Due in part to the increasing development of the hospitalist movement, NP roles on hospitalist teams are growing. Hospitalists are defined as practitioners whose primary professional focus is the general medical care of hospitalized patients and the improvement of the systems of care surrounding those patients.1 Although the term was first used in the 1990s, hospitalist groups began providing inpatient medical management of patients in the 1980s.2 Early models of hospitalists focused on traditional internal medicine practice, which encompassed care for medical inpatients and consultations for surgical inpatients.2 Factors such as managed care, decreased length of stay, more complicated and sick patients, and primary care physician workloads influenced the expansion of hospitalist services.

Currently, hospitalists direct the management of a wide variety of inpatients, including general medical surgical care and critical care management. In 2006, survey results uncovered that there were more than 19,000 hospitalists at community hospitals.3 This number expanded in 2007 when a separate study revealed that between 21,000 and 23,000 hospitalists were currently in practice.1 Based on this figure, the hospitalist role is expected to grow to about 30,000 in the United States by 2010.1

A growing number of healthcare settings are using hospitalists to manage hospitalized patients. Survey results found that 44% (2,188) of 4,936 community hospitals implement hospitalists-this figure grew by 40% over a 3-year period between 2003 and 2006.3 Today, hospitalists represent over 70% of total national hospital beds.1 Some facilities use hospitalists to supplement the care provided by primary physicians. Others use them to manage patients when primary care physicians do not have admitting privileges or choose not to manage their patients in the hospital setting due to acuity of illness or complexity of care.4 Select hospital settings mandate that hospitalists care for primary care patients upon admission to the hospital to promote focused care management and continuity of care.2 This evolving paradigm of providers caring exclusively for hospitalized patients provide opportunities for NPs to work on the hospitalist team.5

The NP's Role

NPs work on hospitalist services in a variety of capacities (see Roles of the NP on a Hospitalist Team). They provide direct patient care management as part of the hospitalist service, which entails obtaining and dictating the admission history and writing initial admitting orders; daily rounding of hospitalized patients including patient assessment, ordering, interpreting, and follow-up of test results; patient and family education regarding diagnosis, results, and medications; anticipating and planning for discharge needs; preparing and dictating discharges and education regarding home care; providing family counseling and end of life care; and collaboration and daily consultation with the hospitalist physician. Other NPs on hospitalist teams provide in-house, 24 hour-a-day coverage to manage critical care support for intensive care unit patients, acute care consultation, and the management of hospitalized patients.6 Some roles also incorporate serving on the rapid response team and as the on call house officer, working on hospital committees, providing patient and staff education, and leading quality initiatives.

Hospitalist NPs often have acute care NP (ACNP) training, as the scope of practice of a hospitalist team includes critical care patient care. NPs with adult NP (ANP) training and geriatric NP (GNP) training also function in roles on hospitalist teams. However, as NP education and training determine the scope of practice, ensuring appropriate preparation for the role is an essential aspect.7,8 NPs prepared as ANPs or GNPs who find their role expanding on the hospitalist team to include patient care management for acute and critical care illness can seek post-master's ACNP certification.9

Outcomes

The majority of the current literature on the hospitalist team is focused on describing team roles and functions. A recent study comparing outcomes of care for over 76,926 hospitalized patients with common acute care conditions including pneumonia, heart failure, chest pain, ischemic stroke, myocardial infarction, acute exacerbation of chronic obstructive pulmonary disease, and urinary tract infection found that hospitalist directed care resulted in shorter length of stay and lower costs compared to general internist managed care.10 Several studies have focused on outcomes, including the integration of NP roles. Research demonstrates that a hospitalist-directed service created to admit low-risk chest pain patients that incorporated NPs had a lower median length of stay and lower median hospital charges (P= less than 0.0001) compared to patients cared for by a traditional internal medicine resident-based service.6 Another investigation followed 1,207 general medicine patients comparing usual care by attending physicians (n=641) and care provided by a hospitalist team that incorporated an ACNP (n=581).7 The average length of stay (LOS) was significantly lower for patients managed by the ACNP/hospitalist team compared to control patients (5 versus 6 days, P= less than 0.0001). As a result of the decreased LOS, a cost savings of $1,591 per patient in the ACNP/ hospitalist team was estimated.12 Additional research found improved communication and collaboration as a result of an ACNP/hospitalist team on an acute inpatient medical unit, highlighting the additional value of hospitalist care coordination.13 While studies support the benefits of the hospitalist team and of the role of the NP, additional research is needed that further explores the impact of this area.

Housewide Care

Hospitalist medicine offers expanding career opportunities for NPs and multidisciplinary teams to provide inpatient care management housewide. Additionally, the expanding role of the NP on hospitalist teams and their integration in a collaborative healthcare model is supported by hospital medicine groups.14 Continued publication of successful models of care incorporating NPs on the hospitalist team, as well as research identifying outcomes of care, will promote the use of NPs in this evolving area of practice.

Roles of the NP on a Hospitalist Team

* Provide patient care management.

* This includes conducting admission history and physical exams, writing orders, interpreting laboratory, radiologic and diagnostic tests, performing diagnostic and therapeutic procedures, prescribing medications, providing subsequent care visits, participating in multidisciplinary rounds, using critical thinking skills to prioritize care, writing daily notes, discussing patient care with attending physicians and the hospitalist team, admitting and following patients whose primary care clinician does not have admitting privileges or for patients who do not have a primary care provider, comanaging surgical patients, and implementing discharges.

* Patient care consultation.

* Coordinate hospital follow-up care.

* Continuity of care.

* Coordinate the interdisciplinary team.

* Transfer patients to higher level of care.

* Communicate with the primary care provider.

* Patient and family education.

* Rapid response team provider.

* Assist in the education of staff.

* Contribute to quality improvement initiatives.

* Discharge planning.

* Palliative care management.

* Hospital committee involvement.

References