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Point and Counterpoint |

POINT: Should Nurse Practitioners Perform Transbronchial Biopsies? YesNurses and Transbronchial Biopsies? Yes FREE TO VIEW

Nancy P. Blumenthal, MSN, ACNP-BC
Author and Funding Information

From the University of Pennsylvania Lung Transplant Program; and the Doctor of Nursing Practice Program, Yale University, West Haven, CT.

CORRESPONDENCE TO: Nancy P. Blumenthal, MSN, ACNP-BC, University of Pennsylvania Lung Transplant Program, 3400 Spruce St, Philadelphia, PA 19104; e-mail: nancy.blumenthal@uphs.upenn.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


Chest. 2015;147(3):594-595. doi:10.1378/chest.14-2838
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Published online

The model of health-care delivery in the United States is evolving to endorse collaborative and multidisciplinary care delivered to more people with fewer complications at a lower cost. In response to the nation’s demand for health-care reform, the Institute of Medicine (IOM) produced the landmark report, The Future of Nursing: Leading Change, Advancing Health.1 Herein, the IOM sounded a clarion call for nurses to practice to the full extent of their education and training. Can nurse practitioners (NPs) do transbronchial biopsies? Yes. Should they? According to the IOM, if they can, they should. This is consistent with the balanced ideals of quality, access, and cost which must be given due consideration in any theoretical debate about delivery of health care.2

Physicians and NPs view clinical dilemmas from the perspectives of different scientific disciplines. However, our philosophies of care are compatible and, when realized appropriately, mutually supportive. Our academic paradigms are immaterial to this debate. We learn the same human anatomy. We share the same concern for our patients. We are all committed to providing timely care with precision and accuracy. Rather than set limits on which clinicians perform a needed procedure, the professional and lay communities are better served by interdisciplinary cooperation aimed at defining and validating optimally safe and effective procedural training, techniques, and environments of care. NPs should perform transbronchial biopsies because excuses for prohibition are unfounded.

This argument is predicated on two assumptions. (1) Care should only be delivered by clinicians who have been educated and trained in their practice area and have demonstrated competency in their skills. (2) Competition in the business of health care should not impede a patient’s access to health care. The first assumption is self-evident. The second distills market competition and restraint of trade from the discussion.

As in medical education, didactic and practical preparation of NPs includes indications and performance of invasive procedures. The American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties have put forth a statement that guides NP training and certification.3 This statement establishes that demonstration of competency is a requirement of the basic preparation of an NP. As is the case in medical training, NPs’ mastery of skills is achieved in practice with supervision and support. Like physicians, NPs must be individually assessed and deemed competent to perform an invasive procedure before being granted privileges to do so by their hospital credentialing committees.

Meeting standards of care, NPs are prepared to safely and effectively perform myriad invasive procedures. For example, performing colonoscopy and placing chest tubes, Swan-Ganz catheters, intracranial pressure monitors, and dialysis catheters are all de rigueur for NPs trained and practicing in acute care settings. Several randomized, controlled studies describe that complication rates and patient satisfaction rates are comparable between NPs and physicians.4-8

Essential to the ability to competently perform an invasive procedure is the recognition and management of potential complications. The most common complications associated with transbronchial biopsies are bleeding and pneumothorax. Following advanced cardiac life support protocols and placing thoracostomy tubes are well within the purview of the NP, though support in the bronchoscopy suite should be available to all bronchoscopists.9

In establishing the American College of Chest Physicians (CHEST) guidelines for interventional pulmonary procedures, Ernst and colleagues9 advocate for consistency in determining basic skills and competency of bronchoscopists. The international work group was composed of pulmonologists, thoracic surgeons, academics, and private practitioners who achieved consensus in defining parameters for the indication, technique, risks, and training requirements to perform interventional pulmonary procedures. A medical degree was not identified as a prerequisite. Rather, the group prioritized the importance of experience in establishing and maintaining competency in each of the bronchoscopic interventions. Recognizing interoperator variability, they specified that the personalized determination of competency should be made by senior or supervising bronchoscopists.9

The role of the NP was developed in the 1960s to meet a void in primary care and public health in rural communities.10 More recently, physician shortages born from residency work hour restrictions have given rise to broader responsibilities of NPs in tertiary care settings.11 By virtue of the Affordable Care Act (ACA), an estimated 32 million Americans will be newly insured and brought to medical attention.12 As lung cancer remains the most common lethal malignancy worldwide, we should expect an increased demand for diagnostic procedures such as transbronchial biopsy. It is in the population’s best interest to promote rather than limit access to the number of providers who can perform diagnostic services. Optimizing access to care is also sound business planning.

It has been demonstrated that significant downstream revenue is captured following a single encounter for endobronchial ultrasound.13 This is generalizable to other diagnostic pulmonary procedures. While overhead is significant and includes malpractice insurance as well as equipment and staff expenses, the procedure should be recognized as an ingress for patients who will require further evaluation, monitoring, and management. Reimbursed by Medicare at 85% of physician rates, NPs are more cost effective in delivering the same care. Minimizing cost has been mandated by legislators, payors, and patient advocacy groups.

In this time of scientific advancement, patient influx and regional provider shortages, the American health-care system is scrambling to react and prepare for more patients. The Affordable Care Act promises to bring millions of patients into a health-care system already fraught with inefficiencies and excesses. The IOM has identified the optimal utilization of nurses as essential to health reform. Advanced practice nurses, in particular, offer a skill set focused on prevention, adaptability, and independence. The debate about who should provide what kind of care should be settled on metrics of quality, access, and cost. Interdisciplinary collaboration benefits everyone.

Ultimately, the safe performance of transbronchial biopsy requires knowledge, dexterity, critical thinking, and experience. These attributes are not unique to graduates of medical schools.

IOM

Institute of Medicine

NP

nurse practitioner

PJP

Pneumocystis jirovecii pneumonia

TBLB

transbronchial lung biopsy

Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
 
Carroll A. The “iron triangle” of health care: access, cost, and quality. The JAMA Forum. news@JAMA website. http://newsatjama.jama.com/2012/10/03/jama-forum-the-iron-triangle-of-health-care-access-cost-and-quality/. October 3, 2012. Accessed August 31, 2014.
 
American Association of Colleges of Nursing. Adult gerontology acute care nurse practitioner competencies. http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/adult-geroaccompsfinal2012.pdf. Published 2012. Accessed September 4, 2014.
 
Ahnen DJ, Lieberman DA. Colonoscopy training for nurse endoscopists: is it possible? Is it wise? Is it worth doing? Gastrointest Endosc. 2009;69(3 pt 2):696-699. [CrossRef] [PubMed]
 
Bevis LC, Berg-Copas GM, Thomas BW, et al. Outcomes of tube thoracostomies performed by advanced practice providers vs trauma surgeons. Am J Crit Care. 2008;17(4):357-363. [PubMed]
 
Gershengorn HB, Johnson MP, Factor P. The use of nonphysician providers in adult intensive care units. Am J Respir Crit Care Med. 2012;185(6):600-605. [CrossRef] [PubMed]
 
Hill M, Baker G, Carter D, et al. A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. J Neurosci Nurs. 2012;44(4):188-193. [CrossRef] [PubMed]
 
Hopchik J. Expanding the role of the advanced practice registered nurse as an endoscopist. Gastroenterol Nurs. 2013;36(4):289-290. [CrossRef] [PubMed]
 
Ernst A, Silvestri GA, Johnstone D; American College of Chest Physicians. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717. [CrossRef] [PubMed]
 
DeAngelis CD. Nurse practitioner redux. JAMA. 1994;271(11):868-871. [CrossRef] [PubMed]
 
Gordon CR, Axelrad A, Alexander JB, Dellinger RP, Ross SE. Care of critically ill surgical patients using the 80-hour Accreditation Council of Graduate Medical Education work-week guidelines: a survey of current strategies. Am Surg. 2006;72(6):497-499. [PubMed]
 
Updated estimates for the insurance coverage provisions of the Affordable Care Act. 2012. Congressional Budget Office website. www.cbo.gov/publication/43076. Published 2012. Accessed July 12, 2014.
 
Pastis NJ, Simkovich S, Silvestri GA. Understanding the economic impact of introducing a new procedure: calculating downstream revenue of endobronchial ultrasound with transbronchial needle aspiration as a model. Chest. 2012;141(2):506-512. [CrossRef] [PubMed]
 

Figures

Tables

References

Institute of Medicine. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
 
Carroll A. The “iron triangle” of health care: access, cost, and quality. The JAMA Forum. news@JAMA website. http://newsatjama.jama.com/2012/10/03/jama-forum-the-iron-triangle-of-health-care-access-cost-and-quality/. October 3, 2012. Accessed August 31, 2014.
 
American Association of Colleges of Nursing. Adult gerontology acute care nurse practitioner competencies. http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/competencies/adult-geroaccompsfinal2012.pdf. Published 2012. Accessed September 4, 2014.
 
Ahnen DJ, Lieberman DA. Colonoscopy training for nurse endoscopists: is it possible? Is it wise? Is it worth doing? Gastrointest Endosc. 2009;69(3 pt 2):696-699. [CrossRef] [PubMed]
 
Bevis LC, Berg-Copas GM, Thomas BW, et al. Outcomes of tube thoracostomies performed by advanced practice providers vs trauma surgeons. Am J Crit Care. 2008;17(4):357-363. [PubMed]
 
Gershengorn HB, Johnson MP, Factor P. The use of nonphysician providers in adult intensive care units. Am J Respir Crit Care Med. 2012;185(6):600-605. [CrossRef] [PubMed]
 
Hill M, Baker G, Carter D, et al. A multidisciplinary approach to end external ventricular drain infections in the neurocritical care unit. J Neurosci Nurs. 2012;44(4):188-193. [CrossRef] [PubMed]
 
Hopchik J. Expanding the role of the advanced practice registered nurse as an endoscopist. Gastroenterol Nurs. 2013;36(4):289-290. [CrossRef] [PubMed]
 
Ernst A, Silvestri GA, Johnstone D; American College of Chest Physicians. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717. [CrossRef] [PubMed]
 
DeAngelis CD. Nurse practitioner redux. JAMA. 1994;271(11):868-871. [CrossRef] [PubMed]
 
Gordon CR, Axelrad A, Alexander JB, Dellinger RP, Ross SE. Care of critically ill surgical patients using the 80-hour Accreditation Council of Graduate Medical Education work-week guidelines: a survey of current strategies. Am Surg. 2006;72(6):497-499. [PubMed]
 
Updated estimates for the insurance coverage provisions of the Affordable Care Act. 2012. Congressional Budget Office website. www.cbo.gov/publication/43076. Published 2012. Accessed July 12, 2014.
 
Pastis NJ, Simkovich S, Silvestri GA. Understanding the economic impact of introducing a new procedure: calculating downstream revenue of endobronchial ultrasound with transbronchial needle aspiration as a model. Chest. 2012;141(2):506-512. [CrossRef] [PubMed]
 
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