Nurse practitioners improve discharges, reduce readmissions, and save hospitals money
Case study from Loyola University Medical Center
A recent study from Loyola University Medical Center illustrates how adding a nurse practitioner (NP) to a medical or surgical department can improve patient discharges, reduce unnecessary readmissions through the ED, and save hospitals money.
According to the study, although the Accreditation Council for Graduate Medical Education's resident duty hour restrictions have reduced resident fatigue, they have negatively affected continuity of patient care. When residents are required to go home after working their prescribed 80 hours, someone has to follow pa-tients to ensure they are discharged properly, and that is where NPs come in.
By ensuring that patients and family members have all of the information and instructions they need to care for themselves at home, NPs can prevent those patients from presenting in the ED days later with simple com-plications. Reducing the number of ED visits and readmissions saves hospitals money, and who can argue with that, especially when Medicare plans to stop reimbursing hospitals for readmissions within 30 days starting in 2012?
Study results at a glance
The Loyola University Medical Center study focused on a surgical oncology department in Maywood, IL, that consisted of three surgical attendings. The attendings hired an NP to coordinate discharge plans and communicate with patients after discharge. The study retrospectively reviewed 826 patient charts that were separated into two groups: before and after the NP was hired. The chart review focused on discharges and whether the patients returned to the ED unnecessarily (an unnecessary ED visit was defined as one that did not result in an inpatient admission).
Having an NP coordinate the discharge process led to significant improvements in three major areas. The first area was telephone communications between nurses and discharged patients. Prior to bringing an NP on board, nurses telephoned discharged patients 846 times; after the NP started working on the unit, phone calls increased to 1,319, a 64% improvement.
The second area was the department's use of visiting nurses and physical/occupational therapy services. Prior to the NP joining the department, these services were only rendered to 25% of patients. After the NP joined, 39% of patients received the services.
The third area was unnecessary visits to the ED. Prior to the NP joining the staff, 103 of 415 ED visits were unnecessary; after the NP joined, only 54 of 411 ED visits were unnecessary, a 50% decrease. (For a detailed breakdown of all three areas, see "Calls, ED visits, and hospital readmissions before and after hiring an NP" on p. 4.)
Considering that the average charge for postoperative patients seen in the ED is $800 (without tests), reducing unnecessary visits by 50% saved the hospital considerable money-about $800,000, says Mary Kay Larson, NP, the NP in the surgical oncology unit examined in the study.
Hospitals that are interested in leveraging NPs and physician assistants (PA) to facilitate a more thorough discharge process may ask themselves the following questions.
How do NPs prevent readmissions?
Preventing patients from unnecessarily returning to the ED is a three-step process. The first step is ensuring patients have the resources they need to successfully transition to the home setting. This requires the NP to arrange for at-home care via social workers.
"I talked to the social worker daily to give her my recommendations, such as ‘Joe Brown needs two tube feedings per day, a wound vac, and home physical therapy.' The social worker would then make the phone calls and process the paperwork to set that up," Larson explains.
The social worker plays an important role in discharge planning, but that role must be kept separate from the NP's role, says Tracy Sanson, MD, FACEP, associate professor of emergency medicine at the University of South Florida in Miami. "If a patient can't get to a follow-up appointment because he or she can't drive, it is not the best use of the NP's time to be looking at bus passes or finding them a ride. I think what you really need is a transition team," says Sanson. The NP can identify the medical needs and establish a relationship with the patient, while the social worker can make arrangements for the patient's home care.
"The residents don't get involved with that kind of stuff. That is why before an NP got involved, patients didn't get a physical therapy evaluation and social work wasn't called. Residents are more focused on the surgical case and the recovery time; they don't really look at the psychosocial stuff, which they should," says Larson.
The second step is educating patients and family members to care for themselves at home. Although physicians can educate patients, doing so is not an optimal way to spend their time, says Sanson.
"Physicians need to be involved in discussing the discharge process with the patients and answering questions, but I don't think it is the best use of their time or their level of postgraduate education to be the one discussing dressing changes and how to use the restroom when you have just had wrist surgery," Sanson explains.
Educating patients on how to flush a gastric tube or change a wound dressing can take hours of teaching that is sometimes spread over several days, notes Larson. NPs are better equipped than physicians and have more time to explain self-care to patients who may lack basic medical or anatomical vocabulary (or, conversely, well-educated patients with access to the Internet who try to prescribe their own discharge plans).
The third step to reducing unnecessary readmissions through the ED is communicating with patients after discharge and treating patients with postoperative complications, when appropriate, in an outpatient clinic associated with the hospital.
Communicating with patients post-discharge is likely what led to the significant decrease in ED visits, according to the study. Larson routinely called patients to check on their progress and helped troubleshoot the problems that patients encountered. She also was able to call in prescriptions or recommend over-the-counter medications for common postoperative symptoms without involving a physician. If a patient experienced non-emergent yet concerning symptoms, Larson could order lab tests and have the patient see a surgeon in the outpatient clinic.
With her knowledge of oncology and colorectal surgery, Larson can easily eyeball a patient in the outpatient clinic and determine that he or she is dehydrated and needs a bag of fluid. The patient would wait hours to be seen in the ED, where the staff, being unfamiliar with the patient and his or her recent surgery, would perform a full workup; it might be another few hours before the patient finally receives fluids. In the outpatient clinic, where Larson is familiar with the patients and the type of surgery, she can administer fluids within half an hour.
In addition to generating cost savings for the hospital, reducing the number of unnecessary ED visits makes the ED more accessible for patients with true emergencies.
How does an outpatient clinic save money over the ED?
NPs bill at about 80% of what physicians bill, so the care an NP provides in an outpatient clinic is significantly less expensive than the care a physician provides in the ED. Thus, when the issue is as simple as dehydration or constipation, why rack up a high bill in the ED when the issue can be cleared up in less time and with fewer resources in an outpatient clinic?
Larson explains that having an outpatient clinic where postoperative patients can go for common, non-emergent complications can also help prevent patients from incurring costs at other hospitals' EDs. "Sometimes patients come to university centers like ours from different parts of the Chicago area, so they might end up at a community hospital's ED. The physicians there are unlikely to know what to do with these patients, so they admit them and do a workup, and that incurs further costs," she says.
Can another type of provider render the same benefits?
Although the Loyola study focused on the use of an NP, hospitals can choose to instead incorporate a PA. The NP or PA must be able to prescribe medications and perform simple procedures in the outpatient clinic. Nurses, although they can often provide patients with the necessary education, may not have enough education, experience, or training to handle the complex postoperative issues that an NP can tackle. "A nurse can't open a wound and prescribe an antibiotic if needed," says Larson. "Nurse practitioners are better able to handle the problems than a floor nurse or case manager who is not real familiar with the patients."
Although NPs are the best choice for surgical units, an NP might not be necessary in the ED. The University of South Florida is leveraging licensed practical nurses (LPN) as discharge planners in the ED, says Sanson. "This person is an administrative/clinical person, usually an LPN, whose job is to do the discharge planning with the patient as they are leaving the ED."
How many NPs do we need?
It depends on whether the department handles complex patients. For example, the surgical oncology unit at Loyola deals with much more complicated patients than Loyola's general surgery unit and may require more NPs.
In general, Larson suggests one NP per every three to four physicians. If departments spread an NP's responsibilities too thin by assigning him or her to too many physicians, the NP won't be able to coordinate discharge planning as well and, therefore, won't be able to save the hospital as much money.
Would the cost of hiring an NP negate the cost savings?
According to Larson, by adding the NP position to the oncology surgery department, Loyola saved $800,000 in readmissions, CT scans, and ED visits.
"It is a very smart thing for hospitals to do. In the study, one ED visit is about $800, so if you figure you've stopped one or two ED visits a week, you have paid for your NP. The economics make sense," says Sanson.
Sanson says that hospitals will be seeking more roles for NPs and PAs because of the economic benefit. "Physicians are at a higher level of training and therefore a higher level of reimbursement, so we are going to be looking at ways to get patients information at a level of care that is appropriate."
Larson adds that hospitals get more bang for their buck with NPs than they do for physicians. "We do so many other things that physicians don't do. A physician may know how to hang a bag for hydration, but they aren't going to do it. Nurse practitioners can order lab tests and prescribe antibiotics, and it is a lot cheaper than hiring another physician."