Development of APN Hospitalist Role

The traditional role of the nurse practitioner has been primary care, with emphasis on health promotion, illness prevention, and management of common ambulatory health problems. By the 1990s, the evolution of the role of the acute care nurse practitioner (ACNP) highlighted the diagnostic and management skills of nurse practitioners and the specialized knowledge necessary to care for patients with acute illnesses. More than 70 graduate programs are training ACNPs today (1).

Many hospitals have been hiring or adapting this specialty role of the nurse practitioner to serve as hospitalists. In this model, the nurse practitioner usually admits the patient, performs some emergency procedures and either monitors or helps the hospitalist monitor the patient (2). Other hospitals, after seeing the benefits of utilizing ACNPs in the role hire nurse practitioners without specialized education to fulfill this role and have come to adapt the role to hospital policies. (3).

Studies have been conducted of nurse who serve as hospitalists are on teams with hospitalists. Conducted in various settings and on various units, all have found benefits in the use of nurse practitioners as hospitalists (4). "Systems such as the VA have historically made more use of nurse practitioners," says Lucy N. Marion, PhD, RN, professor and associate dean of academic nursing at the University of Illinois at Chicago School of Nursing.

At the University of Virginia Health System, for example, "a nurse practitioner model introduced in the neurosciences area in 1999 cut about 2,000 inpatient days on a similar volume and case mix of patients, resulting in a $2.4 million savings the first year," says Dale Shaw, RN. "This on an investment of about $150,000 in salaries and benefits--a return on investment of about 1,600 percent."

At the University Hospitals Health System, Cleveland, "nurse practitioners not only serve as dedicated care managers in high-intensity service areas, including heart failure, they also admit and supervise general medical patients," says Robin J. Rowell-Leinweber, RN, manager of the nurse practitioner service.

The University of California, San Francisco, Medical Center, an academic facility used changes in healthcare delivery to incorporate creative models of care in the medical service. One such model included the use of hospitalists and ACNPs primarily to expand the medical service's capacity, but also to improve the efficiency and quality of patients' care.

A growing number of hospitals are suing MD hospitalists, physicians who are specialized in hospital care, to manage patients while they are at the hospital. However, attending physicians in academic medical centers usually cannot spend enough time on inpatient activities to meet the definition of a hospitalist. In many places, it is not feasible to have full-time MD hospitalists at the bedside; and non-hospitalist attending physicians in academic medical centers do not spend as much time as hospitalists in inpatient care setting. Thus, studies of hospitalists tend to reflect use of multidisciplinary teams. A 2002 study supported by the Agency for Healthcare Research and Quality (HS10734) indicated that teams comprised of multidisciplinary physicians and nurse practitioners (NPs), working together on daily rounds and post-discharge patient follow up, can reduce the costs of inpatient care (5). This study, combined with the body of studies of nurse practitioners used in this role, specifically supports the quality of care and economies of scale offered with the inclusion of nurse practitioners and clinical nurse specialists on hospitalists teams (6).

NPs followed protocols to minimize overuse of unneeded services, such as limiting the use of cardiac monitoring and narrowing use of broad-spectrum antibiotics when indicated. Intervention costs were $1,187 per patient and were associated with a significant $3,331 reduction in usual care costs. About $1,947 of the savings were realized during the initial hospital stay, with the remainder attributable to reductions in post-discharge service use. A reasonable estimate of the cost offset was $2,165, minus an estimated $1,187 per-patient cost for the intervention, for a net cost savings of $978 per patient. Patient perceptions of care and health-related quality of life were at least as good for intervention as usual care patients (7-9).

When nurse practitioners or clinical nurse specialists are tasked with this role or the role of interventionist (10), the collective bargaining unit should immediately review the collective bargaining agreement to ascertain whether it addresses the following concerns:

Note: Many have questioned whether this hospitalists role is being used in the collective bargaining setting. As I wrote this e-blast, I conducted a survey of the internet listings for nurse practitioner hospitalists and found advertising for such services at the following collective bargaining and non-collective bargaining institutions: Exeter Health Resources, Exeter, Massachusetts, OhioHealth, Columbus, Ohio; Baptist Health, Jacksonville, Florida, Team Health, Tifton, Georgia, The Hospitalists Company, Quincy, Massachusetts, Fairview Health Services, Minnesota; Hospitalists Management Group, New York, New York; Aspirus Clinic, Wasau, Wisconsin; Spartanburg Regional Healthcare System, Spartanburg, S.C. Additionally, I also found advertisements for RN hospitalists and RNs to work in Critical Care Centers with hospitalists.