1. Using VPS to Assess Impact of Advance Practice Staffing Changes Emilie Henry, MD, FAAP Amy Harrell, RN, BSN Pediatric Critical Care The Children’s Hospital at OU Medical Center

2. Speaker Disclosure No financial disclosures or affiliations to disclose

3. About us PICU at Children’s Hospital at the University of Oklahoma in OKC 25 beds ~1600 admissions per year Developing CTS program New surgeon January 2014 ~300 cases 2014

4. About us Staff 7 full time attendings 1 part time 2 on service during day, 1 on service at night Advance Practice Team 7 full time 2 part time 3 Physician Assistants 6 Acute Care Nurse Practitioners 12 hour shifts

5. Vision of the APP Provide exceptional patient care with emphasis on continuity education and research

6. Dilemma With busier cardiac unit and only one physician on at night, how staff APP team most effectively? Meet vision of excellent patient care and continuity Asked AP team recommended a swing shift Looked at VPS data

7. Extracting Data from MyReports View Report ICU Summary – Here we looked at the which days and time of day the PICU had the most admissions. 1300-0100 Swing Shift recommended by APP.

9. APP “Swing Shift” Started August 1, 2014 From 1pm to 1am, Tues-Thurs One APP Predominantly to assist with new admissions and evening coverage in CVICU APP team loved this additional coverage But was it truly helpful with providing excellent patient care?

10. Study Objective Determine if the addition of the APPs for a “swing shift” three nights per week led to 1. Decreased length of stay (LOS) for pediatric post-operative cardiac patients admitted to the PICU and 2. Decrease in mortality, length of intubation, duration of chest tubes, arterial lines, or central venous lines.

11. Study Design R etrospective chart review all pediatric post-operative cardiac patients March 1-July 31, 2014 - before “swing shift” (Group 1) August 1-December 31, 2014 - after “swing shift” (Grop 2) Data from our Virtual PICU Systems database and Meditech

12. Using MyReports, a query was built using a population of: Admission dates from March 1, 2014-July 31, 2014 (before swing shift) and Admission dates from August 1, 2014- December 31, 2014 (after swing shift). Had a cardiac procedure = yes

14. Variables included: Age Gender LOS PIM2 ROM score PRISM3 score Disposition Outcome

16. Extraction of procedure duration for: Endotracheal tubes Chest tubes Arterial Catheters Percutaneous Central Venous Catheters STS procedures divided into Single Ventricle physiology vs not.

19. Statistics The two groups were compared using: Descriptive statistics (Table 1) Fisher’s exact for categorical variables (Table 2) Wilcoxon-Mann-Whitney for non-normal continuous variables (Tables 2&3) A multiple regression model comparing the “swing shift” with LOS as the dependent variable

20. Demographics Group 1 N=103Freq. Group 2 N=94Freq. Male5250.5%5255.3% Female5149.5%4244.7% Single Ventricle Physiology1615.5%1313.8% Mortality54.9%33.2% Age at ICU Admit (mo)* 10 (3, 141) - 5 (2, 67) - Patient Characteristics * Non-normally distributed variables reported as median (25th, 75th percentile)

21. Length of Stay Group 1 Median (IQR) n=103 Group 1 mean (SD) N=103 Group 2 Median (IQR) n=94 Group 2 Mean (SD) n=94P-value 2.80 (1.33, 5.89)*6.20 (10.7) 3.00 (2.01, 5.26) 4.96 (5.69)0.5423 Multiple regression model comparing Group 2 with LOSLower CIUpper CIP-value Estimate of change in LOS0.87 days0.741.020.0759 * Non-normally distributed variables reported as median (25th, 75th percentile)

22. Secondary Outcomes Duration of Continuous Variables Group 1 N Group 1 Median Group 2 N Group 2 Median P- value Arterial Line * 101 1.13 (0.89, 3.00) 93 1.14 (0.80, 2.86) 0.3054 Central Line* 92 2.75 (1.82, 5.84) 78 2.15 (1.78, 4.66) 0.2413 Chest Tube * 91 1.49 (0.96, 2.50) 88 1.53 (1.26, 3.42) 0.1754 Endotracheal Tube * 86 0.68 (0.13, 2.97) 88 0.72 (0.23, 2.92) 0.2915 * Non-normally distributed variables reported as median (25th, 75th percentile)

23. Results Group 1 (before “swing shift”) similar to Group 2 (after “swing shift” ) Groups not normally distributed No statistically significant change in LOS after addition of APP “swing shift” (p=0.5423) However, multiple regression analysis revealed trend toward shorter LOS Estimated change in LOS when “swing shift” was available was 0.87 days, or 21 hours Accounted for factors such as patient disposition, PIM 2, age at ICU admission, mortality, single ventricle physiology No significant difference between groups regarding secondary outcomes

24. Conclusions Trend toward shorter LOS has positive impact Financially (average cost of one PICU day $8,200) PICU resources Families emotionally and psychologically Lack of significance may be related to Small sample size “Swing shift” only 3/7 nights Some patients are transferred back to NICU prior to lines and tubes being removed

25. Future Studies As the APP team expands, night coverage will increase Just recently expanded to include Monday night swing Team will eventually have full coverage of nights Inotropes Patient satisfaction

26. Thanks Kathryn Rougraff, PA-C Summer Frank, MPH Michael Anderson, PhD

27. Questions?