At present, the U.S. population uses 23.2 million intensive care unit (ICU) days at an estimated cost of $81.7 billion each year. This equates to 13.4% of hospital costs and 4.1% of the national health expenditure. It has been suggested that $3.3 million in annual cost savings could be realized for each 12- to 18-bed ICU if care were delivered by intensivist-led teams. Currently, though, less than 40% of all ICU patients are treated with this model. The Association of American Medical Colleges expects a shortage of more than120,000 physicians by the end of this decade. A deficit of this magnitude is likely to threaten access to care, including ICU care.
One strategy for meeting ICU workforce needs is the addition of advanced practice professionals to ICU teams. Advanced practice providers, including nurse practitioners (NPs) and physician assistants (PAs), are an increasingly important component of the nation’s health-care workforce. More than 250,000 (>180,000 NPs and >85,000 PAs) practice in the U.S. health-care system. Consistent with the Institute of Medicine’s report, NPs and PAs play a vital role in delivering patient care, promoting multiprofessional collaboration, and advancing team approaches to care. These clinicians provide primary, acute, and specialty care services to patients in countless acute and nonacute care settings.
Nurse Practitioner and Physician Assistant Roles
NPs are registered nurses who are prepared at either the master’s or doctoral level, have an independent license, and are required to pass a national certification examination in most states to practice. NPs practice autonomously in most states with a scope of practice that is dependent on education, licensure, accreditation, and certification. To be in compliance with the National Council of State Boards of Nursing’s recommendations for the Advanced Practice Registered Nurse Consensus Model for practice in the ICU setting, NPs should be certified in either acute care or adult gerontology acute care. Similarly, PAs are health-care professionals who are certified by a national examination process. Most PAs are prepared at the graduate level, but some have bachelor’s degrees. PAs are licensed health-care professionals who practice under the supervision of a responsible physician who must be available for consultation by phone or in person.
NPs and PAs often have similar roles in the ICU, but in some settings differences exist. PAs focus on direct medical management or surgical assistance, whereas NP care encompasses direct patient care in addition to continuity of care components such as discharge planning; nursing, patient, and family education; and quality improvement/research, among other subroles ( Table 86-1 ).
| Category | PA | NP |
|---|---|---|
| Definition | Health-care professionals licensed to practice medical care with physician supervision. | Registered nurses with advanced education and training who have independent license. |
| Philosophy/model | Medical/physician model, disease centered, with emphasis on the biological/pathologic aspects of health, assessment, diagnosis, treatment. Practice model is a team approach relationship with physicians. | Medical/nursing model, biopsychosocial centered, with emphasis on disease adaptation, health promotion, wellness, and prevention. Practice model is a collaborative relationship with physicians. |
| Education | Affiliated with medical schools. Previous health-care experience required; most require entry-level bachelor’s degree. The program curriculum is advanced science based. Approximately 2000 clinical hours. All PAs are trained as generalists (a primary care model), and some receive postgraduate specialty training. Education is procedure and skill oriented with emphasis on diagnosis, treatment, surgical skills, and patient education. Currently, more than 50% of programs award master’s degrees and all are currently transitioning to the master’s level. | Affiliated with nursing schools. BSN is prerequisite and education is at master’s or doctoral level; curriculum is biopsychosocial based, based on behavioral, natural, and humanistic sciences. Approximately 750 to 1000 clinical hours. NPs choose a specialty training track in adult, acute care, pediatric, women’s health, or gerontology. |
| Certification/licensure | Separate accreditation and certification bodies require successful completion of an accredited program and NCCPA national certification exam. | National certification is required in majority of states. |
| Recertification | Recertification requires 100 hr of CME every 2 years and exam every 10 years. All PAs are licensed by their State Medical Board and the Medical Practice Act provisions. | Recertification requires, on average, 75 CEUs every 5-6 years. NPs are licensed by their State Board of Nursing. |
| Scope of practice | The supervising physician has relatively broad discretion in delegating medical tasks within his/her scope of practice to the PA in accordance with state regulations. PAs in Maryland may prescribe Schedule II-V controlled substances if the physician delegates this. On-site supervision is not required. | NP scope of practice is based on licensure, accreditation, certification, and education. NPs have independent practice in majority of states; some states have physician collaboration requirements. NPs may prescribe controlled substances. On-site supervision is not required. |
| Third-party coverage and reimbursement | PAs are eligible for certification as Medicaid and Medicare providers. Commercial payer reimbursement is currently variable. | NPs are eligible for certification as Medicaid and Medicare providers and generally receive favorable reimbursement from commercial payers. |
Use of Nurse Practitioners and Physician Assistants in the ICU
Data from national surveys on the use of NPs and PAs indicates that utilization in hospital settings has increased because of the higher acuity of hospitalized patients, restrictions placed on medical resident work hours, the need for continuity of care, and workforce shortages. In university-based hospital settings where the new Accreditation Council for Graduate Medical Education duty-hour regulations for physicians in training have been implemented, the integration of NPs and PAs into multidisciplinary provider models represents a solution to the gap in coverage. A study of 25 academic medical centers indicated that an additional role for NP and PA care has resulted from the need for improved access, improved continuity of care, patient throughput, and medical resident training restrictions, among others ( Fig. 86-1 ). Role components of NPs and PAs in the ICU are detailed in Table 86-2 .
| Patient care management |
| Rounding |
| Obtaining history and performing physical examinations |
| Diagnosing and treating illnesses |
| Ordering and interpreting tests |
| Initiating orders, often under protocols |
| Prescribing and performing diagnostic, pharmacologic, and therapeutic interventions consistent with education, practice, and state regulations |
| Performing procedures (as credentialed and privileged, such as arterial line insertion, suturing, and chest tube insertion) |
| Assessing and implementing nutrition |
| Collaborating and consulting with the interdisciplinary team, patient, and family |
| Assisting in the operating room |
| Education of staff, patients, and families |
| Practice guideline implementation |
| Lead, monitor, and reinforce practice guidelines for ICU patients (e.g., central line insertion procedures, infection prevention measures, stress ulcer prophylaxis) |
| Research |
| Data collection |
| Enrollment of subjects |
| Research study management |
| Quality assurance |
| Lead quality-assurance initiatives such as ventilator-associated pneumonia bundle, sepsis bundle, rapid response team |
| Communication |
| Promote and enhance communication with ICU staff, family members, and the multidisciplinary team |
| Discharge planning |
| Transfer and referral consultations |
| Patient and family education regarding anticipated plan of care |
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