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Original Research: Critical Care |

Nurse Practitioner/Physician Assistant Staffing and Critical Care MortalityStaffing and Critical Care Mortality

Deena Kelly Costa, PhD, RN; David J. Wallace, MD, MPH; Amber E. Barnato, MD, MPH; Jeremy M. Kahn, MD
Author and Funding Information

From the Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (Drs Costa, Wallace, and Kahn), Department of Emergency Medicine (Dr Wallace), and Division of General Internal Medicine (Dr Barnato), University of Pittsburgh School of Medicine; and Department of Health Policy and Management (Dr Kahn), University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA.

CORRESPONDENCE TO: Jeremy M. Kahn, MD, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Scaife Hall, Room 602-B, 3550 Terrace St, Pittsburgh, PA 15221; e-mail: kahnjm@upmc.edu


Part of this article has been presented in abstract form at the American Thoracic Society International Conference, May 17-22, 2013, Philadelphia, PA, and the AcademyHealth Interdisciplinary Research Group on Nursing Issues Interest Group Meeting, June 22, 2013, Baltimore, MD.

FUNDING/SUPPORT: This work was supported by the National Institutes of Health National Heart, Lung, and Blood Institute [T32HL007820 to Dr Costa, K23HL082650 to Dr Kahn, and K12HL109068 to Dr Wallace].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1566-1573. doi:10.1378/chest.14-0566
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BACKGROUND:  ICUs are increasingly staffed with nurse practitioners/physician assistants (NPs/PAs), but it is unclear how NPs/PAs influence quality of care. We examined the association between NP/PA staffing and in-hospital mortality for patients in the ICU.

METHODS:  We used retrospective cohort data from the 2009 to 2010 APACHE (Acute Physiology and Chronic Health Evaluation) clinical information system and an ICU-level survey. We included patients aged ≥ 17 years admitted to one of 29 adult medical and mixed medical/surgical ICUs in 22 US hospitals. Because this survey could not assign NPs/PAs to individual patients, the primary exposure was admission to an ICU where NPs/PAs participated in patient care. The primary outcome was patient-level in-hospital mortality. We used multivariable relative risk regression to examine the effect of NPs/PAs on in-hospital mortality, accounting for differences in case mix, ICU characteristics, and clustering of patients within ICUs. We also examined this relationship in the following subgroups: patients on mechanical ventilation, patients with the highest quartile of Acute Physiology Score (> 55), and ICUs with low-intensity physician staffing and with physician trainees.

RESULTS:  Twenty-one ICUs (72.4%) reported NP/PA participation in direct patient care. Patients in ICUs with NPs/PAs had lower mean Acute Physiology Scores (42.4 vs 46.7, P < .001) and mechanical ventilation rates (38.8% vs 44.2%, P < .001) than ICUs without NPs/PAs. Unadjusted and risk-adjusted mortality was similar between groups (adjusted relative risk, 1.10; 95% CI, 0.92-1.31). This result was consistent in all examined subgroups.

CONCLUSIONS:  NPs/PAs appear to be a safe adjunct to the ICU team. The findings support NP/PA management of critically ill patients.

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