After five years as a surgical ICU nurse, University of Maryland nurse practitioner Michelle Willis, CRNP, received an interesting offer from a former classmate, Sharon Boswell.
Boswell wanted Willis to help her develop a team of advanced practice clinicians at the R. Adams Cowley Shock Trauma Center in Baltimore, one of the only stand-alone trauma hospitals in the country. At the time, the hospital was cutting back on medical residents’ hours. Concerned about patient care, hospital administrators wanted to fill the gaps with NPs and PAs.
Willis, who did not have any trauma experience, was a bit intimidated, but also intrigued. After hitting the books to enhance her training, she accepted the job. When she started, the hospital had eight NPs on staff. Today, the R. Adams Cowley Shock Trauma Center has a vibrant interdisciplinary team of more than 30 clinicians, who are integral to the hospital’s success.
“I came to understand it was an honor to be one of the first people in this role,” Willis says. “I still learn something new every day.”
Vulnerable Patients, Unique Needs
In the past six years or so, these talented NPs and PAs have improved patient care and overall efficiency. Communication and continuity of care are at the heart of the improvements they have made, says Benjamin Laughton, MBA, MSN, CRNP, one of Willis’s colleagues: “It’s not one individual that makes us great. It really is the way we work together to create synergy that allows us to have amazing outcomes.”
It’s that reputation for amazing outcomes, and the center’s ability to perform rare and unique life-saving procedures, that attracts patients from all over the world—even the battlefields in Iraq. Some of the wounded soldiers who arrive at the Walter Reed Medical Center via Germany end up at the trauma center when their wounds are so complex that they require interventions no other hospital could offer. Several soldiers with collapsed lungs ended up being treated there with a rare and sophisticated ECMO lung bypass machine.
In addition to veterans of the conflicts in Iraq and Afghanistan, patients at the trauma center have included a man who lost his memory after being hit on the head by a falling tree, another with compound fractures from a car accident, and a motorcyclist who had a broken wrist, fractured pelvis, serious lacerations, and internal bleeding after colliding head-on with a car. Many of the patients are airlifted via helicopter from other cities around the United States.
While the clinicians at the shock trauma center certainly have highly specialized skills and top-of-the-line equipment, it’s something more basic that makes them stand out: good communication skills.
For example, their care extends beyond the immediate emergency in the operating room. They continue to work with patients several weeks after discharge. And they also work closely with the patient’s family and caregivers, since traumatic injuries tend to impact nearly all aspects of life for both patients and families.
Willis says working with families post-discharge is one of her favorite parts of the job. “We see it as an honor to be with the families,” she says. “They are part of our family, too—they’re so much a part of who we are.”
Laughton remembers working with a Spanish-speaking patient who had a feeding tube due to a facial injury. During that time, staff members helped the family learn to create nutritious liquid meals with a blender. “Everybody learned the word for blender in Spanish: liquidora.”
Personal details like those are what hospital administrators are trying to include as they build a new Critical Care Tower at the University of Maryland. They plan to include comfortable waiting areas and services for families on all floors.
When attending physicians cannot be present, it is often an NP or a PA who steps in to be the face of the organization that interacts with caregivers and relatives. “There is so much to be said for the human piece of what we do,” Willis says.
Innovating to Improve Care
Communication between the staff also improves patient care at the trauma center. Since the NP and PA team came aboard, the center has been able to increase the number of patients they treat from 3,000 to 8,000 per year.
Both Willis and Laughton point to the team’s unique system, called discharge rounds, as the key to their success in this area. Each day, all of the health care providers on the team, from physicians and nurses to physical therapists, walk from floor to floor, visiting patients at the bedside.
“We come up with a game plan within about 15 seconds,” Laughton explains. “From that very first day, we start to formulate discharge plans.”
Discharge rounds help the patient get exactly the right level of care at the right time, he says. Everyone is present, so it prevents a lot of wasted time sending missed e-mails and voicemails. Decisions can be made on the spot without a lot of back and forth.
During rounds, patients often reveal new symptoms or issues the staff may not have known about. By listening to patients during discharge rounds, clinicians can zero in on gaps in care. Based on the information they gather during the process, they have been able to change the system to make it work more efficiently.
“These rounds are imperative,” Willis says. “We give better care because problems are identified and addressed quickly.”
The ability to communicate effectively is at the top of the trauma team’s list when they interview new candidates. “It is so much a part of our job, it’s something we select for here,” Laughton says.
Laughton and Willis hope other NPs and PAs might adapt their model of using an interdisciplinary team of clinicians and doing discharge rounds. While it has been especially useful for shock trauma, the model could apply to multiple settings.
For Willis and Laughton, working with other NPs and PAs to improve quality of care at the R. Adams Cowley Shock Trauma Center in Baltimore has been both challenging and empowering.
“I love my job,” Willis says. “It’s a rewarding area of patient care to be in—it takes a lot, but it also gives back a lot.”