For many years, advanced practice providers (APPs), otherwise known as nurse practitioners (NPs) and physician assistants (PAs), have been incorporated into intensive care staffing models, providing high quality, cost-effective care (1). Numerous studies have evaluated the effectiveness of APPs as part of a multiprofessional team. Kleinpell et al (2) conducted a review of literature supporting APP staffed intensive care teams and concluded that APPs contribute to positive patient outcomes. In this issue of Critical Care Medicine, Kreeftenberg et al (3) report a systematic review and meta-analysis on the impact of staffing APPs in the critical care environment. They conclude that there is no difference in APP teams supervised by physician attendings compared with physician trainee teams with the same level of supervision, in regards to length of stay or mortality. They suggest that APPs may add to care by way of improved communication with nursing staff, higher rates of protocol adherence, patient satisfaction and continuity of care, but evidence is still evolving. This article adds to the growing evidence supporting APP staffing as part of a multiprofessional team.
Over the last few decades, the demand for APP staffed intensive care teams in the United States has increased at exponential rates. This demand has been fueled by many concurrent factors. In 2003, the Accreditation Council for Graduate Medical Education imposed workhour restrictions for physician trainees thus leading to disparity in patient care coverage (4). As a result, APPs began to fill this coverage deficit prompting many comparison studies between the two groups (5). This article reviews staffing models integrating APPs in lieu of physician residents. However, workhour restrictions are only one component contributing to the critical care workforce crisis. In the United States an increasing aging population, increased disease burden with advancements in medical therapies, intensivist burnout, and provider retirement all play a role in this crisis (6). There is an urgent need to look outside the traditional staffing paradigm and move to more innovative ways of caring for the critically ill population. Some innovative staffing models which employ APPs directly at the bedside with supervision from electronic ICU have shown improved length of stay, reduction in readmission rates and significant reduction in costs (7). Therefore, the impact of the APP staffed intensive care teams far exceeds employing APPs as an alternative for physician trainees. Research evaluating the impact of APP staffed teams should be studied accordingly to account for all contributions.
APPs with established and verified critical care competency can participate and manage all patient care activities such as obtaining data points and making therapeutic changes with minimal collaboration from their supervising physician. APPs can also perform many common procedures necessary to stabilize the critically ill patient (8). However, integrating new graduate APPs into critical care teams can be challenging (9). It is important to briefly discuss the educational background and requirements for practice to encourage proper onboarding thus ensuring a high performing team. In the United States, both NPs and PAs are licensed providers having completed an advanced degree in their respective fields and successfully passed a national certifying examination. NPs who provide care to patients exhibiting a higher acuity, such as a critically ill patient, should hold a certification in acute care (certified pediatric nurse practitioner [NP]-acute care, adult gerontologic-acute care NP, or acute care NP certified adult gerontology) (10). Completion of the certification examination ensures entry-level competency, based on core curriculum. Both NP and PA core curricula lack necessary advanced critical care competencies needed to provide care to our most acutely ill patients (11, 12). Outside the United States, educational programs for both NPs and PAs have begun to proliferate, many with their beginnings in the early 2000s. Pathways to obtain certification and licensure as a PA or NP in other countries is similar to the U.S. process. Significant differences are noted in the role, scope of practice and level of autonomy for critical care APPs, both within the United States and internationally. This is partly due to varying levels of onboarding of new graduate APPs. Integrating new graduate providers into critical care teams requires significant mentorship and training to ensure a high level of care. Transition of the novice provider into competent critical care provider can be difficult for mentors who are burdened by work requirements. Development, evaluation, and verification of critical care competencies for APPs are essential for ensuring efficiency of the multiprofessional team and thus delivery of high-quality care (13). When critical care competency is attained and verified, APPs practice to the full scope of their license lending to efficient and cost-effective staffing models. In the United States many healthcare institutions, recognizing a deficit of critical care knowledge in new graduate APPs have moved to structured onboarding processes which have evolved to become APP critical care residency and fellowship programs (14). Residency and fellowship programs guide the novice APP through practice transition allowing them to advance quickly in critical care competencies. Critical care residency programs serve to develop, evaluate and verify competency of the provider. In 2015, the Institute of Medicine Future of Nursing Report upheld previous recommendations to support the growth of residency training for NPs (15). At the time of this writing, roughly 15 critical care residency/fellowship programs are in operation in the United States (16). Of those, only five are accredited for NPs (17). Currently, no PA programs are accredited, although PA accreditation is being refashioned. Organizations supporting APP residencies should advocate for a joint process of accreditation as most residency and fellowship train both NPs and PAs together. Accreditation is necessary to ensure a robust structure of training as well as consistency and standardization. Standardization by way of accreditation can led to a higher quality of evidence to support residency training. Although many institutions supporting APP residencies recognize the added benefit and return on investment, published evidence supporting these programs is lacking. Significant research is needed to fully understand added benefit of practice transition programs.
As APP critical care training advances so will the roles and responsibilities of these vital team members. With the current projections of provider shortages, innovative staffing models employing APPs who practice to the full scope of their license will become necessary for management of our critically ill population. Proper development, evaluation, and verification of critical care competencies for APPs is necessary for successful implementation of innovative staffing models. Future research should focus on a variety of APP led contributions to patient care outcomes.
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