9/30/2016 I have no financial or business relationships to disclose - PowerPoint PPT Presentation

9/30/2016 � I have no financial or business relationships to disclose David M. Gordon, DNP Acute Care & Adult Nurse Practitioner Lung Transplantation Program University of California San Francisco � 1950s: Medical specialization expanded, � Brief history of Nurse Practitioners shortage Primary Care Physicians, � Current governing legislation for NPs especially rural � The education of an NP � 1965: University of Colorado first NP program � The role of the NP � 1967: Boston College first Master’s programs for NPs � Benefits of the NP � 1973: More than 65 programs for NPs in � UCSF Lung Transplant Program NPs the US � Inpatient and Outpatient NPs � 1979: Approximately 15,000 NPs in the US � Collaborators, Educators, and Innovators � 1989: 90% of NP programs are Master’s or Post Master’s degrees � 1999: 68,000 NPs in the US 1

9/30/2016 250000 � Currently there are more than 205,000 NPs practicing in the U.S. 200000 � 14,000 new NPs completed their academic programs in 2014 150000 � NPs conducted over 900 million patient visits NPs in 2012 100000 Resident Hours � MDs 2013 1,045,910 in practice increasing 50000 19,000 annually 0 1979 1999 2003 2007 2010 2012 2014 DC 2

9/30/2016 � RNs with bachelors degree in nursing (BSN) � Required all NPs have Masters Science Nursing (MSN), preferred Doctorate (DNP) � Clinical hours � A minimum of 500 faculty-supervised clinical hours � Competency based, not time based � National Board Certification Exam � AANP, ANCC � Adult-Gerontology (Primary & Acute Care), Pediatrics Neonatal, Family, Psychiatric-Mental Health, Women’s Health � Recognized in 50 states, Medicare, Medicaid, VA, private insurances, Canada � Re-certify nationally every 5 years � Additional state requirements � Ohio and California additional education class and clinical hours for Schedule II authority Attending NP? Fellow NP? Resident NP? 3

9/30/2016 2011 2016 � Fellow centered model � NP centered model � Systematic review 37 studies: � Rotate monthly, � Permanent stability, � Consistent evidence LOS, ED visits, hospitalizations for NP constant shuffle & flux continuity care is equivalent to MD care (Newhouse et al, 2011) � Introduction NP Model in neuroscience practice � Consult service � NP Admitting service � $2.4 million savings the first year, ROI 1600% � Multiple layers to � Direct interaction � Expansion of the NP model across the health system brought communication patient to transplant comparable savings (Larkin, 2003) provider � Increased potential for � United Health NPs to manage nursing home pts medical errors � Continuity of care � Predicted $166 billion healthcare savings (United Health, through patient � Transplant limited role 2009) transplant life � Collaborative NP/MD management models � No direct transplant � Decreased LOS and costs, higher hospital profit (Cowan et � NP available for triage contact for RNs al., 2006; Ettner et al., 2006) contact for RNs � >100 studies NP care is not inferior to MD � Outpatient education � Inpatient education � Inpatient � Outpatient � Manage the day to day operations of patient care � Manage acute & chronic care of the transplant patients � Pre-operative, Post-operative, Medical & Surgical Dichotomy � Pre-operative, Post-operative, Medical & Surgical � Immunosuppression, pain management, blood pressure control, critical care, recovery from OR, chest tube Dichotomy management, glucose control, antimicrobial and infectious � Immunosuppression, pain management, blood pressure management, monitoring postoperative complications, control, glucose control, antimicrobial and infectious transplant complications, medical co-morbidities management management, monitoring postoperative complications, � First triage call from Admission to Discharge transplant complications, medical co-morbidities � ICU critical care, Step-down acute care management � Examine, Diagnose, Order, Evaluate, Prescribe, Follow-up � Examine, Diagnose, Order, Evaluate, Prescribe, Follow-up � Daily rounds with Transplant Surgeon and � Independent billing and Shared billing with Attending Pulmonologists � Procedures � Independent billing and Shared billing with Attending � Procedures 4

9/30/2016 � Educator Nursing � Pulmonary Fellow Education Case Consult Management Services Weekly chalkboard lectures on transplant topics � ECMO, Immunosuppression, Post-op Management Lung Transplant � � RN Education Family, Physical and Caregivers, � Created formal, annual, core curriculum for all nursing staff caring for Occupational Discharge Therapists transplant patients Planning Pharmacology, pathophysiology, annual research/clinical updates � Chalkboard lectures � Patient � NP Education Speech Precept Social Work � Therapists Mentor � Fellowship � � Multi-disciplinary Students Med, RN, NP, Pharm, Dieticians � Respiratory Financial Therapists Coordinators � Family/Caregiver Education Education binders � Nutritionists, Education videos Pharmacy � Dieticians � Innovator � Nurse Practitioners have evolved to become a � Policy/Protocol vital member of any multi-disciplinary team � Removing barriers to care based model � Initiation of NP pigtail catheter placement � 30 day re-admit program � NPs offer time become experts in their � Procedures specialized population � Central lines, bronchoscopies, large and small bore chest tubes, arterial lines, procurements, OR assist, remove venous- � NPs maintain continuity of care venous ECMO � Research � NPs can thrive in any setting as they are � Sildenafil use in pre-transplant hypoxic ILD w/PH adaptable, innovative, and collaborative � Meditation & conscious awareness to ameliorate anxiety with dyspnea in pre-transplant patients � Combining TPA and DNAse for trapped lung post lung transplant 5