It is well recognized that patients undergo numerous tests and procedures during a hospital stay or clinic visit. In an effort to promote judicious use of testing, the Choosing Wisely (CW) campaign was launched by the American Board of Internal Medicine Foundation, as an effort to identify tests and procedures commonly used but whose necessity should be evaluated. While reports of CW projects exist in the literature, little is known about the impact of advanced practice-nursing-led initiatives targeting the CW recommendations.
In response to this, an Advanced Practice Registered Nurse (APRN) led initiative was launched in 2015 at Vanderbilt University Medical Center, working in conjunction with an interdisciplinary CW committee. For a 12 month period, lab and chest-x-ray use were tracked in 6 intensive care units and in several specialty units to assess the impact of APRN-led unit based projects. Educational materials including promotional fliers, a slide deck that was customized for individual and group presentations, and email communications were used to launch the projects. APRN teams promoted awareness of the initiative and served as champions to reinforce the project aims over the duration of the initiative. Data was tracked on lab and x-ray use and reviewed at monthly taskforce meetings. Interdisciplinary committee representation including medical, nursing, quality, lab services, and data analyst support reviewed key metrics on a monthly basis in order to refine data collection and review ongoing project results.
Overall, the APRN led initiative resulted in increased clinician awareness and better ordering practices with a decrease in unnecessary testing/care measures. The results highlight the role that APRNs can play in promoting clinical practice changes to improve better use of tests and care measures as part of the CW campaign.
As a result of the success of the initiative, The Vanderbilt Advanced Practice Nursing Collaborative (Collaborative) is being launched in order to enable APRN teams at other institutions to participate in implementing a CW initiative, track outcomes, and disseminate results.
The Collaborative will target APRNs including: nurse practitioners (NP), Certified Registered Nurses (CRNAs), Certified Nurse Midwifes (CNM), Clinical Nurse Specialists (CNS) and physician assistants (PA). Nationally, it is well acknowledged that APRNs play a significant role in managing healthcare for patients in hospital and clinic settings. At Vanderbilt University Medical Center, over 850 APRNs provide care in various clinical settings. Several of these APRN teams provide 24/7 oversight of patient care management. As a result, these practitioners have the potential to significantly impact the use of unnecessary testing/care measures.
Specific Aim: Engage APRN teams to implement the CW recommendations, track outcomes, and disseminate results through national presentations and publications.
Framework: The Collaborative will use the Institute for Healthcare Improvement (IHI) model for achieving breakthrough improvement to measure the impact of implementing the CW recommendation with the aim of improving quality and reducing healthcare costs with a target of decreasing unnecessary testing/care measure >15% from baseline a goal identified by the Center for identified by the Center for Medicare Services Transforming Clinical Practice Improvement model.
Participating teams will identify up to 3 tests/other care measure to target in reducing unnecessary testing/procedure/care measure. The APRN/PA Collaborative website will be launched from the home page of the Vanderbilt University Medical Centers Office of Advanced Practice. An online registration process using Research Electronic Data Capture (REDCap) will be used for teams to register to participate and to gain access to the Collaborative materials. These will include sample flyers, sample slide deck, examples of data tracking and displays, and lessons learned by the Vanderbilt APRN/PA teams.
Participation in the APRN/PA Collaborative will enable APRN/PA teams to receive guidance and support to work to: 1) implement one or several CW recommendations to make clinical practice changes, 2) collect, analyze and compare data, 3) evaluate resulting quality of care and cost of care changes 4) disseminate results through presentations and publications
Collaborative tools for implementing the APRN-led initiative
Sharing of strategies for project implementation from expert APRNs and PAs
Quarterly reporting of the progress, evaluation activities, and interim findings as well as operational or administrative issues identified
Conference calls for project team coaching and sharing
Tracking of manuscripts submitted and published
Repository of abstract submissions for presentations at regional, national and international venues for dissemination