Page 49 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

18 PART 1: An Overview of the Approach to and Organization of Critical Care

TABLE 3-2 Published Literature on Impact of Nonphysician Providers in the ICU
Study First Author, Year,
Reference Number Staffing Comparison Patient Population Study Design Outcomes
Dubaybo et al, 1991 87 PA vs house staff MICU Historical control study No difference in mortality
Russell et al, 2002 83 NP addition to team as overseer, NSICU Historical control study ↓ Hospital LOS
outcomes manager ↓ ICU LOS
↓ Rates of UTI
↓ Rates of skin breakdown
↓ Time to bladder catheter removal
↓ Time to mobilization
Burns et al, 2003 81 NP addition to team as overseer, CCU, MICU, NSICU, surgical trauma Historical control study ↓ Duration of mechanical ventilation
outcomes manager ICU, CTICU ↓ Hospital LOS
↓ ICU LOS
↓ Hospital mortality
↓ Hospital costs
Hoffman et al, 2003 84 NP vs pulmonary/CC fellow Step-down MICU Observational study of alternating weeks ↓ Time in off-unit activities
of service ↑ Time in coordination of care activities
Hoffman et al, 2005 85 NP vs pulmonary/CC fellow Step-down MICU Alternating blocks of 7 months No difference in LOS, duration of
mechanical ventilation, mortality ↓
rates of reintubations
Hoffman et al, 2006 86 NP vs pulmonary/CC fellow Step-down MICU; patients with Alternating blocks of 7 months No difference in LOS, ventilator wean-
tracheostomies ing success, readmissions
Gracias et al, 2008 82 NP in semiclosed format vs SICU Simultaneous comparison (split service ↑ Compliance with clinical practice
mandatory ICU consult into two) guidelines
Kawar et al, 2011 76 PA vs house staff MICU Simultaneous comparison of two MICUs No difference in hospital LOS, hospital
mortality, 28-day mortality
Gershengorn et al, 2011 75 NP/PA vs house staff MICU Simultaneous comparison of two MICUs No difference in mortality, ICU LOS,
hospital LOS
CCU, coronary care unit; CTICU, cardiovascular thoracic ICU; MICU, medical ICU; NSICU, neuroscience ICU; SICU, surgical ICU.
Reproduced with permission from Gershengorn HB, Johnson MP, Factor P. The use of nonphysician providers in adult intensive care units. Am J Respir Crit Care Med. March 15, 2012;185(6):600-605.

all reduced. 81,83 Adding an NP in an open-model surgical ICU resulted in consistency may improve communication between ICU staff members
increased adherence to clinical practice guidelines when compared with and, thereby, ICU culture and safety. Improvements in care quality have
mandatory critical care consultation without a physician or physician been associated with better communication and a more safe work envi-
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extender tied to the unit. 82 ronment. Second, procedural proficiency is known to increase with
At the University of Pittsburgh, the use of NPs as an alternative to practice 90-92 ; as a consistent presence in the ICU, nonphysician providers
ICU fellows has been examined in a step-down ICU. NPs were more will have more opportunity to hone procedural skills than more tran-
engaged in coordination of care and less involved in off-unit projects. sient care providers. Further, by being present in the ICU consistently,
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There were no differences in mortality, LOS, or difference in duration nonphysician providers will be repeatedly exposed to ICU-specific
of mechanical ventilation. For patients with respiratory failure and interventions (eg, continuous renal replacement therapy, mechanical
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a tracheostomy, there was no difference in LOS, success in ventilator ventilation, extracorporeal membrane oxygenation) for which comfort
weaning, or ICU readmissions. 86 only comes with practice and experience. Finally, over long periods of
Three studies have been published attesting to the comparability of time, nonphysician providers in the ICU should become expert in care
nonphysician providers to house staff in the adult ICU setting. Using a of critically ill patients. While fewer than 5% of internal medicine house
historical controlled design, in 1991 Dubaybo et al reported similar mor- staff choose to pursue a career in intensive care medicine, ICU-based
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tality rates for medical ICU patients cared for by house staff compared nonphysician providers have already selected the discipline and are,
with PAs. Two more recent studies also support the notion that care by therefore, likely to be more invested in learning the nuances of diagnosis
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nonphysician provider-based ICU teams is similar to that provided pri- and management of the critically ill patient.
marily by house staff. Both of these two studies compared a medical ICU As with all staffing models, there are several potential downsides of
staffed by house staff to another staffed by NPs/PAs operating simultane- the use of nonphysician providers in the ICU worthy of consideration.
ously in a single academic institution. Kawar et al reported that patients First, often NPs and PAs receive less formal in-school education on the
in the unit staffed by PAs had similar hospital LOS as well as ICU, hospi- pathophysiology, evaluation, synthesis, and presentation of complex
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tal, and 28-day mortality to those cared for by house staff. Gershengorn medical cases than do medical school graduates. As such, a signifi-
et al found that ICU patients whose care was provided by NPs/PAs versus cant upfront investment of time and resources for on-the-job training
house staff experienced comparable ICU and hospital LOS, hospital mor- of these providers has been used 72,74 and may be needed. Second, as
tality, and discharge destination for hospital survivors. 75 consistent ICU staff members, nonphysician providers may be at high
Additional benefits are potentially realizable with the use of nonphy- risk for developing job burnout. This syndrome is known to be highly
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sician providers in the care of ICU patients. First, unlike rotating resi- prevalent in ICU care providers and, when present, to negatively impact
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dents, these providers become a consistent workforce in the ICU. This care quality and to push providers to seek other lines of work. Finally,

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