Background:
Increasing work‐hour restrictions, older and sicker patients, and fragmented care may result in poorer quality care by inpatient medicine house staff. Recognizing this, the Accreditation Council for Graduate Medical Education proposes reducing noneducational work and working in multidisciplinary teams. Nurse‐practitioners (NPs) provide high‐quality care in primary care and subspecialties. Their effect on care by inpatient medicine house staff is largely unknown. This study compared the quality of care delivered by inpatient medicine house staff “teaching” teams that include NPs to similar teams without NPs.
Methods:
Inpatient medicine care at our academic, metropolitan Veterans Administration hospital is provided by 4 medicine teams (A, B, C, and D). Each team has an attending, house staff, and students. Patients are assigned per a call schedule. One NP per team was added to teams B and D to provide direct clinical care and care coordination. We compared teams with NPs (B and D; team 1) to teams without NPs (A and C; team 2). Subjects were a prospective cohort of consecutively discharged patients. Outcomes included length of stay, discharge delays, 90‐day mortality, telemetry use, and house staff satisfaction. Covariates included age, sex, discharge diagnosis, and Charlson Comorbidity Index. Analyses include f test, chi‐square, Wilcoxon, and regressions. Our Institutional Review Board approved the study.
Results:
One hundred and thirty‐three subjects on team 1 were compared to 109 subjects on team 2. For all subjects, mean age was 68.9 years, 96% were male, and mean Charlson Index was 4.0. There were no statistically significant differences between teams for covariates. In unadjusted bivariate analyses, there were no significant differences between team 1 and team 2 for mean length of stay (4.8 vs. 5.6 days, P = 0.24), discharge delays (32.6 vs. 28.2%, P = 0.61), and 90‐day mortality (15.0 vs. 12.8%, P = 0.71). In adjusted regressions there was no significant difference for length of stay (P = 0.23) or discharge delays (OR = 0.74, 95% Cl = 0.37–1.48). NP review resulted in a mean reduction of 19.9 days of telemetry use per month for all teams. Among 97 house staff surveys, more house staff on team 1 reported that important system components of patient care could be provided without difficulty (90.2 vs. 71.2%, P = 0.04). Although more house staff on team 1 reported that they were readily able to find information (70.7 vs. 59.6%), provide high‐quality care (80.5 vs. 75.0%), the VA provided a good learning atmosphere (92.7 vs. 82.7%), and patient care interfered less with teaching conferences (63.4 vs. 48.1%), these differences were not statistically significant. On team 1 43.8% of house staff reported that the NP was the most helpful factor in efficiently caring for patients.
Conclusions:
Compared to teams without NPs, inpatient medicine house staff teams with an NP may provide greater house staff satisfaction, decrease telemetry use, and help house staff efficiently care for their patients.
Author Disclosure:
A. Kartha, none; C. Shah, none.