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Editorial |

New ICU Team Members: The Effective Inclusion of Critical Care Advanced Practice Providers FREE TO VIEW

Craig M. Lilly, MD, FCCP; Adam W. Katz, MPAS, PA-C
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Craig M. Lilly, MD, FCCP, Department of Medicine, University of Massachusetts Medical School, 281 Lincoln St, Worcester, MA 01605


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(5):1119-1120. doi:10.1016/j.chest.2016.02.666
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Today, the treatment of critically ill and injured adults involves complex care paradigms that are delivered by interprofessional teams at the time of the day or night when evaluation or management is needed. The need for time-sensitive critical care interventions and the steadily rising numbers of adult critically ill and injured patients have sparked interest in new ways to provide timely and effective treatments. Optimal outcomes for patients with serious infections, coronary artery occlusion, stroke, bleeding victims of blunt or penetrating trauma, and patients with acute respiratory failure require distinct treatments that are time sensitive. The rising need for critical care was accurately predicted from models of the aging dynamics of our population and increasing utilization of critical care with decades of life after adolescence.

FOR RELATED ARTICLE SEE PAGE 1146

The effectiveness of one increasingly common approach is presented in this issue by Janna Landsperger who is an acute care nurse practitioner from Vanderbilt. This important study was inspired by the late Arthur Wheeler, MD. Arthur was a preeminent leader in the field of pulmonary and critical care medicine who understood the power and importance of true interprofessional collaboration. This landmark study addresses one of the most pressing and challenging questions facing the critical care community: How are we going to provide high quality care for all of the critically ill and injured patients who need it?

The problem of caring for high-acuity patients who require time-sensitive interventions dates to the time that the first ICUs were created. A closer working relationship of physicians, nurses, and other clinical professionals was central to making the cohorting of high-acuity patients an effective and nearly universally accepted care model. Nearly all effective solutions for high-acuity patients involve team care. In the context of critical care medicine, value has been derived from the creation of interprofessional teams with each team member having a defined role and providing a scope of services that is dictated by training, experience, and license. The current study tests the hypothesis that access to high-quality critical care can be increased by creating new types of critical care professionals who are able to prescribe and perform procedures.

In the Landsperger study, acute care nurse practitioners (ACNPs) that had additional critical care specialty training were supervised by critical care specialists. This study was possible by the interprofessional study team that was assembled by Dr Wheeler and the guided experiential training program that they created and implemented at Vanderbilt. This new class of ICU providers was not made up of recent graduates left to unguided task-oriented work assignments; rather, the ACNPs of this study received 4 months of direct critical care specialist supervised, hands-on, and mentored patient care experience. The formal training paradigm included direct supervision of the ability to recognize critical illness, perform initial patient stabilization tasks, broker the admission process, and ensuring that time-sensitive treatments and procedures were performed successfully when they were needed. The effectiveness of ACNP communication skills that are critical for effective intensivist oversight was documented. Importantly, their professional and procedural competencies were reviewed by critical care specialists who completed formal evaluations of their performance.

The study demonstrated that there was essentially no difference of 90-day mortality for ACNP care team patients compared with resident team patients for teams with equivalent intensivist oversight; the primary study end point. Similarly, secondary end points demonstrated equivalently positive hospital mortality and ICU lengths of stay. Overall, the study demonstrated that nonphysician ICU team members who have adequate training and proper supervision can provide care of comparable quality to the care delivered by a traditional resident model at a highly respected academic medical center.

The finding that ICU teams that include properly trained and supervised advanced practice providers can provide care that is of equivalent quality to that provided by resident staffed teams is consistent with most prior studies.,, Limitations of resident work hours have been associated with the inclusion of nurse practitioners and physician assistants on to an increasing number of critical care teams. Estimates of the inclusion of these provider types from the Medicare and Medicaid databases suggest that their contributions are underestimated from administrative data because the important services of these providers are often outside of professional reimbursement requirements.

The team at Vanderbilt and its late leader, Dr Arthur Wheeler, are to be congratulated for putting together a nonphysician-based care team with a formal, dedicated, mentored, training model that documented proficiency of key critical care delivery skills. The study is important because it supports an increasingly common approach to providing high quality adult critical care. As with most important studies, this work raises interesting new questions. Taken in the context of its predecessor studies, it provides a foundation for defining the scope of practice and training requirements that should be used to grant credentials to advanced practice providers who practice in ICUs. It also raises the question of how the longitudinal educational and professional needs of ICU advanced practice providers should be supported. Unfortunately, there is little to be learned about longitudinal support or the professional needs of advanced practice providers from our experience with ICU residents and fellows. The description of the intervention at Vanderbilt may understate the importance of the encouragement and vision for individual professional growth that Dr Wheeler provided for the advanced practice providers that he mentored.

The accumulated evidence suggests that properly trained and supervised nonphysician prescribing providers can provide high-quality critical care. The question remains: “Where and when should they provide care?” It appears that properly trained advanced practice providers that can effectively communicate with a supervising board-certified intensivist should provide care wherever patient need exists and they are credentialed to provide it.

References

Angus D.C. .Shorr A.F. .White A. .et al Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016-1024 [PubMed]journal. [CrossRef] [PubMed]
 
Alsarraf A.A. .Fowler R. . Health, economic evaluation, and critical care. J Crit Care. 2005;20:194-197 [PubMed]journal. [CrossRef] [PubMed]
 
Landsperger J.S. .Semler M.W. .Wang L. .Byrne D.W. .Wheeler A.P. . Outcomes of nurse practitioner-delivered critical care: a prospective cohort study. Chest. 2016;149:1146-1154 [PubMed]journal
 
Gershengorn H.B. .Wunsch H. .Wahab R. .et al Impact of nonphysician staffing on outcomes in a medical ICU. Chest. 2011;139:1347-1353 [PubMed]journal. [CrossRef] [PubMed]
 
D'Agostino R. .Halpern N.A. . Acute care nurse practitioners in oncologic critical care: the Memorial Sloan-Kettering Cancer Center experience. Crit Care Clin. 2010;26:207-217 [PubMed]journal. [CrossRef] [PubMed]
 
Christmas A.B. .Reynolds J. .Hodges S. .et al Physician extenders impact trauma systems. J Trauma. 2005;58:917-920 [PubMed]journal. [PubMed]
 
Pastores S.M. .O'Connor M.F. .Kleinpell R.M. .et al The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med. 2011;39:2540-2549 [PubMed]journal. [CrossRef] [PubMed]
 
McCarthy C. .O'Rourke N.C. .Madison J.M. . Integrating advanced practice providers into medical critical care teams. Chest. 2013;143:847-850 [PubMed]journal. [CrossRef] [PubMed]
 
Manaker S. . Who will care for our critically ill? Chest. 2013;143:594-595 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Angus D.C. .Shorr A.F. .White A. .et al Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016-1024 [PubMed]journal. [CrossRef] [PubMed]
 
Alsarraf A.A. .Fowler R. . Health, economic evaluation, and critical care. J Crit Care. 2005;20:194-197 [PubMed]journal. [CrossRef] [PubMed]
 
Landsperger J.S. .Semler M.W. .Wang L. .Byrne D.W. .Wheeler A.P. . Outcomes of nurse practitioner-delivered critical care: a prospective cohort study. Chest. 2016;149:1146-1154 [PubMed]journal
 
Gershengorn H.B. .Wunsch H. .Wahab R. .et al Impact of nonphysician staffing on outcomes in a medical ICU. Chest. 2011;139:1347-1353 [PubMed]journal. [CrossRef] [PubMed]
 
D'Agostino R. .Halpern N.A. . Acute care nurse practitioners in oncologic critical care: the Memorial Sloan-Kettering Cancer Center experience. Crit Care Clin. 2010;26:207-217 [PubMed]journal. [CrossRef] [PubMed]
 
Christmas A.B. .Reynolds J. .Hodges S. .et al Physician extenders impact trauma systems. J Trauma. 2005;58:917-920 [PubMed]journal. [PubMed]
 
Pastores S.M. .O'Connor M.F. .Kleinpell R.M. .et al The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med. 2011;39:2540-2549 [PubMed]journal. [CrossRef] [PubMed]
 
McCarthy C. .O'Rourke N.C. .Madison J.M. . Integrating advanced practice providers into medical critical care teams. Chest. 2013;143:847-850 [PubMed]journal. [CrossRef] [PubMed]
 
Manaker S. . Who will care for our critically ill? Chest. 2013;143:594-595 [PubMed]journal. [CrossRef] [PubMed]
 
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