Outcomes of Nurse Practitioner-Delivered Critical Care: A Prospective Cohort Study

Establishing excellence: Implementation of an onboarding and continuing education curriculum for pediatric intensive care unit nurse practitioners and physician associates

ABSTRACT

This study describes a novel curriculum for onboarding and clinical education for nurse practitioners and physician associates (NPs and PAs) in the pediatric intensive care unit setting. The objective was to provide details on the initial orientation and continuing education program to ensure the attainment of knowledge and skills needed to care for critically ill patients safely and effectively. A needs assessment was completed, and a knowledge gap identified in five themes: (1) in-depth knowledge on common critical care diagnoses; (2) understanding of pathophysiology; (3) disease management processes; (4) critical thinking; and (5) procedure competency. Using Kern 6-step curriculum and the Kirkpatrick evaluation model, we designed a program for orientation and continuing education for critical care NPs and PAs. Transformative learning theory provided the framework for the program because the cyclical steps of disorienting dilemma, critical reflection, discourse, and action were used repeatedly to transform a new graduate to a competent critical care provider and then into an expert who is able to, in turn, teach others. A total of 31 NPs and 5 PAs completed the 12-week orientation phase. Participants reported that the orientation phase was valuable to their educational advancement and increased critical care knowledge. All participants showed improvement in knowledge, skills, and ability to provide competent patient care.

Teams in Transition: Increasing Role of Advanced Practice Providers in Antimicrobial Use and Infectious Diseases Consultation

Background

Advanced practice providers (APPs) have taken on increasing responsibilities as primary team members in acute care hospitals, but the impact of this practice shift on antimicrobial prescribing and infectious diseases (ID) consultation requests is unknown. Here we describe longitudinal trends in antimicrobial days of therapy (DOT) and ID consultation by attributed provider type in 3 hospitals.

Methods

We performed a retrospective time series analysis of antimicrobial use and ID consultation from July 2015 to June 2022 at a major university hospital and 2 community hospitals. We evaluated antimicrobial DOT and ID consultation over time and assessed attribution to 3 groups of providers: attending physicians, trainees, and APPs. We used multinomial logistic regression to measure changes in percentage of DOT and ID consultation across the clinician groups over time using physicians as the referent.

Results

Baseline distribution of antimicrobial DOT and ID consultation varied by practice setting, but all subgroups showed increases in the proportion attributable to APPs. Large increases were seen in the rate of ID consultation, increasing by >30% during the study period. At our university hospital, by study end >40% of new ID consults and restricted antimicrobial days were attributed to APPs.

Conclusions

Hospitals had differing baseline patterns of DOT attributed to provider groups, but all experienced increases in DOT attributed to APPs. Similar increases were seen in changes to ID consultation. APPs have increasing involvement in antimicrobial use decisions in the inpatient setting and should be engaged in future antimicrobial stewardship initiatives.

Exploring the influence of a financial incentive scheme on early mobilization and rehabilitation in ICU patients: an interrupted time-series analysis

BACKGROUND

Clinical guidelines recommend early mobilization and rehabilitation (EMR) for patients who are critically ill. However, various barriers impede its implementation in real-world clinical settings. In 2018, the Japanese universal healthcare coverage system announced a unique financial incentive scheme to facilitate EMR for patients in intensive care units (ICU). This study evaluated whether such an incentive improved patients' activities of daily living (ADL) and reduced their hospital length of stay (LOS).

METHODS

Using the national inpatient database in Japan, we identified patients admitted to the ICU, who stayed over 48 hours between April 2017 and March 2019. The financial incentive required medical institutions to form a multidisciplinary team approach for EMR, development and periodic review of the standardized rehabilitation protocol, starting rehabilitation within 2 days of ICU admission. The incentive amounted to 34.6 United States Dollars per patient per day with limit 14 days, structured as a per diem payment. Hospitals were not mandated to provide detailed information on individual rehabilitation for government, and the insurer made payments directly to the hospitals based on their claims. Exposure was the introduction of the financial incentive defined as the first day of claim by each hospital. We conducted an interrupted time-series analysis to assess the impact of the financial incentive scheme. Multivariable radon-effects regression and Tobit regression analysis were performed with random intercept for the hospital of admission.

RESULTS

A total of 33,568 patients were deemed eligible. We confirmed that the basic assumption of ITS was fulfilled. The financial incentive was associated with an improvement in the Barthel index at discharge (0.44 points change in trend per month; 95% confidence interval = 0.20-0.68) and shorter hospital LOS (- 0.66 days change in trend per month; 95% confidence interval = - 0.88 - -0.44). The sensitivity and subgroup analyses showed consistent results.

CONCLUSIONS

The study suggests a potential association between the financial incentive for EMR in ICU patients and improved outcomes. This incentive scheme may provide a unique solution to EMR barrier in practice, however, caution is warranted in interpreting these findings due to recent changes in ICU care practices.

Prioritizing Quality over Quantity: Defining Optimal Pharmacist-to-Patient Ratios to Ensure Comprehensive Direct Patient Care in a Medical or Surgical Unit

Background

The expanding scope of practice of hospital pharmacists has contributed to improvements in patient care; however, workload remains a barrier to the provision of optimal pharmaceutical care. Established ratios to guide clinical pharmacy staffing on medical and surgical units are lacking in Canada.

Objectives

To determine the pharmacist-to-patient ratio that allows for provision of comprehensive pharmaceutical care to each patient on a medical or surgical unit and to determine which comprehensive care tasks can be delivered in settings where staffing is limited.

Methods

A multiphase study was conducted in 6 hospitals. First, a modified Delphi study was conducted to define and prioritize the elements of comprehensive pharmaceutical care. Next, a work sampling study was conducted to establish the frequency of each task and the time required for completion. Finally, a workforce calculator was used to determine pharmacy staffing ratios.

Results

Ten pharmacists participated in the modified Delphi study, and 31 participated in the work sampling study. A total of 15 comprehensive care tasks were identified, 7 of which were categorized as tasks to prioritize in settings where staffing is limited. The optimal staffing ratios were 1 pharmacist to 13 patients in internal medicine teaching units, 1 pharmacist to 26 patients in hospitalist or internal medicine nonteaching units, and 1 pharmacist to 14 patients in surgical units.

Conclusions

The optimal staffing ratios determined in this study should enable pharmacists to provide comprehensive care to each patient. Implementing these staffing ratios could increase the consistency of clinical pharmacy services, improve patient outcomes, and improve pharmacists' work satisfaction. Further research is required to validate these ratios in a variety of settings.

Implementierung einer „Nurse Practitioner“-Rolle in der stationären Chirurgie

Zusammenfassung. Hintergrund: Die Studie beschreibt die Einführung und Erprobung einer Nurse-Practitioner-Rolle in der akutstationären Chirurgie in einem schweizerischen Krankenhaus über ein Jahr. Der Einsatz Nurse Practitioner kann die Kontinuität in der Betreuung, die Versorgungsqualität und die Patientensicherheit verbessern. Ziel: Aufgezeigt werden die kurzfristigen Ergebnisse einer solchen Rolle im stationär chirurgischen Bereich nach einem Jahr Laufzeit. Die Zielgrößen umfassten neun Messkriterien. Methode: Die Evaluation erfolgte mittels eines Mixed-Methods-Ansatzes, teilweise im Prä-post-Vergleich. Quantitativ wurden Anzahl betreute Patient_innen, Austrittszeit, interprofessionelle Zusammenarbeit, Liegedauer, Störungen im Alltag und die Verfügbarkeit der Austrittsdokumente erfasst. Die qualitative Erfassung beinhaltete das Erleben der Beteiligten. Ergebnisse: Die Ergebnisse der Evaluation weisen auf einen Mehrwert durch die neue Rolle hin. Hinweise finden sich in der Betreuungskontinuität und Zugänglichkeit in medizinischen Fragen der Beteiligten sowie in der Optimierung der Patient_innenprozesse. Erschwerend erwies sich die gesetzlich ungeklärte Situation in der Schweiz. Schlussfolgerungen: Die Stärke dieser Rolle lag in der Erhöhung der Betreuungskontinuität, der Verbesserung der Ansprechbarkeit in medizinischen Fragen für Patient_innen und Pflegende sowie in der Optimierung der Patientenprozesse und damit auch der Patientensicherheit. Die gesetzlichen Vorgaben bezüglich der Kompetenzen erschweren derzeit den Einsatz von Nurse Practitioner im stationären Bereich.

Advanced Practice Providers as Leaders of a Rapid Response Team: A Prospective Cohort Study

In view of the shortage of medical staff, the quality and continuity of care may be improved by employing advanced practice providers (APPs). This study aims to assess the quality of these APPs in critical care. In a large teaching hospital, rapid response team (RRT) interventions led by APPs were assessed by independent observers and intensivists and compared to those led by medical residents MRs. In addition to mortality, the MAELOR tool (assessment of RRT intervention), time from RRT call until arrival at the scene and time until completion of clinical investigations were assessed. Process outcomes were assessed with the crisis management skills checklist, the Ottawa global rating scale and the Mayo high-performance teamwork scale. The intensivists assessed performance with the handoff CEX recipient scale. Mortality, MAELOR tool, time until arrival and clinical investigation in both groups were the same. Process outcomes and performance observer scores were also equal. The CEX recipient scores, however, showed differences between MRs and APPs that increased with experience. Experienced APPs had significantly better situational awareness, better organization, better evaluations and better judgment than MRs with equal experience (p < 0.05). This study shows that APPs perform well in leading an RRT and may provide added quality over a resident. RRTs should seriously consider the deployment of APPs instead of junior clinicians.

Pilot of rapid implementation of the advanced practice provider in the workflow of an existing tele-critical care program

Incorporating the advanced practice provider (APP) in the delivery of tele critical care medicine (teleCCM) addresses the critical care provider shortage. However, the current literature lacks details of potential workflows, deployment difficulties and implementation outcomes while suggesting that expanding teleCCM service may be difficult. Here, we demonstrate the implementation of a telemedicine APP (eAPP) pilot service within an existing teleCCM program with the objective of determining the feasibility and ease of deployment. The goal is to augment an existing tele-ICU system with a balanced APP service to assess the feasibility and potential impact on the ICU performance in several hospitals affiliated within a large academic center. A REDCap survey was used to assess eAPP workflows, expediency of interventions, duration of tasks, and types of assignments within different service locations. Between 02/01/2021 and 08/31/2021, 204 interventions (across 133 12-h shift) were recorded by eAPP (n_routine = 109 (53.4%); n_urgent = 82 (40.2%); n_emergent = 13 (6.4%). The average task duration was 10.9 ± 6.22 min, but there was a significant difference based on the expediency of the task (F [2; 202] = 3.89; p < 0.022) and type of tasks (F [7; 220] = 6.69; p < 0.001). Furthermore, the eAPP task type and expediency varied depending upon the unit engaged and timeframe since implementation. The eAPP interventions were effectively communicated with bedside staff with only 0.5% of suggestions rejected. Only in 2% cases did the eAPP report distress. In summary, the eAPP can be rapidly deployed in existing teleCCM settings, providing adaptable and valuable care that addresses the specific needs of different ICUs while simultaneously enhancing the delivery of ICU care. Further studies are needed to quantify the input more robustly.

Effect of intensive care provided by nurse practitioners for postoperative patients: A retrospective observational before-and-after study

Nurse practitioners are increasingly now members of intensive care teams in Japan, but no data exist about their effect on the outcomes for critically ill patients. This study aimed to compare the outcomes of postoperative patients on mechanical ventilators before and after the participation of nurse practitioners in intensive care teams. We retrospectively identified 387 patients who underwent postoperative mechanical ventilation at a University Hospital in Japan, using data from medical records from 1 April 2015 to 31 March 2017. We extracted data and compared patients' length of stay in the intensive care unit and the hospital, mechanical ventilation days, postoperative rehabilitation start date, rehabilitation prescription, intensive care unit and hospital mortality, and intensive care unit readmission. Multiple regression analysis was used to analyze the factors affecting length of stay in the intensive care unit. Patients who received care from nurse practitioners and physicians had significantly shorter stays in intensive care (4.8 ± 4.8 days versus 6.7 ± 10.3 days, p < 0.021). Mechanical ventilation days, total length of hospital stay, rehabilitation prescription, mortality in intensive care and hospital, and readmission to intensive care were all similar to those who received care only from physicians. The multiple regression analysis suggests that participation of nurse practitioners in intensive care reduced the length of stay in the unit by 2.6 days (p = 0.003). These findings could help to increase use of non-physician healthcare providers in intensive care. Our results demonstrated that it is both effective and safe for nurse practitioners to participate in intensive care teams that provide care for postoperative patients receiving mechanical ventilation.

Outcomes of daytime nurse practitioner-staffed versus resident-staffed nonsurgical intensive care units: A retrospective observational study

BACKGROUND

Rapid developments in medical care-such as monitoring devices, medications, and working hours restrictions for intensive care personnel-have dramatically increased the demand for intensive care physicians. Therefore, nurse practitioner (NP)-staffed care is becoming increasingly important. This study was aimed to compare the outcomes of daytime NP-staffed and daytime resident-staffed nonsurgical intensive care units (ICU).

METHODS

We retrospectively assessed patients admitted to a nonsurgical ICU from March 2017 to December 2017. We collected basic patient data, including age, sex, admission diagnosis, transferring unit, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Primary endpoints were ICU mortality, hospital mortality, and 30-day mortality. Secondary endpoints were 48-h readmission, discharge to nonhome locations, and lengths of ICU and hospital stay.

RESULTS

A total of 838 subjects were analysed: 334 subjects in the NP-staffed group and 504 in the resident-staffed group. The NP-staffed group was more likely to come from inpatient units (38.3% vs 16.5% for resident-staffed group; p < 0.001) and had lower disease severity (APACHE II score, 13.9 ± 8.4 vs 15.1 ± 8.2 for resident-staffed group; p = 0.047). After adjusting for age, sex, location before ICU admission, APACHE II score, and significantly different basic characteristics, there were no differences in ICU mortality, hospital mortality, or 30-day mortality between the two groups. Secondary analysis showed the NP-staffed group had a lower discharge rate to nonhome locations (2.1% vs 6.3%; p = 0.023) and shorter hospital stay (12.1 ± 14.1 vs 14.2 ± 14.3 days; p = 0.015).

CONCLUSIONS

We observed no difference in mortality between daytime NP-staffed and resident-staffed nonsurgical ICUs. Daytime NP-staffed care is an effective, safe, feasible method for staffing nonsurgical ICUs.

Value of Nurse Practitioner Inpatient Hospital Staffing

BACKGROUND

Evidence indicates hospitals with better registered nurse (RN) staffing have better patient outcomes. Whether involving more nurse practitioners (NPs) in inpatient care produces better outcomes is largely unknown.

OBJECTIVE

The objective of this study was to determine whether the presence of more NPs produces better inpatient outcomes net of RN staffing.

RESEARCH DESIGN

This was a 2015-2016 cross-sectional data on 579 hospitals linked from: (1) RN4CAST-US nurse surveys; (2) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient surveys; (3) surgical patient discharge abstracts; (4) Medicare Spending per Beneficiary (MSPB) reports; (5) American Hospital Association (AHA) Annual Survey. Hospitals were grouped according to their NP/beds ratios [<1 NP/100 beds (N=132), 1-2.99 NPs/100 beds (N=279), and 3+ NPs/100 beds (N=168)].

SUBJECTS

RNs randomly sampled nurses from licensure lists yielded 22,273 RNs in study hospitals; discharge data for 1.4 million surgical patients; HCAHPS data for 86% of study hospitals.

MEASURES

Mortality, readmissions, lengths of stay, MSPB, patient experience, and quality reported by patients and nurses.

RESULTS

After adjustments, patients in hospitals with 3+ NPs/100 beds had lower odds than patients in hospitals with <1 NP/100 beds of 30-day mortality [odds ratio (OR)2=0.76; 95% confidence interval (CI)=0.67-0.82; P<0.001] and 7-day readmissions (OR2=0.90; 95% CI=0.86-0.96; P<0.001), shorter average length of stay (incident rate ratio2=0.92; 95% CI=0.88-0.96; P<0.001) and 5.4% lower average MSPB (95% CI=3.8%-7.1%). Patients and nurses in the hospitals with higher NP/bed ratios were significantly more likely to report better care quality and safety, and nurses reported lower burnout, higher job satisfaction, greater intentions of staying in their jobs.

CONCLUSIONS

Having more NPs in hospitals has favorable effects on patients, staff nurse satisfaction, and efficiency. NPs add value to existing labor resources.

The Cost of Not Training a Surgical Resident

OBJECTIVE

To quantify surgical trainees' direct financial impact on an academic medical center (AMC) by modeling the cost of replacing them.

DESIGN

The authors developed a model that estimates the financial costs to an AMC if surgical residents were replaced with surgical first assistants (SFAs) and physician assistants (PAs).

SETTING

One AMC providing tertiary level clinical care.

PARTICIPANTS

The model accounts for the training, work hours, and salary differential of residents, as well as other factors that are specific to education and support of residents, SFAs, and PAs.

RESULTS

After accounting for the expenses of surgical residents and the replacement providers in our model, the authors determined that the net cost of replacing 30 surgical residents with PAs and SFAs at one institution is $1,728,628 or $57,621 annually per resident.

CONCLUSIONS

Without considering other larger and arguably more important issues of educational value or population needs, we provide a reproducible model of financial considerations regarding residents in an AMC. The costs (and foregone benefits) of not training residents may provide additional support for the funding of graduate medical education and finding the optimal balance of graduate medical education and other providers.

Origin and Outcomes of Acute Care Nurse Practitioner Practice

Acute care nurse practitioners (NPs) are educated, clinically trained, and board certified to care for acutely and critically ill patients, largely in hospital settings. Acute care NPs can positively impact patient care outcomes and are often added to acute care teams to drive optimal, reliable, efficient, and safe care, often referred to as "high value" care.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey

BACKGROUND

A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings.

METHODS

Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact.

RESULTS

Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment.

CONCLUSION

This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Identifying contexts and mechanisms in multiple behavior change interventions affecting smoking cessation success: a rapid realist review

Background

Smoking continues to be a leading cause of preventable chronic disease-related morbidity and mortality, excess healthcare expenditure, and lost work productivity. Tobacco users are disproportionately more likely to be engaging in other modifiable risk behaviours such as excess alcohol consumption, physical inactivity, and poor diet. While hundreds of interventions addressing the clustering of smoking and other modifiable risk behaviours have been conducted worldwide, there is insufficient information available about the context and mechanisms in these interventions that promote successful smoking cessation. The aim of this rapid realist review was to identify possible contexts and mechanisms used in multiple health behaviour change interventions (targeting tobacco and two or more additional risk behaviours) that are associated with improving smoking cessation outcome.

Methods

This realist review method incorporated the following steps: (1) clarifying the scope, (2) searching for relevant evidence, (3) relevance confirmation, data extraction, and quality assessment, (4) data analysis and synthesis.

Results

Of the 20,423 articles screened, 138 articles were included in this realist review. Following Michie et al.’s behavior change model (the COM-B model), capability, opportunity, and motivation were used to identify the mechanisms of behaviour change. Universally, increasing opportunities (i.e. factors that lie outside the individual that prompt the behaviour or make it possible) for participants to engage in healthy behaviours was associated with smoking cessation success. However, increasing participant’s capability or motivation to make a behaviour change was only successful within certain contexts.

Conclusion

In order to address multiple health behaviours and assist individuals in quitting smoking, public health promotion interventions need to shift away from ‘individualistic epidemiology’ and invest resources into modifying factors that are external from the individual (i.e. creating a supportive environment).

Trial registration

PROSPERO registration number: CRD42017064430

Systematic review of the characteristics of brief team interventions to clarify roles and improve functioning in healthcare teams

AIM

Describe brief (less than half a day) interventions aimed at improving healthcare team functioning.

METHODS

A systematic review on brief team interventions aimed at role clarification and team functioning (PROSPERO Registration Number: CRD42018088922). Experimental or quasi-experimental studies were included. Database searches included CINAHL, Medline, EMBASE, PUBMED, Cochrane, RCT Registry-1990 to April 2020 and grey literature. Articles were screened independently by teams of two reviewers. Risk of bias was assessed. Data from the retained articles were extracted by one reviewer and checked by a second reviewer independently. A narrative synthesis was undertaken.

RESULTS

Searches yielded 1928 unique records. Final sample contained twenty papers describing 19 studies, published between 2009 and 2020. Studies described brief training interventions conducted in acute care in-patient settings and included a total of 6338 participants. Participants' socio-demographic information was not routinely reported. Studies met between two to six of the eight risk of bias criteria. Interventions included simulations for technical skills, structured communications and speaking up for non-technical skills and debriefing. Debriefing sessions generally lasted between five to 10 minutes. Debriefing sessions reflected key content areas but it was not always possible to determine the influence of the debriefing session on participants' learning because of the limited information reported.

DISCUSSION

Interest in short team interventions is recent. Single two-hour sessions appear to improve technical skills. Three to four 30- to 60-minute training sessions spread out over several weeks with structured facilitation and debriefing appear to improve non-technical skills. Monthly meetings appear to sustain change over time.

CONCLUSION

Short team interventions show promise to improve team functioning. Effectiveness of interventions in primary care and the inclusion of patients and families needs to be examined. Primary care teams are structured differently than teams in acute care and they may have different priorities.

Developing and Implementing the Family Nurse Practitioner Role in Eswatini: Implications for Education, Practice, and Policy

Introduction:

Eswatini, a small, largely rural country in Southern Africa, has a high burden of morbidity/mortality in the setting of a critical shortage of human resources for health. To help achieve universal access to healthcare across the lifespan, the advanced practice family nurse practitioner (FNP) role was proposed and is in the process of being implemented.

Methods/Approach:

The PEPPA framework (Participatory, Evidence-based, Patient focused Process for Advanced practice nursing) illustrates the steps in the process of developing and implementing the FNP role in a country. These steps include: determining the need for the role, deciding on a model of care, developing/implementing the curriculum, relevant policies, and scope of practice (SOP), and integrating the role into relevant nursing regulations and Ministry of Health (MOH) guidelines and documents.

Outcomes:

The assessment has been completed, a locally tailored competency-based FNP curriculum has been developed, revised, and implemented, the FNP SOP has been approved and MOH guidelines are being updated to reflect current evidence-based practice and to integrate the FNP role. Continuous cycles of improvement/revision were needed to adapt the curriculum and SOP to meet local needs. Clinical placements were challenging since this is a new health cadre, but most challenges were overcome and many resulted in important opportunities for interdisciplinary collaboration.

Summary:

Outcomes from this quality improvement initiative demonstrate that it is feasible to develop and implement a locally responsive, competency-based FNP program in a low resource setting and enroll students, despite time and financial constraints. Adapting the curriculum and SOP from western countries can provide a foundation for program development but revision to assure that the program is responsive to local context is then needed. There is general acceptance of the role among Eswatini communities and professional stakeholders with emphasis on the need for FNP graduates to be clinically competent and able to function independently. Policy work related to deploying new graduates is ongoing.

Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018

OBJECTIVES

To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings.

DATA SOURCES

Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018.

STUDY SELECTION

Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting.

DATA EXTRACTION

Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice.

DATA SYNTHESIS

Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes.

CONCLUSIONS

Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.

Procedural Pain in the Adult Neurological Intensive Care Unit: A Retrospective Study Examining Arterial Line Insertion

BACKGROUND

This was a retrospective chart review of procedural pain assessments and interventions during arterial catheter insertion in an adult neurological intensive care unit where patients with impaired consciousness are common. Overall, pain assessment was well documented (100%) by Registered Nurses, but not specific to arterial line insertion. Nurse practitioners commonly placed arterial lines and used local analgesia in over 75% of the documented procedures.

AIMS

The purpose of this study was to examine healthcare providers' pain-related practices documented during arterial catheter insertion, one of the most painful procedures in a neurological intensive care unit. Secondary purposes were determining whether patient characteristics, procedure-related factors, or provider licensure were associated with pain assessment or procedural pain interventions.

DESIGN

A retrospective records review design was used.

METHODS

120 electronic patient medical records were reviewed during a one-year period.

RESULTS

100 charts met inclusion criteria. Nurses assessed all pain within 4 hours following the procedure in all charts but procedure-specific pain assessments were documented in 4% of charts. Pain-related interventions for arterial line insertion were local analgesic (76% of charts) and other procedure-specific interventions (10%). Significant associations occurred between procedure specific pain assessments and decreased number of insertion attempts (p = .006) and between pain interventions and number of insertion attempts (p = .003). No provider documented procedural pain assessment regarding arterial line insertion. Associations between patient characteristics and pain interventions were significant for patient ethnicity (F = 8.967, p = .007).

CONCLUSIONS

Overall pain assessment was documented (100%) but not specific to arterial line insertion. Although arterial line insertion can be extremely painful, patients were rarely assessed for such pain by any clinician; 14% did not receive any preprocedural analgesia.

CLINICAL IMPLICATIONS

The lack of procedural pain assessment in this vulnerable population indicates a need for increased pain management education for clinicians and further investigations to determine whether sufficient analgesia is provided to reduce procedural pain during arterial line insertion.

The Value of Surgical Graduate Medical Education (GME) Programs Within An Integrated Health Care System

OBJECTIVE

Surgical graduate medical education (GME) programs add both significant cost and complexity to the mission of teaching hospitals. While expenses tied directly to surgical training programs are well tracked, overall cost-benefit accounting has not been performed. In this study, we attempt to better define the costs and benefits of maintaining surgical GME programs within a large integrated health system.

DESIGN

We examined the costs, in 2018 US dollars, associated with the surgical training programs within a single health system. Total health system expenses were calculated using actual and estimated direct GME expenses (salary, benefits, supplies, overhead, and teaching expenses) as well as indirect medical education (IME) expenses. IME expenses for each training program were estimated by using both Medicare percentages and the Medicare Payment Advisor Commission study. The projected cost to replace surgical trainees with advanced practitioners or hospitalists was obtained through interviews with program directors and administrators and was validated by our system's business office.

SETTING

A physician lead, integrated, rural health system consisting of 8 hospitals, a medical school and a health insurance company.

PARTICIPANTS

GME surgical training programs within a single health system's department of surgery.

RESULTS

Our health system's department of surgery supports 8 surgical GME programs (2 general surgery residencies along with residencies in otolaryngology, ophthalmology, oral-maxillofacial surgery, urology, pediatric dentistry, and vascular surgery), encompassing 89 trainees. Trainees work an average of 64.4 hours per week. Total health system cost per resident ranged from $249,657 to $516,783 based on specialty as well as method of calculating IME expenses. After averaging program costs and excluding IME and overhead expenses, we estimated the average annual cost per trainee to be $84,171. We projected that replacing our surgical trainees would require hiring 145 additional advanced practitioners at a cost of $166,500 each per year, or 97 hospitalists at a cost of $346,500 each per year. Excluding overhead, teaching and IME expenses, these replacements would cost the health system an estimated additional $16,651,281 or $26,119,281 per year, respectively.

CONCLUSIONS

Surgical education is an integral part of our health system and ending surgical GME programs would require large expansion of human resources and significant additional fiscal capital.

Addition of Advanced Practice Registered Nurses to the Trauma Team: An Integrative Systematic Review of Literature

The total cost of inpatient care from a traumatic mechanism of injury in the United States between 2001 and 2011 was $240.7 billion. Medical resident work hour reductions mandated in 2011 left a shortage of available in-hospital providers to care for trauma patients. This created gaps in continuity of care, which can lead to costly increased lengths of stay (LOS) and increased medical errors. Adding advanced practice nurses (APNs) specializing in acute or trauma care to the trauma team may help fill this shortage in trauma care providers. The purpose of this integrative systematic review of the literature was to determine whether adding APNs to the admitting trauma team would decrease LOS. A systematic review of primary research in CINAHL and PubMed databases was performed using the following terms: nurse practitioner, advanced practice nurse, trauma team, and length of stay. Included studies examined the effects of adding APNs to trauma teams, were written in English, and were published in 2007-2017. Six studies were included in the final sample, and all were completed at Level I trauma centers in the United States except one from Canada. Combined sample size was 25,083 admitted trauma patients. All 6 studies reported a decrease in LOS ranging from 0.8 to 2.54 days when APNs were added to the trauma team. More research is needed to identify the best utilization of an APN on a trauma team. It is recommended that all trauma centers add APNs to the trauma team to not only decrease admitted trauma patients' LOS but also provide continuity of care, decreasing costs, and minimizing errors.

Comprehensive care of ICU survivors: Development and implementation of an ICU recovery center

PURPOSE

To describe the design and initial implementation of an Intensive Care Unit Recovery Center (ICU-RC) in the United States.

MATERIALS AND METHODS

A prospective, observational feasibility study was undertaken at an academic hospital between July 2012 and December 2015. Clinical criteria were used to develop the ICU-RC, identify patients at high risk for post intensive care syndrome (PICS), and offer them post-ICU care.

RESULTS

218/307 referred patients (71%) survived to hospital discharge; 62 (28% of survivors) were seen in clinic. Median time from discharge to ICU-RC visit was 29days. At initial evaluation, 64% of patients had clinically meaningful cognitive impairment. Anxiety and depression were present in 37% and 27% of patients, respectively. One in three patients was unable to ambulate independently; median 6min walk distance was 56% predicted. Of 47 previously working patients, 7 (15%) had returned to work. Case management and referral services were provided 142 times. The median number of interventions per patient was 4.

CONCLUSIONS

An ICU-RC identified a high prevalence of cognitive impairment, anxiety, depression, physical debility, lifestyle changes, and medication-related problems warranting intervention. Whether an ICU-RC can improve ICU recovery in the US should be investigated in a systematic way.

Telemedicine in the ICU: clinical outcomes, economic aspects, and trainee education

PURPOSE OF REVIEW

The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value.

RECENT FINDINGS

Recent publications and a recent meta-analysis confirm that tele-ICU improves core clinical outcomes for ICU patients. Recent evidence further demonstrates that comprehensive tele-ICU programs have the potential to quickly recuperate their implementation and operational costs and significantly increase case volumes and direct contribution margins particularly if additional logistics and care standardization functions are embedded to optimize ICU bed utilization and reduce complications. Even though the adoption of tele-ICU is increasing and the vast majority of today's medical graduates will regularly use some form of telemedicine and/or tele-ICU, telemedicine modules have not consistently found their way into educational curricula yet. Tele-ICU can be used very effectively to standardize supervision of medical trainees in bedside procedures or point-of-care ultrasound exams, especially during off-hours. Lastly, tele-ICUs routinely generate rich operational data, as well as risk-adjusted acuity and outcome data across the spectrum of critically ill patients, which can be utilized to support important clinical research and quality improvement projects.

SUMMARY

The value of tele-ICU to improve patient outcomes, optimize ICU bed utilization, increase financial performance and enhance educational opportunities for the next generation of providers has become more evident and differentiated in the last 2 years.

Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review

OBJECTIVES

To assess-by literature review and expert consensus-workforce, workload, and burnout considerations among intensivists and advanced practice providers.

DESIGN

Data were synthesized from monthly expert consensus and literature review.

SETTING

Workforce and Workload section workgroup of the Academic Leaders in Critical Care Medicine Task Force.

MEASUREMENTS AND MAIN RESULTS

Multidisciplinary care teams led by intensivists are an essential component of critical care delivery. Advanced practice providers (nurse practitioners and physician assistants) are progressively being integrated into ICU practice models. The ever-increasing number of patients with complex, life-threatening diseases, concentration of ICU beds in few centralized hospitals, expansion of specialty ICU services, and desire for 24/7 availability have contributed to growing intensivist staffing concerns. Such staffing challenges may negatively impact practitioner wellness, team perception of care quality, time available for teaching, and length of stay when the patient to intensivist ratio is greater than or equal to 15. Enhanced team communication and reduction of practice variation are important factors for improved patient outcomes. A diverse workforce adds value and enrichment to the overall work environment. Formal succession planning for ICU leaders is crucial to the success of critical care organizations. Implementation of a continuous 24/7 ICU coverage care model in high-acuity, high-volume centers should be based on patient-centered outcomes. High levels of burnout syndrome are common among intensivists. Prospective analyses of interventions to decrease burnout within the ICU setting are limited. However, organizational interventions are felt to be more effective than those directed at individuals.

CONCLUSIONS

Critical care workforce and staffing models are myriad and based on several factors including local culture and resources, ICU organization, and strategies to reduce burden on the ICU provider workforce. Prospective studies to assess and avoid the burnout syndrome among intensivists and advanced practice providers are needed.

System-Level Factors Associated With Use of Outpatient Specialty Palliative Care Among Patients With Advanced Cancer

PURPOSE

The proportion of patients with advanced cancer who receive outpatient specialty palliative care (OSPC) is as low as 2.0%. Improved understanding of the system-level factors influencing use of OSPC could inform adaptations to the delivery of palliative care to maximize access. We examined associations between OSPC use among patients with advanced solid tumors and oncology-OSPC clinic colocation and patient travel time to an OSPC clinic.

PATIENTS AND METHODS

We conducted a retrospective cohort study of patients with advanced solid tumors receiving oncologic treatment between January 1 and December 31, 2016, within a comprehensive cancer center network with well-established, oncology-specific OSPC clinics. Multivariable logistic regression analysis was used to evaluate the associations of clinic colocation and geographic access with OSPC use.

RESULTS

Of 9,485 patients with advanced solid tumors, 478 (5.0%) received OSPC services in 2016. After controlling for age, sex, marital status, cancer type, insurance, treatment intent, and illness severity, patients whose oncologist practices were colocated with OSPC clinics were more likely to use OSPC (odds ratio [OR], 19.2; 95% CI, 14.1 to 26.2). Compared with patients who lived > 90 minutes from an OSPC clinic, patients with travel times of < 30 minutes (OR, 3.2; 95% CI, 2.2 to 4.6) and 31 to 60 minutes (OR, 2.4; 95% CI, 1.6 to 3.6) were also more likely to use OSPC.

CONCLUSION

Among patients with advanced solid tumors, colocation of oncology and OSPC clinics and shorter patient travel time were associated with greater odds of using OSPC. Future efforts to increase OSPC use in this population should consider clinic colocation and travel burden.

Decision-making skills improve with critical care training: Using simulation to measure progress

PURPOSE

Health care professionals are expected to acquire decision-making skills during their training, but few methods are available to assess progress in acquiring these essential skills. The purpose of this study was to determine whether a simulation methodology could be used to assess whether decision-making skills improve during critical care training.

MATERIALS AND METHODS

Sixteen simulated scenarios were designed to assess a critical care provider's ability to make decisions in the care of a critical ill patient. Seventeen (17) critical care providers managed 8 of the scenarios early during their training and then managed a second set of 8 scenarios (T2) at the conclusion of their training.

RESULTS

Provider's mean global scenario scores (0-9) increased significantly fromT1 and T2 (5.64 ± 0.74) and (6.54 ± 0.64) with a large effect size (1.3). Acute care nurse practitioners and fellows achieved similar overall scores at the conclusion of their training (ACNP 6.43 ± 0.57; Fellows 6.64 ± 0.72).

CONCLUSIONS

These findings provide evidence to support the validity of a simulation-based method to assess progress in decision-making skills. A simulation methodology could be used to establish a performance standard that determined a provider's ability to make independent decisions.

Social support and factors associated with self-efficacy among acute-care nurse practitioners

AIMS AND OBJECTIVES

To investigate the relationship of nurse practitioners' social support as well as other factors associated with perceived self-efficacy.

BACKGROUND

There is a growing demand for nurse practitioners in Taiwan, for whom self-perceived efficacy is associated with performance. Nevertheless, research on the self-efficacy and social support of nurse practitioners is limited.

DESIGN

This is a cross-sectional survey study.

METHODS

Questionnaires were distributed to nurse practitioners in seven hospitals in northern Taiwan from May 2015 to March 2016. In total, data from 335 (78% return rate) certified nurse practitioners were analysed. Social support was measured by the Multidimensional Scale of Perceived Social Support (MSPSS) and the Job Content Questionnaire (JCQ), and perceived self-efficacy was measured by the General Self-Efficacy Scale (GSE). Data were analysed by ANOVAs with post hoc test and multiple linear regression.

RESULTS

The mean score for self-efficacy was 27.60 ± 6.17. Support scores were 11.574 ± 2.37 for supervisors, 12.795 ± 1.92 for coworkers and 64.07 ± 10.16 for family, friends and significant others. nurse practitioners in the high monthly salary group had significantly higher self-efficacy than nurse practitioners in the medium and low monthly salary group (F = 8.99; p < .01). Social support from coworkers (β = 0.18, p < .01) and family, friends and significant others (β = 0.15, p < .01) and a higher monthly salary were significant factors.

CONCLUSIONS

The self-efficacy of nurse practitioners in hospitals in Taiwan is insufficient. Monthly salary and levels of social support were found to contribute to nurse practitioners' self-efficacy. Thus, to enhance nurse practitioners' self-efficacy and work performance, nursing leaders should address these issues.

RELEVANCE TO CLINICAL PRACTICE

The findings inform hospital administrators to be aware of the importance of salary in relation to nurse practitioners' perceptions of social support and self-efficacy.

Advanced Critical Care Practitioners - Practical experience of implementing the Advanced Critical Care Practitioner Faculty of Intensive Care Medicine Curriculum in a London Critical Care Unit

With a chronic shortage of doctors in intensive care, alternative roles are being explored. One of these is the role of the Advanced Critical Care Practitioner. The Advanced Critical Care Practitioner Curriculum was developed by the Faculty of Intensive Care Medicine and is used to provide a structured programme of training. The Advanced Critical Care Practitioner programme consists of an academic and clinical component. This article outlines a practical approach of how the programme was developed and is currently being delivered at a single institution. This new advanced practice role offers opportunities to fill gaps in the medical workforce, improve continuity of patient care, provide mentoring and training for less experienced staff as well as offering a rewarding clinical role.

The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review

BACKGROUND

The prevalence of chronic illness and multimorbidity rises with population aging, thereby increasing the acuity of care. Consequently, the demand for emergency and critical care services has increased. However, the forecasted requirements for physicians have shown a continued shortage. Among efforts underway to search for innovations to strengthen the workforce, there is a heightened interest to have nurses in advanced practice participate in patient care at a great extent. Therefore, it is of interest to evaluate the impact of increasing the autonomy of nurses assuming advanced practice roles in emergency and critical care settings on patient outcomes.

OBJECTIVES

The objectives of this study are to present, critically appraise, and synthesize the best available evidence on the impact of advanced practice nursing on quality of care, clinical outcomes, patient satisfaction, and cost in emergency and critical care settings.

REVIEW METHODS

A comprehensive and systematic search of nine electronic databases and a hand-search of two key journals from 2006 to 2016 were conducted to identify studies evaluating the impact of advanced practice nursing in the emergency and critical care settings. Two authors were involved selecting the studies based on the inclusion criteria. Out of the original search yield of 12,061 studies, 15 studies were chosen for appraisal of methodological quality by two independent authors and subsequently included for analysis. Data was extracted using standardized tools.

RESULTS

Narrative synthesis was undertaken to summarize and report the findings. This review demonstrates that the involvement of nurses in advanced practice in emergency and critical care improves the length of stay, time to consultation/treatment, mortality, patient satisfaction, and cost savings.

CONCLUSIONS

Capitalizing on nurses in advanced practice to increase patients' access to emergency and critical care is appealing. This review suggests that the implementation of advanced practice nursing roles in the emergency and critical care settings improves patient outcomes. The transformation of healthcare delivery through effective utilization of the workforce may alleviate the impending rise in demand for health services. Nevertheless, it is necessary to first prepare a receptive context to effect sustainable change.

Preparation and Evolving Role of the Acute Care Nurse Practitioner

Acute care nurse practitioners (ACNPs) are increasingly being employed as members of critical care teams, an outcome driven by increasing demand for intensive care services, a mandated reduction in house officer hours, and evidence supporting the ability of ACNPs to provide high-quality care as collaborative members of critical care teams. Integration of adult ACNPs into critical care teams is most likely to be successful when practitioners have appropriate training, supervision, and mentoring to facilitate their ability to practice efficiently and effectively. Accomplishing this goal requires understanding the educational preparation and skill set potential hires bring to the position as well as the development of an orientation program designed to integrate the practitioner into the critical care team. Pediatric ACNPs are also commonly employed in critical care settings; however, this commentary focuses on the adult ACNP role.

The quality of primary care provided by nurse practitioners to vulnerable Medicare beneficiaries

BACKGROUND

Studies suggest nurse practitioners are heavily represented among primary care providers for vulnerable Medicare beneficiaries.

PURPOSE

The purpose of this study was to compare quality indicators among three groups of vulnerable beneficiaries managed by MDs and nurse practitioners (NPs).

METHODS

The methods include retrospective cohort design examining 2012 and 2013 Medicare claims for three beneficiary groups: (a) initially qualified for the program due to disability, (b) dually eligible for Medicare and Medicaid, and (c) both disabled and dually eligible. Validated quality indicators in four domains were analyzed.

DISCUSSION

Gaps in outcomes suggest better performance for primary care nurse practitioners (PCNPs) in preventable hospitalizations and adverse outcomes. Outcome gaps suggesting better performance for primary care physicians in chronic disease management were diminished for beneficiaries who were both disabled and dually eligible suggesting improved performance for PCNPs within this subpopulation.

CONCLUSION

These findings add new evidence indicating the quality of primary care provided to vulnerable Medicare beneficiaries by PCNPs is generally consistent with clinical guidelines and the less intensive use of costly health care services.