Nurse Practitioner Triage of the Neurosurgical Patient: A Patient-Centered Care Delivery Model.
Background: Nurse practitioners (NPs) are helping to bridge the gap not only in primary care but also in specialty practice. In an outpatient, neurosurgical spinal clinic in the midwest, patient volume exceeded provider availability, and to rectify this problem, a proposal for an NP triage system and an NP-led spinal clinic was presented. Purpose: The aim of this project was to use NPs to facilitate patient triage in an outpatient neurosurgical practice to expedite patients' access to care and ultimately improve patient satisfaction, outcomes, and healthcare expenditure. Methods: A prospective comparison study was conducted in which NP patient triaging involved surgeons and NPs simultaneously reviewing patient cases over a 1-month period, with a total number of reviews equaling 100 reviews per NP, for a grand total of 200 test reviews. Data were analyzed for a comparison of NP and surgeon input, in reference to patient diagnosis and appropriate NP referral for surgical consultation. Institutional review board approval was sought and granted. Results: Nurse practitioner and surgeon diagnoses were congruent 100% of the time. Patients triaged were correctly referred to the clinic for surgical consultation, with a sensitivity of 95.7% (95% confidence interval, 90.8%-98.4%) and a specificity of 73.8% (95% confidence interval, 60.9%-84.2%). Discussion: Utilization of NPs to facilitate triage and treatment of the outpatient neurosurgical spine patient is a sustainable patient-centered care delivery model that leads to improvements in access and ensures exceptional quality outcomes.
Keywords: neurosurgery spine, NP-led clinic, NP triage, nurse-led clinic, nurse practitioner, spinal disorder
The Affordable Care Act has led to the influx of millions of patients entering the healthcare arena. This flood of new patients has led to a gap in available providers, with a primary concern of the availability of timely access to healthcare. Nurse practitioners (NPs) are helping to bridge the gap, not only in primary care but also in specialty practice, including care of the neurosurgical patient. (1) In fact, in 2012, the National Sample Survey of Nurse Practitioners reported that approximately one-third of the NP workforce is caring for patients in specialty practices. (1,2) Of equal consideration, the Association of American Medical Colleges predicts an insufficient supply of specialty physicians by 2025, with the deficit ranging from 28 000 to 63 000. (2) With this deficit in specialty providers and a greater number of NPs in specialty practice, one can see where the bridge is being built, and the gap will fill with NPs providing high-quality care to patients. (3)
With patient satisfaction being used as a benchmark for quality care, it must become a priority in developing patient care delivery models that encompass patient satisfaction and high-quality care delivery. (4) Furthermore, it is well established in the literature that long wait times for appointments negatively affect patient satisfaction. (5) Therefore, innovative strategies to address quality, effective, and efficient care must be developed interprofessionally for this surge of patients. (5)
The utilization of NPs were integral in facilitating outpatient care to neurology patients by producing a 30-fold decrease in appointment wait time with no significant reduction in patient satisfaction scores. (6) One successful patient-centered care delivery model that led to increased outpatient access to care in the neurology practice was using NPs and physician assistants (PAs) to triage and treat patients. (7) A review of an NP-led spinal clinic in Canada reports that neurosurgical patients are appropriately referred to the surgeon for surgical decision making on a timelier basis, when compared with patients awaiting surgeon consultation. (8) The utilization of the NP to facilitate a timelier diagnosis, treatment plan, and referral to the surgeon may improve patient satisfaction and quality care delivery.
In an outpatient, neurosurgical spinal clinic in the midwest, patient volume exceeded provider availability, which led to long appointment wait times and delays in treatment. To rectify this problem, a proposal for an NP triage system and an NP-led spinal clinic was presented to key stakeholders. The aims of this project were to use NPs to facilitate patient triage in the outpatient neurosurgical practice to expedite patients' right to access to care and ultimately improve patient satisfaction, outcomes, and healthcare expenditure. This study compares NP and surgeon triage of the outpatient neurosurgical spinal patient and is the first step in the development of an NP-led outpatient spinal clinic.
This prospective comparison study was approved by the institutional review board within the organization. A convenience sample of 100 patient cases (50 from 2 different practicing surgeons within the group) was selected and entered into the test database by a study assistant. Nurse practitioners involved in the triage of patients averaged 5 to 10 years of experience in caring for the outpatient neurosurgical patient, and no other specific training was necessary. Patient triaging of NPs involved surgeons and NPs simultaneously reviewing cases over a 1-month period, with a total number of reviews equaling 100 reviews per NP, for a grand total of 200 test reviews. Two NPs reviewed the same 100 cases in a test database, whereas physicians reviewed the identical patient cases in the actual database for patient-specific diagnosis, disposition, and treatment implementation. Analyses were conducted for a comparison of NP and MD input, in reference to patient diagnosis, patient disposition, diagnostic studies ordered in review, and appointment type made (first available, expedited [within 5-14 days], or urgent [within 2-5 days]).
Upon completion of 200 NP reviews in the telehealth triage database, data were collected and analyzed by a consultant statistician using a 95% confidence interval (CI). Data were analyzed to determine whether NP and surgeon diagnoses matched using a congruency statistic, as well as determine sensitivity and specificity in regard to whether patients were correctly referred to the clinic for surgical consultation by the NP. Nurse practitioner and surgeon diagnoses were congruent 100% of the time. Patients triaged were correctly referred to the clinic for surgical consultation, with a sensitivity of 95.7% (95% CI, 90.8%-98.4%) and a specificity of 73.8% (95% CI, 60.9%-84.2%). Referral patterns were further assessed between the 2 NPs, with NP 1 reviews resulting in a sensitivity of 100% (95% CI, 94.8%-100%) and a specificity of 61.3% (95% CI, 42.2%-78.2%). Reviews of NP 2 revealed a sensitivity of 91.4% (95% CI, 82.3%-96.8%) and a specificity of 86.7% (95% CI, 69.3%-96.2%).
Results of this study further the evidence that NPs are a valuable resource in facilitating timely access to neurosurgical care for spinal disorders and are qualified in diagnosis and treatment plan management of the nonsurgical patient and that patients are appropriately referred for surgical consultation on a timelier basis.
Nurse practitioners are forging the path in diverse specialty practices around the world and in the United States. They are autonomously caring for patients in nurse-led clinics (NLCs) in numerous healthcare specialty practices, including orthopedics, rheumatology, oncology, neurosurgery, and cardiology. The American Academy of Orthopaedic Surgeons (9) released a report in 2011 indicating the "must-haves" in running a successful profitable practice. One of the first requirements is personnel in way of NPs and/or PAs. These providers lead to improvements in physician productivity, patient satisfaction, and quality of care, (9) making them vital to the successful operation of an orthopedic practice.
With orthopedic spine surgeons presenting one of the largest competitive markets for the care of patients with spinal disorders, a question of why would a nurse-led spinal clinic in neurosurgery be any less productive or necessary for a successful practice becomes apparent. Appropriate diagnostic testing and nonsurgical treatment could be facilitated by the NP and ultimately reduce the length of time from referral to the surgeon and then to surgery in an NLC or a triage system in outpatient neurosurgery. (10)
Low specificity of statistical analysis can be explained by the NPs, involved in triage of the patients, being more likely to refer the patients to the office before making a definitive decision that the patients were not surgical candidates.
Nurse practitioners contribute to the improvement in patient health outcomes and patient satisfaction while delivering high-quality, patient-centered care to the neurosurgical patient on a timely basis. Initiation of the NP triage of the outpatient neurosurgical patient improves patient access to a provider and more efficient initiation of a diagnosis and treatment plan, as well as care for those patients who were deemed not surgical. The need for conservative care before surgical intervention is a step that cannot be ignored, and NPs are essential in providing this care for this population of patients on a more efficient and effective basis. Implications of an NP-led patient triage of the neurosurgical patient will lay the foundation for future nursing advancements in patient care and outcomes, leadership, scholarship, interprofessional collaboration, community health, and policy change, furthering the evidence to support a national agenda of improving healthcare quality, reducing cost, and promoting innovation in developing healthcare delivery models that support and foster this agenda.
Future research should be focused around long-term patient outcome data, patient satisfaction, and cost-effectiveness in relation to NP-led specialty clinics and triage methods, in particular, NP-led outpatient spinal clinics responsible for triaging patients.
(1.) US Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. Highlights From the 2012 National Samples Survey of Nurse Practitioners. Rockville, MD; 2014.
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(4.) Sawatzky JA, Christie S, Singal RK. Exploring outcomes of a nurse practitioner-managed cardiac surgery follow-up intervention: a randomized trial. J Adv Nurs. 2013;69(9): 2076-2087.
(5.) Prentice JC, Davies ML, Pizer SD. Which outpatient wait-time measures are related to patient satisfaction? Am J Med Qual. 2014;29(3):227-235.
(6.) Iglehart JK. Expanding the role of advanced nurse practitioners--risks and rewards. N Engl J Med. 2013;368(20): 1935-1941.
(7.) Ross SC. An option for improving access to outpatient general neurology. Neurol Clin Pract. 2014;4(5):435-440.
(8.) Sarro A, Rampersaud YR, Lewis S. Nurse practitioner-led surgical spine consultation clinic. J Adv Nurs. 2010;66(12): 2671-2676.
(9.) Grogan T, Soyer, A, eds. Enhancing Your Practice's Revenue: Pearls and Pitfalls a Primer for Orthopaedic Surgeons. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011.
(10.) Murray MM. Reflections on the development of nurse-led back pain triage clinic in the UK. Int J Orthop Trauma Nurs. 2011;15:113-120.
Questions or comments about this article may be directed to Jody L Miniard, DNPACNP-BC, at email@example.com. Assistant Professor, University of Cincinnati, Cincinnati, OH.
Kathleen Ballman, DNPACNP-BC, is Associate Professor, Coordinator of AGACNP Programs, University of Cincinnati, Cincinnati, OH.
The authors declare no conflicts of interest.
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|Author:||Miniard, Jody L.; Ballman, Kathleen|
|Publication:||Journal of Neuroscience Nursing|
|Date:||Aug 1, 2018|
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