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  1. The nationwide shortage of intensivists has prompted US hospitals to effectively develop and integrate alternative staffing models into their intensive care unit (ICU), including the use of nurse practitioners (NPs), physician assistants (PAs), and hospitalists.

  2. Patients managed by NPs, PAs, and hospitalists have been shown to have similar outcomes in hospital mortality and length of stay and greater compliance with evidence-based practice guidelines when compared to those cared for by residents.

  3. Hospitalists may serve as the primary providers in ICUs without critical care consultants or assist in the co-management of patients with intensivists.

  4. With the myriad of ICU practice models available, additional studies are needed to help sculpt styles based on the particular needs and preferences of an institution.

  5. Regardless of the chosen staffing model, the key determinants for the success and growth of the critical care workforce will rely heavily on organization, strategic planning, and communication.


Historically, physician providers in the form of intensivists, critical care fellows, and housestaff trainees delivered care in adult intensive care units (ICUs). In recent years, alternative staffing models, including advance practice providers (APPs) [mainly nurse practitioners (NPs) and physician assistants (PAs)], nonintensivist physicians (hospitalists), and telemedicine, have been increasingly used to manage the critical care physician supply and demand gap.1 The reasons for this gap are well documented and include an aging and growing population of the chronically ill requiring ICU care,2 workforce shortage of intensivists,2,3,4 and increasing work-hour restrictions on resident duty hours by the Accreditation Council for Graduate Medical Education (ACGME).5 A survey of internal medicine housestaff also showed that less than 5% will choose to pursue a career in critical care medicine (CCM) partially as a result of the well-documented intensivist burnout6 and the sensed mismatch between a heavy work schedule and monetary compensation.7

The nationwide shortage of intensivists has been occurring in the midst of ongoing increases in the number of critically ill patients and ICU beds.,9 In 2005, there were approximately 94,000 ICU beds in nearly 6500 ICUs in approximately 5000 US acute care hospitals.8 In order to deal with these realities, institutions need to effectively develop and integrate alternative staffing models into their ICU.

This chapter will focus primarily on the use of advanced practice providers and hospitalists in the adult ICU setting. (Telemedicine is covered elsewhere in a separate chapter of this textbook.)


The acute care nurse practitioner (ACNP) specialty evolved in the late 1980s1 and is considered the best fit for adult critical care based on the competencies and scope of standards set by the American Association of Critical Care Nurses.1,10 There are currently more than 192,000 NPs in the United States.11 In 2012, approximately 14.2% ...

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