Impact of the 24/7 nurse practitioner model on emergency department stay at a level 1 trauma center: A retrospective study.

AIMS: The aim of the study was to assess the impact of 24/7 trauma nurse practitioner service model on the emergency department patient flow. BACKGROUND: Seamless transition of trauma patients through the emergency department to inpatient hospital care is crucial for coordination of care, clinical safety and positive health outcomes. A level 1 trauma centre located in Southern West Virginia, USA expanded their trauma nurse practitioner service covering the emergency department 24/7. DESIGN: Retrospective cohort study conducted in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines. METHODS: Patients admitted to the trauma centre between March 2019 and February 2020 were divided into two groups: trauma patients managed by trauma nurse practitioners versus the hospitalist service. The hospital service group was chosen as the comparator group because any admission prior to night coverage by the trauma nurse practitioners were managed by the hospitalist service. RESULTS: The emergency department length of stay was significantly lower in trauma nurse practitioners' patients by an average of 300 min (772.25 ± 831.91 vs. 471.44 ± 336.65, p = <.001). Similarly, time to place emergency department discharge order was shorter by 49 min (277.76 ± 159.69 vs. 228.27 ± 116.04, p = .001) for this group. Moreover, trauma nurse practitioners on an average placed one less consultation (1.06 ± 0.23 vs. 1.46 ± 0.74, p < .001). CONCLUSION: The patient care provided by trauma nurse practitioners aided in the reduction of strain felt by their emergency department. They were able to help facilitate patient flow thus lessening the pressure of boarding in an overcrowded emergency department. The study institution hopes to sustain the current service model and continue to review outcomes and processes managed by trauma nurse practitioners to ensure consistency and quality. RELEVANCE TO CLINICAL PRACTICE: Similar trauma centres should evaluate the structure of their trauma service that includes the role of trauma nurse practitioner service and work towards allowing them to manage patient care from the emergency department 24/7.

Trauma Bay Time Clocks: Influence on Emergency Department Length of Stay.

BACKGROUND: To monitor the time elapsed since patient arrival in the emergency department, Trauma Services at the study institution installed a large digital stopwatch timer placed at the head of each trauma bay on June 5, 2017. This quality improvement endeavor became an essential component of performance evaluation. OBJECTIVE: The purpose of the study is to measure the impact of trauma bay time clocks on emergency department length of stay. METHODS: This is a retrospective before-and-after study of trauma activation patients between June 2015 and May 2019. Two 24-month intervals were compared before and after installation of time clocks. RESULTS: In full activation patients, outcomes of emergency department length of stay ≤50 min (39.2% vs. 61.7%, p < .001) and time to transfer to intensive care unit ≤56 min (45.3% vs. 55.1%, p = .002) were significantly favorable in the postimplementation phase. Time to first computed tomography scan and time to first operating room from arrival to the emergency department were comparable between both phases. For limited activation patients, positive changes were noted in emergency department length of stay ≤87 min (41.4% vs. 60.6%, p < .001), time to first computed tomography scan ≤32 min (47.7% vs. 53.0%, p = .015), and time to transfer to intensive care unit ≤74 min (50.2% vs. 57.2%, p = .008). Time to first operating room remained comparable between two periods. CONCLUSIONS: The study institution improved their provision of immediate care by using time clocks in trauma bays. This is a simple and cost-effective intervention and may benefit similar institutions.

Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model.

The American College of Surgeons (ACS) mandates all trauma centers conduct individual case reviews of nonsurgical admissions when rates of allocation to this service exceed 10% of all inpatient traumas. Nonsurgical admission rates at the study institution, which is a Level I trauma center, historically exceeded this ACS criterion. In an effort to decrease nonsurgical admissions, the study institution recruited trauma nurse practitioners (TNPs) who began managing low acuity patients with oversight from trauma attending physicians. This study examines the impact of TNPs on the rate of nonsurgical admissions. A retrospective cohort study was conducted with 1,400 patients between January 2017 and October 2018. Two cohorts examined in this study included trauma patients whose care was managed by the TNPs versus those admitted under the care of hospitalists. The rate of admission to nonsurgical services (NSS) was 19.6% in 2017 and 13.9% in 2018, which yielded a significant decrease from previous years' percentages (p < .001). The average hospital length of stay was 1.17 days shorter in the TNP group, which translated into a savings of approximately $876,330 in hospital charges for the study period. Additional significant findings noted in favor of the TNP cohort were for discharge orders placed prior to noon, discharge location, and reduced time to the operating room. This TNP model proved to be successful in significantly reducing admissions to NSS and substantiated the quality of patient care provided by TNPs. Hospitals struggling to meet the ACS criterion for NSS admissions may consider implementing a similar TNP model.

Nurse Practitioners' Role in Improving Service for Elderly Trauma Patients.

Preexisting conditions and decreased physiological reserve in the elderly frequently complicate the provision of health care in this population. A Level 1 trauma center expanded its nurse practitioner (NP) model to facilitate admission of low-acuity patients, including the elderly, to trauma services. This model enabled NPs to initiate admissions and coordinate day-to-day care for low-acuity patients under the supervision of a trauma attending. The complexity of elderly trauma care and the need to evaluate the efficacy of management provided by NPs led to the development of the current study. Accordingly, this study endeavored to compare outcomes in elderly patients whose care was coordinated by trauma NP (TNP) versus nontrauma NP (NTNP) services. Patients under the care of TNPs had a 1.22-day shorter duration of hospitalization compared with that of the NTNP cohort (4.38 ± 3.54 vs. 5.60 ± 3.98, p = .048). Decreased length of stay in the TNP cohort resulted in an average decrease in hospital charges of $13,000 per admission ($38,053 ± $29,640.76 vs. $51,317.79 ± $34,756.83, p = .016). A significantly higher percentage of patients admitted to the TNP service were discharged home (67.1% vs. 36.0%, p = .002), and a significantly lower percentage of patients were discharged to skilled nursing facilities (25.7% vs. 51.9%, p = .040). These clinical and economic outcomes have proven beneficial in substantiating the care provided by TNPs at the study institution. Future research will focus on examining the association of positive outcomes with specific care elements routinely performed by the TNPs in the current practice model.

An Outcome Analysis of Nurse Practitioners in Acute Care Trauma Services.

The department of trauma at a Level 1 trauma center sought to improve outcomes by enhancing the continuity of care for patients admitted to trauma services. Departmental leadership explored opportunities to improve this aspect of patient care through expansion of existing trauma nurse practitioner (NP) services. The restructured trauma NP service model was implemented in September 2013. A retrospective study was conducted with patients who presented at the trauma center between September 2012 and August 2015. Patients with at least a 24-hr hospital length of stay (LOS) were separated into 3 comparator groups by 12-month increments: 12 months pre-, 12 months during, and 12 months postimplementation. Data revealed improvement in hospital LOS, intensive care unit LOS, time to place rehabilitation consultation, and placement of discharge orders before noon. A significant decline in the rate of complications including pneumonia and deep vein thrombosis (DVT) was also noted. Accordingly, expansion of the trauma NP model resulted in significant improvements in patient and process of care outcomes. This model for NP services may prove to be beneficial for acute care settings at other hospitals with high volume trauma services.