Urgent care medicine and the role of the APP within this specialty

The field of urgent care medicine offers an additional medical pathway for patients who have immediate, but non-life-threatening, medical concerns. Urgent care medicine offers a more varied set of resources and services than a physician office setting, with more flexible hours. This gives patients an opportunity to not have to go to the emergency department for non-emergent care. As a newer specialty within the medical field, certain roles of healthcare providers other than physicians are becoming established, including the advanced practice provider (APP). An APP is a nurse practitioner or a physician assistant, who is licensed to treat under the supervision of a physician. Nurse practitioners’ (NP) and physician assistants’ (PA) role in urgent care is often seen as an effective, lower cost option to manage common acute minor illnesses seen in the community. Benefits to utilizing APPs in urgent care include decreasing costs to both the patient and health system, enhancing the physician's ability to see more patients, and decreasing wait times, all while continuing to maintain high standards of care. The goal of the authors within this publication is to discuss urgent care as a specialty and further explore the role of advanced practice providers within this setting.     

Physician Perceptions of Advanced Practice Providers on Hospitalist Teams

Little is known about physician perceptions of nurse practitioners (NPs) and physician assistants (PAs) on hospitalist teams and the factors that impact their perceptions. Academic physician hospitalists were surveyed to better understand those factors, focusing on NP/PA experience, training, and physician experience with NPs/PAs. Perceptions by hospitalist physicians of NPs/PAs were strongly positive. Notable findings include the perceived positive impacts of NPs/PAs on clinical care provided, practice efficiency, and physician satisfaction. Most respondents prefer working with NPs and PAs with multiple years of clinical experience, particularly those who have participated in training beyond NP/PA graduate programs of study.     

Nurse Practitioners Leading Neonatal Transport Teams: A Proven Success

Historically in Australia, neonatal transport teams consisted of a physician training in pediatrics and a retrieval nurse. Even though nurse practitioners (NP) are used more commonly in retrieval services internationally, there is limited information about the effectiveness of the NP model of care in the neonatal emergency retrieval setting. In response to a key strategic goal by the management team, our regional pediatric emergency transport service introduced a retrieval NP into our neonatal emergency service team. This study evaluated the outcomes and satisfaction levels of an NP model of neonatal emergency retrieval.     

Developing an economic IQ in primary care

PURPOSE: To describe elements of an economic intelligence quotient (IQ) that can be used to enhance the nurse practitioner's (NP) fiscal viability in a primary care setting. DATA SOURCES: Anecdotal data from providers and administrators; clinical experiences of the authors; scientific and government publications and guidelines. CONCLUSIONS: In the United States, managed care cost-containment initiatives have led to competition among physicians and NPs for patients and jobs. An understanding of the economic base of a practice is essential to fiscal viability in this market. PRACTICE IMPLICATIONS: When turf and job competition are the norm, it is essential that the NP develop an economic IQ. Knowledge of coding, billing, reimbursement, and documentation are critical to identifying the NP's value to the practice and promoting job retention. The challenge is for the NP to give high-quality, cost-effective, and safe patient care and to be a productive provider.     

Perceptions of roles, practice patterns, and professional growth opportunities

Broadening the scope of advanced practice providers (APPs) has been offered as a solution to increasing healthcare costs, workforce shortage, and increased demand. To understand present scope and barriers to broadening it, the authors describe the perceptions and practice patterns of APPs. This cross-sectional study used a computerized self-report survey of 32 targeted nurse practitioners and physician assistants employed in the cancer center of an urban teaching hospital; 31 were included in the quantitative analyses. Survey items covered education and training background, expertise, professional resources and support, duties, certification, and professional development. Respondents practiced in a variety of oncology specialty areas, but all had advanced degrees, most held specialty certifications, and 39% had attended a professional or educational meeting within the last year. They spent a majority of their time on essential patient-care activities, but clerical duties impeded these; however, 64% reported being satisfied with the time they spent with patients and communicating with collaborating physicians. A model of advanced oncology practice needs to be developed that will empower APPs to provide high-quality patient care at the fullest extent of their knowledge and competence.     

Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors

Background

Non-physician advanced practice providers (APPs) such as nurse practitioners and physician assistants are being increasingly utilized as critical care providers in the United States. The objectives of this study were to determine the utilization of APPs in the intensive care units (ICU)s of academic medical centers (AMCs) and to assess the perceptions of critical care fellowship program directors (PDs) regarding the impact of these APPs on fellowship training.

Methods

A cross-sectional national survey questionnaire was distributed to program directors of 331 adult Accreditation Council for Graduate Medical Education-approved critical care fellowship training programs (internal medicine, anesthesiology and surgery) in US AMCs.

Results

We received 124 (37.5%) PD responses. Of these, 81 (65%) respondents indicated that an APP was part of the care team in either the primary ICU or any ICU in which the fellow trained. The majority of respondents reported that patient care was positively affected by APPs with nearly two-thirds of PDs reporting that fellowship training was also positively impacted.

Conclusions

Our survey revealed that APPs are utilized in a large number of US AMCs with critical care training programs. Program director respondents believed that patient care and fellowship training were positively impacted by APPs.     

The future of population medicine: Investigating the role of advanced practice providers and simulation education in special patient populations

Advanced practice providers (APPs) have come to play an increasingly significant role in the United States healthcare system in the past five decades, particularly in primary care. The first portion of this paper will explore the utilization of APPs in specific patient populations: pediatrics, obstetrics, geriatrics, and psychiatry. After a brief discussion of the demand for these specialties, the authors will outline the educational preparation and competencies that nurse practitioners and physician assistants must achieve before working with these special populations. Finally, the authors will discuss the current and future roles of APPs in pediatric, obstetric, geriatric, and psychiatric populations.Simulated patient interactions and scenarios have become integrated into clinical education for many health care providers. Although traditionally utilized only in emergency medicine education, medical simulation has grown to become a staple of training in nearly every area of medicine. Healthcare providers of all levels can benefit from both individual and team-based training designed to improve everything from patient communication to procedural competence. The flexible nature of simulation training allows for customized teaching that is directly relevant to a specific specialty. The second half of this paper will demonstrate simulation's versatilite applications in the specialty areas of urgent care, pediatrics, mental health, geriatrics, and obstetrics.     

Tertiary nurse practitioner reimbursement: An in-depth look at neonatal nurse practitioner billing

This report reviews the history of nurse practitioner reimbursement legislation specifically as it pertains to neonatal nurse practitioners (NNPs) in the tertiary care setting (inpatient/acute care). Barriers to reimbursement are reviewed, along with ways in which NNPs can continue to demonstrate their worth to the public and to health insurance providers. Specific steps are discussed on how hospital and health care providers are reimbursed for services rendered; obtaining a billing provider number is the initial step of establishing a billing service. Each state varies on how provider numbers are obtained and who is eligible to receive these numbers. Care must be taken to ensure that duplicate billing by different providers is avoided. The state's Medicaid Provider Manual is often helpful in determining which services are covered and which guidelines accompany each billable code. As tertiary care and/or follow-up providers, it is our responsibility to educate ourselves about the nurse practitioner reimbursement laws currently in effect and educate our legislators about our critical role in providing care to the sick inpatient population. Copyright © 2001 by W.B. Saunders Company     

Advanced life support skills undertaken by nurses--UK survey.

Many nurses successfully complete the Resuscitation Council (UK), European Resuscitation Council, advanced life support (ALS) Provider Course. Acquiring ALS provider status is not necessarily a licence to practice and individual hospital policy determines which skills these nurses can then perform without direct medical supervision. This postal survey aimed to determine which ALS skills are utilised by nurse ALS providers working in a variety of clinical areas within acute hospitals in the UK. A questionnaire was sent to the Resuscitation Officer or Nursing Director of all acute hospital groups in the UK. Almost 261 (87%) of the questionnaires were completed and returned. Nurse ALS providers in 99% of coronary care units, 89% of intensive care units, and 88% of accident and emergency departments undertook manual defibrillation. The majority of hospitals ran compulsory in-house training sessions for intravenous cannulation. Laryngeal mask insertion by nurse ALS providers was permitted in 19% of coronary care units and in the wards of 16% of the responding hospitals. Tracheal intubation by nurse ALS providers working in coronary care units, intensive care units and emergency departments was permitted by 11% of the responding hospitals. This survey has demonstrated that many acute hospitals do not permit nurse ALS providers to use a number of the skills taught on the ALS provider course. General ward-based nurse ALS providers, in particular, are restricted in the ALS skills, they are permitted to use. It would be more efficient for nurses to be trained and assessed specifically in skills they are then permitted to use. Having been assessed in a given skill and achieved a nationally recognised standard, nurse ALS providers should be permitted to use it in clinical practice.     

A national survey of nurse practitioners’ patient satisfaction outcomes

BackgroundThe research findings about nurse practitioner (NP) patient experiences (satisfaction) are limited to small sample sizes from local community clinics. No national studies with large sample sizes were found.PurposeTo analyze responses from the Consumer Assessment of Healthcare Providers and Systems survey and compare the patient experiences from four different provider categories.MethodsSecondary data analysis was completed on survey responses from 53,885 patients.FindingsIn the sample, medical doctor providers were disproportionately represented in greater number than NPs, doctor of osteopathy, or physician assistant. Further analysis comparing patient experiences between providers revealed NP to be rated significantly higher than their colleagues.DiscussionRecognizing the factors associated with patient satisfaction with their providers can lead to improvements in patient-provider interactions that can result in increased quality of care.ConclusionPolicy makers should find opportunities to employ NP in primary care settings and achieve greater patient satisfaction that can influence outcomes associated with patient-centered care initiatives.     

Outcomes of tube thoracostomies performed by advanced practice providers vs trauma surgeons

BACKGROUND: The role of advanced registered nurse practitioners and physician assistants in emergency departments, trauma centers, and critical care is becoming more widely accepted. These personnel, collectively known as advanced practice providers, expand physicians' capabilities and are being increasingly recruited to provide care and perform invasive procedures that were previously performed exclusively by physicians. OBJECTIVES: To determine whether the quality of tube thoracostomies performed by advanced practice providers is comparable to that performed by trauma surgeons and to ascertain whether the complication rates attributable to tube thoracostomies differ on the basis of who performed the procedure. METHODS: Retrospective blinded reviews of patients' charts and radiographs were conducted to determine differences in quality indicators, complications, and outcomes of tube thoracostomies by practitioner type: trauma surgeons vs advanced practice providers. RESULTS: Differences between practitioner type in insertion complications, complications requiring additional interventions, hospital length of stay, and morbidity were not significant. The only significant difference was a complication related to placement of the tube: when the tube extended caudad, toward the feet, from the insertion site. Interrater reliability ranged from good to very good. CONCLUSIONS: Use of advanced practice providers provides consistent and quality tube thoracostomies. Employment of these practitioners may be a safe and reasonable solution for staffing trauma centers.     

Emergency Medical Practice: Advancing Cultural Competence and Reducing Health Care Disparities

In an increasingly diverse patient population, language differences, socioeconomic circumstances, religious values, and cultural practices may present barriers to the delivery of quality care. These obstacles contribute to the health care disparities observed in all areas of medical care. Increasing cultural competence has been cited as part of the solution to reduce disparities. The emergency department (ED) is an environment where cultural sensitivity is particularly needed, as it is often a primary source of health care for the underserved and ethnic and racial minorities and a place where high patient volume and acuity place the provider under demanding time pressures, yet the emergency medicine (EM) literature on health care disparities and cultural competence is limited.
The authors present three clinical scenarios highlighting challenges in providing equitable emergency care to minority populations. Using these cases as illustrations, three processes are proposed that may improve the quality of care delivered to minority populations: 1) increase cultural awareness and reduce provider biases, enabling providers to interact more effectively with different patient populations; 2) accommodate patient preferences and needs in medical settings through practice adjustments and cultural modifications; and 3) increase provider diversity to raise levels of tolerance, awareness, and understanding for other cultures and create more racially and/or ethnically concordant patient–physician relationships.     

Stakeholder Perspectives on Improving an Advance Practice Provider Emergency Department Critical Care Step-Down Unit

In response to concerns about the continued care and safety of critically ill and injured patients, our academic, urban, tertiary care, level I trauma center adult emergency department (ED) created an advanced practice provider (APP)-staffed critical care step-down unit (CCSU). We conducted semistructured interviews of ED physicians, APPs, and nursing staff about the value added by the CCSU as well as suggestions for its improvement. The results from the interviews showed staff were highly complimentary of the CCSU and recommended expansion of its hours and APP staffing, but indicated areas of improvement. Future research can evaluate how implementation of stakeholder suggestions improved the CCSU’s operations.     

Nurse practitioners and physician assistants revisited: do their practice patterns differ in ambulatory care?

The education and regulation of nurse practitioners and physician assistants would suggest unique role differentiations and practice functions between the professions. This study explored to what extent their practice patterns in primary care actually differ. It was hypothesized that the primary care services provided by nurse practitioners would tend to be women and family health services, health prevention and promotion oriented, provided to minority and socioeconomic disadvantaged patients, and less dependent on physician supervision. In contrast, the services provided by physician assistants would more likely be medical/surgical oriented; diagnostic, procedural, and technical in nature; likely to be in rural areas; and more dependent on physician supervision. The study used patient data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Although some differences emerged, the argument is not compelling to suggest strong, unique, practice differences across all ambulatory care settings between the two types of nonphysician providers. It is the specific type of ambulatory setting that influences the practice pattern for both provider groups. If practice patterns are less distinctive than previously believed, more opportunities for interdisciplinary education need to be explored, and health policies that promote a discipline-specific primary care workforce may need to be reexamined.     

Reducing Nonemergent Visits to the Emergency Department in a Veterans Affairs Multistate System

Study ObjectiveThe purpose of this quality improvement study was to reduce nonemergent visits to the emergency department attendance within a multistate Veterans Health Affairs network.MethodsTelephone triage protocols were developed and implemented for registered nurse staff to triage selected calls to a same-day telephonic or video virtual visit with a provider (physician or nurse practitioner). Calls, registered nurse triage dispositions, and provider visit dispositions were tracked for 3 months.ResultsThere were 1606 calls referred by registered nurses for provider visits. Of these, 192 were initially triaged as emergency department dispositions. Of these, 57.3% of calls that would have been referred to the emergency department were resolved via the virtual visit. Thirty-eight percent fewer calls were referred to the emergency department following licensed independent provider visit compared to the registered nurse triage.ConclusionTelephone triage services augmented by virtual provider visits may reduce emergency department disposition rates, resulting in fewer nonemergent patient presentations to the emergency department and reducing unnecessary emergency department overcrowding. Reducing nonemergent attendance to emergency departments can improve outcomes for patients with emergent dispositions.     

Supporting Advanced Practice Providers’ Professional Advancement: The Implementation of a Professional Advancement Model at an Academic Medical Center

Organizational commitment to a structured professional advancement model (PAM) is critical for advanced practice provider (APP) development to promote and reward excellence, enhance job satisfaction, and improve retention and recruitment. A PAM may also serve as a motivational tool for personal and professional growth by developing and promoting a professional, evidence-based, collaborative practice environment. A voluntary PAM was implemented at a large Midwestern academic medical center to recognize experienced APPs, including certified nurse practitioners, certified nurse-midwives, and physician assistants. This report describes the case for creating a PAM and implementation and evaluation.