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Integrating Advanced Practice Providers Into the Multiprofessional Critical Care Team*

Meissen, Heather H., ACNP, CCRN, FAANP, FCCM

doi: 10.1097/CCM.0000000000003704
Editor's Choice

Emory Healthcare, Emory Critical Care Center, Atlanta, GA

*See also p. 722.

Ms. Meissen received funding from American Association of Nurse Practitioners (speaker) and law firms (expert witness case review); she is also an appraiser for the American Nurses Credentialing Centers Practice Transition Accreditation Program.

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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1. Grabenkort WR. Using the role of PA’s in the critical care units Chest 1992; 101:293
2. Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review. Crit Care Med 2008; 36:2888–2897
3. Kreeftenberg HG, Pouwels S, Bindels AJGH, et al. Impact of the Advanced Practice Provider in Adult Critical Care: A Systematic Review and Meta-Analysis. Crit Care Med 2019; 47:722–730
4. Pastores SM, O’Connor MF, Kleinpell RM, 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
5. Buchman T, Grabenkort R, Coopersmith C, et al. The workforce crisis: A functioning solution. Am J Respir Crit Care Med 2015; 191:1340–1341
6. Angus DC, Kelley MA, Schmitz RJ, et al; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS): Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? JAMA 2000; 284:2762–2770
7. Buchman TG, Coopersmith CM, Meissen HW, et al. Innovative interdisciplinary strategies to address the intensivist shortage. Crit Care Med 2017; 45:298–304
8. Kleinpell RM. Acute care nurse practitioner practice: Results of a 5-year longitudinal study Am J Crit Care 2005; 14:211–219
9. Yeager S. Detraumatizing nurse practitioner orientation. J Trauma Nurs 2010; 17:85–101
10. APRN Consensus Work Group and the National Council of State Boards Of Nursing APRN Advisory Committee: Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, Education. APRN Joint Dialogue Group Report. July 7, 2008
11. Donaworth SL. Making the case for adult-gerontology critical care nurse practitioner fellowships. OJIN 2017; 22
12. National Commission on Certification of Physician Assistants: PANCE Eligibility Requirements. Competencies for the Physician Assistant Profession. 2012. Available at: Accessed January 24, 2019
13. Meissen H. LaRosa J, Kaufman K. Development, evaluation, and verification of competencies: What advanced practice providers and physician leaders can learn from each other. In: Current Concepts in Adult Critical Care. 2017, pp Mt Prospect, IL, Society of Critical Care Medicine, 65–74
14. Harris C. Bridging the gap between acute care nurse practitioner education practice: The need for postgraduate residency programs. J Nurse Pract 2016; 12:545–552
15. Institute of Medicine: The Future of Nursing: Leading Change, Advancing Health. 2015Washington, DC, The National Academics Press.
16. Association of Post Graduate APRN Programs. Available at: Accessed January 24, 2019
17. American Nurses Credentialing Center Practice Transition Accreditation Programs. Available at: Accessed January 24, 2019

acute care nurse practitioners; advanced practice providers; critical care staffing models; multiprofessional teams; physician assistants

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