The total cost of inpatient care from a traumatic mechanism of injury in the United States between 2001 and 2011 was $240.7 billion (DiMaggio et al., 2016). Trauma care is the second leading health care expenditure in the United States and requires major policy considerations related to the care of admitted trauma patients (Newgard & Lowe, 2016). Costs of caring for the injured patient will undoubtedly increase over the next decade (Fakhry, Couillard, Liddy, Adams, & Norcross, 2010). According to the National Trauma Data Bank (NTDB), there were almost 800,000 hospital admissions for patients with a traumatic mechanism of injury (American College of Surgeons [ACS], 2015) in 2015, with an average length of stay (LOS) of 5.1-7.5 days nationwide (DiMaggio et al., 2016). Expensive hospital-based health care is often required by admitted trauma patients; therefore, the longer they remain admitted, the higher the expense (Hemmila et al., 2008). Medical resident work hour reductions instituted by the Accreditation Council for Graduate Medical Education (ACGME) in 2011 left a shortage of available in-hospital providers to care for trauma patients, which may contribute to the increase in LOS for this population of patients. Limited work hours for residents created gaps in continuity of care that could lead to an increased LOS and increased errors due to discontinuity (Peets & Ayas, 2012).
Length of stay for admitted trauma patients can be longer than necessary if advanced medical treatment is not provided immediately or when there is poor collaboration and communication between the multidisciplinary teams caring for the patient (Reeves, Pelone, Harrison, Goldman, & Zwarenstein, 2017). Adding advanced practice nurses (APNs) specializing in acute or trauma care to the trauma team may help fill this shortage in trauma care providers and increase communication between multidisciplinary teams, resulting in continued optimal outcomes for trauma patients and reduced LOS and health care costs.
An advanced practice registered nurse (APRN or APN) is an advanced degreed nurse. Advanced practice registered nurses with a specialty in acute care or trauma care are known as acute care nurse practitioners (ACNPs) or may be referred to as trauma unit-based nurse practitioners (TUBNPs) or trauma mid-level practitioners (TMLPs). These advanced providers work in a multitude of settings ranging from outpatient clinics to inpatient settings. Inpatient settings include floor units varying from medical-surgical floors to intensive care units (ICUs). Other than providing assessments, treatment plan creations, diagnosing, and prescribing medication, these providers often also hold competencies for interventions such as chest tube insertions, central line placements, airway insertions, and more, depending on the hospital's credentialing and required competencies.
There are no existing practice guidelines regarding the makeup of a trauma team. Each trauma center decides the members who make up their trauma team including whether or not APNs are added. Trauma teams minimally comprise a trauma attending surgeon and trauma surgical residents. Other members who could be on the trauma team include trauma coordinators (registered nurse in the emergency department [ED]), trauma nurse clinicians (registered nurse in a trauma services department), family nurse practitioners for clinic care, ACNPs, and TUBNPs. When the ACGME mandated that medical residents are limited to an 80-hr workweek along with limited night call hours in July 2011 (ACGME, 2010), this significantly impacted all Level I trauma centers because having a surgical residency program is a requirement to be a verified ACS Level I trauma center.
There are several research studies focused on comparing LOS and patient outcomes when care is provided by trauma teams including an APN with those that are physician-led, without an APN. A study completed in 2014 noted trauma patients who received care provided only by a resident and/or an attending surgeon were more likely to have a missed injury than those who received care by a nurse practitioner (Resler, Hackworth, Mayo, & Rouse, 2014). The authors concluded that ACNPs performed more consistent tertiary assessments than physicians. Missed injuries can cause an unexpected patient readmission, which would require at the minimum another ED visit and evaluation. Another study in 2016 identified ICU patients had a lower mortality rate and LOS for patients cared for by ACNPs than by resident-run (RR) teams (Landsperger et al., 2016). A study in 2007 stated that trauma APNs could effectively replace some functions that the senior trauma house staff fulfilled after identifying that the trauma APNs had the same outcomes as their traditional RR team (Haan et al., 2007). Given the number of studies focused on this question and the need to work toward decreasing escalating health care costs in this area, a systematic review of this work will provide trauma centers with the ability to alter or compose their trauma teams based on compiled evidence in order to ensure optimal patient outcomes while focusing on patient throughput and decreasing health care costs.
The purpose of this integrative systematic review of literature was to determine whether adding APNs to the admitting trauma team will decrease the LOS for admitted trauma patients. Limited resident work hours coupled with increasing patient volumes seen in trauma centers throughout the United States mean longer length of time between provider rounding and lack of communication between the multidisciplinary services. Missed communication often leads to unnecessary financial burdens and longer LOSs (Lang et al., 2014). Does the admitted trauma patient have a shorter LOS when being cared for by a trauma team including an APN versus a trauma team without an APN?
METHODS
Search Strategy
A systematic review of CINAHL complete and PubMed was performed. Articles were searched using the following terms: nurse practitioner, acute care nurse practitioner, advanced practice nurse, trauma, trauma team, and length of stay. Inclusion criteria for studies included (1) primary research focused on the effects of adding nurse practitioners to trauma teams; (2) written in English; and (3) published between 2007 and 2017. Exclusion criteria included studies focused on nurse practitioners who solely work in the ED and not as part of the trauma team.
Analysis
An adapted Quality Appraisal Review Checklist and Assessment Criteria tool was used for screening studies (Kmet, Lee, & Cook, 2004). This scoring system assesses the quality of research covering a wide range of study designs. Studies must have received at least 3.5 out of 5 points to be included in the review. Data extracted for analysis from each study were as follows: authors, publication date, purpose of the study, sample and sampling method, design and limitations, methods and tools used, findings/results, and conclusions. All data extracted can be seen in the evidence table (Table 1).
RESULTS
Characteristics of the Studies
The systematic search yielded 38 articles after 13 duplicates were removed. Of these articles, 26 did not meet the inclusion criteria because they did not focus on APNs on a trauma team. Twelve articles met the inclusion criteria based on the title and were further investigated. Two articles focusing on role expansion were excluded. Ten articles were reviewed in their entirety. The full article reviews found three articles not addressing adding APNs to the trauma team and the outcomes on LOS, and one did not meet the quality rating needed for inclusion. Six studies were included in the review and are synthesized and further described in detail in Table 1.
The sample consisted of five quantitative, descriptive, retrospective studies (Collins et al., 2014; Gillard et al., 2011; Morris et al., 2012; Sherwood et al., 2009; Sise et al., 2011). All articles were from trauma centers in the United States except for the systematic review, which was from Canada. Their purposes ranged from improving throughput in the hospital and overall LOS (Collins et al., 2014; Gillard et al., 2011; Sise et al., 2011) to evaluating the quality of care provided by APNs versus RR teams (Morris et al., 2012; Sherwood et al., 2009). All of the studies were conducted in Level I trauma centers (Collins et al., 2014; Gillard et al., 2011; Morris et al., 2012; Sherwood et al., 2009; Sise et al., 2011). Sample sizes ranged from 967 to 9,172 admitted trauma patients, with a total sample size across all studies of 25,083 admitted trauma patients.
Methods varied from adding APNs to the trauma team specifically to a trauma step-down care unit (Collins et al., 2014; Morris et al., 2012; Sise et al., 2011), all inpatient areas (Gillard et al., 2011), and one article had an APN assuming almost all of the resident roles 24/7 including ED trauma resuscitations and advanced skills (Sherwood et al., 2009). Two studies reviewed the financial impact of adding APNs to the admitting trauma team to decrease LOS and hospital costs (Collins et al., 2014; Sise et al., 2011).
Synthesis of Findings Across Studies
Findings across the studies strongly support the addition of APNs to the trauma team to aid in the reduction of admitted trauma patients' LOS. All six studies reported a decrease in LOS, with 40% reporting a reduction of 0.8 days (Collins et al., 2014; Gillard et al., 2011), 25% reporting a decrease of 0.5 days (Morris et al., 2012), and a maximum reported decrease of 2.54 days (Sise et al., 2011) when APNs were present on the trauma team. Forty percent of the studies reported a total summation of reduced hospital days over their study period of more than 390 patient-days (Gillard et al., 2011; Morris et al., 2012). Although all the studies discussed the impact and reduction of LOS, they did not all address complications and mortality of admitted trauma patients cared for by APNs on the trauma team. One of the main limitations of the studies included reliance on trauma registry data collection and the possible selection bias (Morris et al., 2012; Sherwood et al., 2009; Sise et al., 2011). This limitation did not influence the results because the admitted trauma patients' LOS did not require any interpretation of information; it was taken directly from date of admission and date of discharge.
DISCUSSION
Advanced practice nurses in hospital settings are becoming more common for varying reasons. One of these reasons is in response to the ACGME resident duty hour restrictions as evident in the studies. The purpose of this integrative systematic review of literature was to determine whether adding APNs to the admitting trauma team would decrease the LOS for admitted trauma patients. The results are collectively in favor of the addition of APNs to the trauma team to decrease the admitted trauma patient's LOS. Significant reductions in overall hospital LOS and ICU LOS were identified after the addition of APNs to the trauma team.
Decreased LOS correlates to decreased hospital charges. Collins et al. (2014) reported a very significant financial decrease of $8,878,000 in hospital charges during the first 6 months of adding APNs and an estimated reduction of $27.8 million in hospital charges during the 3-year period. Morris et al. (2012) reported a decrease of more than 1,300 hospital patient-days during their study time frame. One hundred percent of the studies on this sample showed that quality of care was maintained and outcomes were clinically equivalent to an RR trauma team. Adding APNs can provide continuity of care and help close the gap caused by resident duty hour restrictions. The admitted trauma patient does have a decrease in LOS when being cared for by a trauma team including an APN versus a trauma team without an APN.
A consistent decrease in LOS was found across studies. This finding is similar to that of Johal and Dodd (2017), who agreed and found that adding APNs to the trauma team not only reduced admitted trauma patient's LOS but also increased patient satisfaction rates, morbidity and mortality remained stable, and an overall improvement in quality and continuity of care was reported. In support of our findings, the study conducted by Lafferty (2011) found adding an APN in the academic setting provided continuity of care as residents often rotate every month or two and attending surgeons can rotate every week or more. These studies reinforce the findings of the research studies included in this sample.
This review is not without limitations. All of the studies were retrospective studies. No randomized controlled trials or quasi-experimental studies were located during the searches. The literature is lacking the inclusion of expenses to hire and train an APN and patient complications such as deep vein thrombosis, pneumonia, urinary tract infections, or other complications as defined by the NTDB.
Nursing Implications
Based on the findings in this integrative systematic review of literature, all trauma centers, especially Level I centers, should add APNs to the trauma team to not only decrease admitted trauma patients LOS but also provide continuity of care. More high-quality research is needed to assess the economic impact and effect on patient outcomes (including mortality, complications, and morbidity) when APNs are added to the trauma team. Functions of the APNs on the trauma team varied across all studies, with the main theme of utilization being in a specific treatment unit. Finally, this review affirms a need for intervention research to identify the best utilization of an APN on a trauma team. Hospital executive team members should consider adding APNs to the trauma team to aid in facilitating communication, decreasing LOS, reducing hospital charges, increasing quality patient outcomes, and increasing patient satisfaction.
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