Who Are Those Clinicians? ICUs Look to PAs, NPs

The Role of NPs and PAs in Critical Care

Aimee Abide, PA-C MMSc, PA; Heather H. Meissen, DNP(s), MSN


March 23, 2020

It's late in the evening, and a frantic woman rushes into the intensive care unit (ICU) as soon as the automatic doors open to admit her. She is looking for her mother, who was recently transferred from a long-term care facility with suspected COVID-related pneumonia.

The visitor is escorted to the isolation room, where her mother is being assessed by a masked, gowned, and gloved critical care nurse practitioner (NP). The NP introduces herself and begins to explain what's going on, but the visitor interrupts her, demanding, "Where is the doctor? Why isn't the doctor here taking care of my mother?"

The NP isn't surprised—she's heard it before, and so have most physician assistants (PAs). Most people are familiar with the work of NPs and PAs in outpatient clinic settings, but less so in the care of the sickest, most unstable patients in the hospital.

APPs Fill a Critical Hole

The demand for critical care physicians is mounting. More than ever before, this shortage will be felt as the COVID-19 pandemic stretches the healthcare system to the breaking point. The original stopgap measure—covering the ICU with medical residents—has long been curtailed by work hour restrictions. With a population of patients sicker than ever before, there simply aren't enough intensivist physicians to meet the needs of the nation's ICUs.

A solution to this crisis is to integrate NPs and physician assistants (PAs)—collectively known as "advanced practice providers (APPs)"—into critical care settings, but not as substitutes for intensivist physicians. In a still evolving role, APPs expand ICU coverage by collaborating with intensivist physicians as members of a multidisciplinary team managing medical care for the hospital's most complex, seriously ill patients.

It's a strategy that's been growing in popularity for decades. With the exodus of many physicians from primary care into specialty practice in the 1960s, NPs and PAs began to fill provider gaps. Initially, their impact was felt most strongly in primary care, where the provider shortage was most acute.

It wasn't long, however, before APPs were also working in hospital-based critical care settings. As early as the 1970s, APPs had established roles in neonatal, pediatric, and adult intensive care, as well as the emergency department and specialty inpatient areas, such as cardiology, neurology, and surgery.

Today, many tertiary care hospitals have embraced the APP critical care role. A 2019 report from the Society of Critical Care Medicine estimated that between 3650 and 14,500 APPs are currently practicing in critical care, and the number of APPs seeking employment in this area is growing.

What Do APPs Do in Critical Care?

Roles and responsibilities of NPs and PAs can vary among hospitals, but typically, the APP conducts physical exams and obtains medical histories, rounds with the multidisciplinary team, develops daily care plans, orders diagnostics, interprets data from labs or diagnostic testing, orders pharmacotherapeutics, and conducts discharge planning. Appropriately trained, credentialed, and privileged APPs perform invasive procedures, such as intubation, central line placement, arterial line placement, thoracentesis, paracentesis, lumbar puncture, chest tube placement, point-of-care ultrasound, and wound debridement, among others.

The heavy use of technology for monitoring and life support requires a unique type of expertise. APPs also participate on rapid response teams, provide onboarding and education of staff and students, lead quality initiatives, and conduct research. They must be able to triage and manage common ICU occurrences, such as a sudden change in condition or unexpected complication.

Perhaps one of the most valuable contributions of critical care APPs is the continuity of patient care achievable with their presence compared with other staffing models. Physician trainees rotate through the ICU monthly. Attending physician intensivists are also on a rotational schedule sometimes only serving in weeklong blocks seven or eight times per year. Most APPs don't rotate in and out of the ICU, so they are in a position to help maintain quality of care, consistency, and adherence by all staff to protocols and procedures.

How Are APPs Trained for Critical Care Practice?

APPs come from diverse educational and experiential backgrounds. Most APPs hold master's degrees, and many NP educational models are progressing toward doctorate degrees. Programs of study range from 16 to 24 months. APPs who hope to practice in critical care settings should seek education from an accredited program of study that allows for a robust clinical experience.

In terms of critical care content, PA and NP programs of study differ. PA educational programs, established from the medical model, are designed to provide an intense experience as generalists in primary care medicine. While PA students have the option of seeking elective rotations in specialty areas, critical care exposure is rare and not required for graduation.

NP students, on the other hand, have the option of preparing for a career in critical care. The typical acute care NP (ACNP) curriculum focuses on the management of acutely ill or injured patients. Critical care exposure is more common in ACNP programs compared with PA programs, but is likewise not required for graduation. ACNPs are further specialized in either pediatric or adult gerontology care.

While certification, licensure, and credentialing ensure minimum competency, the APP must undergo additional training as part of the multidisciplinary team in the critical care setting. Strong clinical experience in the ICU is recommended for successful practice, but many hospitals are hiring APPs with limited clinical experience in critical care. Even those with a strong clinical background need a period of transition in the clinical setting, gradually assuming the responsibilities they will need for autonomous practice.[1]

Some, but not all, institutions provide immersive onboard training for new graduate APPs, including postgraduate residency or fellowship programs. These competency-based programs provide a strong didactic background in critical care and intense practical clinical experience, with the aim of establishing a high level of proficiency and critical thinking skills.

How Are APPs Staffed in Critical Care Settings?

Staffing models to integrate APPs into critical care units can differ—the type of hospital (community versus academic), the number of beds, and the acuity of the patient population all influence the selection of an APP staffing paradigm.

Typical maximum patient-to-provider ratios are 6:1 during daytime hours and 12:1 at night, but ratios can vary depending on patient acuity; frequency of admissions; and availability of other providers, such as medical residents.[1]

Here are a few examples of staffing models that might be used in different hospitals:

Academic medical center with a 20-bed ICU and four to six medical residents rotating through every month. A daytime APP has six patients, and the medical residents cover the remaining patients. At night, two APPs cover all 20 beds, with a medical resident who can take "strategic naps." The attending physician is on call 24 hours for 7 days.

A community hospital with no medical residents. In this case, the model is simpler. For the average 12-bed ICU, two APPs cover six patients each during the day and one APP covers the entire unit at night, with an attending physician on call for emergencies.

eICU. Another way to staff the night watch is to incorporate eICU, in which the on-site NP or PA has access to a critical care physician for consultation and support via telemedicine. The use of eICU could potentially extend how many weeks an attending is able cover the ICU each year. For small community hospitals, this model is ideal when only one or two physicians cover the ICU. The use of eICU frees up night call responsibilities of the attending physician and has been shown to reduce overall healthcare costs.

Critical care is a high-intensity setting requiring a strong interprofessional team. Sound clinical experience and judgement coupled with a commitment to critical care medicine are characteristics needed for successful APP practice in this specialty area.

Given the projections that shortages of intensivist-trained physicians will continue, and the increasing complexity of patient care, it's expected that APPs trained in critical care medicine will play a growing role in many ICUs. To support this growth, further investigation should assess effective strategies for development and deployment of APPs into the ICU. Furthermore, we need more research into successful practice models that support the work of APPs in various critical care settings.

Aimee Abide, PA-C MMSc, PA, has been a PA at Emory Healthcare in Atlanta, Georgia, since 2000. She is the PA program director for the NPPA critical care residency for the Emory critical care center. Aimee also practices clinically in the Cardiothoracic Intensive Care Unit at Emory University Hospital Midtown.

Heather H. Meissen, DNP(s), MSN, is an acute care nurse practitioner at Emory Healthcare in Atlanta, Georgia. She is the program co-director for the NPPA Critical Care Residency for the Emory Critical Care Center. She is currently enrolled in a DNP program at Vanderbilt University School of Nursing.

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