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Archive for the ‘the ACNP’ Category

Today we are talking to one of my colleagues – Ms. Trisha Hutton.

Ms. Trisha Hutton, CRNFA

Ms. Trisha Hutton, CRNFA, ACNP (student)

Trisha is a certified registered nurse first assistant (CRNFA) .   She performs procedures in the operating room such as endovascular saphenous vein harvesting (EVH) for bypass surgery, and assists in other aspects of surgery, such as suturing, retraction and tissue dissection.

  Years in the operating room:   16

  Years working in cardiac surgery:  8

We’re talking to Ms. Hutton today about her current career and her developing role as an acute care nurse practitioner in cardiothoracic surgery.   Ms. Hutton is currently pursuing her master’s degree for certification in acute care, and will be part of a small but growing sub-specialty of acute care nurse practitioners in surgical practices.

As we’ve discussed during past posts; in the midst of a primary care crisis, advanced practice nurses such as nurse practitioners have moved to the forefront of the health care arena.  While NPs have worked (successfully) in this role since the creation of the specialty in the late 1960’s – the efforts of NPs in this (and other) roles are just now being recognized.

However, for nurses like Trisha Hutton, the increasing recognition (by surgeons) of the utility of nurse practitioners IN and OUT of the operating room is equally important.  So it’s important that nurses like Ms. Hutton receive the exposure to the public that may not always be aware of their role behind the scenes in caring for patients undergoing surgery.

What prompted you to return to school to become a nurse practitioner?

 “I felt like something was missing.  It was like chapters were missing from a book,” Ms. Hutton states, explaining that while she loves her current role, assisting and caring for patients in surgery – she wants to expand her role to encompass the care of patients outside of the operating room; from admission to discharge.

Ms. Hutton (pictured on the right) in the operating room

What drew you to cardiothoracic surgery, specifically?

I have always been interested in vascular surgery, and had been trained by and a vascular surgeon (Dr. Mark Donnelly) who I have worked closely with for many years.  When Flagstaff Medical Center started talking about beginning a heart program, I was immediately interested, and Donnelly encouraged me to be involved in it.  Also, because of our elevation (7000 ft), there was controversy about the success of our program, and that challenge excited me.

How do you see your role evolving after graduation?

To have the ability to continue my care to patients outside of the operating room.  I am looking forward to the opportunity to meet patients pre-operatively, participate in their diagnosis, operate on them, then continue their care through discharge.

Where do you see yourself in five years?

I hope to continue practicing within the CT and vascular specialty, and be comfortable within my expanded role.

Who are your role models?

I began as nurse in the operating room 16 years ago, and was instantly attracted to the vascular specialty.  I developed a relationship with a surgeon named Mark Donnelly, a very respected and talented General/Vascular surgeon.  When I decided to become a RNFA, he supported me, acted as my preceptor, and taught me how to operate.  As mentioned earlier, when word of a heart program started, he encouraged me to join the heart team.  That was a bitter-sweet decision for me….learning CT surgery has been a fantastic choice for me and has opened many doors, but it meant leaving a surgeon that I truly enjoyed operating and spending my day with.  He has been such an important role model for me and “life” coach (advice ranging from career to parenting!!), and I still miss working with him. More recently, our current heart surgeon Dr. Steve Peterson has been an important role model to me.  I joined cardiac surgery with good assisting skills, but he has pushed and challenged me even more.  He continues to test me daily, teaching me the finesse of cardiac surgery.  Without him I would not be  successful within this specialty, and I would never have considered continuing my education.  He has given me endless opportunities, pushed me to grow, and I am very grateful for him.

How do you see the nurse practitioner role in comparison to other peri-operative roles?  Do you think NPs provide any unique perspectives or contributions to surgical care?

NP’s absolutely offer unique contributions to surgical care!  Especially if they have had perioperative experience prior to becoming an advanced practice nurse.  I believe continuity of care is an important factor in delivering high quality care to our patients, and if the NP can follow her patient into the operating room, that continuity of care can be achieved.  They see and experience first hand what occurs during surgery, which can aid in their post op management.

For instance, if closing an aorta post AVR and the aortic tissue is particularly fragile, the NP will know that post op blood pressure management will be even  more critical. If a different practitioner had been operating, that concern may not be communicated adequately.  The surgeon who practices with a NP First Assistant can feel at ease knowing that both HIS needs and the patients’ needs will be met.  The NP who is familiar with the patient will know just what the surgeon will want in the operating room, will have appropriate equipment, supplies, support staff etc available, therefore making the patients’ surgical experience smooth and uneventful. A first assistant that does not have that relationship with the surgeon or patient (ie family practice MD or TechFA) cannot offer that unique service.

Nurse Practitioners in the operating room?  Current issues and controversies

While this seems like a natural and normal progression for many nurses and nurse practitioners within the field – it isn’t as obvious to people outside the profession.  Many people including human resources personnel, staffing companies and the surgeons themselves have pre-conceived notions that exclude nurse practitioners, even those with extensive operating room (peri-operative) experience from assisting in the operating room.  That role is often exclusively assigned to Physician Assistants, often to the detriment of our profession, our nursing colleagues and the patients.

In fact, in this recent statement and study on the role of surgical assistants (2011) only mentions nurses as assistants as a side note.  It fails to recognize the different levels of qualifications (ie. a certified registered nurse first assistant (RNFA) versus a surgical technician (with weeks to months of formalized training).

Now, with the adverse economy, and changes in medicare regulations, nurse practitioners face even more competition for the operating room; the disenfranchised primary care physician.  In several of the facilities where I have worked in the past; more and more of these physicians were taking an active role in assisting in surgery.  These doctors, often primary care doctors ‘moonlight’ in the operating room as a way to augment their salaries.  Conversely, while these physicians had the least amount of surgical training, they were afforded the most reimbursement for their intra-operative role.    This array of peri-operative assistants has led to a wide range of skill sets in this patient care role with little research or comparison of effectiveness of these positions.

Ideally, the best ‘surgical assistants*’ would be patient care roles that encompassed the entire patient surgical experience from pre-operative evaluation to patient discharge, which is the spectrum of both nurse practitioners and physician assistants.  But only nurse practitioners can bring a holistic, patient-centered approach to this

* The ‘surgical assistant’ title like surgical technician/ technologist has also been designated to another career entirely, with similar focus.  However, in this post, we are using the term generically to refer to any individual (NP, RNFA, PA , MD or technician) who acts as an assistant to the surgeon intra-operatively, and performs procedures under the supervision of the attending surgeon.

References/  Literature surrounding nurse practitioners in the Operating Room

Hodson D. M. (1998).  The evolving role of advanced practice nurses in surgery.  AORN J. 1998 May;67(5):998-1009. Erratum in: AORN J 1998 Jun;67(6):1102

Pear, S. M., & Williamson, T. H. (2009).  The RN first assistant: An expert resource for surgical site infection prevention.  AORN, 89(6); 1093 – 1097.  No free full text available.
Schroeder JL. (2008).  Acute care nurse practitioner: an advanced practice role for RN first assistants.  AORN J. 2008 Jun;87(6):1205-15.
Wadas T. M. (2008).  Expanding the scope of acute care nurse practitioners with a registered nurse first assist specialty.  AACN Adv Crit Care. 2008 Jul-Sep;19(3):261-3.

Wadlund D. L.  (2001).  Graduate education: the perioperative nurse practitioner.  Semin Perioper Nurs. 2001 Apr;10(2):77-9

Zarnitz P, Malone E.  (2006).    Surgical nurse practitioners as registered nurse first assists: the role, historical perspectives, and educational training.  Mil Med. 2006 Sep;171(9):875-8.   No free full text available.
More about the Registered Nurse First Assistant (RNFA) role from the Association of peri-Operative Nurses (AORN).
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This is Joanna – she is one of the Medical Officers at Mexicali General Hospital.   She’s smart, pretty, funny and she’s been very welcoming to me while I study at her hospital.

with JoAnna

So, yesterday we were talking – and I start thinking (and advocating) about my profession.

Things run pretty well at Mexicali General – but I starting thinking about how smooth, and nice it would be if they had nurse practitioners here – in the Intensive Care Unit (for example)*.  That’s kind of how I think of nurse practitioners and what we do – we smooth out all the rough edges between doctors and nurses and other disciplines through collaboration.. We also enhance relationships with patients and make them part of our care – we facilitate the practice of medicine by making it a more holistic and integrated phenomenon.  That’s the great beauty of our profession – while we are no longer strictly bedside nurses, we never really lose our love for providing patient care, and that connection to our patients – we just do it in a different way.

So, I thought that for today’s post – I would present some more information about nurse practitioners and how we function in Intensive Care Units and hospital-based practices. (Of course that just the tip of the iceberg as far as how/ where NPs function – but it’s a good start.)

I also think it would be nice for people in Mexico to also have a better understanding of what an acute care nurse practitioner  (ACNP) is, our scope of practice and what we do (and do extremely well) such as very specific tasks like intensive glucose management in hospitalized patients, to a more wide variety of responsibilities – such as seeing consults, daily rounding, diagnosis and treatment of serious disease, advanced procedural skills, and patient and staff education.

But there are also other benefits – less infections, shorter length of stay, reduced costs and greater patient and family satisfaction with care.  (We’ve talked about this before in a previous post**, so some of it may be familiar to readers.)  Here’s one of my favorite articles by Russell, Vorderbruegge & Burns (2002), which set the groundwork for ACNPs like myself, in surgical practices.  There was a lot of literature before this article which demonstrated similar findings – but this is one of the ones that made doctors and hospitals sit up and take notice.

Of course, one of my favorite articles is a little article by Potera (2008) that caused quite a stir when showed that nurse practitioners were better at placing chest tubes that emergency room staff (residents and attendings.)

Notes:

* No, not for me, dear readers (I love surgery – and with a doctorate program on the horizon, I already have my hands full) – but for someone like me; who loves their job with a passion, and loves their patients. In fact – I already have a candidate in mind; I don’t remember her name, but she’s a nurse in the ICU here.  I’ve been watching her interact with the doctors, other nurses and the patients – and I think, that with the right education, she’s be absolutely fantastic.

** this post contains several links to articles about nurse practitioners in surgery – (more specific to what I actually do.)

Resources and References on Acute Care Nurse Practitioners

The Scope of Practice – what we do, and what we are trained to do.

What is a Nurse Practitioner (NP)?  Discussing the role as a part of NP week.

NPs: Improving Care of Patients – Medscape series of articles discussing how NPs improve patient care.

More on the role of the ACNP in surgical specialties  – also linked in text above.

Dial, D (2009) Nurse practitioners in the emergency department.  University of Arizona.

Hoffman et al. (2005). Outcomes of Care Managed by an Acute Care Nurse Practitioner/Attending Physician Team in a Subacute Medical Intensive Care Unit. American Journal of Crit Care, 2005; 14: 121-132.  This article compared the rate of re-intubation among patients cared for by nurse practitioners and residents.

Nyberg, et. al. (2010).  Acceptance of physician assistants and nurse practitioners in trauma centers.  Yeah, we’re great – but do the ‘others’ accept us?

Yeager, et. al. (2006). An Acute Care Nurse Practitioner Model of Care for Neurosurgical Patients. Critical Care Nurse, 2006; 26: 57-64.  The role of the ACNP in neurosurgery.

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In honor of the profession that has brought me so much career and personal satisfaction – I am posting several links about Nurse Practitioners, and National Nurse Practitioner week.

This evening, I had the privilege of speaking with Dr. Angela Golden, DNP.  Dr. Golden is a family nurse practitioner here in Flagstaff, an Associate Professor at the Northern Arizona University (NAU) School of Nursing as well as the president-elect of the American Academy of Nurse Practitioners (AANP).  She’s a fascinating lady, and she was talking about the Institute of Medicine’s  recent statement of the Future of Nursing – and what it means for Nurse Practitioners and the future of health care in the United States.

But, as you know – national borders have never hampered my vision, and I am happy to say that nurse practitioners are growing (and thriving!) in Canada, New Zealand, the United Kingdom and other countries around the world.  We’ve talked about the efforts of surgeons in Japan and other countries in establishing the NP role..

New Zealand poster

This local (Arizona) organization has a nice explanation about nurse practitioners and the services many of us provide.

New Jersey (NJ.com) blog talking about the contributions NPs have made to health care.

NP Fact sheet – AANP information about NPs

NP & PAs – timelines of the Nurse Practitioner profession

US congress recognizes NPs

Nurse Practitioner week article – Amarillo, TX

AANP statement

Meta-analysis of NP care

More about NPs, MDs and Midwives

Just a small selection this evening – I hope you’ve enjoyed.

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One of the questions I field frequently in both practice and here at Cartagena surgery is – What is an acute care nurse practitioner (ACNP)?  This is usually bracketed by statements such as, “I didn’t know NPs could work in surgery.  I thought you only worked in [primary care] clinics.”  Sometimes it’s patients asking the questions – sometimes it’s the surgeons themselves.

This is usually followed by questions or statement about whether ACNPs belong in this role, and if we function at a ‘satisfactory level’ in acute care settings such as intensive care units, emergency departments and specialty surgery practices.

The answer lies in the research, and the overwhelming majority of the literature states that we do, in fact, function very well, in our role to augment  (not replace) physician services.  We do so well, in fact, that the most recent literature is primarily focused on surgeons in other countries and their efforts to import the NP models to their countries (Japan, the UK specifically) over the last few years.

But I don’t expect readers to take my word for it.  Hopefully by now, you’ve all become informed consumers – so I’ve posted some references with links below.  In many cases the entire article was not available [without subscription] so in those cases, particularly long articles – I’ve posted a link to the abstract.  In some cases, there is no abstract available on-line so I’ve included the citation.

Unfortunately many of the larger studies on patient satisfaction are based in the primary care setting, so I have omitted them.

Since I’ve gotten quite a bit of interest on this topic from medical providers, other nurses and readers – I’ve added a section for literature relating to nurse practitioners, which I will try to update periodically, since it is too large of a project for a single post.

Nurse Practitioners in Surgical Specialties/ Acute Care Settings: Review of the available literature

1. The role, productivity, and patient satisfaction of surgical nurse practitioners compared to medical surgeons at VA outpatient clinics.  Palmquist, D. (2010).  Graduate dissertation at Tui University.  This is actually a head to head comparison of NPs to MDs which showed greater productivity by MDs (saw more patients) but greater patient satisfaction with care by NPs. [abstract only].  This isn’t surprising in that surgeons have an enormous amount of responsibilities and demands placed on their time.

2. Patient satisfaction with a nurse practitioner in a university emergency service. Rhyee, K & Dermyer, A. (1995). Annals of Emergency Medicine, Volume 26, Issue 2 , Pages 130-132, August 1995.    Study showed no difference between patient satisfaction with care by either MD or NP. Notably, the primary author was a physician [abstract only].

3. Acute care pediatric nurse practitioner: a vital role in pediatric cardiothoracic surgeryOkuhara CA, Faire PM, Pike NA.  J Pediatr Nurs. 2011 Apr;26(2):137-42  [abstract only].  These NPs are actually dually certified in most cases – in pediatrics and acute care.

4.  The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs.  Cowan MJ, Shapiro M, Hays RD, Afifi A, Vazirani S, Ward CR, Ettner SL.  J Nurs Adm. 2006 Feb;36(2):79-85.  Reduced length of stay, reduced patient costs, and hospital costs on teams with nurse practitioners.

5. The evolving role of the acute care nurse practitioner in critical care.  Howie-Esquivel J, Fontaine DK.  Curr Opin Crit Care. 2006 Dec;12(6):609-13. A nice article that talks about how the NP role is expanding internationally to copy American health care models.

6. The advanced practice nurse in an acute care setting. The nurse practitioner in adult cardiac surgery care.  Callahan M.  Nurs Clin North Am. 1996 Sep;31(3):487-93.  [abstract only].  This article was actually written by researchers at my alma mater, Vanderbilt.

7.  Outcomes of tube thoracostomies performed by advanced practice providers vs trauma surgeons.  Bevis LC, Berg-Copas GM, Thomas BW, Vasquez DG, Wetta-Hall R, Brake D, Lucas E, Toumeh K, Harrison P.  Am J Crit Care. 2008 Jul;17(4):357-63. [full text article].  This is a nice study that actually compares NP/ MDs performing invasive procedures – in this case, chest tube placement.

8. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners.  Russell D, VorderBruegge M, Burns SM.  Am J Crit Care. 2002 Jul;11(4):353-62. [full text article].  This article is one of a series of articles published by researchers at UVA which led the changes in the University of Virginia policy – (the results were so compelling that UVA)  to advocate for exclusive use of nurse practitioners in all acute care areas.  It showed shorter length of stays, less infections for patients care for by NPs versus residents.

Several Japanese researchers are looking at the role of nurse practitioners, as mentioned above.

1.  Nurse practitioners in surgical services in the United States.  Okano A.  Nippon Geka Gakkai Zasshi. 2011 May;112(3):207-10. Japanese.  No abstract available.

2.  Considering the feasibility of introducing nurse practitioners into Japanese thoracic services.  Komatsu T, Coutler L, Henteleff H, Johnston M, Bethune D. Ann Thorac Cardiovasc Surg. 2010 Aug;16(4):303-4  [full text article].  An interesting article, written by Canadians, who have just started to recognize NPs in the acute care/ surgical settings.The comments from the surgeons at the Canadian facility are quite interesting as well.   I wouldn’t mind helping the thoracic surgeons in Japan get used to ACNPs..  🙂

3.   [Surgeons’ hope: expanding the professional role of co-medical staff and introducing the nurse practitioner/physician assistant and team approach to the healthcare system].  [Article in Japanese]  Maehara T, Nishida H, Watanabe T, Tominaga R, Tabayashi K. Nippon Geka Gakkai Zasshi. 2010  Jul;111(4):209-15.

Summary: The healthcare system surrounding surgeons is collapsing due to Japan’s policy of limiting health expenditure,market fundamentalism, shortage of healthcare providers, unfavorable working environment for surgeons, increasing risk of malpractice suits, and decreasing number of those who desire to pursue the surgery specialty. In the USA,
nonphysician and mid-level clinicians such as nurse practitioners (NPs) and physician assistants (PAs) have been working since the 1960s, and the team approach to medicine which benefits patients is functioning well. One strategy to avoid the collapse of the Japanese surgical healthcare system is introducing the NP/PA system. The division of labor in medicine can provide high-quality, safe healthcare and increase the confidence of the public by contributing to: reduced postoperative complications; increased patient satisfaction; decreased
length of postoperative hospital stay: and economic benefits. We have requested that the Ministry of Health, Labor and Welfare establish a Japanese NP/PA system to care for patients more efficiently perioperatively. The ministry has decided to launch a trial profession called “tokutei (specifically qualified) nurse” in February 2010. These nurses will be trained and
educated at the Master’s degree level and allowed to practice several predetermined skill sets under physician supervision. We hope that all healthcare providers will assist in transforming the tokutei nurse system into a Japanese NP/PA system.

Note: This is also ground-breaking, as other countries have been slow to implement nurse practitioners in any areas of their medical care system.  The fact that this is a surgical setting is  even more encouraging. These researchers have also published research on the introduction of NPs in other surgical specialties.

NPs and Residents: a delicate balancing act

In fact, nurse practitioners are the reason that recent changes (July 2011) in surgical/ medicine residency hours are even possible. Without the services that NPs provide, it would be impossible for large teaching institutions to implement the new mandated resident hour restrictions.

Even before the newest restrictions – nurse practitioners have been called to take up the slack (when resident hours were previously reduced both here and in Canada.)  However, it was these restrictions that gave us our greatest opportunities for larger acceptance in the acute care specialties.  (Nurse practitioners have worked in acute care since our inception but were not widely known in this acute care role.)  Fortunately, the data shows that not only have NPs made up for the lack of residents, we’ve actually improved the level of care and patient satisfaction [in comparison to care given by residents].

More information of resident hour restrictions

Next time – I’ll include several more articles, including some more looking at my own specialty – cardiothoracic surgery.

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