The influence of unit-based nurse practitioners on hospital outcomes and readmission rates for patients with trauma.

BACKGROUND: With the increased restrictions on resident work hours, hospitals increasingly are relying on advance practice nurses and physician assistants to help meet the patient care demand. We have created a workflow model wherein unit-based nurse practitioners (UBNPs) provide the minute-to-minute care for patients with trauma in one specific unit in our hospital, with supervision by the attending surgeons. Patients with trauma may also be admitted to other units, where the care model is a traditional resident-run (RR) service, again with supervision by the attending staff. Our aim was to determine if there were differences between the care provided by UBNPs and residents. METHODS: We queried our trauma database for all patients admitted to our urban, academic, Level I trauma center from January 1, 2007, to August 31, 2010. Patients discharged alive from the trauma service were identified and cross-referenced with an administrative database to collect demographics, injury characteristics, comorbidities, complications, and discharge information. Patients cared for by the UBNPs were compared with those cared for by the RR service. χ², Fisher's exact, and Student's t tests were used to determine significance. Significant factors were then tested with a multivariate linear regression analysis. p < 0.05 was considered significant. RESULTS: During the study period, 3,859 patients were discharged alive from the trauma service, 2,759 (71.5%) from the UBNPs service, and 1,100 (28.5%) from the RR service. Demographic data and mean Injury Severity Score (11.6 vs. 11.1, p = 0.24) were similar for the two groups, although mean abdominal Abbreviated Injury Score was higher for the UBNP group (0.6 vs. 0.5, p = 0.02). UBNP patients were more likely to be diagnosed with deep venous thrombosis (4% vs. 2.5%, p = 0.02) and were more likely to be discharged to home (67% vs. 60%, p = 0.002). Mean (SD) length of stay for UBNP patients was 6.5 (8.8) days compared with 7 (10.8) days for RR patients, although this difference did not reach statistical significance ( p = 0.17). The 30-day hospital readmission rates were similar for both groups (4.0% vs. 4.4%, p = 0.63). CONCLUSION: Care provided by UBNPs is equivalent to that provided by residents. With the restriction on resident work hours and greater reliance on nurse practitioners, patient care does not suffer. Moreover, a difference of 0.5 days in mean length of stay for the UBNP patients equates with more than 1,300 fewer patient care days. This difference, although not statistically significant, may be clinically relevant to physicians and administrators and may offset the cost of hiring UBNPs to help meet the patient care demand.

Complications following thoracic trauma managed with tube thoracostomy.

INTRODUCTION: Tube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma. METHODS: A retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007-12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann-Whitney test, and multivariate analysis. RESULTS: 154 patients were included with 22.1% (n=34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p=0.02 and p<0.001), increased chest AIS (p=0.01), and the presence of an extrathoracic injury (p=0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p=0.03) was a significantly independent predictor of CTCs. CONCLUSIONS: CTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.

Maintaining patient throughput on an evolving trauma/emergency surgery service.

BACKGROUND: The case-management team (CMT) has been an effective tool to decrease denied days and improve hospital throughput on a trauma service. With the addition of emergency general surgery (EGS) to our practice, we reviewed the ability of the case management team to absorb EGS patients on the inpatient trauma service while maintaining the improvements initially realized. METHODS: An interdisciplinary CMT was implemented in January 1999. CRNPs were added in August 2003 to address the Accreditation Council for Graduate Medical Education resident work-hour restrictions. "Key communications" for each CMT member are reported three times per week as defined by a hospital-approved policy. Beginning in August 2001, the trauma service was expanded to include EGS patients. Data from the trauma registry, hospital utilization review, and finance office were analyzed before (1998 and 1999) and after (2003 and 2004) the addition of EGS. Tests of proportion were used to evaluate questions of interest. RESULTS: The number of injured patients admitted to the trauma service remained relatively constant during the study periods, ranging from a high of 1,365 in 1999 to a low of 1,116 in 2003. Beginning in 2003, the influx of emergency surgery patients to the service was marked. By 2004, there were 561 emergency surgery admissions, representing more than 30% of the total service admissions. As a result, the total number of service admissions has dramatically increased, reaching 1,833 in CY 2004, a 56% increase from CY 1998 levels. Hospital length of stay data varied from a low of 5.5 days in CY 1999 to a high of 6.9 days in CY 2003. Length of stay appeared to be associated with injury severity (mean Injury Severity Score 11.8 in 1999 and 13.1 in 2003) and case mix, but not associated with denied days. The percent of denied days decreased over the study periods, from 4.6% in 1998 (before the implementation of the CMT) to 0.5% in 2004 (p<0.01). The percent of readmissions also fell significantly over the study periods (4.0% in 1998 to 1.8% in 2004; p<0.01). CONCLUSIONS: The initial improvements in patient throughput noted after the introduction of a CMT in January 1999 have been maintained in recent years despite the addition of an EGS component to the trauma service. Percent denied days and readmissions have continued to decrease. The length of stay for these patients remains, in part, dependent on other factors. The CMT plays an integral role in maintaining the efficiency of a trauma/emergency surgery service.

Unusual presentations of primary human immunodeficiency virus infection.

Opportunistic infections during primary infection with human immunodeficiency virus (HIV) are rare, with the exception of oral and esophageal candidiasis. HIV-associated nephropathy (HIVAN) and Pneumocystis carinii pneumonia (PCP) typically occur during advanced HIV infection. We report two patients who developed HIVAN and a presumptive diagnosis of PCP, respectively, during primary HIV infection. Serologic testing demonstrated HIV seroconversion. Clinicians need to have a high index of suspicion when evaluating patients even when risk behaviors are not readily apparent.