How can Adult-Gerontology Acute Care Nurse Practitioners (AGACNPs) optimize care in Long-Term Acute Care Hospitals (LTACHs) and is there data to support hiring Nurse Practitioners (NPs) for these roles?

Optimizing Care in Long-Term Acute Care Hospitals with AGACNPs

Adult-Gerontology Acute Care Nurse Practitioners (AGACNPs) significantly improve care quality and outcomes in Long-Term Acute Care Hospitals (LTACHs) and should be hired for these roles based on evidence showing their ability to enhance identification of acute medical problems and improve care delivery. 1

Role of AGACNPs in LTACHs

Benefits of AGACNP Integration

• AGACNPs can enhance identification of acute medical problems in LTACH settings, improving nursing therapies and medication management for complex elderly patients 1
• They serve as critical members of the interdisciplinary care team, bridging the gap between nursing staff and physicians in settings where physician presence is often limited 1
• AGACNPs can implement a 3-tiered clinical evaluation approach for suspected infections and other acute changes, working with CNAs and on-site nurses to improve early detection and management 1

Staffing Considerations

• LTACHs should employ sufficient staff to adequately care for all residents, with AGACNPs helping to meet the Centers for Medicare and Medicaid Services requirements 1
• Recommended staffing ratios that AGACNPs can help optimize include: CNAs to residents (1:12), RNs plus LPNs to residents (1:30), and RNs to residents (1:120) 1
• AGACNPs can supervise and coordinate care between various levels of nursing staff, improving overall care delivery 1

Evidence Supporting AGACNP Integration in LTACHs

Patient Outcomes

• LTACH patients face significant challenges, with median survival of only 8.3 months and 53% never achieving a 60-day recovery period without inpatient care 2
• The median time LTACH patients spend as inpatients during their remaining life is 65.6%, highlighting the need for specialized geriatric care that AGACNPs can provide 2
• Only 1% of LTACH patients receive palliative care consultations despite poor prognosis, an area where AGACNPs with geriatric training can significantly improve care 2

Quality Improvement and Cost Effectiveness

• Similar acute care for elders units with interdisciplinary teams including advanced practice nurses have demonstrated shorter hospital stays (6.7 vs 7.3 days) and lower costs ($9,477 vs $10,451 per patient) while maintaining functional status 3
• AGACNPs can implement quality improvement initiatives specific to geriatric care in LTACHs, addressing common issues such as delirium prevention, fall reduction, and appropriate medication management 4
• AGACNPs can help address the high rates of hospital-acquired infections in LTACHs, including central line-associated bloodstream infections and ventilator-associated pneumonia 5

Implementation Strategies for AGACNPs in LTACHs

Clinical Protocols and Procedures

• AGACNPs should implement standardized protocols for common geriatric syndromes in LTACHs, including evaluation of fever and infection in older adults 1
• They should conduct initial clinical evaluations focusing on respiratory rate, hydration status, mental status, oropharynx, skin, chest, heart, abdomen, and indwelling devices 1
• AGACNPs should be alert to atypical presentations of infection in elderly patients, including decline in functional status, new confusion, incontinence, falls, deteriorating mobility, reduced food intake, or failure to cooperate with staff 1

Transitions of Care

• AGACNPs can serve as critical liaisons between LTACHs and other healthcare settings, improving care transitions and reducing readmissions 1
• They should develop discharge processes with large-font instructions and appropriate collaboration with home health services and home-safety assessments 1
• AGACNPs should recognize that LTACH patients have prolonged carriage of multidrug-resistant organisms (median 270 days), necessitating appropriate infection control practices during transitions 6

Education and Training

• AGACNPs should provide education to LTACH staff on geriatric-specific care needs and evidence-based practices 1
• They should train nursing staff to recognize early signs of deterioration in elderly patients, as studies show CNAs often misattribute symptoms of serious infections to minor conditions like "colds" 1
• AGACNPs should implement continuing education programs focused on geriatric syndromes, medication management, and palliative care approaches 1

Potential Challenges and Solutions

Infection Control

• AGACNPs must address the high risk of multidrug-resistant organism transmission in LTACHs through evidence-based infection control practices 5
• They should implement surveillance protocols for colonization with resistant organisms, recognizing that 83% of patients remain colonized for at least 4 weeks 6
• AGACNPs should develop protocols for appropriate antibiotic stewardship to reduce the development of resistant organisms 5

Multimorbidity Management

• AGACNPs must address the complex care needs of LTACH patients with multiple comorbidities through comprehensive assessment and care planning 1
• They should implement checklists and standardized workflows to inventory and update active medical problems, reconcile medications, and optimize treatment regimens 1
• AGACNPs should consider patient preferences, goals of care, and quality of life when developing treatment plans for complex LTACH patients 1

In conclusion, AGACNPs play a vital role in optimizing care in LTACHs by enhancing identification of acute medical problems, implementing evidence-based protocols, improving transitions of care, and addressing the complex needs of geriatric patients with multiple comorbidities. The evidence supports hiring AGACNPs for these roles based on their ability to improve care quality and potentially reduce costs while maintaining patients' functional status.