- Email: [email protected]
Preparation and Evolving Role of the Acute Care Nurse Practitioner
Accepted Manuscript Preparation and Evolving Role of the Acute Care Nurse Practitioner Leslie A. Hoffman, RN, PhD, Jane Guttendorf, DNP, CRNP, ACNP-BC PII:
S0012-3692(17)31406-X
DOI:
10.1016/j.chest.2017.08.007
Reference:
CHEST 1253
To appear in:
CHEST
Received Date: 27 February 2017 Revised Date:
26 July 2017
Accepted Date: 7 August 2017
Please cite this article as: Hoffman LA, Guttendorf J, Preparation and Evolving Role of the Acute Care Nurse Practitioner, CHEST (2017), doi: 10.1016/j.chest.2017.08.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Word Count text: 2714 Word Count abstract: 134
Title: Preparation and Evolving Role of the Acute Care Nurse Practitioner
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Short running head: acute care nurse practitioner role
Authors:
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Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA
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Jane Guttendorf, DNP, CRNP, ACNP-BC, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA
Corresponding author information: Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Room 336, Victoria Building, Pittsburgh, PA 15261. E-mail: [email protected]
Funding: none
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Financial/nonfinancial disclosures: None declared.
Notation of prior abstract publication/presentation: none
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Abbreviations: Acute care nurse practitioner = ACNP; advanced practice registered nurse (APRN); intensive care unit = ICU; length-of-stay = LOS: nurse practitioner = NP; physician assistant = PA.
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ABSTRACT Acute care nurse practitioners (ACNPs) are increasingly being employed as members of critical care teams, an outcome driven by increasing demand for intensive care services, a mandated
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reduction in house officer hours and evidence supporting ability of ACNPs to provide high
quality care as collaborative members of critical care teams. Integration of adult ACNPs into critical care teams is most likely to be successful when practitioners have appropriate training,
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supervision and mentoring to facilitate their ability to practice efficiently and effectively.
Accomplishing this goal requires understanding the educational preparation and skill set
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potential hires bring to the position and development of an orientation program designed to integrate the practitioner into the critical care team. Pediatric ACNPs are also commonly employed in critical care settings; however, this commentary focuses on the adult ACNP role. INTRODUCTION
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The nurse practitioner (NP) role was initiated in 1965 in Colorado by a nurse/physician team with the goal of improving access to health care for children.1 Initially focused on pediatric primary care, the role expanded slowly to include acutely and critically ill adults. Curriculums designed to prepare adult acute care nurse practitioners (ACNPs) first became available in the
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United States in the 1990’s.2 In 2016, certifying agencies in the United States reported over
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15,500 certified ACNPs.3,4 Practice in intensive care units (ICUs) is common. In the United States, up to 70% of ACNPs and 24% of physician assistants (PAs) report working in ICUs as part of the collaborative care team.5,6 Educational Preparation
Initially, no uniform model of NP education existed. Each state independently determined graduates’ scope of practice and certification requirements. In 2008, this changed with development of the Consensus Model for Advanced Practice Registered Nurse Regulation.7
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The model establishes standards for accreditation, education, licensure and certification and restricts use of the term advanced practice registered nurse (APRN) to four roles: certified registered nurse anesthetist, certified nurse-midwife, certified clinical nurse specialist, and
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certified nurse practitioner. The model also identifies six population foci - adult-gerontology, family, pediatrics, neonatal, psych/mental health and women’s health – and requires that
educational programs include content for one (or more) of these populations. ACNP programs typically select adult-gerontology. Adult-Gerontology ACNP graduates are required to complete
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a minimum of 500 clinical hours providing direct care.7 To obtain certification, graduates must
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complete an accredited program and pass an exam offered by the American Nurses Credentialing Center or the American Association of Critical-Care Nurses. The Consensus Model was developed in response to a recognized need to establish uniform education and regulatory practices for APRNs. To date, 14 states have enacted the Consensus Model for all APRN roles. For certified NPs, 30 states and the District of Columbia have adopted
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legislation for independent practice and 25 states and the District of Columbia legislation permitting independent prescribing.7,8 Once fully enacted, NPs will need to be prepared and employed in an area consistent with their educational specialty and population focus.
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Consequently, preparation as a Family NP will not substitute for training offered by an accredited adult-gerontology ACNP program.9 This differs from current employment which does
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not mandate practice in an area consistent with educational preparation. What happens to currently practicing NPs depends on state regulations. If a state enacts a grandfather clause, NPs who are currently practicing will be able to continue to practice in the state where they are licensed. However, they may need to meet specific additional criteria if they seek licensure in another state or have preparation inconsistent with their specialty area.7 Scope of Practice
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ACNPs may manage a caseload of patients, all patients admitted to a selected ICU, or provide evening/night or weekend coverage. Some institutions integrate ACNPs into existing care delivery teams, whereas others establish an “ACNP team” with 24/7 responsibility for a separate
collaborative members of the multidisciplinary critical care team.
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unit or ICU. In each of these roles, ACNPs function within their scope of practice as
ACNPs are prepared to diagnose and treat medical conditions involving acutely/critically ill
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patients. Experienced ACNPs can perform the admission history and physical assessment, review medical records, labs and radiographic data, develop a differential diagnosis and plan of
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care, order pharmacologic and non-pharmacologic interventions, present patients on rounds, and complete necessary documentation. Important additional contributions include coordinating care delivery, educating patients/families, assisting patients/families to transition from critical illness to recovery or, if not possible, facilitate discussions related to end-of-life decision-making. ACNPs can manage a wide range of problems encountered in critical care, including airway and
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ventilator management, fluid resuscitation, institution and titration of vasopressors, inotropes and antiarrhythmic therapies; management of delirium, pain and sedation, institution of continuous renal replacement therapies, and nutritional support.10-12 Other roles may involve
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initiation of antimicrobial therapies and management of common problems due to cardiovascular, pulmonary, neurologic, renal, or hepatic dysfunction. Specialty procedures
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performed by ACNPs include, among others, endotracheal intubation, insertion of arterial, central venous and pulmonary artery catheters, and placement and removal of chest tubes. ACNPs may also perform lumbar puncture, bone marrow biopsy, paracentesis, joint aspiration, cardioversion, defibrillation, suturing, and wound care.10-12 It is important to note that ACNP programs differ in several aspects that pose important practice considerations. The Consensus Model broadly defines the population focus for ACNP practice (adult-gerontology).7 Consequently, there are wide differences between programs in regard to
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the degree of specialization and time spent managing patients with pulmonary conditions and those who are critically ill. This approach has the advantage of preparing graduates to manage a wide scope of potential problems but, also, may limit disease specific content. Also, programs
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differ in the amount of procedural training they offer and graduates differ in the prior nursing experience they bring to the program. These factors are important when considering applicants and the amount of mentoring required. In some programs, students select a subspecialty, e.g.,
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cardiopulmonary, critical care, and complete didactic content, simulation and clinical rotations with rounding teams in these areas. In other programs, students elect experience that provides this clinical focus. These options provide applicants with content and clinical experience
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focusing on the management of unstable critically ill patients.2,13 In programs without a critical care focus, graduates may have limited exposure to content and clinical experience specific to pulmonary or critical care patients. Notably, prior ICU experience, even if extensive, or preparation as a family NP does not substitute for appropriate population based training offered
Credentialing
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by an accredited ACNP program.9
Credentialing refers to granting authorization to provide care, within defined limits, based on an
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individual's license, education, training, experience, competence, and judgment.12 Privileging refers to authorizing the credentialed individual to perform specific diagnostic or therapeutic
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procedures.12 Joint Commission standards require that the evaluation process for APRNs include assessment of knowledge, interpersonal and communication skills, professionalism, in addition to technical competency, and be ongoing. More intense evaluation is required the first year a provider is credentialed and privileged and when a new privilege is requested.11,12 When ACNPs are hired, a process needs to be developed to allow them to be credentialed and privileged and a list of specific diagnostic or therapeutic procedures identified.11,12 The requested privileges should be consistent with the practitioner’s education and licensure and in
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compliance with Joint Commission Standards, state, and institutional regulations. Importantly, the process utilized needs to insure ability to competently carry out the identified procedures. How this is accomplished differs among institutions. A recent telephone survey of 246 hospitals
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conducted in California reported that 43% credentialed ACNPs to perform invasive procedures.14 ACNPs more often performed invasive procedures in teaching hospitals. The top five procedures were central lines, lumbar puncture, arterial lines, chest tube removal and
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intubation. Proctoring for credentialing was done by a supervising physician in 100% of teaching and 95% of non-teaching hospitals. Most institutions required 4-7 procedures before permitting
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independent practice. Three teaching hospitals utilized cadaver or simulation labs to credential ACNPs. These findings are similar to those from a nationwide survey that also queried ACNPs regarding procedural privileges.15 Studies evaluating outcomes
An expanding literature has evaluated ACNP practice outcomes in regard to a broad variety of
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parameters, including duration of mechanical ventilation, ICU length-of-stay, skill in performing invasive procedures and mortality.16-19 In addition, studies have evaluated care delivery efficiency, satisfaction, and cost.20-23 Findings consistently support safety of ACNP/PA care
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delivery, evidenced by similar outcomes in varied settings and care delivery models. Criticisms of this literature include that most studies were single-center, non-randomized, and did not
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evaluate 24/7 coverage. In addition, most studies did not assess post ICU discharge outcomes. Two recent studies provide data addressing these concerns. A study that evaluated national data comprising 29 ICUs, 22 hospitals and 39,541 patients reported that ICUs with NP/PA participation had similar mortality, after accounting for case mix, ICU characteristics, and subgroups of high-risk patients.6 There were also differences. Patients admitted to ICUs with NP/PA participation had a lower severity of illness and mechanical ventilation rates.6 A 3-year study evaluating outcomes in 9,066 patients admitted to three ICUs, two staffed 24/7 by resident
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physicians and the third 24/7 by ACNPs reported no differences in ICU length of stay or 90-day survival.24 Patients admitted to the ACNP team were similar to those admitted to the resident teams in regard to age, sex and race, but were less likely to be receiving vasopressors or
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mechanical ventilation at ICU admission.24 A third recent study reported no difference in invasive procedure complications over a 1-year period when comparisons were made between an ACNP/PA team and a team consisting of resident physicians.19 In this study, conducted in a
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Level I trauma center, residents performed 1,020 procedures (21 complications; 2% rate) and the ACNP/PA team 555 procedures (11 complications, 2% rate). There is also evidence for
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improved outcomes in time-dependent interventions. In a study conducted in a primary stroke center, addition of 24/7 on-site ACNP first responder coverage for acute stroke code significantly reduced door-to-needle time among acute stroke patients who received tissue plasminogen activator.25 These findings provide support for the use of alternative ICU staffing models, that incorporate ACNPs and PAs as members of the collaborative care team.26,27
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When evaluating findings of these studies, it is important to note that practitioners were experienced providers.28 In the study evaluating procedural complications, ACNPs/PAs completed training that included animal and simulation-based learning, were required to perform
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10 procedures before credentialing and were supervised by attending physicians.19 In the study evaluating 24/7 ACNP outcomes, training consisted of 4 months of attending supervised care
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with daily informal feedback and weekly formal evaluations. Each ACNP had prior experience as a critical care nurse (mean 7 years) and half had previously worked as an ACNP (mean 3 years). There were also differences in patient acuity, as noted previously.6,24 Studies were conducted in academic medical centers with availability of experienced attending physicians and critical care fellows for consultation and input during rounds. Whether similar outcomes would occur in a community and/or rural setting in which such support was less available has not been tested.
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It is also important to consider potential benefits more difficult to objectively measure.29 As unitbased providers, ACNPs are a more consistent presence than house officers/critical care fellows who rotate for blocks of time that can be as short as one week. When changes in
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personnel are frequent, gaps can occur in knowledge of the patient’s history and interventions that have been applied, evaluated and discarded.16 Consistency provided by a unit-based
ACNP/PA team may improve communication between the bedside nursing staff, families and
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respiratory care practitioners.21 Consistent unit presence may also enhance ability to recognize patterns of response and intervene to manage subtle changes in patient condition more rapidly.16,29 There are also potential downsides, i.e., the potential for burnout and need to invest
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time and resources to insure adequate training, supervision and mentoring.29 Practice integration
Models for successful integration of ACNPs into the critical care team include pairing the ACNP with a physician or experienced ACNP for mentoring and developing a structured orientation
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program in which new hires participate in didactic sessions and simulation.30 Post-graduate residency programs, open to both ACNPs and PAs, are another option. These hospital-based programs offer a concentrated didactic and mentored clinical program, typically over 9-12
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months.31,32 These are usually paid positions where the ACNP/PA is immersed as a functioning member of the clinical team. Initially few in number, options continue to increase.32,33 Each
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option has advantages and disadvantages that need to be considered in view of institution/practice needs (Table 1). Regardless of program content and availability, all practice models benefit from the thoughtful structuring of orientation programs, close mentoring of the newly employed ACNP/PA, and clear pathways to promote credentialing and progression toward independent practice. New graduates may have limited ICU exposure, depending on prior nursing experience and/or their educational program, factors which are important to specifically determine. Successful
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integration is, therefore, dependent on match with practice needs, the training and skill set of the new hire, and structure of the orientation program. Several institutions have published examples of their curriculum and planning which led to implementation.30,34
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Reimbursement and billing
Since 1997, NPs and PAs have been able to obtain individual provider numbers and submit bills to Medicare Part B for evaluation and management services, including critical care time. ACNPs
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can submit billing for services provided independently (85% reimbursement) or bill in a shared manner under Medicare’s shared service rule (100% reimbursement) provided the ACNP and
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physician have an employment relationship, i.e., the ACNP must be directly employed by the physician, group practice, or entity that employs the physician or must be a contracted or leased employee. The services billed must be within the ACNP’s scope of practice as determined by the state in which practice occurs and meet state licensure requirements for collaboration, physician supervision, and billing requirements.35,36 Many payers follow Medicare regulations,36
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but individual payers may have additional requirements for non-physician providers that need to be verified before submitting bills.35 Coding for Chest Medicine – 2016 and Coding and Billing
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for Critical Care-A Practice Tool are helpful references for detailed information on this topic.37,38 The current procedural terminology (CPT) codes for adult critical care services are codes 99291
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and 99292.39 Critical care services are time-based codes and the initial critical care time (CPT code 99291) must be met by a single physician or qualified non-physician provider. Additional critical care time (CPT code 99292) in the same calendar day can be billed either by a physician or another NP in the same practice following the guidelines outlined by the Centers for Medicare and Medicaid Services.36-38 If the ACNP works a shift that spans two calendar dates, e.g., 7:00 PM until 7:00 AM, and bills for critical care time on both dates, two claims are required – one for any qualifying encounter on the first date until midnight and a second for time spent during any qualifying encounter after midnight. Two separate progress notes are required to support claims
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made on the two calendar dates and the critical care time documented must match what was submitted on each claim.35-38 Cost is an important consideration when considering addition of ACNPs to a practice. To
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address this question, Edkins and colleagues40 conducted a systematic review that identified 18 studies (2002-2012) evaluating care in the ICU that included physician and non-physician teams. Multiple studies reported cost savings, primarily due to a decreased length-of-stay
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(LOS). This finding prompted the authors to construct models that examined the cost of staffing with varying combinations of physician, resident, and/or NP/PA coverage. They concluded
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employing NPs/PAs provided the most cost-effective means of addressing decreasing resident hours. Kapu and colleagues41 performed a quality and financial impact analysis using retrospective data. Software was used to abstract billing, acuity, and LOS data and NP associated quality metrics. Their conclusion was similar – adding non-physician providers did not increase costs and, in some ICUs, decreased costs. Greatest savings occurred in the
underinsured.
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trauma ICU where LOS decreased substantially and many patients were uninsured or
Ultimately, decisions regarding the cost-benefit of adding ACNPs/PAs to the critical care team
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depend on a complex mixture of factors - coverage needs, availability of resident/fellow trainees, patient volume, time-dependent interventions (acute stroke care), impact on quality of
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care, etc. While some of these factors can be objectively quantified, others are difficult to objectively measure. Each setting, therefore, needs to conduct a quality assessment that incorporates characteristics unique to its practice and needs. Conclusion ACNPs are integral members of many critical care provider teams who provide safe and effective care across a number of practice settings. Increasingly, outcome data supports this
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practice. ACNP educational programs provide varying levels of training specific to pulmonary and critical care patient management, an important factor to consider when hiring applicants and establishing orientation and mentoring agreements. While there is a national mandate to
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adopt standards for education, accreditation, licensure and certification for all APRN roles, progress of individual states in adoption of these recommendations is ongoing. Each provider is encouraged to become familiar with current legislation within their state to assure compliance.
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Limited information exists on how to evaluate cost-benefit when considering the addition of nonphysician providers; studies identifying how to make this determination for varied critical settings
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are needed to provide guidance to those considering this option.
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4. American Association of Critical-Care Nurses. Certification exam statistics and cut scores. https://www.aacn.org/certification/preparation-tools-and-handbooks/examstats-and-scores. Accessed June 14, 2017. 5. 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):28882897 6. Costa DK, Wallace DJ, Barnato AE, Kahn JM. Nurse practitioner/physician assistant staffing and critical care mortality. Chest. 2014;146(6):1566-1573.
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7. National Council of State Boards of Nursing. The consensus model for APRN regulation, licensure, accreditation, certification, and education. https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf. Accessed July 24, 2017.
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8. National Council of State Boards of Nursing. APRN Campaign for consensus: state progress toward uniformity. Implementation status map. https://www.ncsbn.org/2017Marchmapwithpoints.pdf. Accessed July 24, 2017.
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9. Haut C, Madden M. Hiring appropriate providers for different populations: acute care nurse practitioners. Crit Care Nurse. 2015;35(3):e1-e8. 10. Kleinpell RM, Hudspeth RS. Advanced practice nursing scope of practice for hospitals, acute care/critical care, and ambulatory care settings: a primer for clinicians, executives, and preceptors. AACN Adv Crit Care 2013;24(1):23-29. 11. Kleinpell RM, Hravnak M, Hinch B, Llewellyn J. Developing an advanced practice nursing credentialing model for acute care facilities. Nurs Adm Q. 2008;32(4):279-87. 12. Hravnak M. Credentialing and privileging for advanced practice nurses. AACN Adv Crit Care. 2009;20(1):12-14.
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13. Squiers J, King J, Wagner C, Ashby N, Parmley CL. ACNP intensivist: a new ICU care delivery model and its supporting educational programs. Jl Am Assoc Nurse Pract. 2013;25(3):119-125.
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14. Jalloh F, Tadlock MD, Cantwell S, Rausch T, Aksoy H, Frankel H. Credentialing and privileging of acute care nurse practitioners to do invasive procedures: a statewide survey. Am J Crit Care. 2016;25(4):357-361. 15. Kleinpell RM. Acute care nurse practitioner practice; results of a 5-year longitudinal study. Am J Crit Care. 2005;14(3):211-219.
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16. Hoffman LA, Tasota FJ, Zullo TG, Scharfenberg C, Donahoe MP. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am Jl Crit Care. 2005;14(2):121-130.
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17. Landsperger JS, Williams KJ, Hellervic SM, et al. Implementation of a medical intensive care unit acute care nurse practitioner service. Hosp Pract. 2011;39(2):3239. 18. Gershengorn HB, Wunsch H, Wahab R, et al. Impact of nonphysician staffing on outcomes in a medical ICU. Chest. 2011;139(6):1347-1353. 19. Sirleaf M, Jefferson B, Christmas AB, Sing RF, Thomason MH, Huynh TT. Comparison of procedural complications between resident physicians and advanced clinical providers. J Trauma Acute Care Surg. 2014;77:143-147.
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20. Hoffman LA, Tasota FJ, Scharfenberg C, Zullo TG, Donahoe MP. Management of patients in the ICU: comparison via work sampling analysis of an acute care nurse practitioner & physicians-in-training. Am Jl Crit Care. 2003;12(5):436-443.
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21. Hoffman LA, Happ MB, Scharfenberg C, DiVirgilio-Thomas D, Tasota, F. J. Perceptions of physicians, nurses and & respiratory therapists about the role of acute care nurse practitioners. Am Jl Crit Care. 2004;13(6):480-488.
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22. Collins N, Miller R, Kapu A, et al. Outcomes of adding acute care nurse practitioners to a Level 1 trauma service with the goal of decreased length of stay and improved physician and nursing satisfaction. J Trauma Acute Care Surg. 2014;76:353-357. 23. Kahn SA, Davis SA, Barnes CT, Dennis BM, May AK, Gunter OD. Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents” critical care experience. J Surg Res. 2015;199(1):7-12. 24. Landsperger JS, Semler MW, Wang L, Byrne DW, Wheeler AP. Outcomes of nurse practitioner-delivered critical care: a prospective cohort study. Chest. 2016;149(5):1146-1154.
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25. Moran JL, Nakagawa K, Asai SM, Koenig MA. 24/7 neurocritical care nurse practitioner coverage reduced door-to-needle time to stroke patients treated with plasminogen activator. J Stroke Cerebrovasc Dis. 2016;25(5):1148-1152.
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26. Kahn JM, Rubenfeld GD. The myth of the workforce crisis. Why the United States does not need more intensivists physicians. Am J Respir Crit Care Med. 2015;191(2):128-134.
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27. Kerlin MP, Adhikari NKJ, Rose L, et al. An official American Thoracic Society systematic review: the effect of nighttime intensivist staffing on mortality and length of stay among intensive care unit patients. Am J Respir Crit Care Med. 2017;195(3):383393.
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28. Lilly CM, Katz AW. New ICU team members: the effective inclusion of critical care advance practice providers. Chest. 2016;149(5):1191-1120. 29. Garland A, Gershengorn HB. Staffing in ICUs: physicians and alternative staffing models. Chest. 2013;143(1):214-221. 30. Simone S, McComiskey CA, Andersen B. Integrating nurse practitioners into intensive care units. Crit Care Nurse. 2016;36(6):59-69.
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31. Bush CT. Postgraduate nurse practitioner training: what nurse executives need to know. J Nurs Admin. 2014;44(12):625-627. 32. Association of Postgraduate APRN Programs (APGAP). https://apgap.enpnetwork.com/page/24301-program-master-list Accessed July 24, 2017.
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33. Association of Postgraduate PA Programs (APPAP). http://appap.org/wpcontent/uploads/2015/04/Program_Matrix-as-of-March-2017-3.pdf. Accessed July 24, 2017. 34. Kapu AN, Thomson-Smith C, Jones P. NPs in the ICU: the Vanderbilt Initiative. Nurse Prac. 2012:37(8):46-52. 35. McCarthy C, O’Rourke NC, Madison JM. Integrating advanced practice providers into medical critical care teams. Chest. 2013;143(3):847-850. 36. Centers for Medicare & Medicaid Services (CMS). Medicare claims processing manual. Chapter 12: Physicians/nonphysician providers, Sections 30.6 and 120. CMS Web site. https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c12.pdf Revised 4-14-17, Accessed July 26, 2017.
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38. Dorman T, Britton FM, Brown DR, Munro N. Coding and billing for critical care – A practice tool, 6th ed. Society of Critical Care Medicine; 2014. 39. Munro N. What acute care nurse practitioners should understand about reimbursement: critical care issues. AACN Adv Crit Care. 2013;24(3):241-244.
40. Edkins RE, Caims BA, Huttman CS. A systematic review of advance practice providers
in acute care: options for a new model in a burn intensive care unit. Ann Plast Surg. 2014;72(3):285-288.
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41. Kapu AN, Kleinpell R, Pilon B. Qualilty and financial impact of adding nurse
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practitioners to inpatient care teams. J Nurs Admin. 2014;44(2):87-96.
Comprehensive orientation program developed and attended by all hires.
Experienced clinician (ACNP/MD) mentor identified.
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Implementation
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Table 1. Comparison of orientation methods for acute care nurse practitioners Orientation Structured Buddy Postdoctoral Method Orientation System Residency or Fellowship Planning 1. Conduct assessment to determine areas of need and cost. 2. Determine NP role, responsibilities, salary, benefits 3. Write job description (work model, reporting, communication, etc) 4. Establish billing procedures 5. Determine orientation method (length, content, credentialing, privileging) 6. Establish process for initial and ongoing mentoring 7. Determine method for yearly evaluation and merit review 8. Confirm decisions with stakeholders and revise prn
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Components: ● Mentor develops plan to progress new hire through hospital, role, practice orientation & procedural training. ● Over ~ 1 month new hire is mentored toward
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Components: ● Hospital orientation ● APRN role orientation ● Practice orientation, daily routine, rounding process, guidelines for communication ● Procedural training ● Documentation – oral, written, electronic ● Scheduling process
Teaching Methods ● Knowledge & competency
independence. Teaching Methods ● May include competency assessment, lectures, simulation instruction.
Optional 1-2 year residency/fellowship similar to that available to medical trainees.
Components: ● ACNP functions as staff member during residency/fellowship ● Employer pays salary and benefits. Components: ● Program content varies dependent on location residency/fellowship. ● Some options combine clinical training with academic coursework that can be applied toward earning a Doctor of Nursing Practice (DNP) degree.
assessment ● Lecture, case review ● Simulation ● Mentored experiences
Progression ● Varies dependent on prior experience and service needs
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● Competency assessment ● Weekly practice evaluation ● Ongoing professional practice evaluation & focused professional practice evaluation at specific intervals
● Competency assessment ● Weekly practice evaluation ● Ongoing professional practice evaluation at specific intervals
● Varies dependent on program
Pros and Cons
Pros: ● Insures comprehensive orientation for all new hires. ● Formal endof-program assessment facilitates process improvement.
Pros: ● Inexpensive, flexible ● Content and pace can be varied to match learner needs.
Pros ● Expands expertise & skill set of new graduates. ● Mechanism to recruit new hires. .
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Cons: ● Expense required to schedule & maintain resources for instruction. ● Requires dedicated time & commitment from multiple staff. ● Difficult to titrate
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Evaluation
Cons: ● Requires dedicated time & commitment from mentor ● Informal structure, risks omitting critical information. ● If one mentor, limited exposure to team/other
Cons ● After completion, resident/fellow may seek employment elsewhere if no required commitment. ● No evidence to date regarding benefits (improved patient outcomes, competency, confidence, retention).
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practice styles
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content to varying levels of new hire experience.
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Abbreviations: Acute care nurse practitioner = ACNP; advanced practice registered nurse (APRN); intensive care unit = ICU; length-of-stay = LOS: nurse practitioner = NP; physician assistant = PA.
S0012-3692(17)31406-X
DOI:
10.1016/j.chest.2017.08.007
Reference:
CHEST 1253
To appear in:
CHEST
Received Date: 27 February 2017 Revised Date:
26 July 2017
Accepted Date: 7 August 2017
Please cite this article as: Hoffman LA, Guttendorf J, Preparation and Evolving Role of the Acute Care Nurse Practitioner, CHEST (2017), doi: 10.1016/j.chest.2017.08.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Word Count text: 2714 Word Count abstract: 134
Title: Preparation and Evolving Role of the Acute Care Nurse Practitioner
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Short running head: acute care nurse practitioner role
Authors:
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Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA
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Jane Guttendorf, DNP, CRNP, ACNP-BC, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA
Corresponding author information: Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Room 336, Victoria Building, Pittsburgh, PA 15261. E-mail: [email protected]
Funding: none
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Financial/nonfinancial disclosures: None declared.
Notation of prior abstract publication/presentation: none
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Abbreviations: Acute care nurse practitioner = ACNP; advanced practice registered nurse (APRN); intensive care unit = ICU; length-of-stay = LOS: nurse practitioner = NP; physician assistant = PA.
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ABSTRACT Acute care nurse practitioners (ACNPs) are increasingly being employed as members of critical care teams, an outcome driven by increasing demand for intensive care services, a mandated
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reduction in house officer hours and evidence supporting ability of ACNPs to provide high
quality care as collaborative members of critical care teams. Integration of adult ACNPs into critical care teams is most likely to be successful when practitioners have appropriate training,
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supervision and mentoring to facilitate their ability to practice efficiently and effectively.
Accomplishing this goal requires understanding the educational preparation and skill set
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potential hires bring to the position and development of an orientation program designed to integrate the practitioner into the critical care team. Pediatric ACNPs are also commonly employed in critical care settings; however, this commentary focuses on the adult ACNP role. INTRODUCTION
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The nurse practitioner (NP) role was initiated in 1965 in Colorado by a nurse/physician team with the goal of improving access to health care for children.1 Initially focused on pediatric primary care, the role expanded slowly to include acutely and critically ill adults. Curriculums designed to prepare adult acute care nurse practitioners (ACNPs) first became available in the
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United States in the 1990’s.2 In 2016, certifying agencies in the United States reported over
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15,500 certified ACNPs.3,4 Practice in intensive care units (ICUs) is common. In the United States, up to 70% of ACNPs and 24% of physician assistants (PAs) report working in ICUs as part of the collaborative care team.5,6 Educational Preparation
Initially, no uniform model of NP education existed. Each state independently determined graduates’ scope of practice and certification requirements. In 2008, this changed with development of the Consensus Model for Advanced Practice Registered Nurse Regulation.7
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The model establishes standards for accreditation, education, licensure and certification and restricts use of the term advanced practice registered nurse (APRN) to four roles: certified registered nurse anesthetist, certified nurse-midwife, certified clinical nurse specialist, and
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certified nurse practitioner. The model also identifies six population foci - adult-gerontology, family, pediatrics, neonatal, psych/mental health and women’s health – and requires that
educational programs include content for one (or more) of these populations. ACNP programs typically select adult-gerontology. Adult-Gerontology ACNP graduates are required to complete
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a minimum of 500 clinical hours providing direct care.7 To obtain certification, graduates must
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complete an accredited program and pass an exam offered by the American Nurses Credentialing Center or the American Association of Critical-Care Nurses. The Consensus Model was developed in response to a recognized need to establish uniform education and regulatory practices for APRNs. To date, 14 states have enacted the Consensus Model for all APRN roles. For certified NPs, 30 states and the District of Columbia have adopted
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legislation for independent practice and 25 states and the District of Columbia legislation permitting independent prescribing.7,8 Once fully enacted, NPs will need to be prepared and employed in an area consistent with their educational specialty and population focus.
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Consequently, preparation as a Family NP will not substitute for training offered by an accredited adult-gerontology ACNP program.9 This differs from current employment which does
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not mandate practice in an area consistent with educational preparation. What happens to currently practicing NPs depends on state regulations. If a state enacts a grandfather clause, NPs who are currently practicing will be able to continue to practice in the state where they are licensed. However, they may need to meet specific additional criteria if they seek licensure in another state or have preparation inconsistent with their specialty area.7 Scope of Practice
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ACNPs may manage a caseload of patients, all patients admitted to a selected ICU, or provide evening/night or weekend coverage. Some institutions integrate ACNPs into existing care delivery teams, whereas others establish an “ACNP team” with 24/7 responsibility for a separate
collaborative members of the multidisciplinary critical care team.
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unit or ICU. In each of these roles, ACNPs function within their scope of practice as
ACNPs are prepared to diagnose and treat medical conditions involving acutely/critically ill
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patients. Experienced ACNPs can perform the admission history and physical assessment, review medical records, labs and radiographic data, develop a differential diagnosis and plan of
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care, order pharmacologic and non-pharmacologic interventions, present patients on rounds, and complete necessary documentation. Important additional contributions include coordinating care delivery, educating patients/families, assisting patients/families to transition from critical illness to recovery or, if not possible, facilitate discussions related to end-of-life decision-making. ACNPs can manage a wide range of problems encountered in critical care, including airway and
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ventilator management, fluid resuscitation, institution and titration of vasopressors, inotropes and antiarrhythmic therapies; management of delirium, pain and sedation, institution of continuous renal replacement therapies, and nutritional support.10-12 Other roles may involve
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initiation of antimicrobial therapies and management of common problems due to cardiovascular, pulmonary, neurologic, renal, or hepatic dysfunction. Specialty procedures
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performed by ACNPs include, among others, endotracheal intubation, insertion of arterial, central venous and pulmonary artery catheters, and placement and removal of chest tubes. ACNPs may also perform lumbar puncture, bone marrow biopsy, paracentesis, joint aspiration, cardioversion, defibrillation, suturing, and wound care.10-12 It is important to note that ACNP programs differ in several aspects that pose important practice considerations. The Consensus Model broadly defines the population focus for ACNP practice (adult-gerontology).7 Consequently, there are wide differences between programs in regard to
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the degree of specialization and time spent managing patients with pulmonary conditions and those who are critically ill. This approach has the advantage of preparing graduates to manage a wide scope of potential problems but, also, may limit disease specific content. Also, programs
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differ in the amount of procedural training they offer and graduates differ in the prior nursing experience they bring to the program. These factors are important when considering applicants and the amount of mentoring required. In some programs, students select a subspecialty, e.g.,
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cardiopulmonary, critical care, and complete didactic content, simulation and clinical rotations with rounding teams in these areas. In other programs, students elect experience that provides this clinical focus. These options provide applicants with content and clinical experience
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focusing on the management of unstable critically ill patients.2,13 In programs without a critical care focus, graduates may have limited exposure to content and clinical experience specific to pulmonary or critical care patients. Notably, prior ICU experience, even if extensive, or preparation as a family NP does not substitute for appropriate population based training offered
Credentialing
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by an accredited ACNP program.9
Credentialing refers to granting authorization to provide care, within defined limits, based on an
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individual's license, education, training, experience, competence, and judgment.12 Privileging refers to authorizing the credentialed individual to perform specific diagnostic or therapeutic
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procedures.12 Joint Commission standards require that the evaluation process for APRNs include assessment of knowledge, interpersonal and communication skills, professionalism, in addition to technical competency, and be ongoing. More intense evaluation is required the first year a provider is credentialed and privileged and when a new privilege is requested.11,12 When ACNPs are hired, a process needs to be developed to allow them to be credentialed and privileged and a list of specific diagnostic or therapeutic procedures identified.11,12 The requested privileges should be consistent with the practitioner’s education and licensure and in
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compliance with Joint Commission Standards, state, and institutional regulations. Importantly, the process utilized needs to insure ability to competently carry out the identified procedures. How this is accomplished differs among institutions. A recent telephone survey of 246 hospitals
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conducted in California reported that 43% credentialed ACNPs to perform invasive procedures.14 ACNPs more often performed invasive procedures in teaching hospitals. The top five procedures were central lines, lumbar puncture, arterial lines, chest tube removal and
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intubation. Proctoring for credentialing was done by a supervising physician in 100% of teaching and 95% of non-teaching hospitals. Most institutions required 4-7 procedures before permitting
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independent practice. Three teaching hospitals utilized cadaver or simulation labs to credential ACNPs. These findings are similar to those from a nationwide survey that also queried ACNPs regarding procedural privileges.15 Studies evaluating outcomes
An expanding literature has evaluated ACNP practice outcomes in regard to a broad variety of
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parameters, including duration of mechanical ventilation, ICU length-of-stay, skill in performing invasive procedures and mortality.16-19 In addition, studies have evaluated care delivery efficiency, satisfaction, and cost.20-23 Findings consistently support safety of ACNP/PA care
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delivery, evidenced by similar outcomes in varied settings and care delivery models. Criticisms of this literature include that most studies were single-center, non-randomized, and did not
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evaluate 24/7 coverage. In addition, most studies did not assess post ICU discharge outcomes. Two recent studies provide data addressing these concerns. A study that evaluated national data comprising 29 ICUs, 22 hospitals and 39,541 patients reported that ICUs with NP/PA participation had similar mortality, after accounting for case mix, ICU characteristics, and subgroups of high-risk patients.6 There were also differences. Patients admitted to ICUs with NP/PA participation had a lower severity of illness and mechanical ventilation rates.6 A 3-year study evaluating outcomes in 9,066 patients admitted to three ICUs, two staffed 24/7 by resident
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physicians and the third 24/7 by ACNPs reported no differences in ICU length of stay or 90-day survival.24 Patients admitted to the ACNP team were similar to those admitted to the resident teams in regard to age, sex and race, but were less likely to be receiving vasopressors or
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mechanical ventilation at ICU admission.24 A third recent study reported no difference in invasive procedure complications over a 1-year period when comparisons were made between an ACNP/PA team and a team consisting of resident physicians.19 In this study, conducted in a
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Level I trauma center, residents performed 1,020 procedures (21 complications; 2% rate) and the ACNP/PA team 555 procedures (11 complications, 2% rate). There is also evidence for
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improved outcomes in time-dependent interventions. In a study conducted in a primary stroke center, addition of 24/7 on-site ACNP first responder coverage for acute stroke code significantly reduced door-to-needle time among acute stroke patients who received tissue plasminogen activator.25 These findings provide support for the use of alternative ICU staffing models, that incorporate ACNPs and PAs as members of the collaborative care team.26,27
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When evaluating findings of these studies, it is important to note that practitioners were experienced providers.28 In the study evaluating procedural complications, ACNPs/PAs completed training that included animal and simulation-based learning, were required to perform
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10 procedures before credentialing and were supervised by attending physicians.19 In the study evaluating 24/7 ACNP outcomes, training consisted of 4 months of attending supervised care
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with daily informal feedback and weekly formal evaluations. Each ACNP had prior experience as a critical care nurse (mean 7 years) and half had previously worked as an ACNP (mean 3 years). There were also differences in patient acuity, as noted previously.6,24 Studies were conducted in academic medical centers with availability of experienced attending physicians and critical care fellows for consultation and input during rounds. Whether similar outcomes would occur in a community and/or rural setting in which such support was less available has not been tested.
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It is also important to consider potential benefits more difficult to objectively measure.29 As unitbased providers, ACNPs are a more consistent presence than house officers/critical care fellows who rotate for blocks of time that can be as short as one week. When changes in
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personnel are frequent, gaps can occur in knowledge of the patient’s history and interventions that have been applied, evaluated and discarded.16 Consistency provided by a unit-based
ACNP/PA team may improve communication between the bedside nursing staff, families and
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respiratory care practitioners.21 Consistent unit presence may also enhance ability to recognize patterns of response and intervene to manage subtle changes in patient condition more rapidly.16,29 There are also potential downsides, i.e., the potential for burnout and need to invest
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time and resources to insure adequate training, supervision and mentoring.29 Practice integration
Models for successful integration of ACNPs into the critical care team include pairing the ACNP with a physician or experienced ACNP for mentoring and developing a structured orientation
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program in which new hires participate in didactic sessions and simulation.30 Post-graduate residency programs, open to both ACNPs and PAs, are another option. These hospital-based programs offer a concentrated didactic and mentored clinical program, typically over 9-12
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months.31,32 These are usually paid positions where the ACNP/PA is immersed as a functioning member of the clinical team. Initially few in number, options continue to increase.32,33 Each
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option has advantages and disadvantages that need to be considered in view of institution/practice needs (Table 1). Regardless of program content and availability, all practice models benefit from the thoughtful structuring of orientation programs, close mentoring of the newly employed ACNP/PA, and clear pathways to promote credentialing and progression toward independent practice. New graduates may have limited ICU exposure, depending on prior nursing experience and/or their educational program, factors which are important to specifically determine. Successful
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integration is, therefore, dependent on match with practice needs, the training and skill set of the new hire, and structure of the orientation program. Several institutions have published examples of their curriculum and planning which led to implementation.30,34
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Reimbursement and billing
Since 1997, NPs and PAs have been able to obtain individual provider numbers and submit bills to Medicare Part B for evaluation and management services, including critical care time. ACNPs
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can submit billing for services provided independently (85% reimbursement) or bill in a shared manner under Medicare’s shared service rule (100% reimbursement) provided the ACNP and
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physician have an employment relationship, i.e., the ACNP must be directly employed by the physician, group practice, or entity that employs the physician or must be a contracted or leased employee. The services billed must be within the ACNP’s scope of practice as determined by the state in which practice occurs and meet state licensure requirements for collaboration, physician supervision, and billing requirements.35,36 Many payers follow Medicare regulations,36
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but individual payers may have additional requirements for non-physician providers that need to be verified before submitting bills.35 Coding for Chest Medicine – 2016 and Coding and Billing
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for Critical Care-A Practice Tool are helpful references for detailed information on this topic.37,38 The current procedural terminology (CPT) codes for adult critical care services are codes 99291
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and 99292.39 Critical care services are time-based codes and the initial critical care time (CPT code 99291) must be met by a single physician or qualified non-physician provider. Additional critical care time (CPT code 99292) in the same calendar day can be billed either by a physician or another NP in the same practice following the guidelines outlined by the Centers for Medicare and Medicaid Services.36-38 If the ACNP works a shift that spans two calendar dates, e.g., 7:00 PM until 7:00 AM, and bills for critical care time on both dates, two claims are required – one for any qualifying encounter on the first date until midnight and a second for time spent during any qualifying encounter after midnight. Two separate progress notes are required to support claims
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made on the two calendar dates and the critical care time documented must match what was submitted on each claim.35-38 Cost is an important consideration when considering addition of ACNPs to a practice. To
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address this question, Edkins and colleagues40 conducted a systematic review that identified 18 studies (2002-2012) evaluating care in the ICU that included physician and non-physician teams. Multiple studies reported cost savings, primarily due to a decreased length-of-stay
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(LOS). This finding prompted the authors to construct models that examined the cost of staffing with varying combinations of physician, resident, and/or NP/PA coverage. They concluded
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employing NPs/PAs provided the most cost-effective means of addressing decreasing resident hours. Kapu and colleagues41 performed a quality and financial impact analysis using retrospective data. Software was used to abstract billing, acuity, and LOS data and NP associated quality metrics. Their conclusion was similar – adding non-physician providers did not increase costs and, in some ICUs, decreased costs. Greatest savings occurred in the
underinsured.
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trauma ICU where LOS decreased substantially and many patients were uninsured or
Ultimately, decisions regarding the cost-benefit of adding ACNPs/PAs to the critical care team
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depend on a complex mixture of factors - coverage needs, availability of resident/fellow trainees, patient volume, time-dependent interventions (acute stroke care), impact on quality of
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care, etc. While some of these factors can be objectively quantified, others are difficult to objectively measure. Each setting, therefore, needs to conduct a quality assessment that incorporates characteristics unique to its practice and needs. Conclusion ACNPs are integral members of many critical care provider teams who provide safe and effective care across a number of practice settings. Increasingly, outcome data supports this
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practice. ACNP educational programs provide varying levels of training specific to pulmonary and critical care patient management, an important factor to consider when hiring applicants and establishing orientation and mentoring agreements. While there is a national mandate to
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adopt standards for education, accreditation, licensure and certification for all APRN roles, progress of individual states in adoption of these recommendations is ongoing. Each provider is encouraged to become familiar with current legislation within their state to assure compliance.
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Limited information exists on how to evaluate cost-benefit when considering the addition of nonphysician providers; studies identifying how to make this determination for varied critical settings
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are needed to provide guidance to those considering this option.
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40. Edkins RE, Caims BA, Huttman CS. A systematic review of advance practice providers
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practitioners to inpatient care teams. J Nurs Admin. 2014;44(2):87-96.
Comprehensive orientation program developed and attended by all hires.
Experienced clinician (ACNP/MD) mentor identified.
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Implementation
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Table 1. Comparison of orientation methods for acute care nurse practitioners Orientation Structured Buddy Postdoctoral Method Orientation System Residency or Fellowship Planning 1. Conduct assessment to determine areas of need and cost. 2. Determine NP role, responsibilities, salary, benefits 3. Write job description (work model, reporting, communication, etc) 4. Establish billing procedures 5. Determine orientation method (length, content, credentialing, privileging) 6. Establish process for initial and ongoing mentoring 7. Determine method for yearly evaluation and merit review 8. Confirm decisions with stakeholders and revise prn
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Components: ● Mentor develops plan to progress new hire through hospital, role, practice orientation & procedural training. ● Over ~ 1 month new hire is mentored toward
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Components: ● Hospital orientation ● APRN role orientation ● Practice orientation, daily routine, rounding process, guidelines for communication ● Procedural training ● Documentation – oral, written, electronic ● Scheduling process
Teaching Methods ● Knowledge & competency
independence. Teaching Methods ● May include competency assessment, lectures, simulation instruction.
Optional 1-2 year residency/fellowship similar to that available to medical trainees.
Components: ● ACNP functions as staff member during residency/fellowship ● Employer pays salary and benefits. Components: ● Program content varies dependent on location residency/fellowship. ● Some options combine clinical training with academic coursework that can be applied toward earning a Doctor of Nursing Practice (DNP) degree.
assessment ● Lecture, case review ● Simulation ● Mentored experiences
Progression ● Varies dependent on prior experience and service needs
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● Competency assessment ● Weekly practice evaluation ● Ongoing professional practice evaluation & focused professional practice evaluation at specific intervals
● Competency assessment ● Weekly practice evaluation ● Ongoing professional practice evaluation at specific intervals
● Varies dependent on program
Pros and Cons
Pros: ● Insures comprehensive orientation for all new hires. ● Formal endof-program assessment facilitates process improvement.
Pros: ● Inexpensive, flexible ● Content and pace can be varied to match learner needs.
Pros ● Expands expertise & skill set of new graduates. ● Mechanism to recruit new hires. .
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Cons: ● Expense required to schedule & maintain resources for instruction. ● Requires dedicated time & commitment from multiple staff. ● Difficult to titrate
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Evaluation
Cons: ● Requires dedicated time & commitment from mentor ● Informal structure, risks omitting critical information. ● If one mentor, limited exposure to team/other
Cons ● After completion, resident/fellow may seek employment elsewhere if no required commitment. ● No evidence to date regarding benefits (improved patient outcomes, competency, confidence, retention).
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practice styles
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content to varying levels of new hire experience.
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Abbreviations: Acute care nurse practitioner = ACNP; advanced practice registered nurse (APRN); intensive care unit = ICU; length-of-stay = LOS: nurse practitioner = NP; physician assistant = PA.