Management of Patients in the Intensive Care Unit
Management of Patients in the Intensive Care Unit
Background: Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients' outcomes.
Objective: To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients' care in a step-down medical intensive care unit.
Methods: Work sampling techniques were used to collect data when the nurse practitioner had 6 months' or less experience in the role (T1), after the nurse practitioner had 12 months' experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities.
Results: Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001).
Conclusion: The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients' families and collaborating with health team members.
Outcomes have been compared between care managed by an acute care nurse practitioner (ACNP) and care managed by a physician in only a limited number of studies. In most of these studies, patients' outcomes or financial outcomes were compared, for example, morbidity, length of stay, costs, or satisfaction after introduction of one or more ACNPs or a team made up of ACNPs and physician assistants (PAs) to a practice setting. Most studies reported beneficial outcomes. For example, Dahle et al reported lower total hospital costs (P <.03) during the year a nurse practitioner participated in care delivered to patients with heart failure, with primary savings in ancillary, laboratory, respiratory therapy, and electrocardiographic costs. Spisso et al reported a decrease in length of stay and improved discharge documentation when nurse practitioners joined a trauma service. Russell et al compared outcomes for neuroscience patients managed by 2 ACNPs and a retrospective sample of patients admitted to the same unit who were managed by residents. ACNP-managed patients had a shorter stay in the ICU (P < .001), a shorter stay in the hospital (P = .03), a lower rate of urinary tract infection and skin breakdown (P <.05), and a shorter time to discontinuation of the Foley catheter and mobilization (P < .05). Rudy et al compared the activities performed by an ACNP-PA team with activities of residents managing medical patients in an acute care setting. Compared with residents, the ACNP-PA team was more likely (P < .05) to discuss patients' problems with the nursing staff and to interact with patients' family members. Residents managed more patients, participated more actively in patient rounds, and spent more time in lectures and conferences (P <.05).
Although these studies suggest that the ACNP role is associated with good outcomes, they provide limited information about aspects of ACNP practice that might explain why patients' outcomes differ. For example, it is not clear whether these differences are due to more timely monitoring and adjustment of interventions, greater continuity of care, differences in patients' acuity or patient caseload, or other factors.
The introduction of an ACNP into the step-down medical intensive care unit (SD-MICU) at the University of Pittsburgh Medical Center, a tertiary care center, provided the opportunity to prospectively obtain data about the time management of an ACNP and physicians in training in an ICU. Thereby, we hoped to provide further insight into an aspect of practice that might explain differences in patients' outcomes. The purpose of this pilot study was to use work sampling to estimate the proportion of time spent in various work activities by an ACNP and by physicians in training when managing the care of patients admitted to an SD-MICU. The following research questions were addressed:
Background: Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients' outcomes.
Objective: To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients' care in a step-down medical intensive care unit.
Methods: Work sampling techniques were used to collect data when the nurse practitioner had 6 months' or less experience in the role (T1), after the nurse practitioner had 12 months' experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities.
Results: Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001).
Conclusion: The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients' families and collaborating with health team members.
Outcomes have been compared between care managed by an acute care nurse practitioner (ACNP) and care managed by a physician in only a limited number of studies. In most of these studies, patients' outcomes or financial outcomes were compared, for example, morbidity, length of stay, costs, or satisfaction after introduction of one or more ACNPs or a team made up of ACNPs and physician assistants (PAs) to a practice setting. Most studies reported beneficial outcomes. For example, Dahle et al reported lower total hospital costs (P <.03) during the year a nurse practitioner participated in care delivered to patients with heart failure, with primary savings in ancillary, laboratory, respiratory therapy, and electrocardiographic costs. Spisso et al reported a decrease in length of stay and improved discharge documentation when nurse practitioners joined a trauma service. Russell et al compared outcomes for neuroscience patients managed by 2 ACNPs and a retrospective sample of patients admitted to the same unit who were managed by residents. ACNP-managed patients had a shorter stay in the ICU (P < .001), a shorter stay in the hospital (P = .03), a lower rate of urinary tract infection and skin breakdown (P <.05), and a shorter time to discontinuation of the Foley catheter and mobilization (P < .05). Rudy et al compared the activities performed by an ACNP-PA team with activities of residents managing medical patients in an acute care setting. Compared with residents, the ACNP-PA team was more likely (P < .05) to discuss patients' problems with the nursing staff and to interact with patients' family members. Residents managed more patients, participated more actively in patient rounds, and spent more time in lectures and conferences (P <.05).
Although these studies suggest that the ACNP role is associated with good outcomes, they provide limited information about aspects of ACNP practice that might explain why patients' outcomes differ. For example, it is not clear whether these differences are due to more timely monitoring and adjustment of interventions, greater continuity of care, differences in patients' acuity or patient caseload, or other factors.
The introduction of an ACNP into the step-down medical intensive care unit (SD-MICU) at the University of Pittsburgh Medical Center, a tertiary care center, provided the opportunity to prospectively obtain data about the time management of an ACNP and physicians in training in an ICU. Thereby, we hoped to provide further insight into an aspect of practice that might explain differences in patients' outcomes. The purpose of this pilot study was to use work sampling to estimate the proportion of time spent in various work activities by an ACNP and by physicians in training when managing the care of patients admitted to an SD-MICU. The following research questions were addressed:
|