Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA.
J Trauma Acute Care Surg. 2012 Aug;73(2):474-8. doi: 10.1097/TA.0b013e31825882bb.
With the increased restrictions on resident work hours, hospitals increasingly are relying on advance practice nurses and physician assistants to help meet the patient care demand. We have created a workflow model wherein unit-based nurse practitioners (UBNPs) provide the minute-to-minute care for patients with trauma in one specific unit in our hospital, with supervision by the attending surgeons. Patients with trauma may also be admitted to other units, where the care model is a traditional resident-run (RR) service, again with supervision by the attending staff. Our aim was to determine if there were differences between the care provided by UBNPs and residents.
We queried our trauma database for all patients admitted to our urban, academic, Level I trauma center from January 1, 2007, to August 31, 2010. Patients discharged alive from the trauma service were identified and cross-referenced with an administrative database to collect demographics, injury characteristics, comorbidities, complications, and discharge information. Patients cared for by the UBNPs were compared with those cared for by the RR service. χ², Fisher's exact, and Student's t tests were used to determine significance. Significant factors were then tested with a multivariate linear regression analysis. p < 0.05 was considered significant.
During the study period, 3,859 patients were discharged alive from the trauma service, 2,759 (71.5%) from the UBNPs service, and 1,100 (28.5%) from the RR service. Demographic data and mean Injury Severity Score (11.6 vs. 11.1, p = 0.24) were similar for the two groups, although mean abdominal Abbreviated Injury Score was higher for the UBNP group (0.6 vs. 0.5, p = 0.02). UBNP patients were more likely to be diagnosed with deep venous thrombosis (4% vs. 2.5%, p = 0.02) and were more likely to be discharged to home (67% vs. 60%, p = 0.002). Mean (SD) length of stay for UBNP patients was 6.5 (8.8) days compared with 7 (10.8) days for RR patients, although this difference did not reach statistical significance ( p = 0.17). The 30-day hospital readmission rates were similar for both groups (4.0% vs. 4.4%, p = 0.63).
Care provided by UBNPs is equivalent to that provided by residents. With the restriction on resident work hours and greater reliance on nurse practitioners, patient care does not suffer. Moreover, a difference of 0.5 days in mean length of stay for the UBNP patients equates with more than 1,300 fewer patient care days. This difference, although not statistically significant, may be clinically relevant to physicians and administrators and may offset the cost of hiring UBNPs to help meet the patient care demand.
随着住院医师工作时间限制的增加，医院越来越依赖执业护士和医师助理来帮助满足患者的护理需求。我们创建了一种工作流程模型，即在我们医院的一个特定单元中，由基于单元的护士从业者（UBNP）为创伤患者提供每分钟的护理，由主治外科医生进行监督。创伤患者也可能被收治到其他单元，在这些单元中，护理模式是传统的住院医师管理（RR）服务，同样由主治工作人员监督。我们的目的是确定 UBNP 和住院医师提供的护理是否存在差异。
我们从 2007 年 1 月 1 日至 2010 年 8 月 31 日，对我院城市、学术、一级创伤中心收治的所有存活出院的创伤患者进行了创伤数据库查询。确定了从创伤服务中出院的患者，并与行政数据库交叉引用，以收集人口统计学、损伤特征、合并症、并发症和出院信息。将由 UBNP 护理的患者与由 RR 服务护理的患者进行比较。使用 χ²、Fisher 确切检验和学生 t 检验来确定显著性。然后使用多元线性回归分析测试显著因素。p<0.05 被认为具有统计学意义。
在研究期间，有 3859 名患者从创伤服务中存活出院，其中 2759 名（71.5%）由 UBNP 服务护理，1100 名（28.5%）由 RR 服务护理。两组的人口统计学数据和平均损伤严重度评分（11.6 与 11.1，p=0.24）相似，尽管 UBNP 组的平均腹部损伤严重度评分较高（0.6 与 0.5，p=0.02）。UBNP 患者更有可能被诊断为深静脉血栓形成（4%与 2.5%，p=0.02），更有可能出院回家（67%与 60%，p=0.002）。UBNP 患者的平均住院时间为 6.5（8.8）天，RR 患者为 7（10.8）天，尽管这一差异没有达到统计学意义（p=0.17）。两组的 30 天医院再入院率相似（4.0%与 4.4%，p=0.63）。
UBNP 提供的护理与住院医师提供的护理相当。随着住院医师工作时间的限制以及对执业护士的更大依赖，患者的护理并未受到影响。此外，UBNP 患者的平均住院时间相差 0.5 天，相当于减少了 1300 多天的患者护理时间。尽管这一差异没有统计学意义，但可能对医生和管理人员具有临床意义，并可能抵消聘请 UBNP 以帮助满足患者护理需求的成本。
