Nurse practitioners (NPs) and physician assistants (PAs) are now widely represented on critical care teams. Herein, we review the need, history, training, application, and clinical outcomes of these high quality, cost-effective providers.
Demography is reshaping volumes of care. The demographic changes include an aging population (in America 10,000 people per day are turning 65 [1]), longer life expectancies (2), and expansion of services to previously underserved groups (Patient Protection and Affordable Care Act, PL-11–148). Payors are reshaping quality and value expectations of care: entities such as the Leapfrog Group specify 24-hour ICU coverage because of proven reduction in mortality when physician intensivists are present (3).
Such changes increase the demand for ICU services and strain existing bedside providers (4, 5). While ICU bed space is currently sufficient (6), supplying around the clock provider coverage by board-certified critical care physicians has proven difficult to achieve owing to current and projected (approximately 35%) shortages of these specialists (7). ICU physician coverage has been further constrained in teaching institutions by reduction in physician resident duty hours implemented in 2008 and 2011 by the American College of Graduate Medical Education (ACGME) (8) even with the revision being implemented in July, 2017 (9).
Experienced ICU nurses are similarly aging and consequently their ranks are thinning (10, 11). This parallel trend leads not only to a personnel shortage but a decreased number of the most experienced bedside providers. The loss of their decades of service that has provided continuity of care will have profound effects on quality, efficiency, and safety.
ADVANCED PRACTICE PROVIDERS
The NP and PA professions have emerged to complement the physician and nursing professions in the United States. Both were established around 1965 to augment general medical outpatient care to underserved areas of the nation. Loretta Ford, RN, and Henry Silver, MD, created the first advanced educational track for RNs to assume the role of NPs (12). Dr. Eugene Stead at Duke University began training PAs by educating former naval corpsmen using a fast track medical training model originally designed during World War II to increase the number of military physicians (13). Today there are approximately 220,000 NPs and 114,000 PAs in practice across the country. Both professions require a national certifying examination for state licensure.
As the new professions evolved, graduates of both groups began to appear in inpatient and subspecialty areas of practice including critical care (14, 15). In 1995, academic programs and a certification examination were created for acute care nurse practitioners (15). The majority of NPs and PAs or advanced practice providers (APPs) received additional clinical training in intensive care from their colleagues at the bedside.
Recent surveys of the American Association of Nurse Practitioners (AANP, survey in 2015) and the American Academy of Physician Assistants (AAPA, survey in 2013) suggest that a combined total of 10,000 NPs and PAs list the ICU as their primary site of practice. Their duties include daily rounds, patient data evaluation, decision making and prescribing orders, vascular access procedures, chest tube placement, intubation, lumbar puncture, feeding tube placement, and other tasks particular to the specific ICU (16, 17). Advanced practice providers in the ICU provide care that is at least at the level of care provided by physician residents (12, 18).
THE TRAINING OF ADVANCED PRACTICE PROVIDERS
Owing to the complexity of practice in different arenas, clinical postgraduate programs now provide specialty training beyond entry level NP or PA education. Montefiore Health Systems established the first PA surgical residency in the late 1970s (20) as well as the first critical care postgraduate program for PAs in 2009 (21). The first NP postgraduate program was created in 2007 at Community Health Center in Conneticut (16). This innovative practice transition training–modeled after physician specialty training–was slow to take root. Over the last five years interest in advanced training programs for APPs has flourished due to a national drive to provide additional education to achieve full scope of practice for these individuals. Many residencies (also called fellowships) have been built as training platforms for multiple specialties (22, 23). Several contemporary programs now enroll both NPs and PAs training side-by-side in a common educational experience.
Beginning in the late 1970s, Dr. Donald Finlayson began to use newly graduated PAs for patient care in the Cardiothoracic ICU at Emory University Hospital (EUH) (19). This prototype was subsequently adopted by most ICUs across the Emory system creating individualized “physician extender” models. In 2009, the Emory Critical Care Center (ECCC) was founded as a platform promoting a threefold aim of access, quality, and value. The ECCC united nine ICUs on two campuses under one entity including all attending physician staff and APPs.
As of 2017, the ECCC has expanded to four hospital campuses and 14 ICUs. Currently over 100 APPs and 77 attending physicians staff these units. Additionally, advanced telemedicine (“eICU”) support for bedside staff is provided from sites in the USA and abroad, with experienced critical care nurses available 24 hours/7 days a week and senior intensivist presence during the overnight hours and weekend/holiday periods.
The Emory Critical Care NPPA Residency program was founded in December 2011 and was the second program in the country to train both NPs and PAs together in critical care medicine. In 2011, the Center for Medicare and Medicaid Innovation (CMMI) announced the “Health Care Innovation Challenge” which provided grant funding for innovative solutions to healthcare issues. The ECCC was awarded funding for “Rapid Training and Deployment of Non-Physician Providers in Critical Care,” which trained APPs and placed them into ICUs with additional support from physician intensivists using electronic ICU (e-ICU) technology (24).
The award expanded the program’s capabilities to train additional learners, improved program structure, and promoted a rigorous evaluation process. Collectively, these afforded more efficient and effective training for advanced practice providers in critical care. The award was successful in achieving the triple aim of better health, better experience of care and lower cost: the use of the e-ICU and APP teams reduced Medicare spending by $1486 per patient stay (24). After completion of this program several APP graduates have migrated across the country and three are building programs similar to the one financed by this award.
ACCREDITATION OF TRAINING
In January 2015, the American Nurses Credentialing Center introduced an innovative accreditation process for both RN and Advanced Practice Nurse (APRN) practice transition programs. The ECCC’s NP/PA Residency Program became the first accredited APRN practice transition program in the country. Currently, only two critical care programs hold this designation: the James Oncology and Critical Care ACNP Fellowship at Ohio State University was awarded accreditation in 2016 (25). Also in 2016, the National Nurse Practitioner Residency and Fellowship Consortium began accreditation of APRN residencies and fellowships. At time of this writing, no critical care programs have been accredited by this new organization (26).
In the past, the Accreditation Review Commission on Education for PAs (ARC-PA), the accrediting body for entry level programs, provided a pathway for accreditation for clinical postgraduate PA programs. This optional process began in 2008 and subsequently eight programs received accreditation. The exponential growth in entry level PA programs over the ensuing years created demand for accreditation that stressed staff resources; the ARC-PA therefore paused its postgraduate accreditation process in 2014 (27). Yet, there is an increasing number of clinical postgraduate programs evolving from both academic and healthcare entities, and within the PA community there are concerns for the quality of this training being delivered absent an educational standard.
In 2016, the AAPA House of Delegates indicated that a PA-led effort to establish an accreditation process for postgraduate training would be appropriate (28). The Association of Postgraduate PA Programs (APPAP) is working toward a new accreditation process. The intent of this work is to establish a standardized educational foundation that would accommodate multispecialty training programs to assure basic educational fundamentals and also require outcomes reporting and a quality improvement metrics.
While these two professionally parallel accreditation pathways are in evolution, there is also a need for a joint NP/PA accreditation process in critical care. The two professions not only practice together but also have the same role as Advanced Practice Provider assigned to an ICU. The Association of Post Graduate APRN Programs (APGAP) advocates for excellence in programming as well the development of a joint pathway for accreditation (23).
FUTURE STATES
Data to justify residency and fellowship training are slowly accumulating. One contributor to the delay in accumulating data on the effectiveness and cost-effectiveness of APPs in critical care is the paucity of qualified individuals actually matriculating into these programs. There is a surfeit of qualified candidates. For example, the Emory Critical Care NP/PA Residency has received over 200 applications, interviewed over 110 candidates and has matriculated 39 residents. The problem is the shortage of funded training positions. Extramural funding has since declined and, as a consequence, the number of available training slots at Emory has contracted. Other programs report similar excess of qualified applicants to available slots.
Yet, such advanced training is needed: one study showed an increase in APRN job satisfaction with completion of a residency program (29). Another study noted that almost 50% of new graduate NPs felt they were practicing outside their scope of practice during their first year and that a post graduate training period would have been useful (30). Similar data have been shown for PAs (31). Emory’s internal analyses show that a structured residency training for APPs leads to briefer orientation times, a decrease in open position time/vacancy, a decrease in recruitment cost for staff APPs and an increase in critical care knowledge, competence and confidence. There has been a shorter time period for residency-trained providers to reach maximum productivity when compared to traditional on the job trainees. On average, the residents reached their maximum potential in overall productive time and billable time two months earlier than those trained by traditional orientation methods. Retention provides another window into the value of residency training for NP/PA in critical care: the retention rate in critical care 5 years after completion of the Emory Program is 100%.
CONCLUSION
The demand for–and demands on–critical care practitioners continues to rise. Evidence has shown that having skilled, knowledgeable providers at the bedside decreases mortality (3, 4). The challenge remains to fill these positions with excellent staff who have the clinical knowledge and skills to provide effective and safe patient care.
For more than half a century, APPs have been used in many different specialties–including critical care–providing care to vulnerable patients. Clinical postgraduate training for nurse practitioners and for physician assistants transfers the additional knowledge and skills necessary to practice safely in the critical care unit. Many healthcare systems across the nation are designing these programs for recruitment and training of APPs to work in the ICU.
Educational standards for these proliferating training programs is essential. The accreditation process provides educational consistency, quality assurance, and stated outcome accountability. Moreover, NP/PA programmatic accreditation and research around that accreditation can reasonably be expected to foster improvements in training and outcomes, just as such accreditation processes have fueled improvements in physician training.
There are few large studies to measure outcomes concerning postgraduate NP/PA training. The available small internal studies show increased knowledge, competence, and confidence; decreased time to unsupervised practice; decreased length of time to maximum productivity; and remarkable retention rates. Nascent accrediting organizations should require reporting on related metrics among program graduates and further publish their findings.
The use of structured training programs in critical care for NPs and PAs advances knowledge and skills in these providers. When integrated as professional staff and layered with around-the-clock resource physicians (either on-site or remote e-ICU intensivists), these practitioners may safely and effectively perform at the upper boundaries of their scope of practice. Such teamwork across the intensivist-led, multiprofessional ICU yields patient care with high access, high quality, and high value (32).
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nurse practitioner; physician assistant; critical care; postgraduate training; telemedicine; accreditation
