SPECIAL FEATURE
Integrating Nurse Practitioners into the Critical Care Team
By Leslie A. Hoffman, RN, PhD and Jane Guttendorf, RN, DNP, CRNP
Dr. Hoffman is Professor Emeritus, Nursing and Clinical & Translational Science, University of Pittsburgh.
Dr. Guttendorf is Assistant Professor, University of Pittsburgh School of Nursing.
Dr. Guttendorf reports no financial relationships relevant to this field of study.
INTRODUCTION
Nurse practitioners (NP) have been involved in the care of critically ill patients since the late 1980s.1 Today, multiple universities and colleges offer NP preparation with specialization in a variety of areas. Acute Care Nurse Practitioners (ACNP), prepared to manage care in acute and critical care settings, were the fifth most common specialty in the United States in 2009, representing about 5% of the estimated 135,000 practicing NPs.2 ACNPs practice as members of hospitalist teams and specialty teams such as those in critical care, trauma, organ transplantation, and emergency departments. Surveys indicate that almost half (40%) practice in critical care.2 More than half of adult ICUs in academic teaching institutions in the United States currently employ NPs.1
Nurses prepared in advanced practice roles include certified nurse practitioners (CNP), clinical nurse specialists (CNS), certified registered nurse anesthetists (CRNA), and certified nurse midwives (CNM). In 2008, a nationwide effort was undertaken to define their scope of practice and set requirements for education, accreditation, licensure, and certification to ensure greater consistency in education and practice.3 This effort resulted in the Consensus Model for Advanced Practice Registered Nurse Regulation.4 Under this model, advanced practice nurses must be educated, certified, and licensed to practice in one of four roles (CNP, CNS, CRNA, CNM), and education must be targeted to one of six populations: family/individual across the life span, adult-gerontology, pediatrics, neonatal, women's health/gender-related health, and psychiatric/mental health. The goal was to focus preparation on patient care needs rather than the practice site.3,4 This change resulted in restructuring education for adult ACNPs to include gerontology and changes in the certification examination. The American Nurses Credentialing Center, the primary credentialing body for NPs, currently offers Adult-Gerontology ACNP certification and will retire the current ACNP examination in December 2014.5
The goal for implementing the Consensus Model is 2015. In 2012, 14 states had enacted or had pending legislation related to these changes.3 Once the model is fully enacted, NPs seeking licensure will need to have educational preparation and certification congruent with licensure and will seek employment in an area consistent with their licensure, certification, educational specialty, and population focus. This requirement differs from current practice, which does not mandate that NPs practice only in an area consistent with their specialty preparation. What happens to currently practicing NPs depends on state regulations. If a state enacts a grandfathering clause, NPs who are currently practicing will be able to continue practicing in the state where they are licensed. However, they may need to meet specific additional criteria if attempting to seek licensure in another state or do not have preparation consistent with their specialty area.
THE ACNP IN CRITICAL CARE
Growth in ACNPs practicing in critical care settings has been attributed to several factors. In academic settings, physicians-in-training historically provided a substantial portion of direct patient care. This changed with restrictions placed on resident physician duty hours by the Accreditation Council on Graduate Medical Education. The volume of patients admitted to critical care units has continued to increase and 24/7 coverage by board-certified intensivists has been advocated by organizations such as the Leapfrog Group, further stretching available resources.6 To meet these challenges, several practice changes resulted, including increased hiring of NPs and physician assistants (PAs).7-9
Several studies have examined outcomes of care provided by NPs in acute/critical care settings and perspectives of those involved in these teams. With a consistent presence in the ICU, ACNPs quickly become well versed in managing patient care responsibilities. However, it is advisable to provide a detailed orientation and more time and supervision initially. As noted by Gershengorn and colleagues, ACNPs and PAs who practice in ICUs are typically employed in this setting because it is their chosen practice site and are, therefore, more likely to be engaged in learning about ways to perfect their practice, compared to rotating housestaff whose primary interests may be elsewhere.1 As consistent ICU care providers, ACNPs may have a higher risk of burnout, compared to those who rotate on and off service, making it necessary to monitor for this consequence.1 Several studies evaluating ACNP practice in various settings support that outcomes of care are equivalent to comparative physician groups in a variety of critical care settings, including subacute medical ICU, coronary care unit, cardiovascular thoracic ICU, medical ICU, and other venues, e.g., trauma and neuroscience teams, and rapid response teams.10-16
PRACTICE MODELS INCORPORATING THE ACNP
The addition of ACNPs to intensivist-led ICU teams has the potential to increase the number of ICU patients each intensivist can effectively manage by off-loading some of the routine care and practice to the ACNP. There are a variety of models in which ACNPs can be incorporated into the critical care service team as noted below.
- Smaller ICUs, particularly those in community hospital settings, may benefit by the addition of one or two ACNP positions. Intensivists typically have responsibilities that require attention outside the ICU. The ACNP can practice in the ICU in a collaborative relationship with the critical care team. With this model, minute-to-minute changes in patient condition can be assessed immediately and changes can be made to pharmacologic and treatment pathways. The ACNP assumes primary responsibility for safety and quality metrics applicable to the ICU population, assures compliance with practice guidelines, and works collaboratively with nursing and other ancillary teams to address patient throughput, minimize ICU length of stay, and maximize care and services, e.g., pharmacy services, physical therapy, mobility, nutrition support, discharge planning, follow-up with consultant services.
- In a tertiary care setting, one or more ACNPs can provide similar benefits if assigned to specialty ICU populations or teams such as trauma, coronary care, cardiothoracic surgery, transplant, neuroscience, or medical/surgical ICUs. Familiarity with patient problems, the team of service providers, and practice guidelines ensures that best practices are applied early and with consistency. The ACNP provides continuity when intensivists, fellows, and residents rotate on and off service — a particular benefit to "long-stay" patients whose diagnostic and management challenges and family support may not be known to the new team. The ACNP can also play a pivotal role in educating rotating team members about protocols for care of specialty populations.
- More extensive models are used in academic settings. At Vanderbilt, NP practice teams are formally integrated with medical house staff teams to provide 24/7 NP coverage with 39 NPs across five ICUs.17 Memorial Sloan-Kettering Cancer Center uses an NP staffing model wherein a 20-bed medical-surgical ICU is staffed 24/7 by a team of 23 NPs and additional medical house staff. Thus, NPs may function collaboratively with resident physicians on a house staff/NP team or independently on an NP-only team.18 The University of Pittsburgh Medical Center critical care model includes advanced practice providers (NPs and PAs), critical care fellows, resident physicians, and intensivists working collaboratively to meet needs across a number of surgical ICUs using different staffing models depending on the individual unit requirements.
SCOPE OF PRACTICE, CREDENTIALING, AND PRIVILEGING FOR PROCEDURES
The ACNP can perform the admission history and physical assessment; review medical records, labs, radiographic data, and pharmacologic interventions; develop a differential diagnosis; develop a plan of care; and present patients on formal rounds. In addition, the ACNP can manage the full range of problems encountered in the care of the acutely and chronically critically ill patient, including airway and ventilator management, fluid resuscitation, institution and titration of vasopressors, inotropes and antiarrhythmic therapies, and management of delirium, pain and sedation, and instituting continuous renal replacement therapies, and nutritional support. Other roles may involve initiation of antimicrobial therapies and management of common problems due to neurologic, cardiovascular, pulmonary, renal, or hepatic dysfunction.
Specialty procedures performed by ACNPs include, among others, endotracheal intubation and insertion of arterial lines, central venous catheters and pulmonary artery catheters, thoracostomy tubes and chest tubes, and removal of these. ACNPs may also be credentialed to perform lumbar puncture, bone marrow biopsy, paracentesis, joint aspiration, cardioversion, defibrillation, suturing, and wound care.2 The ACNP will need to be credentialed and privileged by the institution through the same (or similar) procedure as medical staff to perform invasive procedures. The requested privileges should be consistent with the practitioner's education and licensure and should be in compliance with Joint Commission Standards.19 Credentialing usually initially involves direct supervision by another provider credentialed to perform that procedure and documentation of a specified minimum number of successful procedures prior to granting full privileges. To maintain credentialing for specialty procedures, a procedure log documenting the number of procedures performed to meet established thresholds is required.19,20
REIMBURSEMENT AND BILLING
Since 1997, NPs and PAs have been able to obtain individual provider numbers and submit bills to Medicare Part B for evaluation and management services.21 NPs must first meet specified training and certification requirements and maintain a collaborative practice arrangement with a physician, as well as meet state-specific regulations governing their scope of practice. The complexities of critical care billing for non-physician providers have been detailed in prior publications.21 Various approaches have been used, including allowing ACNPs to submit billing for critical care time or for evaluation and management services or billing only through physician providers.
CONCLUSION
The ACNP can be a valuable asset to the critical care team in providing the spectrum of services needed by acutely and critically ill patients. The ACNP provides a constant presence in the ICU, which can promote greater continuity of care. Those who have incorporated NPs and PAs into physician practices tend to uniformly value this collaboration, and studies evaluating practice have shown similar outcomes. Given the escalating need for critical care services, aging of the population, and demands placed on intensivists to meet these challenges, it is likely that integration of ACNPs into critical care teams will continue and likely increase in the future.
REFERENCES
- Gershengorn HB, et al. The use of nonphysician providers in adult intensive care units. Am J Respir Crit Care Med 2012;185:600-605.
- Kleinpell R, Goolsby MJ. American Academy of Nurse Practitioners National Nurse Practitioner sample survey: Focus on acute care. J Am Acad Nurse Pract 2012;24:690-694.
- Kleinpell RM, Hudspeth RS. Advanced practice nursing scope of practice for hospitals, acute care/critical care, and ambulatory care settings: A primer for clinicians, executives, and preceptors. AACN Adv Crit Care 2013;24:23-29.
- APRN Consensus Work Group and National Council of State Boards of Nursing. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education, July 7, 2008. https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf. Accessed on January 21, 2014.
- American Nurses Credentialing Center. http://www.nursecredentialing.org/. Accessed on January 21, 2014.
- Milstein A, et al. Improving the safety of health care: The Leapfrog Initiative. Eff Clin Pract 2000;3:313-316.
- Howie-Esquivel J, Fontaine DK. The evolving role of the acute care nurse practitioner in critical care. Curr Opin Crit Care 2006;12:609-613.
- Lundberg S, et al. Attaining resident duty hours compliance: The acute care nurse practitioners program at Olive View-UCLA Medical Center. Acad Med 2006;81:1021-1025.
- Pastores SM, 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.
- Kleinpell RM, et al. Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review. Crit Care Med 2008;36:2888-2897.
- Hoffman LA, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care 2005;14:121-132.
- Gershengorn HB, et al. Impact of nonphysician staffing on outcomes in a medical ICU. Chest 2011;139:1347-1353.
- Spisso J, et al. Improved quality of care and reduction of housestaff workload using trauma nurse practitioners. J Trauma 1990;30:660-665.
- Gillard JN, et al. Utilization of PAs and NPs at a level I trauma center: Effects on outcomes. JAAPA 2011;24:34-43.
- Russell D, et al. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners.Am J Crit Care 2002;11:353-364.
- Scherr K, et al. Evaluating a new rapid response team: NP-led versus intensivist-led comparisons. AACN Adv Crit Care 2012;23:32-42.
- Kapu AN, et al. NPs in the ICU, the Vanderbilt initiative. Nurse Pract 2012;37:46-52.
- D'Agostino R, et al. The NP staffing model in the ICU at Memorial Sloan-Kettering Cancer Center. In: Kleinpell RM, et al, eds. Integrating Nurse Practitioners & Physician Assistants into the ICU. Mount Prospect, IL: Society of Critical Care Medicine; 2012, pp. 18-25.
- Ackerman M, et al. Credentialing and privileging for nurse practitioners and physician assistants. In: Kleinpell RM, et al, eds. Integrating Nurse Practitioners & Physician Assistants into the ICU. Mount Prospect, IL: Society of Critical Care Medicine; 2012, pp. 66-71.
- Magdic KS, et al. Credentialing for nurse practitioners: An update. AACN Clin Issues 2005;16:16-22.
- Boyle WA, et al. Billing, reimbursement, and productivity for nonphysician practitioners in the ICU. In: Kleinpell RM, et al, eds. Integrating Nurse Practitioners & Physician Assistants into the ICU. Mount Prospect, IL: Society of Critical Care Medicine; 2012, pp. 28-45.
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