Implementing and Measuring an Innovative Approach to the Anesthesiologist Shortage
For the past several years, US hospitals have been coping with a serious manpower shortage in the field of anesthesiology. Children's hospitals have been particularly affected by this shortage as growth in the demand for pediatric surgical services has continued to expand. To address this shortage at Cincinnati Children's, members of the Department of Anesthesia instituted a program to use nurse practitioners for preoperative evaluation and shift anesthesiologists from the preanesthesia clinic to the operating room (OR). After implementing the program, known as the Nurse Practitioner-Assisted Preoperative Evaluation (NPAPE) program, division members concurrently undertook a study to evaluate its quality and effectiveness.
According to Anna Varughese, MD, associate director of the department, the goal of the NPAPE program was to meet the hospital's increasing surgical caseload by increasing the number of anesthesiologists in the OR while still maintaining the quality of preoperative care. Prior to the program, two to three anesthesiologists were assigned to the preoperative clinic to conduct assessments on 80–120 patients daily. After instituting the program, six NPs conducted the same number of preoperative assessments daily under the direct supervision of one anesthesiologist. NPs conduct the history, physical examination and education regarding the anesthesia process and consult with the supervising anesthesiologist for acute illnesses, abnormal physical findings or lab studies.
The Nurse Practitioner-Assisted Preoperative Evaluation program has proved to be highly successful in helping to address the anesthesiologist shortage at Cincinnati Children's.
Measurements Put in Place
For the program to be successful, says Dr. Varughese, quality indicators needed to be developed to measure the program's outcomes. "Nurse practitioner programs have been implemented before," she explains, "but the quality of these programs has not been evaluated." Keeping in mind the need to incorporate the variety of stakeholders affected by the new process – patients, parents, anesthesiologists and preoperative clinic nurses – the study team chose to base their quality indicators on the six dimensions of health care outlined by the Institute of Medicine. These six indicators are patientcenteredness, timeliness, efficiency, safety, effectiveness and equity of care. "We went back to these six aims of improvement and found the appropriate measures for each dimension of health care," explains Dr. Varughese. Based on these, the quality indicators for the NPAPE program were determined to be respiratory complication rate, preoperative preparation time, parent satisfaction with the preoperative process and staff satisfaction.
Operational Advantages
Dr. Varughese and colleagues found that the NPAPE program not only maintained the same level of care, it also offered several operational advantages over the anesthesiologist-only preoperative evaluations. Data for each quality measure were collected at baseline (anesthesiologist-only program) and at three, six, nine and 12 months after initiating the NPAPE program. Results showed that the incidence of respiratory complications, patient preoperative preparation time and levels of parental satisfaction at each time point did not differ significantly between anesthesiologistonly and NP-aided assessments. However, anesthesiologist and preoperative clinic nurse satisfaction increased significantly after the program was implemented. "In the first three months following implementation, the percent of staff satisfaction increased dramatically, from 16 to 84 percent," says Dr. Varughese. She attributes this dramatic increase to the fact that the NP evaluations were detailed, thorough and complete. "Because there are six NPs as opposed to two or three MDs, the NPs have more time to spend with each patient and more time to prepare the reports," she explains. "The coordination and flow of the pre-op process was also improved." In addition, she says, the program has proven to be cost-effective for the institution since the addition of anesthesiologists to the OR has enabled more ORs to be opened.
Initially, the NPAPE was limited to a set number of outpatient procedures. Dr. Varughese says the NPAPE program is now moving into additional areas focusing on different organ systems, including several inpatient cases. Because outcomes data were proactively gathered from the inception of the program, its success has been quantifiable and easily tracked. These data have helped enable the division to continue expanding the program. "The program has grown tremendously in a short time," she says, "From six NPs, the current program now has 11 or 12 and continues to grow."
Anna Varughese, MD, MPH, is associate director in the Department of Anesthesia. This study appeared in Pediatric Anesthesia (2006; 16:723-733)
