With so many of our consulting engagements at Corazon focused in Cardiovascular and Neurosciences and the patients in these service lines often representing the largest percentage of the critical care patient population in any hospital ICU, we are often asked about optimization of APPs within the critical care arena. What is the best practice model?
For those who are not familiar with the Advanced Practice Provider or APP term, it has more recently become the accepted nomenclature for Nurse Practitioners and Physician Assistants. The use of APPs in critical care has steadily increased over the last 20 years. The national shortage of Intensivists Physicians has necessitated innovative solutions to provide quality care. Pre-Covid, we were seeing a decrease in overall hospital beds but an increase in critical care beds to meet the growing volume of complex critically ill patients. The Covid-19 Pandemic only exacerbated the problem.
APPs are not a replacement for the physician, but rather an augmentation of the critical care team. There is a very wide range of duties from obtaining medical histories, to completing physical assessments, interpreting test results and ordering diagnostics and medications, to performing invasive procedures such as intubation, line placements, lumbar punctures, chest tubes, just to name a few, that brings great value to the overall care of the critical care patient. One of the factors that creates a significant enhancement in the care of critical patients is the APPs consistent presence in the ICU. We often see hospital ICUs with intensivists who are also pulmonary physicians who regularly round on the ICU patients but are not present in the ICU all day as they are busy in the bronchoscopy lab or managing pulmonary patients outside the ICU. Even hospitals with interns, residents, and fellows see these providers moving in and out of the ICU throughout the day. Because the APPs are ever present, there is opportunity for rapid assessment and intervention when there is a significant change in a patient’s condition and more importantly, their presence often leads to earlier intervention before the patient takes a major turn for the worse as nursing staff will often ask the NP or PA to take a quick look when smaller changes occur that they might not actually call a physician to come and see.
But how many APPs does an ICU need to provide this enhanced care? There is not a nationally recognized APP to patient ratio and actually a single ratio would not make sense as it would not take into consideration other factors such as patient acuity, average daily census on the unit, number of interns, residents, or fellows present in the unit, additional duties such as code response off the unit, etc. A 2015 study, which published the results of a survey of 400+ NPs and PAs, showed a mean ratio of 1 APP to 5 patients but overall variation between 1:3 and 1:8. This mean ratio of 1:5 also matched a study done by Vanderbilt University in 2012 so it is often used as a reference point for an assessment which can then be adjusted up or down as needed based on the particular ICU situation to create a viable model.
APP models range from night coverage only, to night and weekend coverage, all the way to 24/7 coverage. Each facility and each ICU will have distinct needs which are revealed during the assessment to help guide decisions during the model build. The availability of intensivists in your market creates the starting point for any assessment and development of an intensivist coverage plan. For many hospitals, 24/7 intensivist coverage is simply not possible from an intensivist availability perspective. There is no way to ignore the national intensivist shortage. For some hospitals, eICU or Tele-ICU is the only intensivist coverage available to the facility. Implementing an APP model does not mean the hospital is settling for inferior care, as studies have shown no difference in the outcomes for ICU patients cared for by a team with Intensivist & residents or a team with Intensivist & APPs. There is also significant enhancement for smaller facilities who utilize eICU or Tele-ICU in having an APP with ‘boots on the ground’ in the ICU to manage the hands-on care with the tele-ICU provider on video. In addition to provider availability, as mentioned before, there is a need to assess many other factors like average patient acuity, admission/discharge/transfer volumes, presence or absence of interns/residents/fellows, and determination of the duties to be included in the critical care APP role including any coverage outside of the ICU such as code response.
While there is certainly a cost savings when implementing an Intensivist/APP model versus an all-Intensivist model, we at Corazon believe APPs bring a great value that goes well beyond dollar savings to the Critical Care setting. We find an overall improvement in the quality of nursing care when APPs are present in the ICU. They help to drive evidence-based practice initiatives as well as provide education to the nursing staff to elevate performance. And, a recent study showed improved intern/resident satisfaction when APPs are part of the ICU care team. Corazon often provides this type of ICU provider coverage assessment as part of a larger service line operations assessment or strategic plan but this can also be offered as a stand-alone assessment for organizations looking to advance their ICU care model.