Critical Care Medicine - List
http://www.pitt.edu/~crippen/

Nurse Practitioners and Critical Care Medicine

Presented by Bruce Gipe:


In January 2000, JAMA published an article from a program at Columbia University in New York which compared the performance of nurse practitioners (NPs) to primary care physicians in an outpatient setting and found equal outcomes (Mundinger, et al. JAMA 2000;283:59-68).

The latest trend in training NPs is the "acute care nurse practitioner" (ACNP) track which adds 15 wks. of clinical training and produces ACNPs who will work in the inpatient setting.

The issue of the expanding role of Advanced Practice Nursing (clinical nurse specialists, ACNPs, NPs, CRNAs) is provocative and compelling, especially at a time when some intensivists are trying to fend off hospitalists and when we have an oversupply of physicians and an undersupply of nurses. in order to improve collaboration, critical care physicians need to understand how their colleagues in the nursing profession view themselves.

We have been sampling opinions on this issue via the National Health Care Cost & Quality Assn. website (www.nhcqa.org/poll.html). Are NPs able to function as house physicians = yes nps can function as house physicians. intubation? ACLS? Central Line placement" Thoracostomy? Treating arrhythmias?

Anonymous:

GREAT TOPIC: I am graduating in three weeks from the ACNP program at the University of ___ in ______. Actually the program is Trauma/Acute Care/CNS. During my shock trauma rotation I placed chest tubes, central lines (sub-clavian and femoral), and a-lines. I was trained to assess, treat, admit and follow trauma patients. I also did an ICU rotation at _____ hospital in Washington D.C. where I intubated, placed dialysis catheters, floated Swann-Ganz catheters, inserted A-lines and central lines. I managed patients urgently transferred to ICU who were crashing. Managed many drips (under supervision of the fellow) on my admitted patients. I will be working for a cardiology group when I am certified. I am doing an extra rotation clinically now to fine tune my cardiology skills. I will be expected to manage inpatients and take call. I will see patients in ICU, and tele. and work up ER for admissions. My colleagues who graduated last semester are getting certified,(taught and a letter of proficiency sent to the SBON by the teaching doctor,) so they can perform intubations, insertions of central lines and a-lines, and float Swanns.

If there is an expectation that you will be performing a skill frequently, and get, say a surgeon at the facility to teach you how to insert central lines, you may write this in your practice agreement. In school I was in clinical every day but class days, and every third shift was a 30 hour on-call shift, I will be expected to take call for the cardiology group i will be working with. I would not, however, in the beginning of my career, manage, unstable patients on drips, without consultation with a physician. I will immediately upon getting hospital privileges, find a surgeon to certify my in inserting central lines, and get one of the cardiologists to certify my competence in inserting Swanns.

Very interesting. By the way, I have a friend who is managing all inpatient for a pulmonary group, all their vents and pulmonary patients on her shift. She has a 2 month continuous supervision period after her hire, and then she will take call like anyone else in the group and manage on her own with consultation encouraged. She is expected to intubate and insert chest tubes and perform thoracentesis. Another friend manages patients with a physician in heart transplant and CHF at _______Hospital in _____. Thank you for this interesting survey, I will be interested in the results.

David Crippen:

I'm ambivalent on the subject of NP in critical care. I think they can be of value, but it depends heavily on circumstances.

We considered getting one and decided not to because our situation is radically different. We subsist by billing for our services, and we have enough trouble getting reimbursers to pay for physician services legitimately provided. When we actually sat down and figured out what we would actually "use" a NP for, we discovered they were redundant.

There are eight physicians in our group. We cover 24 beds in the ICU 24 hours a day, 7 days a week. Daytime there are three physicians in house. One covering the ICU proper and teaching housestaff. A second covering consults, procedures overseeing interhospital transports of patients and gofering for the first call attending (some more oppressive than others). There is also a "Third" call person on administrative duty for overflow, disasters and creative work avoidance. Those guys all go home at 5 pm when the night man arrives. His job is to oversee new admissions and keep look after the patients till the following AM when the team comes back on. He gets the day of call and the following day off so being up at night isn't such a bad deal.

A NP doesn't fit into this schedule of events very well for a multiplicity of reasons.

1) I am not at all sure that patients in the rarified atmosphere of critical care are all that interested in NPs making more or less autonomous bedside decisions on their behalf. I can assure you the internal medicine and surgery attendings have no interest. NPs would do a lot of things we consider scut, clearly making life easier for us, but they have to be "supervised" in some fashion. We learned a long time ago that this is much more labor and frustration than just doing it yourself. "Show me the house officer that only triples my work load and I will kiss his feet", or something like that from the House of God.

2) They are highly trained people and must be paid accordingly. It is not by a long shot carved in granite how they are reimbursed for critical care chores. In essence, we would have to PAY them to do things that lighten our work load, and the amount of money we get back for them is iffy. We decided we would rather do the work ourselves and collect the money for our own selfish interests. Sloughing off doesn't pay unless you can sucker someone else to do it for free.

I know Mark Mazer and his partner have one in Johnstown, PA and they are very happy with the arrangement. There are only two physicians in a fairly busy service and a NP allows them to get more work done with less stress. Since there are only two of them and they stretch the work load further, it may work better for them to pay part of their income toward a helper. Perhaps he can give you a brighter. outlook.

Mark Mazer:

Not only do I gratefully have a NP as part of our CCM team, I help to train them. However, I do not suppose that one day my NP, nor any other for that matter, will be able to supplant me in my role as an critical care specialist with twenty-seven years of training and clinical experience (holy shit, has it been that long???).

PA lines, CVP lines, chest tubes...Critical care physicians should not feel belittled if someone else, properly trained and proctored, inserts the damn things...if reimbursement and other such financial concerns were not issues, then I suppose there would be little concern as to who inserted the PA line, as long there was a good indication, and the patient was not butchered in the process...attending intensivist, fellow, resident, PA, NP...competence is competence...I think that some soul searching is in order...perhaps an informal, confidential poll should be conducted...with some probing questions put to NP detractors, such as:

1. Have you ever, even once, knowingly billed a patient for an invasive procedure performed by a resident or fellow under your authority but in your physical absence?

2. Have you ever asked a technically competent resident or fellow to delay performing an invasive procedure just so you could be physically present in order to submit a bill in "good conscious?"

3. Can you look at yourself in the mirror and affirm that every invasive procedure you have performed has always been absolutely necessary?

4. If you scanned your demographic data, would your indigent, self-pay and Medicaid patients have "benefit" from the same number of invasive procedures as your commercially insured patients?

Venal issues aside, it really boils down to the same issues we struggle with in credentialing physicians for ICU privileges: there are matters of technical competence, and matters of cognitive competence. Dr. X, a family practitioner, may not have inserted a central line for fifteen years, but certainly may have the intellectual and cognitive ability to manage a CVP of 0 in face of a hemorrhaging patient...conversely, would your career as a critical care physician be necessarily ended in face of the unfortunate loss of a hand? Hopefully not...your cognitive abilities intact, another colleague could perform the technical acts...while you deal with the numbers, lab values, check the x-rays, talk with families, etc...so what if the colleague is a NP?

At 3 am all of us have wished at one time or another that a PA line could be inserted by an act of prestidigitation...because we really need to know the wedge pressure, but inserting the thing is a pain...what we really wish is that insurers would respect and reward our cognitive juggling of the numbers more than the physical act of inserting the catheter.

Depending upon circumstance, NPs can be creatively and effectively integrated into the critical care team... when the ICU is full, with many unstable patients, and grieving families, harried nurses, demanding = referring physicians, and scared shitless residents, a well-trained, experienced extra pair of hands and brains is priceless...further, any competent NP knows that he or she in not a physician, knows his or her = limits and when to call for help...and is being supervised by a responsible physician, extending his or her effective radius of healing by the creative use of proxy hands and brains.

Mike Dacey:

I really don't agree with nurses in this setting. If it were my family member, I'd want a critical care physician at the bedside.

The duration of training, difficulty of training, depth of training that physicians receive is greater by an exponential amount compared to nurse practice providers. 15 weeks? How about 15 years! Then maybe you can take the critical care boards and have a 60% chance of passing. One leader in this movement was interviewed on a PBS special..."Our people have 400 hours of clinical training!". That's a busy month for me and my residents.

You can always be trained to put lines in, swans, etc...but when do you put them in? More importantly, what do you do with the data you get from the procedure? I teach third year medical students to put swans in and then they spend the next SEVEN years learning how to care for critically ill patients before we call them an intensivist. Treating routine hypertension is one thing, operating on the edge of death and being a manager of extreme risk is quite another. My parents get a boarded doctor.

Anonymous:

I remember doing exactly the same thing while working in a " private" cardiac hospital in London........ ( aka- a renovated house come hospital charging huge prices to perform cardiac surgery on patients who do not make the criteria to have surgery in their own countries) Obvious tamponade, no house officer/ reg/ consultant for miles ( again commonplace..... sigh the naivete of young keen nurses even putting ourselves in this position just to make the big bucks).

To make a long story short........ I cracked the chest- being ably assisted by a RNA equivalent and the specialist giving advice via cell phone.......he was stuck in traffic outside the Brompton hospital in South Kensington. We were in the " outskirts "- a reasonable way away. The patient survives to see another day. Release the pressure, buy some time......and the surgeon arrives to patch the leak.

Comments from the consultant??????? " I would rather have an experienced and trained ICU nurse beside me ANYDAY over some snotty resident straight from his obstetrics diploma." gee, maybe we have some uses after all......

David Crippen:

I think you are comparing apples to oranges. The divisions of labor are different.

We are all a well oiled team. Nurses have (at least) three well defined functions. 1) Rendering many levels of comfort care at the bedside, 2) effecting decisions made by policy makers and 3) early warning systems to warn when things aren't going well. Critical Care physicians are there to evaluate a lot of variables and make primary decisions on how to manipulate them for a better outcome. No one in their right mind would tolerate me doing bedside nursing. I'm not trained for it and I have no aptitude. I don't think many patients want nurses making primary medical decisions regarding therapeutic care plan. Now comes the issue of residents.

(grimace)......Like it or not, residents are going eventually be making primary decisions that affect people's lives. No one ever said the current system of training residents is the most effective, but it has evolved the way it has because no one has found anything better. Kind of like marriage. And I hasten to add at this juncture that I am NOT happy with the way medical education is evolving. They are getting away with less work and less responsibility. They get built in stress relief when the poor babies get tired. They are learning that medicine is an elective art and when the stress starts, they simply go home or call a consultant As a result, they don't have a clue what an emergency is, much less how to deal with it under stress. They look at their watches and relax until till the next shift starts. I greatly fear that Libby Zion is an infinitely greater threat to us than Managed Care. But I digress......

There is a push out there to facilitate non-physicians "extending" the authority of physicians. Isolating physicians to make primary decisions and then "facilitators" carrying out those decisions for them. Doing what physicians consider to be scutwork. Pushing them up further into the realm of the intellectually elite, sitting around and thinking a lot......the fruits of their thought processes translated into action by waiting legions of facilitators. I also suspect that some of those who would perform these chores are less interested in becoming a well oiled cog in the machine as they are carving out a well paying career for themselves and trying their best to function as autonomously as possible because it's ego gratifying. Naturally, this population would find medical housestaff to be their natural enemy because they are competing for the same things.

I don't think this is necessarily a good thing. If you take scut and procedures away from housestaff and give them to nurses or PAs, the entire ambiance of what those experiences and procedures mean is lost from who will eventually be making primary decisions on the how and why of those things, and given it to people who will simply do them for a living and then go home. You will dilute the (if you will) "Holistic" aspects of medicine from those who NEED to understand it, and give it to those who will never have the authority to macro- or micro-manage patient care, what has been accomplished in the end?

Everyone finds housestaff irritating and time consuming. But THESE GUYS are someday going to be running the show, like it or not. That's the way the game is played. If they don't get fully steeped in the experience, like a teabag, they will STILL eventually be making the same decisions but the learning curve will be greatly extended until they either out or learn to act like attending physicians or fail and drop out. And during that extended learning curve, a lot of mayhem is possible. I suggest that actively training nurses to be de facto housestaff dilutes out the quality of the experience for those who will eventually decision makers, and that will simply extend their period of incompetence and facilitate more dropouts.

That is unless there are those out there who think that nurses should be training to make primary decisions. That is a separate issue.

Tim Buchman:

FL (aka Crippen, the Mac User) makes the most important point: stick to the issues and don't confuse opinion with fact.

2. Reimbursement issues aside, demand for critical care services is increasing.

3. There is a shortfall of physicians qualified and willing to deliver critical care.

4. Medicine doesn't like a vacuum any better than nature in general--someone always wants to step up to the plate to provide service that is perceived to be needed.

5. Health care professionals who are not physicians are likely to offer to deliver services if it makes professional and economic sense. Whether they are permitted to do so is as much a matter of politics as ability. For example, in our units, dietitians (highly supervised, of course) place all of the nasoenteral feeding tubes. Their success rate approaches 100%.

These observations are based on multiple events including, but not limited to, the rise of the specialty of emergency medicine; the emergence of the CRNA as a primary provider of peacetime anesthetic care; the invention of geriatric medicine; the appearance of rehabilitation medicine; and so on.

My take on all of this is that the ICU work force will either become more efficient (hard to imagine--everyone in our ICU is really stretched) or will expand as the demand for services increases. The professional composition of the expansion seems unlikely to be physicians. At the same time, I seriously doubt that medical decisions concerning the sickest patients will be simply delegated to non-physicians.

My opinion, therefore, is that critical care physicians are likely to assume more and more of a managerial role. The question, it seems to me, is not whether ACNPs (the terminology may change, but what I am getting at is advanced trained nursing professionals) will assume new roles in the ICU but rather how they will report and be compensated. I do not think they can function through the traditional "nursing hierarchy". I do not think that most physicians will be comfortable with them in the physician hierarchy in a CRNA-like model. It is therefore possible that the rise of the ACNP might catalyze fundamental changes in the way care is organized and delivered in most ICUs. I am not making a value judgment as to whether this is "good" or "bad". But it raises interesting questions about our collective resolve concerning multidisciplinary care.

Perhaps, instead of trying to bridge the chasm, we ought to look at whether the chasm can be filled in to form a continuum.

David Crippen:

Tim Buchman eloquently sez: "Reimbursement issues aside, demand for critical care services is increasing".

But I suspect that as the demand increases, those paying for that increased demand don't see it as a good thing. They are very interested in trying to discouraging it by the tactic of rationing by inconvenience. The whole point of "managed care" and it's future iterations is limiting demand, because as demand goes up, cost goes up with it.

And: "There is a shortfall of physicians qualified and willing to deliver critical care".

That is definitely true. But as the number of physicians trained and experienced to deliver critical care go up, the demand for those services goes up with it, and the cost quickly follows. Managed Care bosses are very worried about this. One way to stop the proliferation of these people is to define critical care in terms of a severity of illness that do NOT require such expertise. THAT is the reason our Unit and I imagine others as well floods with nurses in suits every morning pouring through charts looking for reasons to down code patients so they don't require our expensive services. they are not there to assess what is going on with the patient, they are there to find ways of defining them in ways that our services are no longer reimbursable.

And: "Medicine doesn't like a vacuum any better than nature in general--someone always wants to step up to the plate to provide service that is perceived to be needed".

The general plan of Managed Care is to regress back to the days where patients died quickly of chronic and untreatable diseases, instead of landing in ICUs for four expensive months and then dying. they can't find a way to preclude them prospectively because of politics. SO they are continually looking for ways to avoid paying for it.

And: "Health care professionals who are not physicians are likely to offer to deliver services if it makes professional and economic sense".

That is GREATLY more dependent on politics than ability. Second echelon referring physicians rarely want THEIR patients administered to by (more highly trained) nurses when double Boarded physicians are available 24 hours a day as in our unit. I don't know what the statistics are but it seems logical that patients would have the same preference if offered to them. If I have to be there anyway and I have to personally supervise a nurse, I would generally rather do it myself.

The reimbursement politics are too embryonic to call. Look at the CRNA debacle. Managed Care made a big play for paying CRNAs (Certified Registered Nurse Anesthetists) preferentially instead of Anesthesiologists because they are cheaper and they made a case that they can do the same job equally well. However, my wife has been one for 10 years now and she has not seen any evidence of an increased penetrance of them in Pittsburgh. What sounds good to reimbursers doesn't necessarily translation into guaranteed action because politics is, in the end, more potent.

And: "My take on all of this is that the ICU work force will either become more efficient (hard to imagine--everyone in our ICU is really stretched) or will expand as the demand for services increases. My opinion, therefore, is that critical care physicians are likely to assume more and more of a managerial role".

I guess it is possible that physicians might evolve to more managerial roles and allow others to effect their ruminations. But recall, this was supposed to happen back in the 70s with the rise of Physicians Assistants. that was the theory. Physicians would retreat to thinking positions and PAs would do the busy work and it would be cheaper because there would be fewer expensive Docs and more cheap helpers. That didn't happen because around the same time someone opened the flood gates to multinational physicians who suffused the country and needed to make a living, just like the thousands of lawyers the night law schools churn out yearly, each looking to persuade someone to sue someone else.

"The question, it seems to me, is not whether ACNPs (the terminology may change, but what I am getting at is advanced trained nursing professionals) will assume new roles in the ICU but rather how they will report and be compensated".

When we considered NPs in our practice, it became crystal clear how they would be compensated. We would pay them out of our own pockets. Everything they did was reimbursed at a lower rate than we would be reimbursed for, and we would have to "closely" supervise them. We decided that it wasn't worth it. But I hasten to add that we are radically different than Mark Mazer and his practice. It might work much better for him and his.

I will hazard another guess that the role of the NP in critical care hangs directly on whether or not reimbursers will pay for their services, supervised or not. And whether or not they pay hangs directly on whether or not NPs will cost them less money. If they can get physicians to do that work load more cheaply, by coercing them to take less money or simply not paying for it, NPs will go the way of the Dodo. If they think they can make out on the deal by a microcosm of fewer physicians and more extenders, they will definitely give it a try. I personally think the expression "Fat Chance" fits very well here. When cornered, physicians start acting just like Teamsters.

However, the unknown factor in all this is the P factor (politics). If the predictions of the 70s rang true, we should be flooded by Physicians Assistants and we are definitely not. Accordingly, CRNAs should be making Anesthesiologists an endangered species. They have not. We shall see.

Don Chalfin:

I have followed this thread with great interest and a bit of cynicism, mindful of quotes from Satchell Paige ("Don't look back, someone may be gaining on you"), and Pogo ("We have met the enemy and he is us ").

As much as I believe in the value and benefit of what critical care physicians bring to the table, a belief which was converted years ago to a career choice and values and benefits that so many have fought long and hard for at the bedside and beyond, we all should probably avoid an overzealous defense of what we do, what others do, and what others do not. On so many occasions, here on this list and in other forums, we have decried other specialists and opinions which have minimized the benefit of the intensivist yet at times we seemingly succumb to the same tendency when the primacy of what we do appears challenged and even threatened. I think back, for example, to discussions which concerned respiratory therapists, hospitalists, pharmacists/pharmacologists, surgeons, internists, and other clinicians and medical specialties.

From my perspective, one of the unique aspects of critical care - an aspect that is both a blessing and a curse -- is that the way it is practiced significantly (and almost seismically) varies not only from country to country and region to region, but even within different units in the same hospital. Certain methods of organization that work well in one setting may fail miserably in another. We are not dealing with inviolate laws of quantum physics. Hopefully, a time will come when -- at some level - -- the indispensable value of the intensivist will be universally reckoned and we will be able to move onto other battles and causes (jeez did I just say that !!!). Within the confines of the current environments in which we all work and practice, I believe that we best serve our specialty and ultimately our patients by remaining open to other approaches and practitioners provided that decisions concerning care, benefit, management, and organization are reached on the basis of evidence and science rather than opinion and dogma. Hey we used to bleed fevers and freeze ulcers !!!! Flecainide and encainide also had their unyielding stalwarts not too long ago.

Sharon Bailey:

After lengthy consideration, I have mustered a great deal of my courage to pose this question to the CCM-L. How about any of you acute or critical care types out there that utilize Nurse Practitioners in your practices???? I am new to the NP world, after 21 years in the critical care nursing world. My questions pertain to how you have set up a collaborative practice with an NP, specifically how you utilize this position in the hospital setting?

I am finding a great deal of variation, seemingly geographic (in the US) in the way these positions are set up. I have been poring over the HCFA sites and Provider Manuals to determine the "correct" way to bill Medicare for services for hospitalized patients. What is your experience in the levels of physician involvement, i.e., can your NP's extend your services by performing work-ups, dictating, writing progress notes, etc., and still be OK for Medicare reimbursement?

My interests lie in the NP being employed in private specialty practice, i.e., pulmonary, in a collaborative role with a physician, and being privileged by the hospital.

Kathy Magdic:

While after close to 30 years of practice in a variety of nursing and advanced practice nursing roles, I would still never claim to have the depth of knowledge in the areas of medicine that a physician does. I do, however, have a wealth of knowledge that others don't. Perhaps not in every acute care setting, but I do see a role for NPs in acute care. I love my role and have a passion for what I do, just as many of those who responded on the listserv. I don't see myself as competing, but as having knowledge and skills that can enhance the care of any given patient.

A question I would pose (sincerely) is: How do you see drawing the line between what a physician should be doing and what a NP should/should not be doing? Certainly, through time, nurses have learned and acquired skills that were once only done by physicians, but now have become a routine part of nursing care. As knowledge and technology expand, is there not room for NPs to participate?

Gabi Ford.

Nice piece of writing...your essay on the reasons doctors should not abdicate any of the "less intellectual" work to other members of the staff. I applaud your passion for your profession. And I can see your point.

A similar situation exists in nursing. These days CNAs (certified nursing assistants) do most of the tasks involving physical patient care. They feed patients, bathe them, position them, do "bowel care", help patients to the chair, the toilet, etc... The trend is for nurses to be paper shufflers, number writers, keyboarders, and many times the assistants spend much more time with the patients than the nurse.

Any good nurse will tell you that these tasks performed by assistants are valuable opportunities to gain insights into the patient's status...evaluate his physical response to therapies...and allow for a much deeper understanding of the illness, the patient's response to therapy and a lot of interesting curiosities about people in general.

Yet most nurses are only too glad to let someone else, less trained in evaluating signs and symptoms, take on these tasks for several reasons such as perceived status/ego/hierarchies.....less physically demanding to sit and write numbers instead....and mostly time! You simply can't do a comprehensive nursing job for 6 patients. The pressure is on to do more with less....and it's all about numbers and money.

Anonymous:

I don't know why someone on the NP website recommended this list as an interesting spot for critical care discussion. Also, why someone invited ACNPs to participate in a poll at the cost and quality site and then used the info in postings in the war against NPs. (Not my words!)

Every NP response is broken down and criticized line by line, and false information and scenarios constantly restated. A personal paranoid problem seems to be dominating this list.

You are not really interested in opinions from ACNPs on how they see themselves fitting in, you are just throwing out more of that smelly bait, but your forgetting people like to dine on substance.

I think the exodus from your list indicates dissatisfaction with your tedious topic, and with no end in site, the delete finger gets tired. Maybe this list has always been tedious, maybe you're just hanging on to this topic to get rid of the NPs.

Happily, I will (unsubscribe) myself

Don Chalfin:

Hmmmmm .... this is a rather harsh indictment and one which I strongly disagree.

This list thrives on strong and often impassioned discussions that run the gamut from ACNPs to ICU organization to clinical management to interesting cases to administrative and financial issues, occasionally spiced and smattered with pearls about Ferrari cars and Fender Strats (I'm a Martin, a Guild, and a Tacoma man myself). Most issues are carefully broken down and most responses are thoughtful and posted with the best of intent. Insult and the desire to "hurt" is quite rare and almost always unintended. Comments, though, get harshest when the line is crossed from evidence-based to anecdotal-based medicine and when personal vitriol is hastily masked as professional passion.

Remember, two advantages to this medium are the "delete" key that we all have on our keyboards (which as you allude to does come in handy at times) and the implicit understanding that a multidisciplinary specialty requires a little tolerance for differences of opinions and the ability to entertain discussions with those from a different perspective. Jeez if we can't do this here, then I worry about protection from the potent artillery batteries often launched in the trenches (blue collar and beyond) where it really counts. With respect to the "dissatisfaction", the "smelly bait", the "tedium" and the general air of "revulsion" that you describe, perhaps I may be wrong, but the fault, dear Juliet seems to lie not in the stars, but ..............ahem ......... well you can complete the sentence !!!

Believe it or not, I actually hope that you reconsider your decision to unsubscribe. I mean that with all sincerity and honesty. Aside from tobacco and STD's, since when is avoidance the best policy? These differences of opinion will not go away by plugging ones ears and shieldings ones eyes with a notice of cancellation to the listserv !!!

Anonymous:

I AM WONDERING ABOUT THE WISDOM OF SUBSCRIBING TO THIS WEBSITE!

Critical care medicine? Where? Dr. Crippens NP bashing? Here! (Is that Leslie Gore I hear? "Its my = party, Ill cry if I want to!")

I am impressed with the misinformation presented as fact on this website. Real interest generates research and advancement of knowledge. Most of these comments show a lack of interest or knowledge, and you = certainly haven't done your research because your facts are incorrect. Thank you to any ACNP who speaks forth to interject true statements regarding ACNP roles in acute care.

The ACNP has a Bachelors of Science Degree ( in Nursing) and a Masters Degree in Science. Two years of that instruction is devoted to managing acutely ill adults. We do 500 hours of clinical training in critical = care settings. Decision making in critical care is what we're trained in. That includes interpreting, and intervening based on the "numbers". We understand them. The actual performance of line insertions and invasive procedures are incidental, proficiency in these areas are not required for course work, but indications for and interpretation of data are. We undertake proficiency in invasive lines after we graduate, as needed for our clinical practice.

The ACNP is in no way intended to replace any physician. No ACNP will tell you that is his/her job. In my state, the ACNP has a collaborative relationship with physicians, but can round, assess, write orders for tests, and interpret those tests without direct supervision, she can admit, transfer, refer and discharge. She writes prescriptions without co-signature.

The ACNP can do procedures after competency is documented and agreed to by the state board of nursing. That means she/he will need to perform a certain number of those procedures yearly to keep competency current. The ACNP does not need an attending to stand and direct or supervise over procedures.

The billing issue is confusing to physicians but NPs can clear up any murk that lurks. You don't need to stand with the ACNP to bill 100% for a procedure or visit, because she bills for herself. In fact, the ACNP can see patients and perform other revenue generating activities and bill directly for services. E.g., Medicare reimburses the ACNP at 85%. If an attending is seeing and doing at 100% billing and the ACNP is doing the same at 85% at the same time and on different patients, how is that organization loosing money? They're not! They have increased their revenue by 85%. If you stand and supervise an NP for increased billing revenue then you're losing money. A statistical fact: (I know, but anyway) The average NP increases yearly practice revenue by $220,000.

THANK GOD NP bashers are in the minority (a vocal minority). Paranoia abounds on the critical care and trauma websites. ACNPs are not a threat, you are wrong, and uninformed. In fact, you will not find a group who enjoys working with physicians any more than nurses who love critical care so much they went for an advanced degree in it. No one can force someone to accept nurse practitioners, and we respect patients and doctors rights to decline our care. Please respect our right to practice within our scope.

David Crippen:

What started out as an exploration of the role of NP in critical care is quickly deteriorating to the level of a Union organization movement. "If you are not rabidly for us, then you are against us". "If you won't help us push our agenda to the fullest, you are on our enemies list". Teamsters incarnate.

I don't think it's that way.

No one suggested there was no place in critical care for NP. If you go back and read the original discussion on this subject between me and Mark Mazer, we each make different points about their potential in different situations, and what the problems might be but no one advocated stamping them out like cockroaches. Each of us had an opinion and those opinions were held up to public scrutiny to stand or fall on their merits, not the authority of the opinion giver. And if you ask Mark Mazer what he thinks of my arguments, he will tell you in argument-specific terms, not in terms of what he thinks of me personally (I hope).

If you have opinions about the role of NP, or anything else, put forth your rationale and see how it plays with a large heterogeneous population of health care givers in an international forum. If you force your opinion assertively by demanding that you know more than anyone else so your opinion matters more, or through the back door by whining that you are offended by an otherwise neutral word or term, therefore your biases should prevail over others, you will get some hefty criticism within this group. You pay your nickel and you take your chances.

If you are on the radical fringe and you really think NPs should be allowed to practice medicine, say so and give your reasons. Everyone will consider your rationale, not your personal authority. And if there is any weaknesses in your argument, those weaknesses will be ferreted out here. I know. I have tried to pull a few fast ones and I always get found out.

If you want to argue from the position of degrading the arguments of others if your own argument fails, this is not the place for you and I can and will dump you most unceremoniously.

Kathy Magdic:

I have just recently joined the list (one day ago) and after this brief time, I would like to say something regarding NPs. First, let me state that I am an Acute Care Nurse Practitioner (ACNP) so I can only speak from that perspective. My practice is on an inpatient cardiology service. Our NP service does not go into the CCU, however many of the ACNPs on our service have many years of critical care experience as staff nurses.

It seems to me that there are some negative "feelings" out there regarding NPs and that physicians should be running the ship. I take issue with what I believe is still the tightly held belief that the physician is the "captain of the ship" when it comes to patient care. I believe that changes in health care are forcing us to shift this paradigm. Good patient care is complex and multifaceted. No one can be an expert in all areas of patient care. Physicians are the experts within their field and all other members of the team should respect that expertise; however, physicians are not experts in the whole arena of patient care and as a whole need to recognize and respect the expertise that is brought by others. Without each contribution quality care will suffer.

It seems to me that from the brief time I have been reading comments on this list, physicians are focusing on a belief that NPs' goal is to take over medical practice. That can not be further from the truth. The fact is, NPs, like other nurses, are striving to practice what they are experts in--nursing. Inherent in that role is the ability to diagnose and manage patient issues. Becoming a NP involves additional training that enables us to diagnose and manage medical issues, but again, that does not mean we want to replace physicians. As a ACNP, I believe I have a unique expertise to bring to the table. The nursing piece, which I can practice independently according to the Nurse Practice Act and the medical piece, which allows me to participate in the diagnosis and management of the illness that impacts that patient.

The blend of those two makes me a very valuable and equal partner. Yes, there are many NPs who are performing procedures (which seems to be a sore spot with some on this list) but if they are properly educated in not only the technique but also the rationale, it is an appropriate procedure given the patient population for which they care, and it is mutually agreed upon with their collaborating physician, why shouldn't they (unless, of course, reimbursement dictates otherwise). My point is that patient care needs to be a collaborative practice where each expert (physician, nurse, CRNA, etc) is allowed to make his or her contribution to the care of that patient. Just like our body, if we don't use it, we lose it and the whole will suffer.

Don't take care of patients with suspicion and enmity towards each other. None of us should stifle any of us. Lord knows we have enough of that to deal with with third party payers and health care conglomerates. Let each expert contribute his or her piece to the care of the patient.

One more thing I forgot to mention in my last email. The use of the term "physician extender" is offensive to me as it continues to encourage the notion that NPs are "under" physicians. I do not see myself as a physician extender at all. I am a NP, and while my area of expertise is different than a physician's, it is not less.

Mark Mazer:

Kathy, I help to train, proctor and supervise NPs...I wholeheartedly endorse NPs...so please accept the following comments without an explosive emotional diatribe:

The limits and bounds of what critical care NPs and PAs may or may not do are generally prescribed and dictated by acquiescence of the medical staff of the institutions where they practice...and most if not all so-called CCM physician extenders practice under the ultimate authority and responsibility of supervising physicians...let's be real and pragmatic...for now and perhaps forever (and I am not being judgmental).

Physicians are going to refer their critically ill patients to other physicians skilled in various aspects CCM medicine...not to NPs and PAs...I believe that NPs are valuable members of the CCM team...but like it or not, most CCM NPs and PAs do practice under the aegis of a physician...and are considered to be "physician extenders"...the term is not meant to be denigrating or demeaning...but it aptly describes the chain of authority in most institutions...most if not all surgeons, FPs, GPs, IM types will never refer critically ill patients directly to an NP...please do not waste your energy railing against a system which for the most part embraces you for what you are and what you do best...

Janice Wojcik.

There seems to be a slight misunderstanding--I must have missed the part where the ACNP in question wanted to "practice medicine". All critical care professionals have valuable contributions that are unique to their individual role. The COLLABORATIVE approach to care of the critically ill begins with recognition of and respect for each professional.

I do not consider myself a "physician extender", my role is that of Advanced Practice Nurse. I have no desire to be a physician--I feel that I make a different (but still valuable) contribution to patient care in my role. I also value the roles and perspectives of the other members of the critical care team.

Ben Laughton

State laws. I can speak for Maryland and Delaware in that there is no law requiring "oversight" per say. In these states NP's are independently licensed providers with "contractual agreements" that basically exist to ensure that NP's have backup if (when) they get over their head. If they (we) screw up and do not consult the physician with whom we practice then the screwup is all ours.

NP's are especially tight with money.... and I am no expert in this area...but if a surgeon operates and does not consult a critical care physician to manage the patient postop, I don't think that he/she can bill critical care codes for postop management (this is not an issue in closed ICU's with obligatory CCM coverage). Should same MD have an NP working with him/her the NP could bill for critical care management. I should also comment that many MD's do not have the time to document in the laborious manner that Medicare/insurance mandates for max billing. I am all about laborious pointless documentation. After all, I am a nurse (have you ever looked over our admission paperwork?)

David Walker: I have given this latest thread more thought than it is worth, but I would like to make a few comments. I personally have worked in intensive care both neonatal through adult for more than 30 years and feel extremely fortunate to have this wonderful position that I currently fill. I am very proud of being a Respiratory Therapist (registered) with a Masters in Cardiopulmonary Physiology as well as an MBA, which adds value to my clinical and administrative roles at Valley Children's Hospital. However, I am always aware that the physician is in charge of the total care to my patients and I have no problem with being a physician extender.

In this current health care environment, what is important is to bring value to the intensive care unit under the direction of the attending physician. Since we sell our expertise as a product, we owe it to our patients to have the best available teams present when the patients face life threatening illnesses and or injuries. One way to do this is to become value added knowledge ICU teams. We must share our knowledge base with our colleagues so that the best care possible is immediately available to our patients.

Patients admitted to the ICU expect and deserve to have well-trained and caring physicians to supervise their care while having a superb multi-disciplinary team assisting the physicians by the best methods available. Perhaps in the future as information technology makes sharing knowledge much easier many of the issues discussed previously will disappear since we will be more concerned about sharing our knowledge than who is actually doing what procedure. I am optimistic for this New Year in that we will learn new ways of improving the care to our patients while maintaining their respect for all the ICU teams worldwide.

Ken Mattox:

I have been watching this discussion for a long time. Quite frankly, it is beginning to bother me. I do not know how this got started, nor what the hidden agendas are, but we have gotten the cart before the horse. If I wanted to be an administrator or an attorney, I would have gone to school and obtained the degree to give me the authority to do so. If I had wanted to be a nurse, I would have quite frankly, have gone to nursing school, and I almost did. If a nurse wishes to practice medicine, quite bluntly and in all due respect, that nurse wanting a dozen letters after his/her name enabling them to practice medicine (without a license), then they should have gone to medical school and gotten a doctor's degree.

This turf creep and strutting what one can and cannot do under certain regulatory jurisdictions, is wearing a bit thin. Perhaps it is because I took the trauma call all day yesterday and all night last night, and I find that none of the NPs are here in the middle of the night when the patients seem to get the sickest. If a nurse goes to nursing school and becomes a nurse, then I vote to let the nurse be a nurse. If that nurse gets an administrative or doctors degree (MD) on top of that and wishes to be an administrator or a physician, then they should cease to be a nurse and think and act as the new profession. Just what is the problem for which this extended role of nursing and PAs was generated? For the life of me, I cannot discern the problem for which this trend is the solution.

Power, position, turf, control? Certainly it is NOT collaboration. Collaborative practice, in my few years of experience translates into the physicians giving up authority and practice and gaining nothing but headaches in return. My reading of collaboration is a two-way exchange. Certainly NOT what has been reflected in the debates on this web site the last few weeks. Quite frankly, I have been embarrassed by some of the logic and mandates, and seeming aloofness displayed by some of the NPs.

Jim Cowan:

Outstanding question. When I get a patient admitted to the ICU, say a suspected exacerbation of COPD who is retaining CO2 and is headed for a ventilator, it is not uncommon now for that patient to have been seen by a NP as their primary care provider. Studies supporting this...

Conclusions; JAMA. 2000;283:59-68

"In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians,and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements and patient population as primary care physicians, patients' outcomes were comparable."

But what of the ICU? The patient crashes and heads for the ICU. The NPs are saying they can still care for the patient. Order meds, manage the ventilator, etc. It is left to the "comfort zone" of the NP to decide when a physician must be called. (I am concerned that FL seems to believe NPs are required to have physician collaboration. I believe that's a state-by-state requirement that is slowly being eliminated)

The rest of the ICU staff (as well as the patient) is pretty much at the mercy of this drama as it plays out. Our patient may get a doctor, they may not. Politically, NPs are saying this isn't practicing medicine (because it's a political death sentence if they say it is). They say they don't want to practice medicine, they just want to manage ICU patients.

I must plead ignorance at this point. Exactly why isn't an autonomous nurse managing ventilators, prescribing medication and placing lines considered practicing medicine? Is this not being reduced to the level of semantics on a state-by-state basis with the end result being the NP can pretty much do whatever? I am very concerned about the silence on the part of the medical profession as this slowly unfolds.

David Crippen:

I will have to take a look at this cite to see how it was done. Better yet, Gordo Doig might comment as an authentic expert on the validity of studies.

Superficially I would hazard a guess on the validity of this cite from an intuitive viewpoint. Specifically,

1) Who funded or sponsored it. If an organization friendly to NP had anything to do with it, any conclusions drawn are fruits from a poisoned tree. Just like when a pharmaceutical company "supports" a study that says their product is better than some other.

2) Unless the trial is rigorously controlled, randomized and pronounced kosher by a lot of ombudsmen, studies that show that one faction is "better" than another faction are usually advertisements. Frequently paid advertisements. My wife's mother proudly pointed out "studies" in the Chiropractic literature that proved definitively that Chiropractic is beneficial for HER ailments.

3) This trial seems to suggest that NPs might be effective functioning autonomously as health care providers. this is a stance I have heard many say in this forum is NOT their desire. If it is not the desire of the NP industry to practice autonomously, why is this study popping up on CCM-L?

There appears to be a dichotomy as to the intentions of NPs here.

In one breath they say:

"The ACNP is a nurse, the physician is a physician. The ACNP practices advanced practice nursing. The physician practices medicine. Why on earth would I, a nurse go to medical school to practice advanced practice nursing! Try to understand. I love the nursing approach to health care! That is why I am an advanced practice nurse."

That sounds reasonable. Then in the next breath they say:

"And, in my state an ACNP can assess, test, admit, diagnose, invade, treat, transfer, refer, prescribe and discharge as agreed to in her/his practice agreement. Some physicians disagree, but many see it as a win-win situation and ACNPs have a job before they're even out of school."

That is NOT the same as your first statement. To my mind, these two situations are mutually exclusive of each other.

To those in the group who would champion NPs in medicine, what exactly do you want? These are not jabs. I am really interested to know what you want to do and how you want to do it and I am confused.

Anonymous:

What we have here is an interesting place to visit. In the "spirit" of spirited, open expression of ideas, and opinions (because surveys with a sample size of ONE, are opinions not facts) I guess there is always some value gained from the viewpoints of others. I am saddened by the warlike trajectory of some of the statements but interested in these viewpoints nonetheless.

Just to restate the original, which was mis-restated. Procedures done by ACNP do not need to be supervised, often collaborative attendings are 45 minutes or further away from the facility. NPs working with a physician group, manage a group of patients and bill at NP rates, physicians see other patients and bill at physician rates. The number of patients seen in a period of time increases and so does revenue for the group. Collaboration between group members occurs on all patients in the group. This increases diversity of opinion and educational experience and enhances the holistic value of the groups approach to care.

The ACNP is a nurse, the physician is a physician. The ACNP practices advanced practice nursing. The physician practices medicine. Why on earth would I, a nurse, go to medical school to practice advanced practice nursing! Try to understand. I love the nursing approach to health care! That is why I am an advanced practice nurse. And, in my state an ACNP can assess, test, admit, diagnose, invade, treat, transfer, refer, prescribe and discharge as agreed to in her/his practice agreement. Some physicians disagree, but many see it as a win-win situation and ACNPs have a job before they're even out of school.

Some may think the ACNP will simply fall from favor, dry up, blow away, and never amount to anything. Some said the same about managed care. One more time, I must restate: The ACNP will not replace the physician, we work collaboratively to deliver the highest quality in critical care.

David Crippen:

It is my humble opinion that the above, as you have started it, is as frightening a concept as I have heard in many years. Can you elaborate on exactly how one can do that and what "supervision' is brought to bear.

Mark Mazer:

And I join to the refrain:

Agreed! That an ACNP can state the above, and maintain that he or she is not practicing medicine is quite frankly ludicrous...and this is Mark, Blue-Collar-in-the-Trench-NP-zealot commenting... Further, if the above train of thought is common among NPs, I may have to consider rethinking my own position on the matter...it one thing to integrate you into the team, it is quite another for you to rise up and undermine the political foundations upon which critical care medicine stands.

David Crippen:

Someone said: "Though your comments are correct, the tone is unfair".

Bureaucratic decisions involving money are quite toneless. I am ruthlessly cutting to the heart of the matter. If you perceive tone in my description of them, the burden is on you to show how it is unfair and to whom.

AND: "When Medicare and HCFA are ethically and morally correct in their behavior, we should not bash them. Lets save that for when they are nonsensical and capricious and G-d knows they give us plenty of opportunity for that."

These agencies have no understanding or interest in ethics or morality. They are like the lioness catching and eating the Gazelle. There is no morality, they exist in a food chain to serve their own interests. We don't so much criticize the decisions they make per se, but the consequences to the rest of the food chain of those decisions.

AND: "If we all practiced the model of critical care most supported in the literature, a high level physician staffing model, then we would be present or at least available to be present for the majority of procedures on our (intensivist, surgeon, internist, etc) patients in our units".

I think this is why Critical Care is destined to be a 24-hour a day specialty, just like Emergency Medicine. Emergency doctors don't go home at five and expect the nurses to handle problems in the middle of the night with some advice over the phone. We deal with the sickest and most unstable patients in the hospital. it is a 24-hour job. Physician extenders work best when they extend the influence of (not enough) knowledgeable physicians. There are two problems with that. I don't see critical care as a discipline where there is much room for extension and I also suspect a NP radical fringe who wants to be autonomous and I see no room at all for that in critical care. NP is not an end in itself. it is a stopgap measure until there are enough qualified intensivists to handle the workload. That's the way I feel about it and why.

Janice Wojcik

The term "collaborative" can also be applied to an agreement between a Nurse Practitioner and Physician (although there doesn't seem to be much agreement in the threads on this list :-), A.K.A., the "collaborative practice agreement". When the term is used in THAT context, "collaborative" is defined by the law of the state in which the collaborative practice agreement exists and the physician and NP practice.

David Crippen:

I think the term "collaborative" means different things to different people, depending on their personal and political agenda (visible or hidden.).

My wife is a CRNA. She likes what she does, she does it well (I think) and she feels strong enough about doing it that she gets up at 0530 four mornings a week to do it, returning at 4 PM just in time to deal with three kids............three kids with MY genetic makeup. Need I say more. She has never demonstrated the slightest interest in the Great CRNA vs Anesthesiologist Debacle that has torn several Gas-Passers Lists to shreds. She is a working mother and her interest is in being "collaborative" in the sense of a working mother trying to do the right thing on the job, not a career person looking to rise through the social and quasi-academic ranks. She has been given a great deal of responsibility, I think, in terms of independent action. She puts people to sleep, intubates, maintains, solves problems and extubates them, frequently on the basis of her own judgment. I think that is an AWESOME responsibility.

That she has been allowed to do this implies a contract of sorts with her MD "supervisors". They give her the authority for independent thinking processes and she knows to call them when she is not completely comfortable with any proceedings. This contract works because both parties know their place. The doctors know that they will be accessed quickly when she runs out of expertise, and she knows the limits of her expertise. It isn't a perfect symbiotic relationship because there is always some overlap between how much the doctors want her to think and how effectively she thinks she can think, but by and large it works Because in the end, they are able to work more efficiently as a team than as individuals. She is happy with that arrangement because she can use her thinking powers while maintaining a safety factor.

When I hear the word "collaboration" used thus far, I get the flavor those using it desire their thinking processes be accepted as valid on the same level of ICU physicians. At the risk of getting into even more trouble than I am already, I will volunteer my personal opinion that "collaboration" between ICU physicians and Nurse Practitioners is slightly different because NPs are more employees and less independent contractors. ICU physicians rely on bedside ICU nurses to yield extremely important information about the ongoing condition of patients. One level up, the thinking process of how to deal with that information is done by ICU physicians. I think that the area in between those levels is very thin, and I don't see too clearly how NPs fit into it. If my medical group employs a NP, it would mainly be to "spread the work load", and that work load to my mind would have very little room for "collaboration" in terms of independent judgment by NPs. NPs would do a lot of jobs that are simply assigned. So in this sense "collaboration" would simply mean getting them done :-)

I know that will get me into trouble so I am trying to paint a word picture of how I feel about it any why, so that it will be seen not as a "tone" or tirade against NPs but merely a personal opinion thrown out for whatever value anyone might find with it.

Don Chalfin:

We have all followed this debate and have been throughout impressed, surprised, and perhaps even stunned not only by the points expressed but by how strongly and even viscerally many of these opinions are actually held. While we may differ with the opinions that are tendered, we should nevertheless admire the passion, the zeal, and the spirit in which most -- if not all -- of these opinions and thoughts are tendered. These strongly held beliefs and the dedication from those who present them in this forum are not only testaments to the strength and attraction of this list but to the overall spirit and passion of the fields in which we work. At some level, the list makes me proud of what we all do and ultimately strive for.

Nevertheless, while I and undoubtedly others have issues and concerns regarding the ultimate goal and role of nurse practitioners along with real problems regarding what appears to be the public disclaimer against a desire to practice medicine yet a seemingly subtle course of action that seems to proceed otherwise , I would hardly equate these actions and sentiments to the politics and "actions" of Hitler and the Nazi regime. Such undue comparisons provide little benefit to the subject matter and may unnecessarily inflame the debate and convert it to mere emotional polemic. Although I know that in no way was this an intended effect, such politically polarizing comparisons are nevertheless harshly inaccurate and downright unfair.

Although we may disagree with the method and perhaps even the motive and the mission of others, the ultimate goal of all on this list is to improve the science of our field, to our own personal understanding of important clinical and societal controversies, and to improve the overall well-being of our patients who we serve. I believe that the passion exhibited on this list emanates from this desire to "do well by doing good" and hence, such passion and zeal usually enable me to crack a smile upon reading a post even when I strongly disagree with the opinions that are stated.

We can't forget what remains at the core.

Tim Buchman:

Coincidentally I, too, took trauma call all day and all night. It was an interesting night. I do not think there is much that an ACNP would have added to the team of "me and my resident". That is a "teaching team" with well-defined supervisory responsibilities. I am ultimately responsible for a spectrum of actions carried out by the resident under my supervisory aegis. Some (particularly the operative activities) require my physical presence as part of that responsibility. My resident learned a thing or two about controlling hepatic bleeding (yes, even in St. Louis, stabbed livers can bleed to the point of requiring operative management) and a bit about discriminating those small bowel obstructions that require operative intervention from those that may not. The relationship with my resident is supervisory, instructional and interdependent. There are things I check (like the pertinent pieces of the history and those aspects of the physical exam that bear on the next three decisions) but do not "do/repeat" (like the complete H and P) as part of the transaction.

Not all critical care environments have the luxury/responsibility of resident training. It seems to me that ACNPs can share in relationships with MDs where there are well-defined supervisory responsibilities. Note the terms well-defined and supervisory. I fully agree that if an ACNP wants to diagnose, treat, prescribe, invade as an _independent provider in a critical care environment_ , s/he should run, not walk, to the nearest source of applications to medical school and begin the process. On the other hand, physicians routinely empower nurses to administer medications, dress wounds, start IVs, ..., on their behalf via written orders that de facto create a supervisory relationship. Should CRNAs administer anesthetics without supervision by a qualified anesthesiologist? I think not. That is my opinion, an opinion which is generally held by physicians and not generally held by CRNAs. Should any nurse--RN, CCRN,ACNP-- deliver critical care without supervision by a qualified intensivist? I think not. Again, this is my opinion.

What is at issue, I think, is how (and how much) responsibility can be delegated based on training, experience and certification. Delegate and abdicate are two quite distinct concepts.

David Crippen:

Someone said: "Hey I got an idea ! Why not wonder, instead, about the wisdom in the method with which we decide who's going to become a good doctors How absolutely certain are we that selecting a good student that is smart & driven, represents the best way at picking future doctors ?! It is the prevailing wisdom ... hhhmmmm !?"

The factors that determine what makes a good doctor are multifaceted, involuted and complex, and have nothing to do with how Nurse Practitioners function in a medical ecosystem. That is unless one desires to use a separate issue to divert attention from an otherwise ineffective argument.

And: "Now their also used to be a time where Apprentiship was the way to approach that particular issue It definitely implied a more thorough & objective driven evaluation process. Academia is great but things in life (as in death) are not all black & white. Think t'would be wise, here, to keep all options open".

The training of medical house staff is decidedly more multifaceted, involuted and complex than an apprenticeship and that training has nothing whatsoever in common with the training of any species of nurses.

And: "Now, there is a subgroup of nurses That are not doctors, don't pretend to be But none the less, are in a position to be of great service to the Pt & to the whole system of health care in an albeit extended role that blurs the line with the MDs practice... of course it may depend on your vision... or lack thereof".

There is no blur in the functions of physicians and nurses. Their roles are very clear. I am getting the flavor that there are a subgroup of nurses that desire to be something that they define in terms of negative propositions rather than just coming out and stating flatly what they want. that is unless the agenda of one of those groups is to specifically blur that distinction for the purposes of creating an employment niche. If that were the case, blurring that distinction would become a religious obsession and ANY objections would be quickly quelled with evangelistic zeal. And if some objection seemed to stand on merit, it would be quelled by undermining the objector or diverting the argument by comparing apples to oranges.

Ruth Kleinpell:

Typically, ACNPs working in ICU settings are specialty based - ie. they are hired by an MD group, say peripheral vascular surgery. They then follow the patients on this service by rounding with the MD team, following through with the plan of care (ie. covering the unit when the MD's are in the OR with cases, adjusting orders based on changes in the patient's condition to facilitate post op recovery) etc. The way that NPs can impact costs of care, length of stay, readmission rates, patient education and patient satisfaction vary depending on their role on the team. Examples of some specifics include:

1. reinforcing caremap/critical paths are followed by the nursing staff, decreasing variances on pathways can facilitate prompt/early discharge>

2.being able to dialogue with family members about the patient's progress family knowledge about the plan of care, patient care issues, medications, etc. can prevent unnecessary readmissions for signs/symptoms that the family recognizes are not life-threatening for an ER visit but require MD follow-up, or symptoms such as shortness or breath that need to be reported, as they were sufficiently educated prior to discharge

3. interacting with social service/discharge planning to begin planning for possible discharge needs, etc. ICU based discharge planning can prevent longer length of stays if it is identified early on that discharge needs will require special arrangements, home based nursing, etc.

4. following a caseload of postoperative patients and overseeing care on the unit throughout the day ie. ensuring that unnecessary standing order tests are not performed by nursing staff - abg's not being done for frequent oxygen changes but rather pulse oximetry is used for monitoring - leading to cost savings

5. leading the development of quality assurance initiatives for the practice ie. working on qa projects that will decrease ie. postoperative wound infections - thereby ultimately impacting hospital costs, los, patient satisfaction

As care is team-based, individual contributions to care cannot be easily isolated. Rather than saying ACNPs are responsible for X outcome, they help to contribute to X outcome by their care.

Much of the recent research I alluded to that has demonstrated positive outcomes from ACNP practice has been conducted in specialty practice settings - ie. role of the ACNP in a heart failure clinic, role of the ACNP in an MICU with ventilator patients and their weaning, role of the ACNP in a fast track ER setting etc, where interventions can be more readily quantified. As the ACNP is a new practitioner (certification has only been available since 1995, we do not have much outcomes research to date on their role. However, more are beginning to monitor their activities and how they contribute to patient outcomes.

David Crippen:

Ruth Kleinpell sez: "Typically, ACNPs working in ICU settings are specialty based - ie. they are hired by an MD group, say peripheral vascular surgery"

I have little doubt that for these kinds of doctors, they can be useful. Our Infections Disease group use PAs the Cardiac surgeons use PAs too. It isn't uncommon around here, but for reasons I don't fully understand, PAs are preferred. However, critical care groups are different breeds of cats and their needs are different, and not necessarily amenable to the same kind of services provided by NP.

And: "1. reinforcing caremap/critical paths are followed by the nursing staff decreasing variances on pathways can facilitate prompt/early discharge"

Mercifully, Critical Pathways have gone the way of the Duckbill in critical care here. They didn't work and made extra work for all concerned. RIP another bureaucratic boondoggle designed to standardize medical care and create employment niches for more hospital bureaucrats. Hi Dandy Don :-)

And: "2. being able to dialogue with family members about the patient's progress family knowledge about the plan of care, patient care issues, medications, etc".

We have RN Family -patient coordinators hired by the hospital to do just that . I know I will get flak for this because at least one of ours is a member of CCM-L, but they are shall we say....more moderately priced than NPs, they do the same job exceptionally well and they are paid by the hospital.

And: "3. interacting with social service/discharge planning to begin planning for possible discharge needs, etc. ICU based discharge planning can prevent longer length of stays if it is identified early on that discharge needs will require special arrangements, home based nursing, etc."

"Discharge Planning" is a boondoggle dreamed up by the same hospital bureaucrats who brought you "Pre-Certification" (rolls eyes......snickers with evil bent) Discharge planning has never been shown to be of any benefit to anyone in the ICU. Patients who are predictable in their outcome are easily dealt with at the lowest level of entry level services. Patients who are unpredictable obviously cannot be predicted by discharge planners. The whole outcome of discharge planning is that the predictions of Discharge Planners are no batter than chance. Why would any Critical Care group utilize one of their expensive NPs to do a job a high school dropout (paid by the hospital) throwing darts at a list of names on the wall can do with the same element of chance.

And: "4. following a caseload of postoperative patients and overseeing care on the unit throughout the day ie. ensuring that unnecessary standing order tests are not performed by nursing staff - abg's not being done for frequent oxygen changes but rather pulse oximetry is used for monitoring - leading to cost savings"

Dupliticious. The attending physician deals with these issues on rounds. Diluting with other inputs is expensive out of proportion to utility.

And: "5. leading the development of quality assurance initiatives for the practice ie. working on qa projects that will decrease ie. postoperative wound infections - thereby ultimately impacting hospital costs, los, patient satisfaction"

All done by hospital employees. No convincing evidence that any of these plans result in any improvement in care. They document things that either can't be fixed or are natural fluctuations in the ether. Filed and forgotten until they are trotted out for JACHO, then filed and forgotten again. A boondoggle by any other name would cost as much.

And: "As care is team-based, individual contributions to care cannot be easily isolated. Rather than saying ACNPs are responsible for X outcome, they help to contribute to X outcome by their care".

Data anywhere to support this broad and sweeping optimism as it pertains to the ICU?

And: "As the ACNP is a new practitioner (certification has only been available since 1995, we do not have much outcomes research to date on their role. However, more are beginning to monitor their activities and how they contribute to patient outcomes".

If you have three ICU physicians covering an 18 bed ICU that is 80% occupied, and they hire a NP, it will be necessary for an increase in productivity for them to afford the NPs services. They will have to dredge up more patients. I don't know how they would do that. Certainly not be advertising the availability of NPs to referring physicians. That means that the NP will have to do things (and get reimbursed for them) that the physicians cannot for some reason accomplish. In this scenario, the doctors would presumably want to be busy. This is their livelihood. 18 beds for three doctors is not oppressive. The have the time and presumably the energy to encompass the work load. the variable is whether they want to do the work.

All the things you say that NPs "help" are either performed by hospital employees the ICU physicians don't have to financially underwrite, or the benefit is couched in data that is either proven in other non-ICU venues or not proven at all. If a NP does a procedure, it is reimbursed at a lower rate and the physician must still be in the area to supervise it. That means that for this kind of practice, NP is a vanity item. A group would employ one if they wanted a lazier lifestyle, letting the NP do their normal chores and paying them for it out of their own pockets. It strikes me that this is an unlikely scenario in a medical marketplace with continuing reimbursement cuts for physicians.

Sharon Baliey:

After 22 years in this business, I am always amazed at the energy and time that is spent by both nursing and medicine, and here with RT, in widening the Rift.....or in some senses creating the darn thing to start with. Correct me if I am wrong, but your initial post stated NP's don't "work" (as in: aren't feasible) for you, in your practice setting..??? My deduction: your setting is 1) teaching staff; 2) 24 hour covered already; and 3) geared toward educating residents and you neither have the time, energy, desire, nor need to add NP's to the mix.

Did it not also state that NP's work well in other settings, ie. Dr. Mazer's?? Sorry, but if I weed out the little personal jabs which always seem to escalate from BOTH sides of this fence, I can't really be too threatened. Guess I have been around the business too long.

And yes, in this geographic area, hospitals grant us (NP's) privileges, based on accountability of our, (Oh Lord, forgive me......) "collaborating" doc. (Mine is wonderful, by the way.) What hospitals require, has little to do with the type of practice that is allowed by the Practice Act. In some areas here, just because you are an MD......doesn't necessarily mean that you can admit to the ICU, either.

I think we all have to face the reality, that what makes us whatever quality "practitioner" we are, is first of all, what we choose to be, and secondly, how far "out of our way" we will go to learn it. I think a major area of conflict arises as a result of doctors not knowing any more about nurse, or in this case NP preparation than most nurses know about the nitty gritty of medical school or residency. I have read posts by physicians on this list that nurse practitioners have "15 weeks" of training, as contrasted to 15 years (personally for that MD). Give me a break, if we're going to get personal, I have a 4 year nursing degree, 20 years in the trenches, and 2 years Masters preparation for embarking on this Nurse Practitioner thing (another personal statement)....and I figure as long as I go to work every day.......I am still "in school". How 'bout you?

Some of us live out here in private practice land with groups that admit to hospitals that don't have residents running around 24/7. We may bill for what we personally do and are reimbursed 85-100% of the MD reimbursement rate(depending on the situation).

So, now, I will retire to lurking.......but I won't leave, FL, unless you decree a prohibition on NP's or perhaps females...(as exiting females are equated to NP's, in your current post) and somehow, I really haven't gotten the impression that you particularly dislike females or NP's....Please, no gender wars!!!!

David Crippen:

Someone said: "I am saddened by the warlike trajectory of some of the statements but interested in these viewpoints none the less".

For the true zealot, any opinion that differs is the opinion of the enemy. Differing opinions are known to be unrighteous before they are articulated. The task is simply how to defuses them. If you ask a Teamster if there is ANY reason the world should not be unionized, he will tell you it is the righteous obligation of humanity to do so and any contrary reason is either fallacious by its nature or an evil plot to avoid doing the right thing. to the evangelical, there is only one way.....the true and right way...the way of the movement.

And: "Procedures done by ACNP do not need to be supervised, often collaborative attendings are 45 minutes or further away from the facility. NPs working with a physician group, manage a group of patients and bill at NP rates, physicians see other patients and bill at physician rates".

My understanding is that NPs must have physician supervision. Rules on supervision of NP differ from State to State and from hospital to hospital and group to group. It is not standardized. Our situation is different because there is a critical care physician in the ICU 24 hours a day seven days a week. Therefore, the utility of NP in this particular situation is marginal if I have to be there and supervise someone else that gets reimbursed less than if I do it. All things considered, I would rather do almost anything myself than watch someone else do it and ultimately be responsible for resultant problems. I do not feel that way about training residents to do things. They are different breeds of cat.

And: "The number of patients seen in a period of time increases and so does revenue for the group".

That's a VERY interesting thought. Part of the charm of NP is increasing the number of billable patients? Now picture yourself the CEO of a Managed Care organization, or HCFA. You are the NP evangelist and your job is to convince this penny pinching bastard that would put his own saintly mother in a Mexican nursing home to save ten bucks a month, that NP is good for medicine and will save him money.

How does NP save money? Only one way. By decreasing the number of expensive physicians who supervise them. What is the point of NP if there is "more" physician manpower? The whole point is paying some people less to be supervised by fewer expensive ones. But out of the other side of your mouth comes a selling point to physician groups.........that because of NP, they can corner a larger population of billable patients?

Does it seem to you that both these selling points are mutually incompatible? What works for reimbursers doesn't work for physicians and vice versa?

And: "Collaboration between group members occurs on all patients in the group. This increases diversity of opinion and educational experience and enhances the holistic value of the groups approach to care".

Most physicians are less interested in collaboration than they are some palpable benefit to them, specifically if they are going to have put take money out of their pocket and put it in yours. How does NP collaboration improve "holistic" care of patients. Specifically the stragglers cornered by NPs and brought to the corral of a physician group specifically interested in finding extra billable patients?

And: "The ACNP is a nurse, the physician is a physician. The ACNP practices advanced practice nursing. The physician practices medicine. Why on earth would I, a nurse go to medical school to practice advanced practice nursing! Try to understand. I love the nursing approach to health care! That is why I am an advanced practice nurse".

There are a lot of contradictions in terms in the above. many of them clash in actually practice. I think it might be useful for you to tell me how NP would benefit a practice other than by the traditional scheme of physician extending, a concept that has yet to be found righteous by the reimbursement industry.

Ruth Kleinpell:

I have been following the discussions on ACNPs and have to finally comment. ACNPs are master's prepared advanced practice nurses who have graduated from a graduate program (2 year post baccalaureate full time program of study)which includes physiology, pathophysiology, pharmacology, advanced diagnostics, physical assessment and other courses (research, statistics, professional role, etc.) along with at least 600 clinical hours. The course work, clinical hours, and graduate degree are requirements to sit for the national ACNP certification exam.

To date, over 2000 persons have taken the national ACNP certification exam. Nationally, the number of ACNPs who are working in ICU settings is 10-20% or less and the number performing invasive procedures is 10-15% or less, based on an ongoing 5 year national longitudinal survey of certified ACNPs.

NPs work under collaborative practice agreements, the language of which is often dictated by state laws. Collaborative practice agreements outline what an NP is authorized to do (ie. perform H & P's, write orders in a chart based on protocols, etc.), and which direct procedures require physician supervision. ACNPs are often credentialed and privileged under medical staff committees and the degree of supervision by the collaborating physician(direct, proximate) is specifically outlined. ACNPs DO NOT independently practice medicine.

While there are some ACNPs working in ICU settings doing some very invasive procedures (intubating, inserting central lines, chest tube insertion), it is definitely not the majority. ACNPs are working in a variety of practice settings including hospitals, specialty clinics, subacute care, urgent care, home care, and physician practice groups.

ACNPS are not practicing medicine, they are practicing advanced practice nursing. ACNPs help to Enhance patient care by providing direct care as well as providing patient education, educating and interacting with family members, planning and coordinating discharge planning, serving as a consultant and educator to staff nurses and serving as a resource person in their area of expertise. Recent outcome studies on ACNP practice support that they help to decrease readmission rates, decrease hospital length of stay, reduce costs, increase patient knowledge and increase patient satisfaction.

Unfortunately, the experiences by a few members of the list serve have served to fuel a debate about ACNP practice. That's definitely not how the majority of ACNPs practice.

Anonymous:

If you are looking for a black and white answer, I don't think there is one. As I see it, how an NP "fits" or "participates" is going to vary from place to place and situation to situation. If we start with the given that the NP's educational preparation and experience is acute/critical care, there are still variables which will dictate the level of involvement. First, I believe that an NP can be involved in the care of any patient but that level will vary depending on the experience of the NP, the written agreement and level of trust between the NP and the collaborating physician, and the privileges which have been granted by the institution.

Regarding the scenario you have painted, I think the level of involvement (based on what I said above) can go anywhere from assisting the attending physician in the overseeing and coordination of care between all the disciplines up through performing certain procedures (ie, changing central lines, inserting art lines) and making decisions directly related to the management of that patient. Having been around as long as I have, I am well aware that "simply assisting" in coordination of care is no small fete, especially in an academic center where each specialty pretty much focuses on only their specialty. Yes, the patient may be seen by many, but that does not always equate with holistic patient care. In this case, the attending and the NP may be the only two consistent folk seeing that patient every day. Even nurses in many places don't keep the same pt from admission to transfer.

Do I think than an NP should solely manage a patient like you have described--No, at least not in an academic center, however, I can't answer for those who may work in the hinterlands where all the resources we have are not available and there may only be one doc and an NP in a small ICU.

Jim Cowan:

Lets look at it this way. I have a patient with ARDS in an ICU. The patient has around the clock ICU nursing, around the clock ICU RTs, a pulmonologist managing the vent, a pharmD, a renal consult and an infectious disease specialist in addition to the admitting cardiologist. That's not counting the case managers, the social worker, pastoral care, PT and OT, etc. Each of these physicians, or one of their partners, attends to the patient daily and each of the other ancillary personnel also sees the patient daily.

I currently see anywhere from 12 to 25 ventilator patients a day in seven different ICUs and the patient outlined above is not uncommon.

So you tell me, where does the NP fit into that mix? Try not to give some generic cliches like "advanced practice nursing"....be specific, exactly what are you talking about adding?

Eric Dobkin MD:

I have worked many years in critical care with both Physician Assistants (PA) and Nurse Practitioners (NP). Both can function extremely well as physician extenders. I have great confidence in their abilities. They have filled in the gap that has resulted from downsizing of residencies and the unfortunate resident work hours mandates. The economic issues raised by Dr. Crippen vary from state to state. Those that allow them to bill for their work do so at a reduced rate of payment. This is obviously to the benefit of third party payers. They can only be of economic advantage to the supervising/cooperating physician if they are paid a straight salary and their collections of their billings surpass this salary. Note that only the PA defines themselves as working in support of the physician and thus is dependent on him/her. Of course many of them are quite capable of independent decision making and, in my experience are granted that.

They usually function at the level of a mid- to upper-level surgical resident and are given the appropriate levels of independence. Like residents, the good ones (again, in my experience, the overwhelming majority) are eager to learn and know and respect their limitations and also like to make sure there are no surprises for the critical care attending (i.e. good communication of unusual events). Good NPs are the same. Perhaps they view things with a different perspective, which can usually be of benefit. The difference is that while many NP (in my experience), in critical care at least, actually function as physician extenders and are satisfied, a number of them, and obviously a great number of them in non critical care fields want to practice autonomously. I agree with Dr. Mattox that if they want to practice medicine, sign up for the training. I think this is really a political issue dealing with the age old battle between nursing and physicians formalized as the "Doctor - Nurse Game" in a NEJM article several years ago (can't recall the reference). It is about power and control in my the rise of managed care, the politicization of the cost of health care, and the extraordinary failure of American physicians to work together has provided an excellent opportunity for those eager to step in and alter the current structure of medicine.

One can determine that by the rhetoric we have seen on the list. I too am totally confused by the "jabberwocky". What does cooperation and collaboration mean to them? (Anyone remember the Alan King Ali McGraw film "Just Tell Me What You Want"?) As an aside, I fully concur with Dr. Mattox on the meaning of collaboration. In my experience, it usually means a one way street, that whatever the nurse suggests is correct and if those recommendations are not taken as authoritative, then we are not being collaborative. We have been asked to abdicate our responsibility and fiduciary relationship with our patients. I have been grimly amused at times when a nurse proclaims him/herself as the Patient's Advocate on rounds. When did the doctor become the patient's adversary? Perhaps there is some double meaning here?

There are at least 2 articles I have read recently about collaboration in medicine. The most recent was an editorial in the British Medical Journal, 3/15/00 by a heaLthcare researcher and a nursing school researcher (no MDs). After reviewing 1000 articles written on the subject, they pointed out that most were rhetorical or editorial and there has not been any data to show that "collaboration" improves outcomes or has any cost savings. This is not to deny the findings of the JAMA study of NP function in COMMUNITY PRIMARY CARE PRACTICES WITH YOUNG POPULATIONS. There may be a role for NP in the field of primary care. There is no data to support their autonomous role in specialty fields including critical care. Are nurses, NP, PA, RT, resident etc valuable members of the ICU team? Of course. Should they be respected and their counsel listened to? Of course. Are they entitled to a different opinion and to lobby for that opinion in regards to the plan of care for a patient? Absolutely. Should they have the final say in the therapeutic plan and/or practice independently in critical care? I don't believe so. We have tried to make this a team specialty. Every team needs a leader, we can't all be the quarterback. The team leader in the ICU is the ICU attending. Period. All NP, PA, who want to work in that framework, come on in. Those who choose to be politically and power motivated, I would prefer you wouldn't waste my time or the patient and nurses time with your distractions. I know that some on this list will choose to take these remarks as inflammatory. I hope not. I have tried to express my highest respect and my enjoyment of working with NP and PA who wish to work in a critical care team setting led by a critical care physician.

Kathy Magdic:

Regarding the scenario you have painted, I think the level of involvement (based on what I said above) can go anywhere from assisting the attending physician in the overseeing and coordination of care between all the disciplines up through performing certain procedures (ie, changing central lines, inserting art lines) and making decisions directly related to the management of that patient. Having been around as long as I have, I am well aware that "simply assisting" in coordination of care is no small fete, especially in an academic center where each specialty pretty much focuses on only their specialty. Yes, the patient may be seen by many, but that does not always equate with holistic patient care. In this case, the attending and the NP may be the only two consistent folk seeing that patient every day. Even nurses in many places don't keep the same pt from admission to transfer. (snip)

David Crippen:

I have been thinking about the NP thread and how to offer some constructive comments (in penance for appearing to roundly trash them before). I would like to do that for what it might be worth to anyone but in order to make any of it meaningful I need to put out some disclaimers and cut through some bullshit.

There are problems with every faction of the way health care is delivered in this country. NPs are not unique. I want to talk plainly now. And I will do my best to make this an issue-specific discussion.

I think that there is a radical faction of NPs out there who really think they can and should practice medicine autonomously, with only token backing from responsible physicians. They aggressively promote this stand politically. These factions point to ludicrous literature cites that suggest NPs treat "ambulatory" patients equally as well as physicians. So what. Ambulatory patients aren't sick. My maiden aunt can treat them as well as physicians, and a lot cheaper. And grandiose sweeping generalizations that NPs reduce LOS and improve benefit to patients (compared to what......a typhoon?) But I will tell you up front that I have a grudging respect for their intellectual honesty and sincerity. I believe they are sincerely wrong and frighteningly dangerous.

I also believe there is another faction that believes they can and should practice medicine autonomously but are not willing to come out and actively promote it. They ride along with the activists silently, helping form a critical mass movement by proxy and help create networks where NPs find loopholes in the law in areas where they can practice medicine with minimal or no supervision. I have mainly contempt for them more than activists because they don't have to balls (or female equivalent) to just come out and say what they believe and take the rap for it. The hottest spots in Hell are reserved for these factions.

Having said all that, I honestly think that there are a number of talented and hard working NPs out there who really want to fit into a team and do the right thing. I also think there is a role for NPs in critical care, but not a full cross section of the way it's done in every center. Different practices could utilize them in different ways so it's necessary to construct a model and then predict how they would fit into it. So lets make a model and see. Remember our previous model of a 16 bed ICU in a 450 bed general/community/voluntary hospital in a city of 500,000? Let's call it St. Morticia Hospital Center. St. Morticia is not a trauma center, deals mainly with medical and surgical bread and butter cases and competes with two other similar sized hospitals down the pike. It gets resident staff (FP, Internal medicine and anesthesia) from the nearby State Medical Center which takes all the trauma, pediatrics, Gyn and OB.

St. Morticia medical/surgical ICU admissions come from neurosurgical cases, general surgery, urology and peripheral vascular. Some urokinase cases in the radiology suites. Most of the ICU cases are acute/chronic heart failure, COPD, renal failure and multi system organ failure/sepsis. Some overdoses from the Psych ED. The ICU is normally 80% occupied. Nurses are competent and experienced. the requisite number of respiratory techies, PharmDs and all that are on board. Acute MIs are put in the CCU, cardiac surgery patients are put in the CVICU and none of these physicians consult an intensivist.

There are three boarded ICU specialists, all fellowship trained in general ICU medicine (not pulmonology). They are experienced and well regarded by the medical staff of St. Morticia. They see patients by consult in the ICU and they are actively consulted for most of the patients, lets say 80%. They intubate, place PA, central lines, art lines. chest tubes and IABP if needed. They write orders as co-attendings, do procedures, teach housestaff, manage ventilators and other life support systems. One attending rounds each week with the residents and another is around to do consults, procedure consults in the house and evaluate prospective admissions. At any given time, the third member rotates off. Every third night every third weekend home call, come in if necessary.

The intensivists are incorporated into a professional association, and bill insurance companies, Medicare and Medicaid for their services daily. They get a stipend from the hospital for educational activities. They also have a contract with several HMOs to provide services. They bill a critical care visit code plus all procedures. They use a voice recognition system to dictate daily notes for the charts. The salary for the physicians is US$150,000 per annum plus the usual bennies such as life, disability, malpractice insurance and some extra for medical meetings, books/equipment and a variable Christmas bonus. They also maintain two secretaries and a billing person.

I have constructed what I think is a fairly "normal" situation for how critical care is delivered in a very lot of hospitals in this country. Into this system I would like to now experiment with how the addition of a NP might be beneficial in four spheres. 1) The physician group, 2) the patients, 3) The hospital administration and 4) those who are indemnifying the care of the patients..the reimbursers.

David Crippen:

So, Ms NP Administrator, you are the leader of your organization that trains NPs as health care providers (or para-providers if you use a strict definition). I have previously described a target group practice in clinical Critical Care in the most prevalent kind of hospital setting in this country. For purposes of our argument, you can assume that this group is now and will be the kind of group that provides Critical Care in the near future.

You have said in the past: "I think the level of involvement........ can go anywhere from assisting the attending physician in the overseeing and coordination of care between all the disciplines up through performing certain procedures (ie, changing central lines, inserting art lines) and making decisions directly related to the management of that patient."

I'm afraid that is a little simplistic for this discussion. Unfortunately, it's more complicated that that because of the entity that we call Managed Care you will not be pitching to physician groups that may or may not have a need or desire for your services. Let me expound just briefly on how managed Care will impact you and this discussion. Bear with me, it will become clear soon where I am going with this and how it applies to you.

In the United States, it costs too much to care for sick patients compared to what other countries put into it and our overall outcomes are not any better. 13.6% of our GNP in 1998, compared to 9.7% in Canada, 10.7% in western Europe and 8.3% in Japan. As I have argued in the past, a great deal of this problem stems from the fact that the consumer of medical services is not the purchaser and has no motive to appreciate their real value. Because the producer of that medical product profits from producing more of it, there is no motive to reduce cost in the fee-for-service system, which rewards physicians, hospitals for over treatment, redundant treatment or any treatment at all regardless of scientific merit of its efficacy.

Managed care was essentially born with the Clintons in 1992 as Utilization Management (US). Utilization managers are clinical auditors that require providers to justify their actions in order to get paid. There is a current backlash against US because it is attuned to over treatment, which isn't the problem. The real waste is not over treatment, it is managed care's reaction to over treatment, infuriating it's insured lives and it's failure to correct under treatment, which is more costly in the long run. US is doomed for those reasons. However, don't for a moment think Managed Care is on its way out. Managed Care is definitely here to stay. With every setback, it simply lays back, examines the failure and then comes back with a more efficient methodology to throttle back the evils of fee-for-service

The next big thing will be Capitation (paying providers so much a head to provide full service care) since it avoids managers taking the heat for throttling back services for those who demand an unlimited supply of them, and who vote. Managers have learned their lessons well. Capitation rewards physicians and hospitals who keep patients healthy and discourages those that give in to unrestrained demand for individuals instead of large groups. Capitation forces hospitals and physicians to provide their own utilization management, and lets them take the heat from angry patients and their greedy lawyers. Parenthetically, critics of Capitation argue that it forces providers to limit beneficial care in order to make a living. managers say the same conflict of interest exists in reverse in Fee-for-Service, but that's another story.

It is clear that Capitation is the next big thing, and it is definitely on a roll. As soon as a patient enters the hospital with a defined disorder, a cash payment is made available for the entire hospital stay and to reimburse all those involved. Managers won't know or care who gets paid and for what. It will be up to whoever takes delivery of the payment, probably the hospital, to divide up the pie on the basis of negotiations from who desire to do what and to whom for how much. And Capitation will be the battleground where all those desiring to provide health care in the hospital setting will stand or fall, not just physicians and Nurse Practitioners.

So, what you tell me you desire your Nurse Practitioners to do in order to fill a niche in health care delivery at the hospital level is NOT subject to how well you think you fit in, or how well you might convince me you might fit in. Your role will stand or fall on how well you negotiate your case with the other factions in the room also negotiating THEIR cases. At first blush it might seem that you would be in an advantageous bargaining position because your big trump card will be the supposition that you can cost less by doing a lot of the chores expensive physicians do, creating a situation where the hospital needs less of them (and more of you). And that argument might be a powerful one were it not for the fact that the same physicians you advocate downsizing will be arguing their case cheek by jowl with you, just like the pit in the New York Stock Exchange. And I can assure you, these negotiations will not be cordial. Bland platitudes on NPs increasing benefit in some abstract sense and decreasing length of stay will be met by shrill demands for you to prove those claims convincingly. Rice bowls will be broken here today.

So, with all that in mind, take a seat here right next to me. St. Morticia is going with capitation, as they all will within five years. I am the administrative head of the critical care group that provides service at St. Morticia Medical Center. It will be my job to convince the Utilization Reimbursement Board that my group should get an adequate piece of the pie for our services in the treatment of critically ill patients. It will be your job to convince the Board that there is an available niche for trained nurse practitioners in that same health care delivery system. The door closes. We must argue our respective cases before the administrative board that will ultimately make a determination as to who gets paid for doing what and to whom. Who presents first. We flip. Tails wins (that's you).

The NP pitches first:

Here is the value of NP for the physician group:

1) Seeing and assessing admissions and preliminary orders until the patient can be seen by the physician. Contributing to a care plan from the enhanced experience bank of nursing expertise.

2) Reinforcing care map/critical paths are followed by the nursing staff decreasing variances on pathways can facilitate prompt/early discharge.

3. Carrying on continuing dialogue with family members about the patient's progress family knowledge about the plan of care, patient care issues, medications, etc.

4. Interacting with social service/discharge planning to begin planning for possible discharge needs, etc. ICU based discharge planning can prevent longer length of stays if it is identified early on that discharge needs will require special arrangements, home based nursing, etc.

5. Following a caseload of postoperative patients and overseeing care on the unit throughout the day, ie. ensuring that unnecessary standing order tests are not performed by nursing staff - ABG's not being done for frequent oxygen changes but rather pulse oximetry is used for monitoring - leading to cost savings.

6. Leading the development of quality assurance initiatives for the practice, ie. working on QA projects that will decrease ie. postoperative wound infections - thereby ultimately impacting hospital costs, LOS, patient satisfaction.

My response as a clinical administrator:

"Now we cut through glitz and hype and talk plainly. Every single benefit pitched by the NP administrator is either a part of the physicians job, part of the ICU nurses job or is performed at no cost to the medical practice by hospital employees. Therefore, it should be VERY clear that the value of these benefits are dependent on who's paying for the service."

"Having a NP hustle admissions and write orders is only of value to the physicians in the group if someone else pays for it. We have previously discussed the work load for the three physicians in this practice. It is busy but not oppressive. We have enough time off to enjoy life. When we are working, we work hard and then we go home and someone else takes over the load. We bill for our efforts and we are well paid. We enjoy a very comfortable lifestyle. We care little about the hospital's efficiency problems. If we choose to purchase a NP, it would be specifically to "lighten the load" for the three physicians. I want you to be VERY clear about this."

"And "lightening the load" comes at a high price. Each of the physicians earns $150.000 per annum plus assorted benefits. For that they expect to work hard. If they choose to lighten their load by the addition of an "extender" provider, these salaries I guess start at US$72,000 and up. When you add benefits (paid for by the physician group) the sum equals a nice round US$100,000 a year. This is inside a closed system, so that salary is paid for DIRECTLY from the physicians salaries. That means that each physician pays for their lightened load to the tune of a salary decrease bringing them down to US$116,700 per year. So they will work less and get paid less. The inverse of the American dream."

"But you say..... the NP can increase billing revenues by his or her presence? I wonder how that works in practice. These physicians are consulted on the basis of advanced post-post graduate sub-specialty expertise. The addition of a NP will be seen by those attending physicians referring their patients to the group as irrelevant, possibly redundant. There are only so many patients that are appropriate for ICU admission in any given population. Adding a NP will not attract more. And, the billing is now done by an "authorized" person but one who captures LESS reimbursability bill for bill than the same procedure done by a physician. In order to break even, MORE procedures will have to be found to make up the difference In such a system, the only way to do that is to contrive them, adding a fraud risk if discovered."

"The rest of the benefits of NP acquisition clearly only benefit the hospital by adding efficacy to the built in-inefficiency of all hospital bureaucracies. What stake does the CCM group have in any of that? None. QA, social work, patient follow up is all the hospitals problem and the physician group has no interest in financially underwriting any of it. So, it is now starting to look like the value of NPs to this CCM group is directly dependent on someone else paying for it. Like Frinstance the hospital hiring a NP and the Group accessing their services for free. Now that's an interesting plan!"

We both pitch to the Hospital Administrator.:

1) NP pitch....."We can help you out with a lot of quality assurance and improvement things, monitor your nurses, guide your house staff and oversee patients when our Docs are not physically around. We can do more effectively and efficiently than your "usual" employees because we have a better understanding of how to deal with critical care issues than they do. We'll save you our salary just like the PharmDs save you a bundle by using their expertise to select the best drugs at the best price."

2) Physician pitch: "We are busy guys and we think that the addition of NPs would smooth out the bumps of patient care by providing additional expert presence when we're tied up doing important things. Our Super-Nurses can ride herd on your Staff Nurses and help teach the residents as well. This is a GREAT deal for the hospital and will definitely improve care!"

The Hospital Administrator glares at us and sneers:

"Who do you guys think you're bullshitting. Do I look like I just fell off the turnip truck? The rules for reimbursement are getting tighter daily. The threshold for denial of payment gets lower minutely. We have involuntarily cut middle managers' salaries 10% two months ago and layed off 100 employees last week. And after that, our ability to provide a decent service went South and we are coming up on another round of layoffs. We haven't paid any vendors, Fed Ex won't deliver anymore and they're threatening to turn the phones off."

"Hire ANOTHER nurse with expanded expertise at an inflated salary to help you you do your job? At TWICE the salary of our usual staff nurses? To oversee them? Have you lost your nut? Super-Nurses monitoring the Staff ICU nurses performance in some fashion will always be met by raging passive-aggressive behavior at the least, LOWERING productivity and the real possibility of someone being met in the parking lot and given a quick, impersonal lecture on the cost of dental work and the difficulties of trying to eat with two broken arms. NPs taking over the duties of house staff (cheap labor) paid by the hospital will invariably make the Chief of the Residency program squeal like a pig in hot oil, and frankly, I don't need that shit. You Docs make the big bucks. You can bust your ass to earn it." I have enough aggravation.

"NOW..let's talk about capitation, which is coming down the pike sure as God made little green apples. When THAT happens, my job is going to be very easy indeed. I will simply apply the Darwinian Tolerance Test. We will compress 50 million years of Natural Selection into 30 minutes no matter who does what and to whom. Each and every one of you who desire to have some of that lump sum will gather in a room with no exits. There will be an assortment of weapons on the table. I will come in, throw the money up in the air, exit quickly and lock the door behind me. I will then wait a prudent period of time and then let out the survivors. How they divide up the money is not my problem. And let me assure both of you that your current concepts of what constitutes "collaboration" will evolve is a very Darwinian fashion as well."

"I am Wearing a bulletproof vest under my suit, I have a remote car starter, I have ten reporters from the Pittsburgh Post camped out in my front yard, I get three malpractice suits dropped off in my office daily, the medical staff is screaming for blood, I MIGHT make the payroll this month only if that deal for my soul goes through, I have a loaded Luger on my dresser and the nurses are threatening to join the TEAMSTERS, for God's sake. You guys are on your own."

And so ends the saga. The bottom line of this conversation is simply that there is a role for NP in critical care but whether or not it will ever be expressed depends directly on who will finance it. That is the fundamental question and as far as I know, it has not been answered. Which is why most if not all NP programs are in more or less limbo and the ones claiming to be prosperous have found niches in areas fairly far out in the boonies where these problems have not found their way yet or lost in huge medical center bureaucracies where no one know who's paying for anything.

Fini

Exunt.

.