- Email: [email protected]
The Cardiac Surgery Advanced Practice Group: A Case Study of APN and PA Collaborative Practice
The Cardiac Surgery Advanced Practice Group: A Case Study of APN and PA Collaborative Practice Sharon Owens, Vijay Ramraj, and Janice Wallop
ABSTRACT In the United States, more than 600,000 surgeries for cardiac disease are performed annually, accounting for millions of dollars in health care expenses. The rise in patient acuity levels from comorbid factors is contributing to these costs. In a health care reform environment, the challenges to the health care system are to maintain quality of care and provide advanced therapies while decreasing the costs associated with that care. Advanced practice nurses (APNs) and physician assistants (PAs) are able to work with multidisciplinary groups to provide comprehensive care and decrease costs. The purpose of this article is to explore the evolution of the role of the APN and PA in an acute care setting. The origins and benefits of this role and future for this model are addressed. Keywords: cardiac surgery, nurse practitioners © 2010 American College of Nurse Practitioners www.npjournal.org
The Journal for Nurse Practitioners - JNP
371
n the United States, more than 600,000 surgeries related to cardiac disease are performed annually.1 These surgeries account for millions of dollars per year in health care expenses. Contributing to these costs is a rise in patient acuity levels due to comorbid factors. In a health care reform environment, the challenges to the health care system are to maintain quality of care and provide for advanced therapies while decreasing the costs associated with the care. Along with this, academic centers must adhere to the 80-hour work-week restriction for residents, implemented by the Accreditation Council of Graduate Medical Education in 2003. The restricted work hours have resulted in gaps in patient coverage and the increased use of advance practice nurses (APNs) and physician assistants (PAs) to fill the roles. APNs are masters-level or doctorally prepared clinical experts who provide patient care across the acute care continuum. Because of their familiarity with the health care system in which they are employed, APNs are able to use this constellation of knowledge to provide comprehensive care and work with multidisciplinary groups to shorten length of stay (LOS) and decrease costs.2,3 In settings such as the intensive care unit (ICU), patient outcomes have been compared between APNs and physicians-in-training. Hoffman et al found that physicians-in-training and nurse practitioners (NPs) spent a similar portion of time performing tasks, but NPs spent more time directly interacting with patients and families and collaborating with other health team members.4-7 The purpose of this article is to explore the evolution of the role of the APN and PA in an acute care setting, a cardiac surgery progressive care unit (CPCU). This is the intermediate care unit where cardiac surgery patients transfer to after leaving the cardiac surgical intensive care unit (CSICU). The origins and benefits of this role and future for this model will be addressed. The traditional medical model of care delivery in academic teaching centers involves the use of resident staff known as house officers. This model serves 2 purposes. The first purpose is to educate the residents in medical management of inpatients and the second is to utilize house staff as a resource in care delivery. These individuals provide care at a relatively low hourly rate and low cost to the institution. The problems inherent in this model included lack of continuity in delivery of care, variability in the quality of care, and increased physician physical and mental stress.8
I
372
The Journal for Nurse Practitioners - JNP
EVOLUTION OF APN ROLE Approximately 1500 open heart surgeries are done annually at Johns Hopkins Hospital (JHH). These surgeries include coronary artery bypass grafting, valve repairs and replacements, aortic root replacements, minimally invasive cardiac surgery, congenital cardiac surgery, heart and lung transplants, and placement of ventricular-assist devices. Patients’ ages range from 16 to 90+ years. These patients generally have multisystem comorbidities such as diabetes mellitus (DM), peripheral vascular disease (PVD), renal insufficiency (RI), and pulmonary diseases requiring medical management. The cardiac surgery service is organized into 2 teams, with attending staff divided accordingly. In the original model, patients in the CPCU were managed by a firstyear cardiac surgery fellow, an intern, and a clinical specialist assigned to each team. The clinical specialist assisted in providing care by educating house staff on patient management, guiding the care of the patients, ordering of tests, discharging patients, writing discharge summaries, and answering all outpatient calls. The model allowed for residents to be trained, and provided continuity of care via the APN. However, at times, confusion existed in terms of practitioner roles as well as overlap in duties. From the residents’ perspective, there was general disappointment with the cardiac surgery rotation due to the limited hours devoted to surgical training, as well as consistently high work hours. These issues, and the evolution of managed care, led to changes in the delivery of care on the cardiac surgery service. Managed care organizations gained popularity in the 1990s in an effort to control utilization of health care resources and costs.9 The cardiac surgery service adopted this model and the use of critical pathways and case managers (CMs). Four case managers, educated as clinical specialists, were hired, and were responsible for maintaining patients on the clinical pathways and reducing LOS. They were also responsible for documenting barriers to timely discharge of patients and identifying areas where utilization of resources could be reduced. The “team” now included 1 senior resident, 1 intern, and 2 CMs. Overlap of roles, excessive work hours, and resident dissatisfaction persisted. The CMs were frustrated by the lack of house staff continuity, as residents rotated on a monthly basis, and by the perceived lack of recognition for their contribution to the service. APNs continued to coordinate and provide care for both inpatients and outpatients. Volume 6, Issue 5, May 2010
The final transition to the current model (The Cardiac Surgery Advance Practice Group) came in 2005, with the mandatory reduction in resident hours. Additional APNs, as well as 2 PAs, were hired to provide coverage 365 days per year from 5:30 AM until 7 PM. These APNs were master’s-prepared acute care NPs. The APNs and PAs perform the same role in managing patients on the CPCU. Today, the CPCU service comprises a total of 10 APNs and 2 PAs. A first- or second-year surgical resident covers this service, as well as 2 other services from 7 PM until 5:30 AM. This cross-covering resident is available to handle urgent and emergent issues but is not involved in any care coordination. The senior cardiac surgery residents are available to assist with emergency situations throughout the day and night and perform complex invasive procedures as necessary. An RN and an NP work with the outpatient clinic and triage calls regarding clinical concerns and arrange for medical follow-up and warfarin management for patients after discharge. ROLE OF THE APN The scope of practice of the APN is delineated by the Board of Nursing. Delineated clinical privileges are granted by JHH, and a collaborative agreement between the APNs and the surgeon group is signed and then must be approved by the Maryland Board of Nursing. The PAs are licensed by the State of Maryland and have a practice agreement with physicians. The APNs and PAs in this role report through an assistant director of nursing to the director of nursing. The CPCU is a high-acuity environment, and patients require close monitoring. All patients are on a continuous electrocardiogram monitor. The APNs/PAs direct patient care at all times and communicate regularly with the attending physician. Clinical management is the main focus of the APN/PA role, along a continuum of critical care. Patients transfer from the ICU and may require mechanical ventilation, vasoactive infusions such as milrinone and dobutamine, and intravenous antiarrhythmics such as amiodarone. The APNs manage these scenarios, stabilizing patients, with the ultimate goal of discharge to home or transfer to an inpatient rehabilitation facility. A small subset of patient management involves coordinating the care for patients awaiting surgical intervention. The APN’s/PA’s day begins at 5:30 AM, with analysis of patient data including vital signs, fluid balance, catheter and drain output, and diagnostic test results. The APN/PA www.npjournal.org
examines each assigned patient prior to meeting with the attending physician. At 7 AM, there is a general meeting with representatives from the CSICU, CPCU, anesthesia, surgeons, surgical residents, operating suite staff, and charge nurses to discuss the cases and flow of patients for the day. Then, each APN/PA meets with the individual surgeon to discuss his or her particular patient group and review the morning assessments, the patients’ progress, and to develop a general plan of care. Both short- and long-term goals are discussed. During the course of the day, the APN/PA continually monitors the ongoing delivery of patient care, reevaluates the patient’s condition, orders and interprets the results of lab and other diagnostic tests, and initiates and readjusts medications. Consults are arranged by the APN/PA, who can discuss the patient’s clinical status, history, and respond to questions posed by the consulting team. The consultants rely on the APN/PA for communication as well as followup relative to recommendations. APNs/PAs work collaboratively with a multidisciplinary team and communicate daily with the professional nursing staff and other team members, including social work, nutrition, physical therapy, the discharge planner, home care nurses, and the outpatient nurse and NP. APNs/PAs are involved in evaluating patients who have had previous cardiac surgery, and determining if readmission for management of an acute issue is necessary. Daily notes are written in the electronic medical record and serve as a communication tool for consultants, nurses, and members of the multidisciplinary team regarding patient status and plan. The APNs/PAs also complete the discharge summary, which is cosigned by the attending physician. BENEFITS OF THE ROLE The continuity of care provided by the APN/PA is essential for management of these complex, acutely ill patients. Interaction with the APN/PA has a positive impact on patient and family satisfaction. Patients and their families value access to a provider throughout the day and early evening. They feel this allows for their questions to be answered in a timely fashion. It also reassures them that a knowledgeable and capable practitioner is readily available to respond to medical and social concerns. Patient satisfaction scores have improved since the implementation of the model in 2005, from an 82.8% to a 90% in 2009 (Table 1). Patients reported higher satisfaction with regard to receiving The Journal for Nurse Practitioners - JNP
373
Table 1. Press Ganey Patient Satisfaction Scores for the Cardiac Surgery Progressive Care Unit 2005-2010 Year
Overall Score (%)
2005
82.8
2006
84.1
2007
88.2
2008
90.0
2009
90.0
The Johns Hopkins Health Care System. 2004-2009.
communication regarding their progress, their plan of care, and response to their questions and concerns. This model has also received positive feedback from the CPCU nursing staff. The APNs/PAs are very accessible to the RNs, whether they are visible on the unit or are promptly responding to pages. The nurses also report that they find the APNs/PAs to be responsive, approachable, and knowledgeable. They particularly value the time the APNs/PAs are willing to spend with the patients and their families. This improves not only the quality of care provided but enhances patient safety. The continuity of care provided by the APNs/PAs allows them to understand the unique needs of the cardiac surgery population and reevaluate their practice to identify areas for improvement and reducing costs. They are able to evaluate the research for this population and place it into practice. Discharge planning has been positively affected by this model. Every APN/PA meets daily (Monday through Friday) with a multidisciplinary team for discharge planning. Issues discussed range from inpatient rehabilitation to home antibiotics and home care nursing. The APNs/PAs lead the discussion with the social worker, charge nurse and staff discharge planner, home care coordinator, outpatient nurse, and physical or occupational therapist to ensure that the needs are addressed and that discharge is not delayed because services have not been arranged. FUTURE DIRECTIONS The APN/PA is instrumental in providing continuity of care for an increasingly acute cardiac surgery population and ensuring timely, comprehensive discharge planning. They provide an avenue for team communication and education to both the patient and their families and the staff. APNs/PAs have demonstrated a positive impact on patient and staff satisfaction and clinical markers. As health care systems become more complex, it will be 374
The Journal for Nurse Practitioners - JNP
imperative for the APN to participate in quality improvement activities and research to demonstrate cost savings with this model. Research related to clinical markers, Surgical Care Improvement Project (SCIP), and National Patient Safety Indicators will contribute to the demonstrating benefits of this model. The APN/PA understands the clinical needs of the patient and the system within which they receive care. The cardiac surgery patients often have several providers involved in their care and the APN/PA is in a unique position to help guide the development of electronic records and communication tools to provide for seamless care within an increasingly complex health care system. References 1. American Heart Association. Heart disease and stroke statistics: update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. AHA Statistical Update Circulation. 2009;119:e21e181. Accessed January 12, 2010. 2. Becker D, Kaplow R, Muenzen PM, Hartigan C. Activities performed by acute and critical care advanced practice nurses: American Association of CriticalCare Nurses Study of Practice. Am J Crit Care. 2006;15:130-148. 3. Meyer SC, Miers LJ. Cardiovascular surgeon and acute care nurse practitioner: collaboration on postoperative outcomes. Adv Pract Acute Crit Care. 2005;16:149-158. 4. Hoffman LA, Tasota J, Scharfenberg C, Zullo TG, Donahoe MP. Management of patients in the intensive care unit: comparison via work sampling analysis of an acute care nurse practitioner and physicians in training. Am J Crit Care. 2003;12:436-443. 5. Kirton OC, Folcik MA, Ivy ME, et al. Midlevel practitioner workforce analysis at a university-affiliated teaching hospital. Arch Surg. 2007;142:336-341. 6. Hoffman LA, Tasota FJ, Zullo TG, Scharfenberg TG, Donahoe Michael P. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14:121-130. 7. Kleinpell RM. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care. 2005;14:211-219. 8. Block AJ. Revisiting the Libby Zion case. Chest. 1994;105:977-978. 9. The Next Generation: An Introduction to Medicine. Managed Care Organizations. 2007;4(1). Available at: http://www.nextgenmd.org/vol1-4/. Accessed January 12, 2010.
Sharon Owens, PhD, CRNP, Vijay Ramraj, CRNP, and Janice Wallop, CRNP, are nurse practitioners in the department of surgery at Johns Hopkins Hospital in Baltimore, MD. Owens may be reached at [email protected]. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/$ see front matter © 2010 American College of Nurse Practitioners doi:10.1016/j.nurpra.2010.02.026
Volume 6, Issue 5, May 2010
ABSTRACT In the United States, more than 600,000 surgeries for cardiac disease are performed annually, accounting for millions of dollars in health care expenses. The rise in patient acuity levels from comorbid factors is contributing to these costs. In a health care reform environment, the challenges to the health care system are to maintain quality of care and provide advanced therapies while decreasing the costs associated with that care. Advanced practice nurses (APNs) and physician assistants (PAs) are able to work with multidisciplinary groups to provide comprehensive care and decrease costs. The purpose of this article is to explore the evolution of the role of the APN and PA in an acute care setting. The origins and benefits of this role and future for this model are addressed. Keywords: cardiac surgery, nurse practitioners © 2010 American College of Nurse Practitioners www.npjournal.org
The Journal for Nurse Practitioners - JNP
371
n the United States, more than 600,000 surgeries related to cardiac disease are performed annually.1 These surgeries account for millions of dollars per year in health care expenses. Contributing to these costs is a rise in patient acuity levels due to comorbid factors. In a health care reform environment, the challenges to the health care system are to maintain quality of care and provide for advanced therapies while decreasing the costs associated with the care. Along with this, academic centers must adhere to the 80-hour work-week restriction for residents, implemented by the Accreditation Council of Graduate Medical Education in 2003. The restricted work hours have resulted in gaps in patient coverage and the increased use of advance practice nurses (APNs) and physician assistants (PAs) to fill the roles. APNs are masters-level or doctorally prepared clinical experts who provide patient care across the acute care continuum. Because of their familiarity with the health care system in which they are employed, APNs are able to use this constellation of knowledge to provide comprehensive care and work with multidisciplinary groups to shorten length of stay (LOS) and decrease costs.2,3 In settings such as the intensive care unit (ICU), patient outcomes have been compared between APNs and physicians-in-training. Hoffman et al found that physicians-in-training and nurse practitioners (NPs) spent a similar portion of time performing tasks, but NPs spent more time directly interacting with patients and families and collaborating with other health team members.4-7 The purpose of this article is to explore the evolution of the role of the APN and PA in an acute care setting, a cardiac surgery progressive care unit (CPCU). This is the intermediate care unit where cardiac surgery patients transfer to after leaving the cardiac surgical intensive care unit (CSICU). The origins and benefits of this role and future for this model will be addressed. The traditional medical model of care delivery in academic teaching centers involves the use of resident staff known as house officers. This model serves 2 purposes. The first purpose is to educate the residents in medical management of inpatients and the second is to utilize house staff as a resource in care delivery. These individuals provide care at a relatively low hourly rate and low cost to the institution. The problems inherent in this model included lack of continuity in delivery of care, variability in the quality of care, and increased physician physical and mental stress.8
I
372
The Journal for Nurse Practitioners - JNP
EVOLUTION OF APN ROLE Approximately 1500 open heart surgeries are done annually at Johns Hopkins Hospital (JHH). These surgeries include coronary artery bypass grafting, valve repairs and replacements, aortic root replacements, minimally invasive cardiac surgery, congenital cardiac surgery, heart and lung transplants, and placement of ventricular-assist devices. Patients’ ages range from 16 to 90+ years. These patients generally have multisystem comorbidities such as diabetes mellitus (DM), peripheral vascular disease (PVD), renal insufficiency (RI), and pulmonary diseases requiring medical management. The cardiac surgery service is organized into 2 teams, with attending staff divided accordingly. In the original model, patients in the CPCU were managed by a firstyear cardiac surgery fellow, an intern, and a clinical specialist assigned to each team. The clinical specialist assisted in providing care by educating house staff on patient management, guiding the care of the patients, ordering of tests, discharging patients, writing discharge summaries, and answering all outpatient calls. The model allowed for residents to be trained, and provided continuity of care via the APN. However, at times, confusion existed in terms of practitioner roles as well as overlap in duties. From the residents’ perspective, there was general disappointment with the cardiac surgery rotation due to the limited hours devoted to surgical training, as well as consistently high work hours. These issues, and the evolution of managed care, led to changes in the delivery of care on the cardiac surgery service. Managed care organizations gained popularity in the 1990s in an effort to control utilization of health care resources and costs.9 The cardiac surgery service adopted this model and the use of critical pathways and case managers (CMs). Four case managers, educated as clinical specialists, were hired, and were responsible for maintaining patients on the clinical pathways and reducing LOS. They were also responsible for documenting barriers to timely discharge of patients and identifying areas where utilization of resources could be reduced. The “team” now included 1 senior resident, 1 intern, and 2 CMs. Overlap of roles, excessive work hours, and resident dissatisfaction persisted. The CMs were frustrated by the lack of house staff continuity, as residents rotated on a monthly basis, and by the perceived lack of recognition for their contribution to the service. APNs continued to coordinate and provide care for both inpatients and outpatients. Volume 6, Issue 5, May 2010
The final transition to the current model (The Cardiac Surgery Advance Practice Group) came in 2005, with the mandatory reduction in resident hours. Additional APNs, as well as 2 PAs, were hired to provide coverage 365 days per year from 5:30 AM until 7 PM. These APNs were master’s-prepared acute care NPs. The APNs and PAs perform the same role in managing patients on the CPCU. Today, the CPCU service comprises a total of 10 APNs and 2 PAs. A first- or second-year surgical resident covers this service, as well as 2 other services from 7 PM until 5:30 AM. This cross-covering resident is available to handle urgent and emergent issues but is not involved in any care coordination. The senior cardiac surgery residents are available to assist with emergency situations throughout the day and night and perform complex invasive procedures as necessary. An RN and an NP work with the outpatient clinic and triage calls regarding clinical concerns and arrange for medical follow-up and warfarin management for patients after discharge. ROLE OF THE APN The scope of practice of the APN is delineated by the Board of Nursing. Delineated clinical privileges are granted by JHH, and a collaborative agreement between the APNs and the surgeon group is signed and then must be approved by the Maryland Board of Nursing. The PAs are licensed by the State of Maryland and have a practice agreement with physicians. The APNs and PAs in this role report through an assistant director of nursing to the director of nursing. The CPCU is a high-acuity environment, and patients require close monitoring. All patients are on a continuous electrocardiogram monitor. The APNs/PAs direct patient care at all times and communicate regularly with the attending physician. Clinical management is the main focus of the APN/PA role, along a continuum of critical care. Patients transfer from the ICU and may require mechanical ventilation, vasoactive infusions such as milrinone and dobutamine, and intravenous antiarrhythmics such as amiodarone. The APNs manage these scenarios, stabilizing patients, with the ultimate goal of discharge to home or transfer to an inpatient rehabilitation facility. A small subset of patient management involves coordinating the care for patients awaiting surgical intervention. The APN’s/PA’s day begins at 5:30 AM, with analysis of patient data including vital signs, fluid balance, catheter and drain output, and diagnostic test results. The APN/PA www.npjournal.org
examines each assigned patient prior to meeting with the attending physician. At 7 AM, there is a general meeting with representatives from the CSICU, CPCU, anesthesia, surgeons, surgical residents, operating suite staff, and charge nurses to discuss the cases and flow of patients for the day. Then, each APN/PA meets with the individual surgeon to discuss his or her particular patient group and review the morning assessments, the patients’ progress, and to develop a general plan of care. Both short- and long-term goals are discussed. During the course of the day, the APN/PA continually monitors the ongoing delivery of patient care, reevaluates the patient’s condition, orders and interprets the results of lab and other diagnostic tests, and initiates and readjusts medications. Consults are arranged by the APN/PA, who can discuss the patient’s clinical status, history, and respond to questions posed by the consulting team. The consultants rely on the APN/PA for communication as well as followup relative to recommendations. APNs/PAs work collaboratively with a multidisciplinary team and communicate daily with the professional nursing staff and other team members, including social work, nutrition, physical therapy, the discharge planner, home care nurses, and the outpatient nurse and NP. APNs/PAs are involved in evaluating patients who have had previous cardiac surgery, and determining if readmission for management of an acute issue is necessary. Daily notes are written in the electronic medical record and serve as a communication tool for consultants, nurses, and members of the multidisciplinary team regarding patient status and plan. The APNs/PAs also complete the discharge summary, which is cosigned by the attending physician. BENEFITS OF THE ROLE The continuity of care provided by the APN/PA is essential for management of these complex, acutely ill patients. Interaction with the APN/PA has a positive impact on patient and family satisfaction. Patients and their families value access to a provider throughout the day and early evening. They feel this allows for their questions to be answered in a timely fashion. It also reassures them that a knowledgeable and capable practitioner is readily available to respond to medical and social concerns. Patient satisfaction scores have improved since the implementation of the model in 2005, from an 82.8% to a 90% in 2009 (Table 1). Patients reported higher satisfaction with regard to receiving The Journal for Nurse Practitioners - JNP
373
Table 1. Press Ganey Patient Satisfaction Scores for the Cardiac Surgery Progressive Care Unit 2005-2010 Year
Overall Score (%)
2005
82.8
2006
84.1
2007
88.2
2008
90.0
2009
90.0
The Johns Hopkins Health Care System. 2004-2009.
communication regarding their progress, their plan of care, and response to their questions and concerns. This model has also received positive feedback from the CPCU nursing staff. The APNs/PAs are very accessible to the RNs, whether they are visible on the unit or are promptly responding to pages. The nurses also report that they find the APNs/PAs to be responsive, approachable, and knowledgeable. They particularly value the time the APNs/PAs are willing to spend with the patients and their families. This improves not only the quality of care provided but enhances patient safety. The continuity of care provided by the APNs/PAs allows them to understand the unique needs of the cardiac surgery population and reevaluate their practice to identify areas for improvement and reducing costs. They are able to evaluate the research for this population and place it into practice. Discharge planning has been positively affected by this model. Every APN/PA meets daily (Monday through Friday) with a multidisciplinary team for discharge planning. Issues discussed range from inpatient rehabilitation to home antibiotics and home care nursing. The APNs/PAs lead the discussion with the social worker, charge nurse and staff discharge planner, home care coordinator, outpatient nurse, and physical or occupational therapist to ensure that the needs are addressed and that discharge is not delayed because services have not been arranged. FUTURE DIRECTIONS The APN/PA is instrumental in providing continuity of care for an increasingly acute cardiac surgery population and ensuring timely, comprehensive discharge planning. They provide an avenue for team communication and education to both the patient and their families and the staff. APNs/PAs have demonstrated a positive impact on patient and staff satisfaction and clinical markers. As health care systems become more complex, it will be 374
The Journal for Nurse Practitioners - JNP
imperative for the APN to participate in quality improvement activities and research to demonstrate cost savings with this model. Research related to clinical markers, Surgical Care Improvement Project (SCIP), and National Patient Safety Indicators will contribute to the demonstrating benefits of this model. The APN/PA understands the clinical needs of the patient and the system within which they receive care. The cardiac surgery patients often have several providers involved in their care and the APN/PA is in a unique position to help guide the development of electronic records and communication tools to provide for seamless care within an increasingly complex health care system. References 1. American Heart Association. Heart disease and stroke statistics: update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. AHA Statistical Update Circulation. 2009;119:e21e181. Accessed January 12, 2010. 2. Becker D, Kaplow R, Muenzen PM, Hartigan C. Activities performed by acute and critical care advanced practice nurses: American Association of CriticalCare Nurses Study of Practice. Am J Crit Care. 2006;15:130-148. 3. Meyer SC, Miers LJ. Cardiovascular surgeon and acute care nurse practitioner: collaboration on postoperative outcomes. Adv Pract Acute Crit Care. 2005;16:149-158. 4. Hoffman LA, Tasota J, Scharfenberg C, Zullo TG, Donahoe MP. Management of patients in the intensive care unit: comparison via work sampling analysis of an acute care nurse practitioner and physicians in training. Am J Crit Care. 2003;12:436-443. 5. Kirton OC, Folcik MA, Ivy ME, et al. Midlevel practitioner workforce analysis at a university-affiliated teaching hospital. Arch Surg. 2007;142:336-341. 6. Hoffman LA, Tasota FJ, Zullo TG, Scharfenberg TG, Donahoe Michael P. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14:121-130. 7. Kleinpell RM. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care. 2005;14:211-219. 8. Block AJ. Revisiting the Libby Zion case. Chest. 1994;105:977-978. 9. The Next Generation: An Introduction to Medicine. Managed Care Organizations. 2007;4(1). Available at: http://www.nextgenmd.org/vol1-4/. Accessed January 12, 2010.
Sharon Owens, PhD, CRNP, Vijay Ramraj, CRNP, and Janice Wallop, CRNP, are nurse practitioners in the department of surgery at Johns Hopkins Hospital in Baltimore, MD. Owens may be reached at [email protected]. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/$ see front matter © 2010 American College of Nurse Practitioners doi:10.1016/j.nurpra.2010.02.026
Volume 6, Issue 5, May 2010