Medical Professional Publications

Surgeon-to-Nurse Practitioner Ratio Offers New Care Model for Orthopedics

(From the November 2014 Issue of PediatricsOnline)

Adopting a 1:1 ratio of orthopedic surgeons to nurse practitioners may offer many benefits for practitioners and patients. The new model helps increase patient volume, reduce wait times, improve patient satisfaction, increase clinic revenue and improve continuity of care in pediatric orthopedic clinics, according to a study conducted by Nationwide Children’s Hospital’s Chief of Orthopaedics, Kevin Klingele, MD, and orthopedic nurse practitioners Pamela Horn and Elizabeth Badowski. The team’s experiences also suggest that the 1:1 surgeon-to-nurse practitioner ratio also offers a way to overcome patient health education barriers, time constraints for scheduling and mentorship, patient confusion regarding procedures and calls regarding at-home care.

“We investigated this care model out of necessity,” says Dr. Klingele, senior author on the study, published in the journal Orthopedic Nursing. “It takes an entire team to help care for the large volume of patients that we have at Nationwide Children’s. This model allows efficient care of such volume to be done in a very personal way. Once we instituted the model, it quickly became apparent how successful it would be.”

The first NP was added to the orthopedic care team at Nationwide Children’s in 2003 to assist with electronic patient records and discharges. As the clinic grew and the NP became more familiar with orthopedic procedures and care, her role was expanded and additional NPs were hired. By 2009, their proficiency convinced the team of physicians that having a greater number of NPs would better address the chief challenges the program faced: long wait times, underutilized caregiver skills and limitations with continuity of care.

The team piloted the 1:1 ratio with a single surgeon-nurse practitioner team in 2011. When patient volume, surgery volume, revenue, continuity of care and patient education improved, the model was expanded to all surgeons on the orthopedic team during 2012. Within one year of instituting the 1:1 care model for all orthopedic surgeons, surgical volumes increased 18 percent — despite the loss of a surgeon — and the percentage of new patients seen increased 3 percent. Improved caregiver and patient satisfaction helped cement the model in the clinic’s care plan.

“This model has markedly improved patient access, allowing more new patient evaluations for physicians, and has substantially improved the preoperative and postoperative care and education of surgical patients,” says Dr. Klingele, who also is the surgical director of Sports Medicine at Nationwide Children’s. “It has also improved efficiency, increased patient and surgeon satisfaction and become a model for other surgical specialties in the hospital to follow.”

The team’s 1:1 care model enables the physician to provide the first evaluation for surgery with a new patient. The NP also sees patients upon their first visit, and that same NP further performs the preoperative consult, postoperative discharge education and follow-up visits in the outpatient clinic. Dr. Klingele credits this continuity of care by the NP with reduced admissions within a seven-day time period over the first year of the model’s implementation.

Although Dr. Klingele is unaware of any other institutions practicing with the same model, his team’s experience has convinced him to highly recommend it. “Many pediatric orthopedic departments utilize physician extenders to manage the volume of patients being seen, but our model encompasses all aspects of patient care,” he says. “This care model could particularly benefit other pediatric orthopedic centers that see a very large population of patients, with high-volume clinics, high inpatient and outpatient surgical volume and a very wide variety of conditions requiring specialized and personalized care.”

Although his program has not yet calculated the precise cost-benefit ratio associated with the NPs’ salaries versus increased clinic revenue, the team projects that over 50 percent of all physician visits will be new patients by 2015. Dr. Klingele says that decreased wait times and increased caregiver and patient satisfaction alone would motivate them to keep the model. And the system’s benefits may not be limited to orthopedics, he suggests.

“Such a model would work in other surgical specialties just as well,” says Dr. Klingele, who also is a clinical assistant professor of orthopedic surgery at The Ohio State University College of Medicine. “With a good group of surgeons and physician extenders, it cannot fail.”

Horn P, Badowski E, Klingele K. Orthopaedic clinical care model in a pediatric orthopaedic setting: outcomes of a 1: 1 model — orthopaedic surgeon and nurse practitioner. Orthopedic Nursing. 2014 May/Jun, 33(3):142-6.

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