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Janna S. Landsperger, ACNP-BC; Matthew W. Semler, MD
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FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN

CORRESPONDENCE TO: Janna S. Landsperger, ACNP-BC, 11611 21st Ave S., T-1218, Nashville, TN 37232-2650


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


Chest. 2016;150(3):746-747. doi:10.1016/j.chest.2016.06.015
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We appreciate the interest demonstrated by Drs Alrajab and Abubaker in our study of critically ill adults cared for by acute care nurse practitioners (ACNPs). Among almost 10,000 patients admitted to a tertiary medical ICU over 3 years, we observed no difference in outcomes between patients cared for by ACNPs vs resident physicians. Drs Alrajab and Abudbaker express concerns over the ability of ACNPs to handle complex patients and the generalizability of ACNP-delivered critical care to community ICUs.

The assertion that “nurse practitioners cannot handle complex ICU patients” is not supported by our study’s findings or other published data.,, In the manuscript, we described the observed mortality for patients on each service across the spectrum of expected mortality. Even among patients with expected in-hospital mortality > 90%, outcomes on the ACNP and resident teams were comparable. This was confirmed in multivariable and propensity score analyses adjusting for vasopressor receipt, mechanical ventilation, and other potential confounders.

Complexity and severity of illness may be difficult to discern from summary measures. An example of a patient cared for by the ACNP team during the study may help. A 36-year-old woman was admitted with septic shock, disseminated intravascular coagulation, and multiorgan system failure from Enterobacter meningitis. In the 24 hours after ICU admission, she was intubated and started on three vasopressors, as well as continuous renal replacement therapy. Over the next 20 days, she was weaned from vasopressors and renal replacement, extubated, and discharged with follow-up in the ICU recovery clinic staffed by the same ACNPs who cared for her throughout her ICU stay.

We agree with Drs Alrajab and Abubaker that caution is required in generalizing our findings. Both arms of our study occurred in a closed academic tertiary ICU. Every patient’s care was overseen by an intensivist attending physician and a critical care fellow. The ACNPs had prior experience as critical care nurses, substantial in situ training, and the support of the division and hospital administration.

However, the assertion that it would be “dangerous to assume…that complex cases can be handled safely by ACNPs” under physician supervision in community ICUs echoes the early resistance to female physicians, certified nurse anesthetists, and other previously unthinkable providers who are now pillars of the US health-care system. Highly trained well-supervised ACNPs are already taking care of complex critically ill patients in busy community ICUs across the country. More research on this model is needed, but the question will not be “Should…” but “How should ACNPs care for critically ill patients in the community?”

References

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. [CrossRef] [PubMed]
 
Gershengorn H.B. .Wunsch H. .Wahab R. .et al Impact of non-physician staffing on outcomes in a medical ICU. Chest. 2011;139:1347-1353 [PubMed]journal. [CrossRef] [PubMed]
 
Kawar E. .DiGiovine B. . MICU care delivered by PAs versus residents: do PAs measure up? JAAPA. 2011;24:36-41 [PubMed]journal. [PubMed]
 
Costa D. .Wallace D. .Barnato A. .Kahn J. . Nurse practitioner/physician assistant staffing and critical care mortality. Chest. 2014;146:1566-1573 [PubMed]journal. [CrossRef] [PubMed]
 
Huggins E. .Bloom S. .Stollings J. .Camp M. .Sevin C. .Jackson J. . A clinic model: post-intensive care syndrome and post-intensive care syndrome-family. AACN Adv Crit Care. 2016;27:204-211 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

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. [CrossRef] [PubMed]
 
Gershengorn H.B. .Wunsch H. .Wahab R. .et al Impact of non-physician staffing on outcomes in a medical ICU. Chest. 2011;139:1347-1353 [PubMed]journal. [CrossRef] [PubMed]
 
Kawar E. .DiGiovine B. . MICU care delivered by PAs versus residents: do PAs measure up? JAAPA. 2011;24:36-41 [PubMed]journal. [PubMed]
 
Costa D. .Wallace D. .Barnato A. .Kahn J. . Nurse practitioner/physician assistant staffing and critical care mortality. Chest. 2014;146:1566-1573 [PubMed]journal. [CrossRef] [PubMed]
 
Huggins E. .Bloom S. .Stollings J. .Camp M. .Sevin C. .Jackson J. . A clinic model: post-intensive care syndrome and post-intensive care syndrome-family. AACN Adv Crit Care. 2016;27:204-211 [PubMed]journal. [CrossRef] [PubMed]
 
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