A circumcision clinic led by nurse practitioners (NPs) had a 5-year complication rate of 4.1% as compared with 3.4% for circumcisions performed by physicians. Neither the overall rate nor any of the rates for specific types of complications differed significantly between NPs and MDs, reported Jonathan A. Gerber, MD, of Texas Children’s Hospital (TCH) in Houston, at the American Urological Association annual meeting.
The second study showed a 3-year complication rate of about 5% for circumcisions performed by a specially trained physician assistant (PA). That compared with complication rates of 4%-5% in published reviews of physician-performed circumcisions. The PA-performed circumcisions also generated substantial revenue for the urology practice, said Kaity Colon-Sanchez, PA-C, of Nemours Children’s Hospital in Orlando.
About 70%-80% of newborn male infants undergo circumcision, making it the most common urologic procedure. An ongoing shortage of pediatric urologists has created a significant imbalance between the need for circumcision and the resources to provide the service. To address the problem, TCH established an APP-led newborn circumcision clinic, said Gerber.
One previous study documented results of a service wherein NPs performed minor urologic procedures, but the procedures all occurred in an operating room. The TCH service is provided in an outpatient setting.
Pediatric urologists trained APPs to perform Gomco clamp circumcisions. The training consisted of observing 10 newborn circumcisions, assisting in 10 procedures, and then performing 10 circumcisions under direct supervision of a pediatric urologist. Thereafter, a pediatric urologist was on call for all APP-performed circumcisions. APPs were limited to performing circumcisions for infants <30 days old and weighing <10 lbs.
Investigators retrospectively reviewed records for circumcisions performed over a 5-year period, which allowed for comparison of outcomes before and after implementation of the APP-led clinic.
Gerber reported data for 314 APP-performed circumcisions and 237 performed by pediatric urologists. The analysis focused primarily on complications. The study population had a mean age of 23.8 days and mean weight of 8.6 pounds. Physicians performed circumcisions on older (28.4 vs 20.3 days, P<0.0001) and heavier (8.9 vs 8.4 lb, P<0.0063) infants and used more lidocaine per procedure (0.96 vs 0.8 mL).
Overall, 21 complications occurred, with no significant differences between the APP and physician procedures:
Total: 13 (4.1%) vs 8 (3.4%)
Revision circumcision: 1 each
30-day return to emergency department (ED): 2 vs 0
Other penile surgery: 2 vs 4
Intraprocedure bleeding: 11 vs 4
The data showed no difference in outcomes for patients <30 vs ≥30 days or weight <10 vs ≥10 lbs, the traditional age and weight cutoffs for uncomplicated circumcision.
Colon-Sanchez reported her 3-year experience performing clinic-based circumcision in a pediatric urology service. She evaluated 371 infants for neonatal circumcision. They had a mean age of 7.8 weeks (range of 1 to 13 weeks) and weighed an average of 5.2 kg (11.4 lbs) and had a weight range of 3.2-7.5 kg. Subsequently, 95 infants did not undergo circumcision, 91 because of an abnormal genital exam. Colon-Sanchez performed 272 circumcisions with the Plastibell device and four with the Gomco device.
The clinic charged $366 for families that paid for the procedures themselves, and billed $722 when procedures were covered by insurance. Colon-Sanchez noted that the 95 patients excluded from the analysis did not represent lost revenue, as the office visit was considered billable and many of the patients required additional surgery.
Records revealed a complication rate of 6.43%, consisting of retained Plastibell device in 1.80% of cases, swelling in 1.40%, adhesions in 1.10%, cosmesis issues in 0.73%, and ED visits for bleeding in 1.40%.
The results compared favorably with those from studies of circumcisions performed by physicians, said Colon-Sanchez. A study of more than 1,000 circumcisions performed by pediatricians and ob/gyns showed an acute complication rate of 3.9%, all involving bleeding. A study of 9,000 surgeries at a pediatric urology service showed that 4.7% of the procedures involved late complications of circumcisions. Additionally, 7.4% of visits to the pediatric urology outpatient clinic during a 1-year period involved concerns related to newborn circumcisions.
In response to a question, she described a training program similar to the one the APPs in Gerber’s study completed. She said she felt comfortable with her abilities after about 30 procedures.
Gerber and Colon-Sanchez disclosed no relevant relationships with industry.
Matt Austin, PhD, an assistant professor in the school’s Armstrong Institute for Patient Safety and Quality, and Jordan Derk, MPH, used the latest data from Leapfrog’s semiannual hospital safety grades to estimate that there are 161,250 such deaths each year, down from the 206,000 deaths they estimated three years prior, according to their report.
Austin and Derk said they used 16 measures from Leapfrog’s 2019 data to identify deaths that could clearly be attributed to a patient safety event or closely related prevention process. The reduction is the result of two main factors, they wrote: One, hospitals have made some improvement on the performance measures included in Leapfrog’s safety grades. And, two, some of the measures “have been re-defined and rebaselined” in the past three years, they wrote.
Furthermore, these data likely represent an undercount, Austin and Derk wrote, noting that other studies have estimated anywhere from 44,000 to 440,000 deaths due to medical errors.
“The measures included in this analysis reflect a subset of all potential harms that patients may encounter in U.S. hospitals, and as such, these results likely reflect an underestimation of the avoidable deaths in U.S. hospitals,” they wrote.
“Also, we have only estimated the deaths from patient safety events and have not captured other morbidities that may be equally important,” they added.
The updated analysis was released to coincide with the latest release of Leapfrog’s controversial scores, which assessed quality data from more than 2,600 hospitals and assigned each an “A” through “F” letter grade.
Less than one-third (32%) of hospitals secured an “A” grade. More than a quarter (26%) earned a “B.” The group gave a “C” to another 36%, a “D” to 6%, and an “F” to less than 1% of hospitals.
The analysis from Austin and Derk found that the rate of avoidable deaths per 1,000 admissions was 3.24 at “A” hospitals, 4.37 at “B” hospitals, 6.08 at “C” hospitals, and 6.21 and “D” and “F” hospitals combined. That means patients admitted to a “D” or “F” hospital face nearly double the risk of those admitted to an “A” hospital, the Leapfrog group said.
Work-life balance is a hot concept in the nursing profession. We hear we need it. We want to achieve it. But does it really exist?
That question has piqued the interest of Adele A. Webb, PhD, RN, FNAP, FAAN, senior academic director of workforce solutions at Capella University in Minneapolis.
Webb plans to study and delve into the concept of work-life balance and nurses. She said recent conversations with nurse executives, including those at HealthLeaders Media 2017 CNO Exchange, left her realizing that the idea needs to be better defined.
For example, if a nurse must take off from work to stay home with a sick child, on that day, family needs more focus than work. And there are times, especially for those who work weekends or holidays, where work will eclipse family.
Still, Webb said she understands the desire behind the idea of work-life balance.
Another question Webb said she is pondering is, “How then do we address or encourage satisfaction and what does that mean?”
She said she has noticed, even among her own family, that different generations of nurses crave different things.
“I have a daughter and a granddaughter who are nurses. My granddaughter is definitely a Millennial. She’s 24, new in her career, and what she wants is opportunity,” Webb said. “She’s always reading, trying to better her skills, and to learn something new.”
This drive to further their skills and their careers is a trait often tied to the Millennial generation. However, it can also be a factor that contributes to their workplace turnover. According to the RN Work Project, almost 18% of newly licensed RNs leave their first employer within the first year.
“How exciting it would be for a young nurse to have the opportunity to be on the quality committee at a hospital. Or to have the opportunity to contribute to care algorithms or standards or care or policies?” she added. “They would learn [so much] from it [and] they could contribute so much.”
While baby boomers are more likely to stay in their positions, they, too, have a need for life satisfaction and often value time and self-fulfillment, said Webb.
For example, offering tuition assistance to pursue a master’s degree may give this generation a sense of satisfaction. Or they may find fulfillment in sharing the knowledge they’ve garnered over their years of experience.
“[Give them] the opportunity to be involved, and be on a budget committee at the hospital and understand the finances and the contributions they make,” Webb suggested. “Train them to be preceptors. Let them share that knowledge with the younger generation.”
What’s Next?
Webb is in the early stages of reviewing published literature for existing information on work-life balance and satisfaction, and plans to interview nurses about their insights. Once she has a working thesis, she plans to connect with nursing professionals through presentations and conferences to see whether her definition and evaluation of work-life balance or work-life satisfaction rings true.
In a recent Health Affairs study, Aiken and colleagues assessed safety at 535 hospitals in four large states during two time points between 2005 and 2016, and reported that the results were “disappointing.” Only 21% of the hospitals showed “sizeable improvements” in “work environment scores” while 7% saw their scores worsen, Aiken said.
Another 71% of hospitals “basically remained the same,” she said.
Aiken also reported a similar lack of improvement in patient safety measures at hospitals that showed little improvement in their work environment. In the study, about 30% of nurses graded their own hospitals “unfavorably” on measures of patient safety and infection prevention and about 31% of nurses had high scores on the Maslach Burnout Inventory.
And despite the “blame-free culture” espoused by the 1999 report, which stressed that errors are due to problems with systems not individuals, 50% of the nurses in the study by Aiken’s group reported that they believed their errors would be held against them, she said.
Aiken said the recommendation for how to fix the situation hasn’t changed since it was outlined in the 1999 report — “identify safe nurse staffing and supportive work environments as patient safety interventions.”
In another Health Affairs study, Margaret Smith, MD, of the University of Michigan Medical School in Ann Arbor, and colleagues examined the interpersonal and organizational factors that may increase the chance of “failure to rescue,” or deaths following a major surgical complication.
“We decided to take a slightly different view and look at interpersonal, organizational dynamics and their relationship with rescue,” she explained at the Tuesday panel.
Recent studies have explored targets for interventions that could improve rescue, and focused on resource-heavy solutions, such as increasing ICU staff or improving nurse-patient ratios. While important, these factors only account for a proportion of the variation seen in rescue rates among hospitals, Smith noted.
The typical course of events is an operation, followed by a seminal complication, then a domino effect of other complications, which ultimately end in a patient’s death, she added.
Smith’s group conducted 50 semi-structured interviews at five hospitals across Michigan with a range of providers (surgeons, nurses, respiratory therapists), and asked what they felt were the greatest contributors to effective rescue. The study was done from July to December 2016.
After recording and transcribing each 30-60 minute interview, Smith and colleagues identified five core elements as being part of the “successful rescue” of surgical patients:
Teamwork: working well together in moments of crisis
Action taking: responding swiftly after identifying a complication
Psychological safety: ability of all clinicians to feel comfortable expressing their concerns regardless of where they fit in the clinical hierarchy
Recognition of complications
Communication
The interviewed clinicians said they generally felt they performed well on the first three measures, but said early recognition of complications and effective communication were areas that needed improvement, Smith stated.
For example, attending surgeons said they did not think complications were spotted early enough. “When we’re talking about early recognition, people have this kind of clinical hunch [that] ‘something’s wrong’… [and] how that’s communicated is often very poor,” Smith said.
The challenge is how to communicate these “hunches” in a way that everyone understands them and ways that trigger actionable steps, she added.
In terms of communication, a senior nurse reported that when more providers cared for a single patient, it was more challenging to pass information along, or have information miscommunicated or misinterpreted.
Smith recommended that hospitals focus upstream of these potential crises by providing all clinicians, regardless of their experience, with the tools to know when a patient is deviating from a normal trajectory.
Her group also stressed the need for more effective language in communicating concerns.
“We need to ‘tool and task’ these providers with the skill-set to work on these multidisciplinary teams to communicate and identify developing complications,” she said.
Smith said her group is developing pilot programs to help clinicians recognize when patients are deviating from a traditional course.
If a patient completes a procedure without a complication, certain daily benchmarks should be expected. These benchmarks would be given to junior nurses and night staff, so that even without years of experience, they can recognize when a patient is not on track, Smith said.
Expect more non-physician professional hires in correctional institutions
When correctional nurse author and educator Lorry Schoenly, PhD, RN, was writing a book about nursing in prison, her publisher asked her who would buy the book. “We were trying to figure out how many correctional nurses there are,” said Schoenly who scoured state boards of nursing for the numbers of those specializing in corrections. But, unlike cardiology or obstetrics, correctional nursing was rarely listed as a specialty and Schoenly was unable to get a reliable count. “It’s an invisible field,” she said.
Although rising rates of overall incarceration leveled off in 2006 and reversed a bit after 2015, life sentences have increased almost five-fold since 1984.
This increase in life sentences, along with longer sentences and more incarceration late in life, has contributed to a trend, often referred to as the greying of the inmates. “People are growing old in prison,” said Owen Murray, DO, MBA, vice president of offender health services at the University of Texas Medical Branch in Galveston.
UConn Health noted that inmates 50 and older are the fastest growing demographic in federal prisons. With advancing age comes an increase in chronic disease, physical disability and cognitive decline. In Texas, there is pressure to either maintain current staffing or add more providers due to this shifting demographic. Spending per state is associated with, among other factors, the percentage of individuals 55 and older who are incarcerated, according to the Pew Charitable Trusts.
Murray has noticed a rising presence of NPs and PAs over the past three decades. “Certainly as it relates to both jail and prison medicine, there has been a significant increase not just within the state of Texas but pretty much every other state that I’m familiar with in terms of the growth opportunities for midlevel providers.”
According to the American Academy of Physician Assistants, the absolute number of PAs working in prisons increased from 1995 to 2015. For NPs, a survey conducted by the American Association of Nurse Practitioners demonstrated that since 1999 the estimated NP population working in corrections has grown from 550, or 0.8%, of total NPs in 1999, to 2,400, or 1.1%, in 2016.
According to UConn Health, staffing depends on the medical acuity of the inmates, the inmate population and the level of onsite infirmary services.
Predicting future workforce demand for NPs and PAs depends on many conditions beyond sentencing, policy, and crime rates, according to National Institute of Corrections, and incarceration rates could change again depending on policy of the Trump administration. Whether that means releasing low-level offenders, potentially increasing the number of immigrant detainees, diverting offenders from the criminal justice system, or rollbacks in sentencing reform is unclear.
As people enter prison with high health needs – from a lack of preventive healthcare, substance abuse, or homelessness — for some, incarceration provides stability. “There’s an expression,” said Mallik-Kane, “three hots and a cot,” meaning regular meals and shelter. “A person with medical needs might now have access to healthcare. On the other hand, there’s criticism of the quality of prisoner health services.”
In an Urban Institute study of a group of people returning to a major city from prison, 80% of men and 90% of women had chronic health conditions requiring treatment or management; 15% of men and more than one-third of women reported a diagnosis of depression or mental illness.
In Texas, as the complexity of care has grown, the demand for PAs and NPs has grown. “The midlevel provider group has really become the backbone of our delivery system augmented with our physician group,” said Murray.
Yet as prisoners’ medical acuity has increased, healthcare spending in corrections has decreased from a peak in 2009. In some states, the downturn stems in part from a reduced prison population. But states with relatively larger shares of older inmates have higher per-inmate spending for these more complex patients continues to pose a fiscal challenge.
According to Maria Schiff of The Pew Charitable Trusts, outsourcing the employment of clinicians has become increasingly appealing for states to overcome the challenges of recruiting healthcare workers to remote prisons. Private entities can offer hiring incentives, student loan repayments, and bonuses where state agencies are prohibited from doing so.
Schiff said there are 50 different programs in the U.S. since each state raises its own tax money and allocates to corrections. “There’s no nurse to patient ratio that is standard among hospitals, and [corrections departments] are no different, but states do track the age, the gender and certainly the average daily census of who they’re incarcerating,” she said. Anecdotally, several states noted that their staffing ratio of NPs or PAs to physicians is about two to 2.5 to one.
Two issues that remain for any provider considering a job in corrections is their personal safety and litigation exposure.
Unlike outpatient settings, providing continuity, rapport and safety in correctional healthcare can sometimes prove impractical. Inmates are moved often and even in secured settings, the risk of violence and danger is ever present. “A big theme is always personal safety,” said Schoenly. “And the expectation is that you’re doing evidence based standard of care because it’s very litigious. We have a saying that if you haven’t been named in a lawsuit, you haven’t been in correctional healthcare very long.”
The Joint Commission’s presence is limited in correctional healthcare. Unless a health care organization is in a state that requires its accreditation or is in part of an agency such as Veteran’s Affairs or the Department of Defense, which also require accreditation, its process is voluntary. The Joint Commission doesn’t require specific staffing levels, but it does require a sufficient number and mix individuals to support safe care. The American Correctional Association (which declined to comment for this article) and National Commission on Correctional Healthcare operate in corrections and can be consulted to review their policies and procedures. Accreditation can sometimes offer a layer of protection against malpractice, but does not ensure immunity.
These risks do come with rewards, said Schoenly, who views correctional healthcare as a mission to serve the most underserved population in healthcare, and one with broad public health implications, since most inmates do return to society. “You realize that this is really a part of our society who is marginalized and who desperately needs healthcare,” said Schoenly. “And the idea that it’s a vulnerable population with great need can draw in individuals who want to possibly help and improve society.”
