Chapter 78: Alternative Staffing Models in the ICU

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% of NPs were prepared in acute care, and 51% of them reported working in an inpatient hospital setting.¹¹ Their role is not defined necessarily by location but by the patient care needs. The patient population they care for ranges from young adults to the elderly with acute, critical, and complex chronic illnesses.¹² The extent of autonomy and physician oversight for ACNPs in relation to diagnosing and prescription writing privileges vary from state to state.¹³

Perquisites to becoming an NP include obtaining a bachelor’s degree in nursing, although some bridge programs from a nonnursing bachelor’s degree do exist, and a registered professional nurse license. Completion of an accredited graduate level education program is mandatory.

The concept of PAs evolved in the early 1960s in response to a shortage of general practice physicians.¹⁴ PAs are nationally certified, state-licensed, and practice medicine as part of a physician—PA team.¹⁵ The fundamental principle of PA practice is physician-dependent delegated autonomy, defined accountability, and reciprocal responsibility for providing supervision and seeking physician consultation. Supervision is defined by state law and hospital policy, but all states have laws allowing off-site supervision by physicians via telecommunications.¹⁶ In mid-2013, there were 84,064 clinically active PAs (those who held a valid state-issued PA or medical license), and 2% overall were ICU/critical care based.^17,18

PA programs are based on the medical model, average 27 months in length, and provide broad-based general medicine education with an emphasis in primary care.¹⁹ Most PA programs award a master’s degree on completion of the entry-level curriculum.²⁰ Unlike NP education, PAs do not have different tracks. The expectation is that entry-level PAs will broaden their medical knowledge and clinical skills with practice-based physician teaching and formal continuing medical education programs. A trend in the PA workforce distribution towards specialization is documented.²¹ Clinical postgraduate PA programs, in the form of residencies, are available for PAs who want added experience in preparation for practice in a medical or surgical specialty.²²

Hospitalist medicine has been the fastest growing specialty in medicine for the past decade. In 2009, 89% of hospitals with over 200 beds had hospitalist presence.²³ Hospital medicine focuses on general medical care for hospitalized patients, allowing primary care physicians to assume responsibilities in the community.²³ The initial intent was to improve patient outcomes and decrease hospital length of stay and costs. Approximately 85% of current hospitalists are board-certified in internal medicine.²³ In 2009, the American Board of Physician Specialists developed the first board certification for the practice of hospital medicine.^23,24

Hospitalists have mostly replaced primary care physicians as the manager of ICU patients in nontertiary hospitals.²³ In community hospitals, about 87% of the hospitalists are providing care for patients in the ICU, and 30% are providing critical care services in academic medical centers.²⁵ The primary models of hospitalist care in the ICU include hospitalists serving as primary ICU providers in centers without critical care consultants or assisting in the co-management of patients in collaboration with intensivists.²⁵

Delineating the roles and responsibilities of APPs and hospitalists will depend on the institution’s needs. The general roles and responsibilities of APPs (Table 78–1) include various levels of autonomy that are dependent on the individual practitioner’s experience, capabilities, and granted privileges. In some institutions where ICU staffing is in-house 24/7, their roles may include that of the code team and rapid response team leader.

Hospitalists’ roles and responsibilities in the ICU vary depending on the institution policies, whether the ICU is an “open” versus “closed” unit, as well as their own level of experience and competency in providing critical care. Issues such as billing and obtaining credentialing and privileges for critical care are also institution-specific. In some institutions, the hospitalist practices as the sole ICU attending with admitting privileges. In other settings, the hospitalists will follow and provide critical care for their ward patients who are transferred to the ICU. Many hospitalists also seek consultation with intensivists to help manage patients with mechanical ventilatory needs or to manage more complicated critically ill patients.²⁶ In some institutions, hospitalists are also being utilized as the initial responders of the rapid response team.²⁷

Nonphysician or nonintensivist models in the ICU can offer several institutional benefits. First, these providers can help overcome the current intensivist and resident shortages as well as become a consistent workforce that can positively impact patient care.¹ Regular exposure and practice will help these providers gain knowledge and expertise in CCM and become proficient in performing invasive procedures.¹ A recent national survey of program directors of ACGME-approved critical care fellowship training programs demonstrated that integrating NPs and PAs can positively impact critical care training for the fellows because it allows greater focus and time on fellow educational needs while the NPs/PAs assume daily clinical responsibilities.²⁸ Additionally, patients managed by NPs, PAs, and hospitalists have been shown to have similar outcomes in hospital mortality^24,29,30 and length of stay^24,29,30,31 when compared to those cared for by residents. NPs have also been shown to have better communication with nurses³² and greater compliance with evidence-based practice guidelines¹⁰ that have resulted in decrease in days on mechanical ventilation,³³ rates of urinary tract infections, and skin breakdown.³¹ Finally, besides improving the quality of patient care, some studies also suggest that the use of NPs and PAs in acute care may decrease hospital costs^31,34 and improve the financial productivity of the institution.¹⁰

Due to the shortages of the traditional ICU workforce, it is evident that APPs and hospitalists are providing care in the ICU. The question then becomes not if but how to successfully integrate them into the ICU. Adding hospitalists, NPs, and PAs into the ICU team as “intensivist extenders” effectively increases the availability of adult critical care services.^{1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23} However, successfully establishing these alternative providers into an ICU team is not as easy as advertising, hiring a few, and scheduling shifts. Integration of these alternative staffing providers needs effective planning with thoughtful consideration and discussion of many factors, including institutional expectations, financial considerations and rationalization, administrative support, current staff acceptance, governance, recruitment, and retention (Table 78–2).

Individual hospitalists’ knowledge and skills for managing the critically ill may vary based on differences in training and clinical practice experience prior to becoming a hospitalist.²³ The costs for educating hospitalists in CCM may at times become an employer’s expense. A competency-assurance process based on an education and skills training process leading to acquisition of competencies beyond those obtained in internal medicine residency training has been suggested.²⁵ However, formal opportunities to broaden general critical care knowledge and obtain skills are reportedly few. Therefore, a traditional critical care fellowship is recommended for those hospitalists who primarily want to work with critically ill patients.²³ In 2012, a position paper endorsed by the Society of Hospital Medicine and the Society of Critical Care Medicine proposed the creation of an expedited ACGME-sanctioned and accredited critical care certification pathway, with the goal of attracting practicing hospitalists to critical care fellowship training.²³ This proposal is still under consideration by the ACGME.

Unlike hospitalists, APPs do not have the preparation and training provided in medical school and residency. They receive less stringent education and therefore have different challenges.¹ However, with a careful selection of motivated individuals and on-the-job training, they can be trained to provide services traditionally performed by ICU physicians. A recent survey showed that NPs and PAs provide care in greater than 50% and approximately 25%, respectively, of adult ICUs in academic medical centers in the United States.^10,35 Thus, teams including APPs or exclusively consisting of APPs, with appropriate physician leadership, can provide critical care that is equivalent to that delivered by traditional teams built around housestaff in a high-intensity ICU setting.^25,28

Integration of APPs into the ICU will require diligent planning and many considerations. These should include the program model one chooses to incorporate APPs into. Will the APPs be integrated into an existing intensivist-led, resident-based team, or as a stand-alone intensivist-APP team? Especially for the novice APPs, the availability of in-hospital physician backup for management decisions and procedural assistance has to be considered.

Staff buy-in is required. This includes the ICU nurses and physicians, hospital staff physicians (particularly if the ICU is transitioning to a “closed” unit), respiratory therapists, dietitians, and pharmacists. If integrating APPs occurs in a teaching institution, the effect on housestaff and CCM fellow training should be considered. The APP’s role and responsibilities need to be clearly defined to avoid any conflict with other team members. The APPs must be presented to all as partners, not competitors.³⁶

Organizationally, which department(s) will be responsible for clinical and administrative oversight must also be defined. Generally, NPs fall under the department of nursing and report to nursing leadership, while PAs typically fall under a clinical department and report to the departmental leadership. Dual governance for NPs in the ICU has been described.³⁷

All APPs require orientation and mentoring, regardless of their previous experience and competence. New NPs may have prior experience as ICU nurses, but the transition to a CCM NP can be quite demanding, as described below. New PAs are expected to broaden their knowledge and skills with on-the-job education and training, so experience in a hospital medicine position prior to seeking a CCM PA position is suggested.³⁸

Knowledge deficits in basic critical care principles, procedural skills, ultrasonography, and management skills are universal. Thus, a comprehensive, competency-based preparation course, as part of a mentored orientation, is necessary. This will require significant work on the part of the intensivists, consultant attendings, staff APPs, respiratory therapists, nutritionists, physical therapists, and other multidisciplinary team members to ensure success. Several samples of orientation programs are available in the literature.^18,37,38,39 For programs with less available teaching staff, outsourcing APP training to a regional program has been reported.^40,41

Establishing or expanding the multidisciplinary ICU team with APPs requires financial considerations. In 2010, the average salary for an APP working in a hospital-based unit ranged from $93,943 to $94,680 plus 33% benefits totaling ~$125,000. The expense for a postgraduate year-1 resident in 2014 in New York City was $55,900 salary plus 32% benefits, totaling $73,788 dollars, which was reimbursed by Medicare. Using a formula in which 30% of a resident’s 80-hour workweek is for educational activities, 56 h/wk is required to replace the resident service hours or ~1.5 full-time equivalents (FTEEs) [42]. At an average cost of $125,000/year (salary + 32% benefits) for an APP, this translates to an additional expense of $187,500 to cover one resident’s service time for 1 year. Allowing 5.5 FTEs to cover one 12-bed unit (1:12 provider/patient ratio) each shift (24/7/365), the total expense is $687,500 dollars per unit/year. The cost will vary with geographic location, years of experience for each practitioner, and ratio of providers to patients.

Salary expense may be partially recovered if the APP is on the hospital cost report as an employee, and their services are reimbursed under part A of Medicare. Alternatively, the APP can bill for their services if they are qualified to do so, and not on the hospital cost report, as will be discussed in the Billing section.

Cost rationalization based on potential benefits as discussed below may include cost savings in the long run by improving patient satisfaction, quality, length of stay, and staffing.

Billing has to be considered when integrating APPs into the ICU. The Balanced Budget Act of 1997 officially recognized APPs as health care providers. This allowed them to be eligible for their own provider numbers and to submit bills to Medicare Part B for evaluation and management (E/M) services and procedures.⁴³ As outlined by the Centers for Medicare and Medicaid Services (CMS), qualified APPs can bill for critical care services under their national provider identifier (NPI) at 85% allowable of the physician rate.⁴⁴ Billing requires documentation of the encounter and must validate the need for critical care service. For services or procedures that are not regularly part of the critical care services bundle, such as insertion of an arterial line or central line, the provider who performs the procedure bills them separately.⁴⁴

CMS requires a physician supervision agreement for PAs and a collaborative practice agreement for NPs. Individual health insurance companies may have different coding methods and rules for reimbursement when it comes to nonphysician providers. However, most companies follow CMS dictations as a basis for reimbursement.⁴⁵

APPs have to obtain credentialing and privileges. This process ensures that they have the necessary qualifications to provide safe and quality care in conjunction with federal and state laws, regulations, and standards set by the Joint Commission. Credentialing and privileging are administrative processes driven by the medical staff bylaws and involve obtaining, verifying, and assessing a provider’s credentials, based on education, clinical training, certification, licensure, and other professional qualifications for appointment to the medical staff and providing patient care in or for the hospital. Most states require NPs to have a collaborative practice agreement with a supervising physician, and all states require PAs to have a supervising physician agreement. For billing purposes, the APP’s scope of practice must include critical care and procedural privileges, and the supervising physician agreement should stipulate that the NP or PA is authorized to provide critical care services.⁴⁵

The evaluation of a practitioner’s performance is now an ongoing process that involves an evidence-based approach. The Joint Commission mandates that the hospital attain an initial Focused Professional Practice Evaluation (FPPE) for a nonphysician provider who is new to the hospital or an existing one who seeks new privileges. FPPE can also be done when existing credentials and privileges are questioned. The Joint Commission also mandates that providers maintain competence and require periodic review by abiding to the requirement of Ongoing Professional Practice Evaluation (OPPE). The OPPE process consists of periodic evaluations, peer review, quarterly chart review by the collaborating physician, demonstrating ongoing competence for procedures, participating in morbidity and mortality rounds, and reviewing any issues that may be substandard.^43,46

Moving from a standard to an alternative ICU staffing model may bring on various issues due to the obstacles naturally associated with a dynamic process and an overall general resistance to change. Although extremely limited, there is literature that describes some of the common obstacles that may occur after a new ICU provider staffing model has been introduced.³⁷

Searching for the right ICU provider can be overwhelming. For example, finding experienced candidates is complicated by the fact that only 2% of PAs and 14.6% of NPs work in acute care settings.³⁵ Conversely, while 75% of hospitalists are already covering ICUs, many are tied into contracts for their services.²³ As a result, recruitment of these alternative ICU providers must rely on setting up relationships or programs to develop internal candidates. An APP residency/fellowship program, clinical/mentorship rotation, or more recently the emergency medicine and internal medicine pathway into critical care fellowships can help to bridge gaps in employment during the transition year(s) of the staffing model. Regardless of the recruitment method, successful candidates are usually those who demonstrate modesty, flexibility, and eagerness. Typical ideal candidates in the APP track include those with critical care experience (either as a nurse or an NP), PAs who have at least 2 years of in-patient hospital experience (although critical care experience is preferred), and hospitalists who have at least 1 year of practice.^37,47

Ironically, experience in critical care, although routinely preferred, may have several drawbacks. An “experienced” APP may find assimilation into a new ICU environment, with various degrees of autonomy, different from what he/she may be used to, challenging their comfort level. Experience has shown that objectives for new hires should be predetermined, with weekly goals being outlined and highly structured. If a new candidate fails to meet the objectives or does so with unacceptable delay, the program must have sufficient structure to recognize and support the transition of the new hire out of the ICU setting.^37,48

ICU “burnout” is well documented; thus, it is not surprising that alternative staffing providers suffer from this similar affliction. It is estimated that 50% of CCM physicians and 33% of critical care nurses suffer ICU burnout.⁴⁹ While the implementation of additional alternative staffing, in conjunction with intensivist staff, has helped to reduce burnout, it should be done with caution (Figure 78–1). The majority of burnout is multifactorial, including working long hours (especially on the night shift), prolonged time without vacation, excessive workloads, sleep deprivation, and ICU conflicts. Consequently, it is important for institutions to consider methods to reduce “burnout” in an attempt to provide a stable ICU workforce. These methods may include providing 12 to 16 hour shifts with adequate staffing (ratios of 3-5 patients per APP have been successful), rotation across various shifts, not reserving day positions for only senior staff, and 4-5 weeks paid and supported vacation. Ultimately, institutional support is mandatory for program success.⁵⁰

Conflicts will arise at some point while implementing a new provider model. These common encounters exist within any discipline, but it has been described (although extremely limited) to occur mostly between the RN and NP, NP and PA, NP/PA and CCM fellow, or between the hospitalist and primary care physician. Regardless of the nature of conflict, structure and processes should be in place to mitigate and provide adequate resolution. Some centers have described preemptive meetings between nursing and medicine, advocating for an advance practice manager and or routine ICU unit meetings. Above all, communication is always of utmost importance in the prevention and resolution of conflicts.

Integrating alternative staffing models into the ICU is a logical, safe, and necessary endeavor to curtail gaps in the workforce as critical care physician shortages increase and available replacements decrease. A recent prospective study showed that outcomes are comparable for critically ill patients cared for by ACNP and resident teams in a medical ICU.⁵¹ The evidence-based studies describe multiple uses of various models to augment staffing, yet there does not seem to be a “best practice” model. With a myriad of coverage and ICU practice models available, additional studies are needed to help sculpt styles based on the particular needs and preferences of an institution; no one model will fit all organizations. However, regardless of the chosen staffing model, the key determinants for the success and growth of the CCM workforce will rely heavily on organization, strategic planning, and communication.