The impact of a structured onboarding program for newly hired nurse practitioners and physician assistants.

BACKGROUND: The return on investment for onboarding programs and their effect on attrition and engagement within health systems across the United States are unclear. LOCAL PROBLEM: The existing onboarding program for nurse practitioners (NPs) and physician assistants (PAs) at a hospital on the west coast was varied and lacked a clinician focus. A structured onboarding program was created to standardize their entry to our workforce. METHODS: A needs assessment was completed with a stakeholder focus group, for which an onboarding curriculum was then created. Participants completed presurveys/postsurveys during the data collection period as the primary outcome. A Plan-Do-Study-Act approach was used to revise session content and improve participant experience. Onboarding costs and attrition were tracked as secondary outcomes. INTERVENTIONS: From July 2017 through June 2019, newly hired NPs and PAs were invited to participate in the program. Six quarterly cohorts attended five in-person 2-hour onboarding sessions over 12 months. RESULTS: One hundred twenty-nine eligible NPs and PAs completed an anonymous pre/post Qualtrics survey. The aggregate responses were significantly improved using Fisher exact test. Measured onboarding value was not significantly changed. Mean pre-onboarding attrition was 10.3% compared with 4.5% for onboarding participants. The annual cost for onboarding participants was $63,470 versus $256,826 as the estimated mean cost of one separation within their first year. CONCLUSIONS: Workforce engagement, standardized knowledge, and participant attrition revealed an improving trend with this structured onboarding program. The investment to formalize onboarding newly hired NPs and PAs was modest, and the findings suggest that an onboarding program has financial and engagement merit.

State of the National Emergency Department Workforce: Who Provides Care Where?

STUDY OBJECTIVE: We describe the current US emergency medicine workforce in terms of clinician type and examine rural and urban emergency medicine workforce differences. METHODS: Using the 2014 Medicare Public Use Files, we performed a cross-sectional study of all clinicians receiving reimbursement for evaluation and management (E/M) services (levels 1 to 5) to Medicare fee-for-service Part B beneficiaries in the emergency department. Providers were defined as emergency physicians, nonemergency physicians, or advanced practice providers, corresponding with the Medicare Public Use Files data set. The primary outcome was the number of clinicians providing greater than 10 E/M claims tabulated as a distinct encounter. Urbanicity data were obtained from the National Bureau of Economic Research. RESULTS: Of 58,641 unique emergency medicine clinicians, 35,856 (61.1%) were classified as emergency physicians, 8,397 (14.3%) as nonemergency physicians, and 14,360 (24.5%) as advanced practice providers. Among nonemergency physicians categorized as emergency medicine clinicians, family practice and internal medicine predominated (41.7% and 19.9%, respectively). Among advanced practice providers, physician assistants (68.4%) and nurse practitioners (31.5%) predominated. A total of 58,565 emergency medicine clinicians were mapped to 2,291 US counties or equivalents. Urban counties had a higher proportion of emergency physicians (63.9%) compared with rural counties (44.8%); 27.1% of counties had no emergency medicine clinicians and 41.4% of counties had no emergency physicians reimbursed by Medicare fee-for-service Part B. CONCLUSION: This work establishes a new baseline estimate of the emergency care workforce, encompassing nearly 60,000 emergency medicine clinicians, of whom fewer than 2 in 3 were emergency physicians. Notable differences exist in the type of clinician staffing of emergency care between urban and rural communities.

When Is "Pseudo-Ludwig's Angina" Associated With Coagulopathy Also a "Pseudo" Hemorrhage?

Sublingual hematoma secondary to short-acting anticoagulants such as warfarin has been labeled "pseudo-Ludwig's angina" to distinguish it from the classic syndrome of localized infection and swelling involving the upper airway. Sublingual hematoma with airway compromise secondary to brodifacoum, a common long-acting anticoagulant rodenticide, has only been reported in the veterinary literature. We report a case of massive tongue swelling and impending airway compromise in the context of an intentional long-acting anticoagulant ingestion leading to coagulopathy. The swelling was initially presumed to be due either to infection or hemorrhage, but this was not supported by computed tomography scan imaging. Instead, the patient's clinical course was consistent with corticosteroid-responsive angioedema, temporally associated with the ingested brodifacoum.

Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service.

Changes in medical education and healthcare reimbursement are recent threats to most academic medical centers' dual mission of patient care and education. Financial pressures stem from reduced insurance reimbursement, capitation, and changes in public funding for medical residency education. Pressures for innovation result from increasing numbers of patients, higher acuity of patients, an aging population of patients with complex problems, and restrictions on residency workloads. A framework for addressing the need for innovation in the medical service at a large academic medical center is presented. The framework enables acute care nurse practitioners to provide inpatient medical management in collaboration with a hospitalist. The model's development, acceptance, successes, pitfalls, and evaluation are described. The literature describing the use of nurse practitioners in acute care settings is reviewed.