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Advanced Practice Providers in the Intensive Care Unit The UCSF Experience
Thomas Farley MS, NP, Assistant Clinical Professor Department of Critical Care Medicine
Advanced Practice Providers in the ICU; The UCSF Experience
“The real challenge is for each of us to determine where we feel we can make the most impact.”
Our experience at UCSF
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Farley, TL, Latham, G. Evolution of a critical care nurse practitioner role within a US academic medical center. ICU Director. 2011; 2(1-2): 16-19.
Advanced Practice Providers in the ICU; The UCSF Experience
The UCSF Experience
4 NP clinicians added in 2004
Limitations on available MD trainees
Goal of providing immediate critical care consultation 24 hours a day
60 adult critical care beds
NPs only in MedSurg ICU
Advanced Practice Providers in the ICU; The UCSF Experience
Geoff Latham NP
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Advanced Practice Providers in the ICU; The UCSF Experience
Evolution of a NP practice
18 NPs covering adult ICUs in 2015
Additional coverage at new Mission Bay hospital began February 2015
Expansion to 90 adult critical care beds
Med/Surg, Cardio/Thoracic, Neuro ICUs
At times no residents on team
Always 2 NPs on service 24/7
Advanced Practice Providers in the ICU; The UCSF Experience
Team at work
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Advanced Practice Providers in the ICU; The UCSF Experience
Why utilize APPs in the ICU?
Imbalance in the supply of and the demand for intensivists
Team based approach to care delivery
It is taking place in the USA, Canada, and the UK already
The literature shows it is safe, effective, and more human than a robot
Advanced Practice Providers in the ICU; The UCSF Experience
NPs in Critical Care
Memorial Sloan Kettering Cancer Center
Columbia University
Emory University
Henry Ford Hospital Detroit
Cleveland Clinic
Vanderbilt University
UC Davis, UCLA, UC Fresno, UCSF
Oregon Health Sciences University
Advanced Practice Providers in the ICU; The UCSF Experience
NPs in Critical Care Garland A, Gershengorn HB. Staffing in the ICUs: physicians and alternative staffing
models. Chest. 2013; 143(1): 214-221.
McCarthy C, O'Rourke NC, Madison JM. Integrating advanced practice providers into medical critical care teams. Chest. 2013 Mar;143(3):847-50.
Kapu AN, Thomson-Smith C, Jones P. NPs in the ICU: the Vanderbilt initiative. Nurse Pract. 2012; 37(8): 46-52.
Gershengorn HB, Wunsch H, Wahab R, et al. Impact of non-physician staffing on outcomes in a medical intensive care unit. Chest. 2011; 139(6): 1347-1353.
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(10):2888-2897
Gracias VH, Sicoutris CP, Stawicki SP, et al. Critical care nurse practitioners improve compliance with clinical practice guidelines in "semiclosed" surgical intensive care unit. J Nurs Care Qual. 2008;23(4):338-344.
Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med. 2003;31(12):2752-2763.
Advanced Practice Providers in the ICU; The UCSF Experience
Recently published
Acquired 2009-10 data from Cerner APACHE system
Adult patients in 29 medical and mixed ICUs in 22 hospitals
Total of 39,500 patients
Examined exposure to an ICU that employed NPs/Pas
Primary outcome was in hospital mortality
Costa DK, Wallace DJ, Barnato AE, Kahn JM. Nurse practitioner/physician assistant staffing and critical care mortality. Chest. 2014; Dec 146(6):1566-73.
Advanced Practice Providers in the ICU; The UCSF Experience
Recently published
21 (72%) of ICUs had NP/PAs
76.5% of patients received care in ICUs with NP/PAs
Total of 30,000 patients
Examined exposure to an ICU that employed NP/PAs
Primary outcome was in hospital mortality
Costa DK, Wallace DJ, Barnato AE, Kahn JM. Nurse practitioner/physician assistant staffing and critical care mortality. Chest. 2014; Dec 146(6):1566-73.
Advanced Practice Providers in the ICU; The UCSF Experience
Recently published
Results:
Unadjusted and risk adjusted mortality was similar between groups
Conclusion:
NPs/PAs do not increase mortality when providing critical care services
Costa DK, Wallace DJ, Barnato AE, Kahn JM. Nurse practitioner/physician assistant staffing and critical care mortality. Chest. 2014; Dec 146(6):1566-73.
Advanced Practice Providers in the ICU; The UCSF Experience
Erika Wilson NP
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Advanced Practice Providers in the ICU; The UCSF Experience
Mirrored at SFGH
At SFGH level 1 trauma center
Recognized need for quality control and improvement
Added 4 NPs to service in 2001
Current environment of limited housestaff and work hour reductions
Now 12 NPs in trauma/general surgery
At times no interns on teams
Advanced Practice Providers in the ICU; The UCSF Experience
Experience at UCSF and SFGH
Employed by hospital not by MD group
Medicare part A not part B
No independent billing performed
Close contact with the UCSF SON
Advanced Practice Providers in the ICU; The UCSF Experience
Gil Ponsones NP
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Advanced Practice Providers in the ICU; The UCSF Experience
NP responsibilities
Follow and teach standard ICU practices and protocols
Quality standards and improvement
Intervene and direct or provide appropriate initial therapy
First call at UCSF and SFGH
Overnight shifts at UCSF and SFGH
Advanced Practice Providers in the ICU; The UCSF Experience
Visiting scholars
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Advanced Practice Providers in the ICU; The UCSF Experience
Critical Care NP Duties
History taking and physical exams
Entering admission histories and physical in to the EMR
Entering daily progress notes into the EMR
Writing admission orders and routine orders
Independently performing procedures
Rounding with the critical care team and presenting patients
Implementing proven care bundles (sepsis, early mobilization, DVT prophylaxis)
Advanced Practice Providers in the ICU; The UCSF Experience
Critical Care NP Duties
Consultative role to admitting services
Consultative role to bedside RNs
Guidance of house staff
Responding to code blue activations
Assisting with rapid response consultations
Serving on hospital wide multidisciplinary committees
Precepting acute care nurse practitioner students
Attending morning teaching and monthly morbidity and mortality conferences
Advanced Practice Providers in the ICU; The UCSF Experience
Our physical therapists
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Advanced Practice Providers in the ICU; The UCSF Experience
Critical Care NP Procedures
Central venous catheter insertion
PICC insertion
Arterial catheter insertion
Chest tube insertion
Lumbar puncture
Suture and drain removal
Airway intubation
RN First Assist for OR role
Advanced Practice Providers in the ICU; The UCSF Experience
Kris Breyer MD and Mellyn Reading NP
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Advanced Practice Providers in the ICU; The UCSF Experience
Why it works
It is essential to have appropriate conduits for collaboration and supervision
Supportive attending MDs
Buy-in from the ICU RNs
NPs have experience as ICU RNs
SON provides excellent job candidates
Dedicated and professional group of NPs
Competency based orientation and training for all new NPs
Advanced Practice Providers in the ICU; The UCSF Experience
NPP Billing in Critical Care
Reference CMS transmittal #1548
http://www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf
Services may be provided by qualified NPPs and reported for payment
Unlike outpatients no ‘incident to’ or ‘shared’ visits allowed
Advanced Practice Providers in the ICU; The UCSF Experience
NPP Billing in Critical Care
For Medicare NP billing as hospital employees (part A) not allowed
To bill Medicare NPs must be employed by clinical departments or groups
For Medicare, reimbursement is 85% of published MD fee schedule
NPs may be credentialed by private payor
Private payors may reimburse up to 100%
Advanced Practice Providers in the ICU; The UCSF Experience
Our pharmacists
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Advanced Practice Providers in the ICU; The UCSF Experience
Survey of physician fellowship programs
Survey of 331 ACGME critical care fellowship directors Roughly 38% response rate
Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors. Joffe AM, Pastores SM, Maerz LL, Mathur P, Lisco SJ. J Crit Care. 2014 Feb;29(1):112-5.
Advanced Practice Providers in the ICU; The UCSF Experience
Fellowship programs
Advanced Practice Providers in the ICU; The UCSF Experience
Fellowship survey Joffe et al, Journal of Critical Care 2014
Advanced Practice Providers in the ICU; The UCSF Experience
Fellowship directors perceptions of APN roles Yes No Don’t Know
Saves time during rounds and evaluating new patients 78% 4% 15%
Aids in maintaining continuity of care 86% 6% 5%
Aids communication with healthcare team and families 86% 3% 9%
Aids in development of quality initiatives 59% 23% 17%
Aids in maintaining workflow 73% 5% 16%
Fellowship survey Joffe et al, Journal of Critical Care, 2014
Advanced Practice Providers in the ICU; The UCSF Experience
Interactions of APNs with medical trainees/fellows Yes No Don’t Know
Aid in fellow training (per program director) 62% 21% 12%
Aids in fellow training (per fellow) 54% 10% 32%
Participate in didactic discussion during rounds 72% 20% 4%
Participate in ICU related research activities 35% 50% 10%
Perform procedures traditionally done by fellow 54% 37% 5%
Are supervised by fellows during procedures 38% 50% 6%
Are supervised by residents during procedures 5% 86% 4%
UCSF Mission Bay Hospital
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Advanced Practice Providers in the ICU; The UCSF Experience
Preparing NPs for the ICU
Focus of education and national certification
Acute Care: generally inpatient care
Adult and Family: primary care
Current recommendation by National Council of State Boards of Nursing is to restrict intensive care roles to acute care nurse practitioners
Advanced Practice Providers in the ICU; The UCSF Experience
Preparing NPs for the ICU
Focus of education and national certification
Acute Care: generally inpatient care
Adult and Family: primary care
Current recommendation by National Council of State Boards of Nursing is to restrict intensive care roles to acute care nurse practitioners
Advanced Practice Providers in the ICU; The UCSF Experience
Struggles
NP education and certification focused on either acute care or primary care
Some specialties exist but no standards for surgical or critical care
New grad ACNPs require additional extensive training in order to succeed as critical care provider at an academic medical center
Advanced Practice Providers in the ICU; The UCSF Experience
Practice Transition Programs
Generally called NP residencies or fellowships
Programs exist at Emory, Vanderbilt, Carolinas Health Care, Mayo Rochester, Hopkins, Univ of Maryland
One year programs for new grad NPs
Credentialed and salaried employees
Advanced Practice Providers in the ICU; The UCSF Experience
UCSF NP Fellowship
First cohort in September 2014
Initiative launched by transplant surgeon Dr. John Roberts
From idea to interviewing in 6 months
Rotations in ICU, KTU, LTU, Trauma, Vascular, NeuroSurg, IR
ANCC Practice Transition Program Accreditation available
Advanced Practice Providers in the ICU; The UCSF Experience
NP fellowship goals
Provide pool of highly trained clinicians for future labor needs
Address gaps in the educational component of masters prepared NPs
Acknowledge that surgical and critical care is a challenging field
Advanced Practice Providers in the ICU; The UCSF Experience
Product of UCSF
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Advanced Practice Providers in the ICU; The UCSF Experience
Product of UCSF
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Advanced Practice Providers in the ICU; The UCSF Experience