Advanced Practice RNs (APRNs) influence outcomes for patients in a number of ways, including better symptom management, reduced costs, and improved health. Demonstrating the outcomes of APRN care remains a priority area of focus to define impact and includes tracking APRN-led initiatives, such as Choosing Wisely®. (See The wise choice.)
As a participant in the Choosing Wisely campaign, the American Academy of Nursing (AAN) developed recommendations specific to the role of nursing. Their recommendations, “Fifteen Things Nurses and Patients Should Question,” help providers and patients discuss evidence-supported options for care and avoid duplicating tests and procedures. In March 2017, the AAN added five more recommendations. (See And 5 makes 20.)
Although reports of Choosing Wisely educational projects for nurses exist, little is known about the effects of APRN-led initiatives targeting these recommendations. In response to the need for more information, an APRN-led initiative launched in 2015 at Vanderbilt University Medical Center (VUMC) began working in conjunction with an interdisciplinary Choosing Wisely committee to reduce unnecessary lab and diagnostic testing. At VUMC, more than 850 APRNs provide care in various clinical settings, with some teams providing around-the-clock patient care management, making it possible for them to significantly impact the use of unnecessary testing.
Using educational materials, including promotional flyers, a slide presentation customized for individual and group presentations, and email communications, APRN teams promoted awareness of the initiative and served as champions to reinforce its goals of reducing overuse of testing. For 12 months, an interdisciplinary committee that included medical, nursing, quality, lab, and data analysis staff tracked lab and chest X-ray use in six intensive care units and several specialty units, reviewing key metrics, refining data collection, and analyzing ongoing results.
Overall, the initiative resulted in increased clinician awareness and improved ordering practices with a decrease in unnecessary testing and care measures. (See The results prove it.)
The initiative’s success led to the formation of the Vanderbilt Advanced Practice Nursing Collaborative to help APRN teams at other organizations implement a Choosing Wisely initiative. Using national presentations and publications, the Collaborative follows the Institute for Healthcare Improvement model for achieving breakthrough improvement by learning from one another to improve healthcare practices and measure the impact of implementing Choosing Wisely recommendations. In alignment with a goal identified by the Centers for Medicare Services Transforming Clinical Practice Improvement model, the Collaborative aims to improve quality and reduce healthcare costs by decreasing unnecessary lab or diagnostic testing by more than 15% from baseline for each organization.
To gain access to the Collaborative materials, teams register online, where they have access to sample flyers, a sample slide deck, examples of data tracking and displays, and lessons learned by Vanderbilt APRN teams. Participants receive guidance and support to implement Choosing Wisely recommendations; collect, analyze, and compare data; evaluate resulting quality of care and cost of care changes; and disseminate results through presentations and publications.
Through the Collaborative, APRN teams share strategies and participate in conference calls and webinars. In addition, they share quarterly progress reports, evaluation activities, interim findings, and operational or administrative issues. The Collaborative also allows for manuscript submission and publication tracking, and it provides a repository of abstract submissions for presentations at regional, national, and international venues.
Through campaigns like Choosing Wisely, APRNs can lead projects and initiatives that demonstrate their impact on patient care, cost savings, and healthcare quality. The Vanderbilt APRN teams and the resulting Collaborative showcase how teamwork and working across institutions can benefit everyone.
Ruth Kleinpell is director of the Center for Clinical Research & Scholarship at Rush University Medical Center in Chicago, Illinois, and visiting professor at Vanderbilt University School of Nursing in Nashville, Tennessee. The following authors work at anderbilt University School of Nursing. April Kapu, associate chief nursing officer at Vanderbilt University Medical Center, is associate professor at the school of nursing; Briana Witherspoon is an acute care nurse practitioner in the neurology/neurosurgery intensive care unit; Lauren Oliver is an acute care nurse practitioner in the cardiovascular intensive care unit; Jayme Gibson is an acute care nurse practitioner in the cardiovascular intensive care unit; Haley Vance is a pediatric nurse practitioner—acute care and an associate in neurological surgery; Janet M. Myers is director of professional development; Roslyn Green is an acute care nurse practitioner in the surgical intensive care unit; Ann Minnick is senior associate dean for research, postdoctoral fellowship director, and Julia Eleanor Chenault professor of nursing; and Pierce Trumbo is an internal medicine resident. Wade Iams is a clinical fellow in hematology/oncology at McGaw Medical Center, Northwestern University in Chicago, Illinois. The authors acknowledge Marilyn Dubree, MSN, RN, NE-BC, and Linda Norman, PhD, RN, FAAN, for administrative support.
Bryant-Lukosius D, Carter N, Reid K, et al. The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: A systematic review. J Eval Clin Pract. 2015;21(5):763-81.
Cassel CK, Guest JA. Choosing wisely: Helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-2.
Donald F, Kilpatrick K, Reid K, et al. Hospital to community transitional care by nurse practitioners: A systematic review of cost-effectiveness. Int J Nurs Stud. 2015;52(1):436-51.
Fabbruzzo-Cota C, Frecea M, Kozell K, et al. A clinical nurse specialist-led interprofessional quality improvement project to reduce hospital-acquired pressure ulcers. Clin Nurse Spec. 2016;30(2):110-6.
Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81.
Hogan PF, Seifert RF, Moore CS, Simonson BE. Cost effectiveness analysis of anesthesia providers. Nurs Econ. 2010;28(3):159-69.
Iams W, Heck J, Kapp M, et al. A multidisciplinary housestaff-led initiative to safely reduce daily laboratory testing. Acad Med. 2016;91(6):813-20.
Jessee BT, Rutledge CM. Effectiveness of nurse practitioner coordinated team group visits for type 2 diabetes in medically underserved Appalachia. J Am Acad Nurse Pract. 2012;24(12):735-43.
Kapu AN, Kleinpell R, Pilon B. Quality and financial impact of adding nurse practitioners to inpatient care teams. J Nurs Adm. 2014;44(2):87-96.
Kilpatrick K, Kaasalainen S, Donald F, et al. The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: A systematic review. J Eval Clin Pract. 2014; 20(6):1106-23.
Kilpatrick K, Reid K, Carter N, et al. A systematic review of the cost-effectiveness of clinical nurse specialists and nurse practitioners in inpatient roles. Nurs Leadersh (Tor Ont). 2015;28(3):56-76.
Marshall DA, Donald F, Lacny S, et al. Assessing the quality of economic evaluations of clinical nurse specialists and nurse practitioners: A systematic review of cost-effectiveness. NursingPlus Open. 2015;1:11-7.
Miller CL. Improving Compliance with Clinical Practice Guidelines to Reduce Urinary Tract Infection in Long Term Care [doctoral project]. Dayton, OH: Wright State University; 2015.
Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990- 2008: A systematic review. Nurs Econ. 2011;29(5):230-51.
Ryan P, Revill P, Devane D, Normand C. An assessment of the cost-effectiveness of midwife- led care in the United Kingdom. Midwifery. 2013;29(4):368-76.
Swan M, Ferguson S, Change A, Larson E, Smaldone A. Quality of primary care by advanced practice nurses: A systematic review. Int J Qual Health Care. 2015;27(5):396-404.