assess the impact of continuity of care provided by NP in terms of the rate of readmission to the cardiac
intensive care unit (ICU), hospital stay, and overall mortality after cardiac surgery.
Patients and methods All patients undergoing cardiac surgery between January 2005 and October 2011 were included. Their data were prospectively collected and validated as part of the requirement for submission to the Central Cardiac Audit Database, National Institute for Cardiovascular Outcomes Research. Patients were categorized to either the pre-NP era (January 2005 to October 2007, n ¼ 2385) or post-NP era (October 2007 to October 2011, n ¼ 3910) according to their surgery date. There were no significant differences (p > 0.05) in preoperative patient characteristics such as age, logistic EuroSCORE, sex, smoking, and the presence of extracardiac vascular problems between the two eras. There were more patients from an Asian background (p < 0.01), more with noninsulindependent diabetes (p < 0.01), and more requiring urgent cardiac surgery (p < 0.01) in the post-NP era (Table 1). Data were analyzed using SPSS version 11.5 software (SPSS, Inc., Chicago, IL, USA). Data are given as mean standard deviation or percentages, as appropriate. Logistic regression analysis was used to determine independent factors related to survival.
Table 1. Patient characteristics and outcomes in the eras before and after the introduction of nurse practitioner grade. Variable
Pre-NP era
Post-NP era
p value
No. of patients Age (years) Male Asian NIDDM Smoker COPD Peripheral vascular disease Urgent surgery Isolated coronary artery bypass Body mass index (kg m2) Logistic EuroSCORE Cardiac ICU readmission Atrial fibrillation Hospital infection Hospital stay (days) Survival
2385 66 10 75% 8.6% 11% 9.6% 11.6% 18.2% 27.4% 67.5% 27.8 4.5 6.6% 9.1% 2.6% 32.1% 19.6% 10.4 12.8 96.5%
3910 66 10 76% 11.8% 14.3% 11.3% 13.1% 17.8% 30% 61.9% 28.3 4.8 5.9% 7.6% 1.9% 29.3% 16% 8.4 10.7 98.0%
0.8 0.8
Continuity of care by cardiothoracic nurse practitioners: Impact on outcome
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(8) 944–947 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314523630 aan.sagepub.com
Dawn Southey1, Pankaj Kumar Mishra2, Alan Nevill3, Dincer Aktuerk2 and Heyman Luckraz2
Abstract Objectives: There have been recent reports on increased mortality in British National Health Service hospitals during weekends. This study aimed to assess the impact on patient care following the introduction of nurse practitioner cover for the cardiothoracic ward, including weekends. Methods: Prospectively collected and validated data of patients operated on from January 2005 to October 2011 were analyzed. The patients were grouped according to era: before (n ¼ 2385) and after (n ¼ 3910) the introduction of nurse practitioners in October 2007. Results: There were no significant differences in preoperative patient characteristics such as age, logistic EuroSCORE, sex, smoking, and extracardiac vascular problems. There were more patients from an Asian background (p < 0.01), more with noninsulin-dependent diabetes (p < 0.01), and more requiring urgent cardiac surgery (p < 0.01) in the later era. Following the introduction of nurse practitioner grade, there was a decrease in the rate of cardiac intensive care unit readmission from 2.6% to 1.9% (p ¼ 0.05) and length of hospital stay from 10 to 8 days (p < 0.01). There was a significant improvement in overall survival after cardiac surgery from 96.5% to 98.0% (p < 0.01). Logistic regression analysis confirmed that the presence of nurse practitioners on the ward was the strongest predictor of survival with an odds ratio of 1.9 (95% confidence interval: 1.23–3.01). Conclusion: The introduction of the nurse practitioner grade to provide continuity in patient care including at weekends has been confirmed to improve patient outcomes including survival after cardiac surgery.
Keywords Advanced practice nursing, health services needs and demand, nurse practitioners, personnel staffing and scheduling, thoracic surgery
Introduction A recent report from the Dr Foster Intelligence group suggested that outcomes for hospital patients were worse over the weekend, possibly reflecting the lack of consultants’ presence within the hospital during that period.1 Consequently, the British National Health Service (NHS) Medical Director, Sir Bruce Keogh, through the British Medical Journal, called for the NHS to work in a similar fashion during the weekend as during a week day.2 The context of nursing practice is varied, dynamic, and complex.3 Yet healthcare professionals have faced extraordinary changes in recent years, due to major developments in clinical practice and reorganization within the work place.4 The development of advanced nursing practice has become a global trend in the last decade.5 Advanced
nursing practice has been used as an umbrella term to describe nursing at a higher level than traditional nurses. Schober and Affara6 stated that the role of the nurse practitioner (NP) is characterized by autonomous extended practice requiring advanced clinical knowledge and skills in stable, variable, and complicated conditions. In our practice, pressure on junior doctors’ 1
Heart & Lung Centre, Wolverhampton, UK Cardiothoracic Unit, Heart & Lung Centre, Wolverhampton, UK 3 Research Institute of Healthcare Sciences, University of Wolverhampton, UK 2
Corresponding author: Pankaj Kumar Mishra, MD, MCh (CTh), MRCS, FRCS (CTh), Cardiothoracic Unit, Heart & Lung Centre, Wolverhampton WV10 0QP, UK. Email: [email protected]
Downloaded from aan.sagepub.com at Bobst Library, New York University on May 31, 2015
Southey et al.
945
hours (European Working Time Directive) and training as well as continuity of care have highlighted the need for specialist ward-based nurse practitioners. Four NP took responsibility for the ward management of adult cardiothoracic patients in our unit from October 2007, under the guidance of 7 consultants, including weekend cover, following discontinuation of the senior house officer posts, with only a cardiothoracic registrar available during the week, with limited hours because the cardiothoracic registrars currently spend the majority of their time in theatres, intensive care units, and outpatient clinics, allowing NP to manage the ward with consultant supervision when needed. This means that the consultant cardiothoracic surgeons were available to discuss their patients’ care, at least over the telephone, on a 24/7 basis. Most consultants conduct daily rounds during weekdays and even over the weekend if patients under their care are poorly, irrespective of being on-call. The NP roles include history taking and clinical examinations, admitting patients, daily ward rounds, chasing results, note documentations as well as advanced roles consisting of independent prescribing and advanced wound management. NP as a team also develop policies and protocols, and undertake audits to highlight improvements in practice. The aim of this study was to assess the impact of continuity of care provided by NP in terms of the rate of readmission to the cardiac
intensive care unit (ICU), hospital stay, and overall mortality after cardiac surgery.
Patients and methods All patients undergoing cardiac surgery between January 2005 and October 2011 were included. Their data were prospectively collected and validated as part of the requirement for submission to the Central Cardiac Audit Database, National Institute for Cardiovascular Outcomes Research. Patients were categorized to either the pre-NP era (January 2005 to October 2007, n ¼ 2385) or post-NP era (October 2007 to October 2011, n ¼ 3910) according to their surgery date. There were no significant differences (p > 0.05) in preoperative patient characteristics such as age, logistic EuroSCORE, sex, smoking, and the presence of extracardiac vascular problems between the two eras. There were more patients from an Asian background (p < 0.01), more with noninsulindependent diabetes (p < 0.01), and more requiring urgent cardiac surgery (p < 0.01) in the post-NP era (Table 1). Data were analyzed using SPSS version 11.5 software (SPSS, Inc., Chicago, IL, USA). Data are given as mean standard deviation or percentages, as appropriate. Logistic regression analysis was used to determine independent factors related to survival.
Table 1. Patient characteristics and outcomes in the eras before and after the introduction of nurse practitioner grade. Variable
Pre-NP era
Post-NP era
p value
No. of patients Age (years) Male Asian NIDDM Smoker COPD Peripheral vascular disease Urgent surgery Isolated coronary artery bypass Body mass index (kg m2) Logistic EuroSCORE Cardiac ICU readmission Atrial fibrillation Hospital infection Hospital stay (days) Survival
2385 66 10 75% 8.6% 11% 9.6% 11.6% 18.2% 27.4% 67.5% 27.8 4.5 6.6% 9.1% 2.6% 32.1% 19.6% 10.4 12.8 96.5%
3910 66 10 76% 11.8% 14.3% 11.3% 13.1% 17.8% 30% 61.9% 28.3 4.8 5.9% 7.6% 1.9% 29.3% 16% 8.4 10.7 98.0%
0.8 0.8
