east advanced practitioner survey

EAST Advanced EAST Advanced PractitionerPractitioner

SurveySurvey

Martin D. ZielinskiMartin D. ZielinskiAdvanced Practitioners Advanced Practitioners

CommitteeCommitteeJanuary 20, 2010January 20, 2010

Why are APs in Demand?Why are APs in Demand?

Increased need for advanced Increased need for advanced practitioners (AP)practitioners (AP) 80 hour work week for residents80 hour work week for residents

Resident goal clearResident goal clear AP goals less clear and variableAP goals less clear and variable

PayPay Life-work balanceLife-work balance EducationEducation AdministrationAdministration

GoalsGoals

Develop “best practice” modelDevelop “best practice” model SatisfactionSatisfaction RetentionRetention Appropriate patient careAppropriate patient care

Meet AP needsMeet AP needs

Nurse Practitioners and Physician Nurse Practitioners and Physician

Assistants considered equivalent for Assistants considered equivalent for

purposes of this reportpurposes of this report

Job DescriptionJob Description

242 total responses242 total responses

70% Surgeons70% Surgeons

19% Advanced 19% Advanced

PractitionerPractitioner

10% Trauma 10% Trauma

CoordinatorCoordinator

ACS LevelACS Level

The “Typical” ACS Advanced The “Typical” ACS Advanced Practitioner:Practitioner:

Works on the Trauma floor service (95.4%)Works on the Trauma floor service (95.4%)

Cares for 6 – 10 (42%) patients per shiftCares for 6 – 10 (42%) patients per shift

Takes no call (71.4%)Takes no call (71.4%)

Has similar responsibilities to a junior resident Has similar responsibilities to a junior resident

(57.3%)(57.3%)

Advanced Practitioner Area Advanced Practitioner Area of Practiceof Practice

Staffing Use on Acute Care Staffing Use on Acute Care Surgical ServicesSurgical Services

Advanced Advanced PractitionerPractitioner ResidentResident

Trauma Trauma ServiceService 78.9%78.9% 81.2%81.2%

SICUSICU 50.4%50.4% 72.1%72.1%

General General SurgerySurgery 36.4%36.4% 64.0%64.0%

Combine Combine Trauma/ICUTrauma/ICU 32.6%32.6% 63.4%63.4%

AP Staffing LevelAP Staffing Level

SurgeonSurgeon APAP

InterchangeaInterchangeable (Junior)ble (Junior) 20%20% 23%23%

InterchangeaInterchangeable (Senior)ble (Senior) 8%8% 21%21%

Independent Independent StaffingStaffing 64%64% 54%54%

Advanced Practitioner Advanced Practitioner Common Floor Common Floor ResponsibilitiesResponsibilities

Daily NoteDaily Note 81.4%81.4%

D/c D/c SummarySummary 88.7%88.7%

Care Care CoordinatioCoordinationn

93.3%93.3%

Phone CallsPhone Calls 69.1%69.1%

Procedure PerformanceProcedure Performance

CertifiedCertified Routinely PerformRoutinely Perform

Central LineCentral Line 86%86% 63%63%

PA CatheterPA Catheter 89%89% 44%44%

BronchoscopyBronchoscopy 76%76% 71%71%

PEGPEG 75%75% 73%73%

Perc TrachPerc Trach 82%82% 67%67%

LacerationsLacerations 83%83% 66%66%

EGDEGD 79%79% 50%50%

FAST/DPLFAST/DPL 71%71% 73%73%

Chest TubeChest Tube 88%88% 61%61%

IntubationIntubation 89%89% 47%47%

OR PresenceOR Presence

AP RoleAP RoleResidenResiden

t t PresentPresent

No No ResidenResiden

tt

OverallOverall 37%37% 77%77%

11stst AssistAssist 25%25% 48%48%

22ndnd AssistAssist 12%12% 29%29%

Other ResponsibilitiesOther Responsibilities

Areas EAST May ImpactAreas EAST May Impact Strategic PlanStrategic Plan

Plan AP billing seminarPlan AP billing seminar

ATLS for APs (they’re in the trauma ATLS for APs (they’re in the trauma

bay!)bay!)

Full EAST membershipFull EAST membership

Recommend AP geared conferencesRecommend AP geared conferences

Areas EAST May ImpactAreas EAST May Impact Garner further knowledgeGarner further knowledge

Refine surveyRefine survey AP specific societyAP specific society

Practice Management GuidelinePractice Management Guideline National StandardsNational Standards RetentionRetention

Other manuscriptsOther manuscripts EnthusiasmEnthusiasm

5-7 minutes5-7 minutes Brief intro and brief summaryBrief intro and brief summary Where they’re used (scope in Jan 2010) – floor, ICU (everywhere!)Where they’re used (scope in Jan 2010) – floor, ICU (everywhere!) What they do – procedures, charting, etc…What they do – procedures, charting, etc… Decide these at EAST meeting:Decide these at EAST meeting:

?PMG for APs?PMG for APs Retention for a future discussionRetention for a future discussion ? Subcommittee's? Subcommittee's Mission statement goalsMission statement goals Discuss to expand AP to allow EAST membershipDiscuss to expand AP to allow EAST membership ?ACS AP accredidation?ACS AP accredidation 2-3 good projects (high impact)2-3 good projects (high impact)

BackgroundBackground

Increased need for advanced Increased need for advanced practitioners (AP)practitioners (AP) 80 hour work week for residents80 hour work week for residents

Resident goal clearResident goal clear AP goals less clear and variableAP goals less clear and variable

PayPay Life-work balanceLife-work balance EducationEducation AdministrationAdministration

BackgroundBackground

Develop a modelDevelop a model SatisfactionSatisfaction RetentionRetention Appropriate Patient CareAppropriate Patient Care

NPs and PAs considered equivalent NPs and PAs considered equivalent

for purposes of this reportfor purposes of this report

Survey AudienceSurvey Audience

Job DescriptionJob Description

242 total responses242 total responses

70% Surgeons70% Surgeons

19% Advanced 19% Advanced

PractitionerPractitioner

10% Trauma 10% Trauma

CoordinatorCoordinator

ACS LevelACS Level

Trauma VolumeTrauma Volume

Advanced Practitioner and Advanced Practitioner and Resident Staffing and Resident Staffing and

InteractionInteraction

Staffing Use on Acute Care Staffing Use on Acute Care Surgical ServicesSurgical Services


Trauma Trauma ServiceService 78.9%78.9% 81.2%81.2%

SICUSICU 50.4%50.4% 72.1%72.1%

General General SurgerySurgery 36.4%36.4% 64.0%64.0%

Combine Combine Trauma/ICUTrauma/ICU 32.6%32.6% 63.4%63.4%

Trauma Staffing per ACS Trauma Staffing per ACS LevelLevel


Level 1Level 1 80.7%80.7% 92.7%92.7%

Level 2Level 2 79.5%79.5% 42.9%42.9%

Level 3Level 3 50.0%50.0% 0%0%

Level 4Level 4 0%0% 0%0%

Trauma Staffing per Trauma Trauma Staffing per Trauma VolumeVolume

Patient Patient VolumeVolume

Advanced Advanced PractitionerPractitioner

ResidentResident

<1000<1000 66.7%66.7% 53.6%53.6%

1000 – 18001000 – 1800 80.0%80.0% 68.8%68.8%

1801 – 35001801 – 3500 80.6%80.6% 93.6%93.6%

3500+3500+ 83.7%83.7% 92.5%92.5%

Surgeon vs AP View of Surgeon vs AP View of Responsibility LevelResponsibility Level

Attending Attending SurgeonSurgeon APAP

Medical Medical StudentStudent 0%0% 5%5%

Junior Junior ResidentResident 66%66% 23%23%

Senior Senior ResidentResident 31%31% 57%57%

StaffStaff 3%3% 17%17%

AP Staffing LevelAP Staffing Level

SurgeonSurgeon APAP

InterchangeaInterchangeable (Junior)ble (Junior)

20%20% 23%23%

InterchangeaInterchangeable (Senior)ble (Senior)

8%8% 21%21%

Independent Independent StaffingStaffing

64%64% 54%54%

Resident and AP InteractionResident and AP Interaction

When residents are present:When residents are present: Similar number of APs per shift (3.2 vs. 2.6)Similar number of APs per shift (3.2 vs. 2.6)

Same patient load responsibility (6-10)Same patient load responsibility (6-10)

Similar rate of bedside proceduresSimilar rate of bedside procedures

Less OR responsibility (48% vs. 18%)Less OR responsibility (48% vs. 18%)

Less number of APs per night call (0.7 vs. Less number of APs per night call (0.7 vs.

0.3)0.3)

Advanced Practitioner Advanced Practitioner Scope of PracticeScope of Practice

The “Typical” Advanced The “Typical” Advanced Practitioner:Practitioner:

Works on the Trauma floor service (95.4%)Works on the Trauma floor service (95.4%)

Cares for 6 – 10 (42%) patients per shiftCares for 6 – 10 (42%) patients per shift

Takes no call (71.4%)Takes no call (71.4%)

Has similar responsibilities to a junior resident Has similar responsibilities to a junior resident

(57.3%)(57.3%)

Advanced Practitioner Area Advanced Practitioner Area of Practiceof Practice

Advanced Practitioner Advanced Practitioner Partners Per ShiftPartners Per Shift

Total Total PartnersPartners

DaytimeDaytime

ShiftShiftNighttimNighttim

ee

WeekenWeekend or d or

HolidayHoliday

TraumaTrauma 3.23.2 2.12.1 0.40.4 0.80.8

SICUSICU 3.03.0 1.41.4 0.30.3 0.60.6

Acute Acute SurgerySurgery 2.62.6 1.11.1 0.20.2 0.30.3

Advanced Practitioner Advanced Practitioner Partners per Shift ViewpointPartners per Shift Viewpoint

Surgeon ViewSurgeon View AP ViewAP View

TraumaTrauma 2.82.8 4.34.3

ICUICU 2.52.5 3.53.5

Trauma/ICUTrauma/ICU 2.22.2 5.35.3

Acute SurgeryAcute Surgery 1.51.5 2.52.5

Advanced Practitioner CallAdvanced Practitioner Call

If APs do take call, 84.4% are in houseIf APs do take call, 84.4% are in house If residents are present, there is less AP call (24% vs. If residents are present, there is less AP call (24% vs.

45%)45%)

NoneNone 72%72%

On houseOn house 17%17%

HomeHome 1%1%

BackupBackup 3%3%

Advanced Practitioner Advanced Practitioner Common Floor Common Floor ResponsibilitiesResponsibilities

Daily NoteDaily Note 81.4%81.4%

D/c D/c SummarySummary 88.7%88.7%

Care Care CoordinatioCoordinationn

93.3%93.3%

Phone CallsPhone Calls 69.1%69.1%

Procedure PerformanceProcedure Performance

CertifiedCertified Routinely PerformRoutinely Perform




PEGPEG 75%75% 73%73%



EGDEGD 79%79% 50%50%




Procedure Performance Procedure Performance PerceptionPerception

SurgeonSurgeon APAP




PEGPEG 45%45% 49%49%



EGDEGD 40%40% 42%42%




OR PresenceOR Presence

AP RoleAP RoleResidenResiden

t t PresentPresent

No No ResidenResiden

tt

OverallOverall 37%37% 77%77%

11stst AssistAssist 25%25% 48%48%

22ndnd AssistAssist 12%12% 29%29%

BillingBilling

SurgeonSurgeon APAP

Independent Independent Billing Billing ViewpointViewpoint

47%47% 3131%%

37% of surgeons believe APs perform procedure notes while 92%of APs state they do

Other ResponsibilitiesOther Responsibilities

RetentionRetention

RetentionRetention

33% > 5 years33% > 5 years

63% leave at 2 – 4 years63% leave at 2 – 4 years

Retention is a problem!Retention is a problem!

Retention - IncentivesRetention - IncentivesSurgeonSurgeon APAP

Differential Differential Shift PayShift Pay 22%22% 33%33%

Time OffTime Off 58%58% 61%61%

Paid Paid Conference Conference AttendanceAttendance

51%51% 80%80%

Paid CMEPaid CME 51%51% 83%83%

Pay per Years Pay per Years of Experienceof Experience 37%37% 38%38%

BonusesBonuses 23%23% 21%21%

ProceduresProcedures 45%45% 50%50%

RetentionRetention

Institutional incentives offeredInstitutional incentives offered AP desires?AP desires?

Work-Life balanceWork-Life balance Time offTime off CallCall

EducationEducation

APs Want To Be Educated!APs Want To Be Educated!

75% attend in-house conferences 75% attend in-house conferences

geared towards surgical residentsgeared towards surgical residents 19% attend in-house AP geared sessions19% attend in-house AP geared sessions Only 62% undergo orientationOnly 62% undergo orientation Average orientation 4-5 weeksAverage orientation 4-5 weeks 71% attend paid conferences71% attend paid conferences

SummarySummary

Trauma services seem to be more Trauma services seem to be more robust and experiencedrobust and experienced Can use trauma as a model to push the Can use trauma as a model to push the

other services forward in practiceother services forward in practice Must be careful as there seems to be Must be careful as there seems to be

poor retention at the year 2-4 levelpoor retention at the year 2-4 level

SummarySummary

Institutional practiceInstitutional practice Clearly insufficient retentionClearly insufficient retention

Future DirectionsFuture Directions

Can we develop a model for each Can we develop a model for each

ACS level? ACS level? Each center is differentEach center is different

Resident availabilityResident availability VolumeVolume ACS level (i.e. acuity)ACS level (i.e. acuity)

Areas EAST May ImpactAreas EAST May Impact Plan AP billing seminarPlan AP billing seminar

ATLS for APs (they’re in the trauma bay!)ATLS for APs (they’re in the trauma bay!)

Recommend AP geared conferencesRecommend AP geared conferences

Garner further knowledgeGarner further knowledge Refine surveyRefine survey

AP specific societyAP specific society

Trial?Trial?

east advanced practitioner survey

Documents

advanced practitioner10

aps theyre

trauma floor service

similar number of aps

resident staffing

acs ap accredidation2

aps state

ap interactionwhen residents