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Nurse practitioner/physician assistant staffing and critical care mortality.

ABSTRACT: ICUs are increasingly staffed with nurse practitioners/physician assistants (NPs/PAs), but it is unclear how NPs/PAs influence quality of care. We examined the association between NP/PA staffing and in-hospital mortality for patients in the ICU.We used retrospective cohort data from the 2009 to 2010 APACHE (Acute Physiology and Chronic Health Evaluation) clinical information system and an ICU-level survey. We included patients aged ≥ 17 years admitted to one of 29 adult medical and mixed medical/surgical ICUs in 22 US hospitals. Because this survey could not assign NPs/PAs to individual patients, the primary exposure was admission to an ICU where NPs/PAs participated in patient care. The primary outcome was patient-level in-hospital mortality. We used multivariable relative risk regression to examine the effect of NPs/PAs on in-hospital mortality, accounting for differences in case mix, ICU characteristics, and clustering of patients within ICUs. We also examined this relationship in the following subgroups: patients on mechanical ventilation, patients with the highest quartile of Acute Physiology Score (> 55), and ICUs with low-intensity physician staffing and with physician trainees.Twenty-one ICUs (72.4%) reported NP/PA participation in direct patient care. Patients in ICUs with NPs/PAs had lower mean Acute Physiology Scores (42.4 vs 46.7, P < .001) and mechanical ventilation rates (38.8% vs 44.2%, P < .001) than ICUs without NPs/PAs. Unadjusted and risk-adjusted mortality was similar between groups (adjusted relative risk, 1.10; 95% CI, 0.92-1.31). This result was consistent in all examined subgroups.NPs/PAs appear to be a safe adjunct to the ICU team. The findings support NP/PA management of critically ill patients.

SUBMITTER: Costa DK

PROVIDER: S-EPMC4251618 | biostudies-other | 2014 Dec

REPOSITORIES: biostudies-other

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Project description:BACKGROUND:The delivery of emergency, trauma, critical, and intensive care services requires coordination among all members of the care team. Perceived teamwork and role clarity may vary among physicians (MDs) and nurse practitioners (NPs). PURPOSE:To examine differences in perceived roles and responsibilities of NPs and MDs practicing in emergency, trauma, critical, and intensive care. METHODS:Secondary Analysis of the National Survey of Emergency, Intensive, and Critical Care Nurse Practitioners and Physicians, a cross-sectional national survey of clinicians. Mail survey of randomly selected stratified cross-sectional samples of MDs and NPs drawn from national lists of clinicians in eligible specialties working in emergency, trauma, intensive, and critical care units in the United States. 814 clinicians (351 NPs and 463 MDs) were recruited from national by postal mail survey. Our initial sample included n = 2,063 clinicians, n = 1,031 NPs and n = 1,032 MDs in eligible specialties. Of these, 63.5% of NPs and 70.1% of MDs completed and returned the survey excluding those who were ineligible due to lack of current practice in a relevant specialty. FINDINGS:NPs in ICU/CCU are more likely to be female and report working fewer hours than do MDs and provide direct care to more patients. 55% of NPs and 82% of MDs agree that their individual role in their unit is clear (p < .001); 34% of MDs and 42% of NPs agree that their unit is an example of excellent team work among professionals (p = 0.021); 41% of MD and 37% of NP clinicians (p = 0.061) agree that their teams are "prepared to provide outstanding care in a crisis or disaster." Perceived role clarity was significantly associated with increased perceptions of excellent teamwork and disaster preparedness. DISCUSSION:At the time of this survey, and majority of NPs and MDs working in emergency, critical and intensive care did not agree that their teams were prepared for a crisis or disaster. Leaders of health organizations should encourage teamwork and professional role clarity to assist units to perform effectively in emergency and disaster preparedness.

Project description:RationaleHospitals are increasingly using critical care outreach teams (CCOTs) to respond to patients deteriorating outside intensive care units (ICUs). CCOT staffing is variable across hospitals and optimal team composition is unknown.ObjectivesTo assess whether adding a critical care medicine trained physician assistant (CCM-PA) to a critical care outreach team (CCOT) impacts clinical and process outcomes.MethodsWe performed a retrospective study of two cohorts-one with a CCM-PA added to the CCOT (intervention hospital) and one with no staffing change (control hospital)-at two facilities in the same system. All adults in the emergency department and hospital for whom CCOT consultation was requested from October 1, 2012-March 16, 2013 (pre-intervention) and January 5-March 31, 2014 (post-intervention) were included. We performed difference-in-differences analyses comparing pre- to post-intervention periods in the intervention versus control hospitals to assess the impact of adding the CCM-PA to the CCOT.Measurements and main resultsOur cohort consisted of 3,099 patients (control hospital: 792 pre- and 595 post-intervention; intervention hospital: 1114 pre- and 839 post-intervention). Intervention hospital patients tended to be younger, with fewer comorbidities, but with similar severity of acute illness. Across both periods, hospital mortality (p = 0.26) and hospital length of stay (p = 0.64) for the intervention vs control hospitals were similar, but time-to-transfer to the ICU was longer for the intervention hospital (13.3-17.0 vs 11.5-11.6 hours, p = 0.006). Using the difference-in-differences approach, we found a 19.2% reduction (95 confidence interval: 6.7%-31.6%, p = 0.002) in the time-to-transfer to the ICU associated with adding the CCM-PA to the CCOT; we found no difference in hospital mortality (p = 0.20) or length of stay (p = 0.52).ConclusionsAdding a CCM-PA to the CCOT was associated with a notable reduction in time-to-transfer to the ICU; hospital mortality and length of stay were not impacted.

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Nurse practitioner/physician assistant staffing and critical care mortality.

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