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