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Background: The role of the advanced practice provider (APP) is rapidly expanding in healthcare, whereas infrastructure to support it is not keeping pace. A large academic healthcare organization implemented the role of a director of APPs; supported by the C-suite, one who understands scope of practice, revenue models, and compliance and addresses engagement and retention to meet this challenge. This article chronicles the implementation of innovative success strategies, supporting APPs across a large academic health system, employing more than 1000 APPs, which has led to improvements in APP-generated revenue, patient access, engagement, and alignment., Methods: Emory Healthcare rapidly expanded the number of APPs (nurse practitioners and physician assistants) over the past 10 years. APPs reported to administration or nursing leadership leading to APP dissatisfaction, questions on return on investment (ROI) and productivity, and poor utilization due to lack of role clarity. An APP leadership structure was created so that every APP reported to an APP leader. In alignment with the goals and plan for Emory Healthcare, standardized service line productivity and accountability expectations were developed and implemented, as well as a vision and strategic plan to support APPs., Results: Improvement in productivity was seen across service lines, supported by the increase in full-time equivalent numbers, while improving the ROI for the organization. A roadmap to aligning an APP and organizational strategic plan has been created and implemented. Improvement in APP engagement was realized., Conclusions: An APP director and leadership structure are vital to the creation of infrastructure to support APPs in this healthcare. Optimization and standardization of APP practice resulted in role clarity and allowed for support of practice development., Competing Interests: The author declares no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Hospitals are under increased pressure to address both financial and capacity constraints to improve their clinical operations. Effective capacity management programs have become a key driver of clinical operations for managing the flow of patients into and out of the hospital. Many high-functioning medical centers have developed capacity management programs to strategically address patient throughput. Discharging patients from the hospital is one fundamental, but complex, patient flow initiative for efficient patient throughput. Despite advances in optimizing patient flow, there is a lack of understanding associated with the structure and processes to efficiently discharge patients. This article outlines a discharge timeliness project where advanced practice providers are principal leaders of designing a safe and efficient patient discharge prototype. Design thinking was used to develop a patient discharge prototype that included 6 key areas that led to improved discharge times on a cardiac surgery step-down unit. High tech solutions were incorporated into the electronic medical record system to enhance communication across phases of care and inform the interdisciplinary team of patient progress.

The US health care system has seen unprecedented growth in health care cost with only a mediocre return on investment. Achieving sustained quality improvement will require innovation that is effectively integrated into complex systems of care. Complexity leadership has the ability to place value on traditional quality improvement processes, with less focus on rigid structure and more attention on the potential for flexibility and creativity at the point of care. Clinical team leaders, such as nurse practitioners, must nurture adaptability to the constantly changing clinical environment while balancing structured thinking of team members. Nurse practitioners operating in interdisciplinary teams are well positioned to foster adaptive change through rapid cycle improvements at the point of care. As a learning approach to quality improvement, the PDSA (plan-do-study-act) method should be seen as a useful tool for organizations to create an emergent quality improvement process. This article discusses the significance of nurse practitioner leadership using the PDSA method informed by complexity leadership theory and the impact for clinical practice.

A nurse leadership program provides advanced practice nurses, many of whom have nursing professional development roles within their agencies, with a year of education, mentoring, and guidance to create and implement innovative models of care designed to improve population health. This article highlights program participants' leadership development outcomes, along with strategies to educate and mentor rising nurse leaders.

In our journey from Magnet designation to a Lean hospital, a team of advanced practice nurses, a nurse scientist, and Lean specialists developed a crosswalk of evidence-based practice (EBP) with Lean to explicitly embed the use of evidence in our organization's 4-step problem-solving method. Once finalized, the blended Lean-EBP model now guides improvement work as highlighted in the example of updating our practice for frequency of changing peripheral intravenous catheters.

In Australia, nurses performing endoscopic procedures is a recent phenomenon and is uncommon. Challenges include gastroenterologist and patient acceptance of the nurse endoscopist role. This article aims to explore Monash Health's experience with the introduction of a nurse endoscopist. A nurse endoscopist trainee undertook a comprehensive training program under the supervision of a gastroenterologist. All procedural data were collected, organizational policy and procedures were developed, and patients (n = 40) completed a telephone interview postprocedure. The nurse endoscopist trainee completed all training requirements during the 12-month program and was deemed competent for independent practice. The trainee performed 255 colonoscopies, with no complications reported. The organization successfully implemented the expanded scope of practice, established a new model of care for patients, and initiated a governance framework for this advanced practice role. Eighty percent of patients (n = 32) reported that overall, they had a very good experience with the nurse endoscopist trainee. A nurse endoscopist initiative can facilitate the expansion of endoscopy services to meet the growing need for gastroenterological procedures within the community. This pilot program has demonstrated that it is possible to integrate an advanced practice nurse role into an established endoscopy unit.

Thirty-eight hospitals participated in falls prevention team training, followed by coaching and mentoring over 3 months to develop unit-based initiatives to reduce falls. Initiatives centered on fall risk assessment, rounding, or postfall assessment. Paired t test of the pre-/postintervention fall rates of 23 of the hospitals revealed reduced fall rates (P < .01). The estimated mean decrease was 1.7 falls per 1000 patient days (95% confidence limits of 0.7-2.7).

The clinical nurse specialist (CNS), one of the 4 advanced practice registered nurse (APRN) categories, has a unique role to play in contributing to high-quality patient care and system-level change across multiple health care settings. CNS practice requires advanced knowledge and skills, including specialty expertise, the ability to integrate new knowledge and innovation into the system of care, the ability to consult and collaborate with all health professions, and the mentoring of nursing staff to support and fully implement that new knowledge. The purpose of this article was to describe the role of the CNS, explain the background of the CNS role as it relates to APRN practice, provide current CNS workforce statistics, and share opportunities for hospitals and health systems to strategically use CNSs to advance patient and organizational goals.

Background: Nurses provide healthcare services to members of the adoption triad (AT; birth parents, adoptive parents, and the child) in a number of settings. However, nurses' perceptions of and interactions with members of the AT have not been investigated., Purpose: This study describes the lived experiences of nurses and the care rendered to the AT using a descriptive phenomenological approach., Method: In response to an invitation published in a national electronic newsletter, nurses were asked to submit narratives about their experiences in caring for members of the AT. Researchers coded 17 narratives using Colaizzi's phenomenological method., Results: Four themes emerged from the texts: (1) Where the personal and professional selves meet ("I see so many issues from both sides"); (2) The paradox of adoption ("...an emotional rollercoaster"); (3) Unique contexts of adoptive families ("We all have a story"); and (4) Reframing nurses' perceptions surrounding adoption ("There are several areas we could improve")., Clinical Implications: Nurses often have a personal connection to adoption and this potentiates the care delivered to AT members. Serving as role models for their peers and advocates for a better understanding of the dynamics of relinquishment and placement, nurses can improve clinical practices for these patients., Conclusions: Themes reflected insights gained from both personal and professional roles and offer specific interventions that enhance care of the AT. Nursing education and practice guidelines should include care rendered to the AT.

Wound ostomy continence (WOC) programs are essential in any healthcare organization, including home care agencies, to provide comprehensive, high-quality care. Advanced practice nurses (APNs) with assessment, diagnostic, and coordination skills are well suited to manage the complex patients being cared for by home care agencies. A number of research studies have assessed the credibility and value of APNs in the home care setting, caring for complex, frail patients. This article describes the role of the APN, and the role of the WOC specialist nurse, comparing similarities and differences. The advanced practice WOC nurse is now essential in the home care setting to manage the care of complex patients.

Cardiac surgery remains one of the most commonly performed surgeries in the world. Intensive insulin therapy has shown to reduce infection in patients undergoing open-heart surgery and is considered standard of care. New technologies are available to achieve and maintain recommended blood glucose goals. These include computer-driven intensive insulin protocols (vs paper-based algorithms) and continuous blood glucose monitors. Managing tight glucose control in cardiac surgery patients has been shown to decrease costs in terms of measurable outcomes including infection, mortality, and length of stay. The advanced practice nurse is uniquely qualified to implement new technologies and can be instrumental in increasing compliance with clinical practice guidelines while decreasing hospital costs.

Significant emphasis has been placed on reducing barriers to implementing evidence-based practice and improving patient outcomes. The purpose of this study was to determine whether a mentor-led evidence-based practice quality improvement project would reduce professional nurses' perceptions of barriers to using best practice research findings in their practice to influence patient outcomes related to pressure ulcer prevalence.

Managing pediatric psychiatric emergencies can be a challenge for any emergency nurse. Young patients may have extreme anxiety about being in the emergency department and may act out as a result. Overwhelmed parents can hinder the assessment process and, in some cases, cause further escalation of their children. Understanding the common diagnoses for different age groups enables the nurse to use management strategies that are appropriate and effective. Establishing rapport, recognizing anxiety, setting effective limits, and facilitating cooperation with these patients and their parents are priorities for the emergency nurse.

A review of recent evidence with translation to practice for the role of advanced practice nurse is presented using a case study module for "What Is Effective Acute Migraine Treatment in the Emergency Department?" The study results showed patients who received prochlorperazine with diphenhydramine had better pain management than those in the sumatriptan group. The implications and clinical relevance of these findings for advanced practice nurses are discussed, highlighting best evidence.

Most children and adolescents who present with extremity pain in the emergency department (ED) have minor injuries or musculoskeletal problems that are easily diagnosed and managed. A history of a child or teenager with persistent extremity pain lasting more than a few weeks or pain that wakes the child at night is of clinical concern and requires investigation. There are serious clinical etiologies that must be included in the differential diagnosis of this group of patients. It is essential to take the time during the initial screening examination to determine the real reason for each patient ED visit and review previous medical care.

The pilot phase begins.This is the 10th article in a series from the Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every other month to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we've scheduled "Chat with the Authors" calls every few months to provide a direct line to the experts to help you resolve questions. See details opposite.

Advanced practice nurses provide expert clinical care for patients and families experiencing chronic and terminal illnesses. However, there is no theoretical framework that guides praxis in palliative care. This article describes a unitary-caring model that transforms national standards of palliative care into a values-based praxis focused on healing and caring.

Noninvasive ventilation has become a widespread tool of treatment and support for patients in acute care settings. The treatment is used for various clinical conditions, particularly chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema. The utilization of a simple nursing care checklist allows treatment in a systematic fashion. This article discusses the respiratory features of this topic: criteria for noninvasive ventilation, choice of the interface for acute clinical conditions, ventilators and modes of ventilation in noninvasive ventilation, management of setting parameters, patient/ventilator interactions, and monitoring.

Throughout the first critical 24 hr after the injury is sustained, the burn patient must receive fluid resuscitation to prevent hypovolemia and ensure adequate tissue perfusion. Delayed or inadequate fluid resuscitation results in suboptimal tissue perfusion, which can lead to multisystem organ failure and death. Overresuscitation can be more problematic than underresuscitation and has been associated with the development of abdominal compartment syndrome, compartment syndrome of the extremities, airway obstruction, and pulmonary edema. The term fluid creep is used to describe the tendency to give too much fluid and can result from the hemodynamic consequence of opioid creep. Experts in the field agree that fluid resuscitation of the burn patient is a priority. Factors affecting fluid resuscitation in the burn patient are at the cornerstone of burn management. The advanced practice nurse (APN) can play a vital role in implementing strategies to ensure optimal resuscitation in the burn patient. Through collaboration, the APN in both the burn center and the emergency department must make certain that the educational needs of the staff are addressed and be diligent in providing significant education, essential tools, and assistance to the staff nurses in an effort to promote best-practice and evidence-based care.

Part I of this two-part series discussed the anatomy, radiographic reading, and clearing of the cervical spine for advanced practice nurses. Part II reviews the mechanisms of injury, pathophysiology, diagnostic evaluation, and patient management of the most common cervical spine injuries.

Annually, millions of patients are treated in emergency departments across the country for upper and lower respiratory infections. The purpose of this article was to articulate optimal antibiotic therapy for community-acquired respiratory infections. A table format has been selected to serve as a direct reference for nurse practitioners and physician assistants. In addition, background, common pathogens, and follow-up are discussed for each disease state.

Ovarian torsion is infrequently seen in the emergency department, however, a delay in diagnosis and treatment can lead to necrosis and loss of the ovary (E. D. Shraga & M. Blanda, 2008). A patient with pelvic pain diagnosed with ovarian torsion is presented in this article. The diagnosis and treatment of ovarian torsion is discussed to help the advanced practice nurse gain a better understanding of this frequently missed problem.

Transverse myelitis (TM) is a neurological syndrome involving destruction of the anterior and posterior (transverse) segments of the spinal cord. The objective of this article is to educate emergency nurses and nurse practitioners about how to recognize, diagnose, and treat TM. A comparison of the neurological findings of TM and Guillain-Barré syndrome is presented. In addition, this article will include an algorithm and specific diagnostic criteria to assist in the diagnosis of acute idiopathic TM.

Emergency department (ED) births are relatively uncommon, but when they occur, the advanced practice nurse is in a unique position to assist the mother through unexpected vaginal delivery in the ED. The purpose of this article is to guide the advanced practice nurse through the process of care for a woman giving birth in the emergency department. Anticipation, preparation, "the catch," the newborn, the placenta, stabilization, and transport are the individual steps reviewed in this article. The focus of this manuscript is also to discuss the management of a mother and neonate during and following an unexpected vaginal birth.

This article is Part I of a two-part series and will focus on the key concepts of radiographic interpretation, functional cervical anatomy, and the interpretation and clearance of cervical spines in emergency care. In the subsequent issue, Part II will cover the additional epidemiology of cervical-spine injuries, specific injuries, case studies, and advanced diagnostic imaging.