SCCM Resource Library-Integrating Advanced Practice Providers Into Critical Care: Nuts and Bolts

Video Transcription

Okay, we're going to begin, everybody. Good morning. My name is Rhonda D'Agostino, and I'll be moderating this session.  We're going to do about 20 minutes for each presenter and then have lots of room for questions. So, don't be shy.  We wanted that opportunity to provide some Q and A. We're also, this session was proposed in part as a prequel to the luncheon, so we're going to have to leave right on time.  If not, maybe two minutes earlier, maybe I have to get out just to go to the luncheon because we're also doing that session. Just a few housekeeping remarks.  Please move to the center of the row. Fill all seats. If you wish to leave the session, please do so quietly. Please silence your cell phones.  Once the session has concluded, please exit quickly as the next session will follow once this is done.  All Congress attendees will gain access to Congress on demand. All speakers have disclosed any conflicts, and please do not publish digital photographs  of any slides displaying the no social media icon on it. And then if you're tweeting or taking pictures, please use CCC49. I made the mistake of using CCM49. It's CCC49.  With that, I'd like to introduce our speakers today. I'm very lucky to have moderated the session with these two experts here.  So, Karina Secutris is the Director of Advanced Practice at the Hospital of the University of Pennsylvania in Philadelphia and a Clinical Instructor  for the Acute Care Nurse Practitioner Program at the UPenn School of Nursing.  In her role, she directs strategic, operational, and clinical aspects of the inpatient APP providers, as well as maintains administrative oversight  for all the advanced practice critical care fellowship programs. She practices as an acute care nurse practitioner in the surgical critical care  and is a fellow of the American College of Critical Care Medicine and the American Association of Nurse Practitioners.  Rob Gravencourt has practiced critical care medicine for over 40 years. And has effectively retired two years ago and now practices as a grandfather extraordinaire.  Prior to his retirement, he was the co-director of the NPPA Critical Care Residency at Emory Healthcare and is currently the co-chair of the ARC PA Task Force  and Clinical Post-Graduate PA Program Accreditation.  He was section chair back in 2000. I don't think I was even a member there. But I'm glad that there's a section back there.  And was one of the first PAs to be elected as a fellow of the College of Critical Care Medicine.  Both Karina and Rob have published extensively and authored and have been very involved in the Society of Critical Care Medicine.  So, please, this is your time to ask lots of questions. With that, I'll let our speaker start. I think our first speaker is Karina.  Thanks, Rhonda. Welcome, everybody. Really excited about this session.  And really excited about the number of sessions that advanced practice providers are participating in this year at Congress. I was sort of whispering to Rob over there.  He's supposedly retired. But he's pretty busy. He's writing chapters and writing papers and doing sessions with us and hosting a table at the networking event.  And I thought, does the work ever stop? Like, I was looking forward to retirement. But here he is, still partnering with me doing great work. So, we're lucky to have him.  So, my talk is focused on Show Me the Money, Why Invest in APPs. I'm going to maybe take a different type of approach to sort of deliver that content.  You guys let me know how it works at the end. Okay. Two objectives for this session for the next 20 minutes or so. So, the first is going to be make a financial case  for adding advanced practice providers to ICU services. I'm going to right off the bat just sort of say this is not a billing talk. I'm not going to address billing specifically.  I'm not going to talk about revenue generation as it relates to billing. I'm going to focus instead on value. And I hope that resonates with this audience a little bit.  If there are billing questions, I will certainly do my best. And I have a couple of plants in the audience who will help me out if I need it.  And then also, the second objective for the session is going to be to recognize the types of infrastructure that lead to successful APP models of care. All right.  So, just to kind of kick off a little bit with what's happening nationally as it relates to advanced practice. So, a bigger perspective.  We're going to fly a little bit higher than just critical care at the moment. So, Sullivan Cotter will say that the advanced practice provider workforce is one  of the most rapidly growing provider workforces in the country today. I think that's not a big surprise to a lot of the room given what we just introduced the session  with in terms of numbers and presence and visibility. And then in many organizations, particularly large organizations with large APP workforces, we actually make up about a third  of the organization's credentialed provider workforce.  There's some stats there on the slide that give you a little bit of a perspective on supply and demand for APPs. And so, there are 270,000 nurse practitioners licensed  and practicing in the United States. 20,000 of them are certified in acute care, which is the board certification that creates eligibility for critical care environments.  And only 12% work in critical care. There are 132,000 practicing physician assistants across the country. 38.5% report working in hospital settings, and 1.4% work in critical care.  So, we're talking about a pretty precious resource. You make up a pretty elite group of a much larger workforce across the country.  In the graphic there on the side, you get a little bit of a sense of some of the drivers behind advanced practice provider workforce growth.  So, from the U.S. Bureau of Labor Statistics, you can see that the projected growth for all provider types, all advanced practice disciplines,  as well as physicians, is listed there. As of 2026, the 10-year growth in physician assistants is estimated to be about 37%. Nurse practitioners, is that 38 or 39?  I didn't bring my glasses. Nurse midwives, 21. Nurse anesthetists, 19. And physicians, 13%. So, a lot of projected growth in the next several years.  U.S. News and World Report is consistently ranking all of our respective healthcare positions as some of the top jobs, and that's creating a lot  of energy around advanced practice providers in the workforce. And then, programs are starting to respond by increasing their class sizes.  New programs are developing all over the place. We're in the Philadelphia marketplace, and there are constantly new NP and PA programs popping up.  And that's really exciting, because at a big organization who's doing a lot of recruiting, we need a pretty robust supply of APPs.  On the other hand, it produces some challenges, as well, with respect to the kind of quality education people are getting, as well as our ability to sort of meet the demand  for meaningful clinical placement. So, it's a little bit of a balancing act for us at this point. The point, I think, of the slide is that people are starting to respond to some  of the changing dynamics in the landscape. So, you know, a lot has changed here within the Society of Critical Care Medicine over the past several years.  And so, I've put up on this slide two time points that I think do a pretty neat job of illustrating how far we've come as critical care advanced practice providers,  and how far the Society has come in thinking about us. And so, in 2012, you know, Ruth Kleinpell was one of the editors of the first edition of Integrating NPs and PAs in ICUs.  And I remember at that time when that book came out being so excited that the Society was making such an investment  in helping people understand how to utilize APPs and sort of valuing the roles that we were playing in healthcare at the time. And I know you can easily read what's on the slide,  but I just kind of want to say the words out loud. This came directly from the preface that she and Dr. Boyle and Dr. Eli had written on that paper there.  And it basically says, this manual was conceived and developed to provide the information and resources necessary for critical care clinicians and institutions that seek  to integrate NPs and PAs into their ICU workforce. For those already utilizing NPs and PAs in the ICU, this publication provides information  that can help reinforce their existing programs and provide additional strategies for maximizing skills and experience of these providers in critical care.  So, we were really sort of at the cusp of thinking about how we were going to deploy, utilize, maximize, and optimize APPs.  Ruth, as if on cue, I was just talking about your 2012 book. Fast forward to last year when Roy and I had the great opportunity to work with Dr. Halpern on the second edition.  And I just want to read a clip from our preface there because I think it gives you an indication of how the roles of APPs have changed in just six short years  in healthcare and in critical care. APPs are now clearly recognized as valued members of the critical care team.  APPs make significant contributions to frontline patient care by working closely with ICU nurses, performing procedures, optimizing transitions in care,  and participating in critical care consults, rapid responses, and co-teams. They oversee critical care patient safety, patient family satisfaction,  develop and execute quality initiatives, improve ICU compliance. APPs are increasingly recognized for their ability to drive value across the critical care continuum.  And I think the spirit of that is what you're seeing play out in the Society of Critical Care Medicine and hopefully at home in your ICUs today.  So, really exciting continuum, I think, and a really exciting evolution for us in our roles.  So, I sort of introduced the session with saying I wanted to focus on value because I think that's  where APPs really make a lot of impact in critical care and in healthcare in general. And so, there's lots of formulas for value, of course.  I think one that's pretty widely accepted is this construct of value is quality over cost. And for the purpose of critical care specifically, but I could easily argue for all APPs,  I tried to bullet a couple of the things that I thought were really strong value propositions for APPs in ICU environments. And they are quality metrics.  They're access to service, both inside and outside of the walls of an ICU. They're the ability to increase, increasingly meet changing clinical demands.  Patient and family experience and satisfaction, reduction in length of stay and continuity and transitions in care.  So, these are all areas where I think APPs can make really significant contributions in patient care, thus driving value.  So, hopefully many of you saw a paper that Ruth led that Rob and I had an opportunity to participate in as well as Roy who's here today in April who's leading another session  at the same time right now where we followed up on the work that Ruth and Rob had done back in 2008 to review the literature on advanced practice provider outcomes  in acute and critical care. And so, you may recall from the original paper in 2008, they took a look at the published work on APPs in acute care environments at that time.  Many of the papers at that point were talking about role development, the education of these providers, their training paradigm, scope of practice, role expansions.  We took another look at it and picked up where that paper left off in 2008 and did the subsequent 10 years and decided to focus very specifically on studies  that spoke to APPs outcomes. So, we really focused very squarely on research because we wanted to be able to describe some of the outcomes we were seeing  when you integrated APPs into critical care environments. Through that, we reviewed two RCTs, five systematic reviews, four literature reviews, and 44 individual studies.  And we organized the results under these following headers that you see listed on the slide here. So, comparison of APP models to medical providers, ICU patient management,  APP staffing models, quality improvement, patient safety and financial impact, and impact on resident and fellow education, which was a new piece for us  that we were just starting to see come out. And so, this comes directly from table two of the manuscript. This is the supplemental table that defines  at a really high level what some of the outcome measures were. All of these very clearly carry financial impact and value associated with them.  So, in the bigger picture of trying to define value for APPs, these are all ways that the literature supports that we've been able to do it today.  And we know from the work that we did reviewing the literature, there are many, many more things out there that you all have contributed to in terms of abstracts  and presentations and work that you're doing locally. And we just implore you to take the opportunity to get it into the literature  so we can capture it in tables like this and create higher impact statements at meetings like the one that we're having today.  So, I wanted to share just a couple of local exemplars as well to bring some of the higher level things you just saw on the previous slide to life in a more tangible way.  And so, I'm going to share two examples for you from some of the critical care environments at my home organization at the University of Pennsylvania.  So, this first one here is an abstract that was actually just presented yesterday by Joan Connery who is our advanced practice leader in our medical intensive care units.  Very briefly, I won't read you this slide, but very briefly what they did was meet a demand that we had at our organization for increasing MICU beds.  And so, like many of you in the room, there were never enough critical care beds. There was never enough space. We couldn't accommodate the growing need.  And so, that resulted in critical care patients being boarded outside of the MICU at times.  That resulted in critical care patients having long length of stays in the emergency department when they really needed to get up to the MICU.  That resulted in patients at other hospitals who needed to come to Penn for critical care services not being able to get in.  And so, we had a unique opportunity when we were doing some kind of restructuring and transitioning to develop a new eight bed MICU, which we did.  We staffed it around the clock with advanced practice providers and intensivists there during the day.  And it just ran as an extension of our traditional pulmonary critical care MICU, which is now what we sort of consider our teaching unit.  And so, this is in no way a comparison of trainees to APPs. This is just to sort of tell you the kind of impacts that this contained eight bed,  fully run APP intensivist unit had on patients and our flow and our environment. And so, you can see down at the bottom in bold,  we were able to increase outside hospital transfers by 25%. So, 25% of people that needed us that prior, previous to this couldn't get in,  now got in and were under the care of our MICU team. We decreased the amount of people that were boarding outside of our ICUs.  Lots of great results there in terms of hospital acquired infections. Our VAP rates are zero, our CLABSI rates .79, CAUTI 2.45 per 1,000 catheter days.  So, really, really impressive clinical outcomes. All of these transition into financial impacts.  So, sort of keeping with the theme about show me the money, not a story about billing, but a story about quality and how quality drives value.  And that makes a significant financial statement at your home organization. The other thing this group did before I move on is they actually surveyed their intensivists  in terms of feelings of wellness overall and burnout and role fulfillment. And the attendings, as you can see there, reported a higher level  of professional fulfillment and less burnout when they were working within the APP ICU. Because, you know, permanent, highly skilled providers understand the cadence, the flow,  the practice, critically ill patients. And that kind of elevated the whole team's ability to function at a higher level. The other example I want to share is out of our HV-SICU.  So, very specifically focused on a couple of challenges there that we thought the APPs might be able to have an impact in.  The first, on the left side of your screen, was all about timing and patient flow. And so, again, like a lot of you, there's never enough ICU beds.  We never can move people out fast enough. The delays on the floor were causing delays getting out of the ICU, were causing delays in the hour. That's certainly never a good thing.  And so, one of the things we did was implement a 5 a.m. round, formal rounds process for the overnight APP who was already in the unit,  with the specific focus of initiating early transfer. So, the patients that were doing well, who were progressing as you'd expect them to,  simply evaluated the patients independently at 5 a.m., made, used their clinical judgment, made clinical decisions, and initiated the transfer process.  Historically, this started to happen in traditional rounds, which happens anywhere between 8 and 2-ish, if I'm generous.  And so, you can imagine the delays in moving people out of the ICUs in that scenario. With this scenario, you can see that we kind of broke the data  down into two six-month time periods. Prior to this 5 a.m. rounding process, about 14.5% of the patients were able to move  out before noon, after the rounds process, 26% of the patients were able to move out before noon. So, this cost us nothing.  We simply added a process step that we didn't have before and got incredible value in terms of flow and efficiency from that.  On the other side of the screen, this is a story about extubation and time on a ventilator.  So, similar construct in that we didn't necessarily add new providers or add new functions, but create a deliberate focus around a problem that we needed to solve,  which is I think what APBs do exceptionally well. And so, we just shifted a staffing model. So, we already had APPs in our HIV-CQ around the clock.  We were having some delays with extubation times for our pathway cardiac surgery patients, simply because of the volume of patients that moved through our HIV-CQ.  And so, we shifted one of the providers to do a kind of a swing shift model, where they came in at midnight, or excuse me, they came in at noon, they left at midnight.  And we kind of scoped their role around facilitating all of the post-ops that are coming out of the OR.  So, we will get 10 to 15 post-op cardiac surgery patients a day in this one ICU. And this provider was kind of the point of care for bringing them in,  getting report from the OR team, settling them in, keeping them on pathway. And you can see we've organized the data by particular surgical procedure here,  but straight down the line, significant increases in our ability to extubate patients post-op within the six-hour time frame that we had identified.  So, I'm going to pivot a little bit away from sort of the clinical outcome piece and talk a little bit about infrastructure. That was the second objective of the talk here today.  So, this slide actually comes directly from Sullivan Cotter. So, I credited them there with it. But I like it because I think what it points out to all of us is,  the solution is not just hire an APP, you need an APP, you should get more APPs. The solution is really about creating a structure around your APP program  that allows the APP models of care and the APP structure and the team to thrive. And the structure needs to be comprehensive, the same way it is in nursing,  the same way it is in medicine, the same way it is in pharmacy. I think because of the ways APPs sort of integrated into the healthcare environment,  we didn't come with such robustness around all of these sort of organizing frameworks, models of care, onboarding, competency assessment, regulatory compliance,  workforce planning, leadership, engagement and compensation. We sort of got inserted into whatever models already existed. And I think that's been hard to overcome.  And that's part of, I think, the value of developing advanced practice leadership infrastructures because you now have people in your organizations, here throughout the society,  all over the country who are thinking about this as their job and who are organizing our activities as a primary focus. And that drives pretty nice returns on investment.  This is a little bit about our local strategy and structure back at Penn. So on the left side of your screen, you see we have kind of a similar circle construct.  And you may not believe this, but we made the circle before we saw Sullivan-Cotter's circle. It just so happens that both are circles.  But regardless, you can see at the very top of our circle is value and outcomes because that is so incredibly important. We are a large workforce.  You saw the beginning slide, sort of the national landscape at Penn. We have almost 1,400 APPs spread across our health system. That is a very large investment in providers.  And so we need to be deliberate about keeping an eye on our outcomes, our investments, the impact that we're having in patient care.  We focus very intently on alignment as a complex health system spread across the state with a lot of providers and a lot of different entities and a lot of different settings.  We really are deliberate about trying to stay aligned and integrated when we can. Innovation around models of care, clinical practice,  which is clearly at the core of all of what we do. Dissemination of research and outcomes and evidence-based care and best practices locally and in forums like this one.  Integration of roles. And so we're increasingly kind of moving into the space where we're thinking more intently about boundary-spanning roles for APPs.  We have teams of providers that span multiple entities and cover clinical settings.  We have teams of providers that are spending their time on inpatient care as well as ambulatory care. And we have leaders that are spanning some of these environments, too,  trying to understand the complexity of healthcare and manage it in the way our patients experience it. So really important, I think, focus.  And then finally, around workforce planning. We talked a little bit about supply and demand. We're growing in numbers, as we can see, in a setting like this.  And so at an organization like ours, in an environment that is really market competitive, we always have to be paying attention to what are the threats  and what are the opportunities regionally. And starting to read the tea leaves a little bit about the directions that we're moving.  On the right side of the screen, then, you'll see a little bit about our infrastructure. And you'll see that, you know, at a higher level,  our entities have directors of advanced practice. That's where a lot of the strategy and planning happens.  And then there are teams of providers underneath of us that I sort of characterize in my head as kind of the who and the what.  And so the who are the formal leaders, the formal clinical teams that we have. And the managers and the leads in these environments are responsible for things like hiring  and recruiting and professional development and human resource issues and models of care and scheduling, you know, a lot of the logistics things,  but also a lot of the professional development things. And then on the other side, and I think probably one of the robust things  about this structure that I'm most proud of is the what. And so these are all of our committees and councils  that really are driving the activities of the department with focuses on practice and education and professional development and recognition and all of these things  that really are kind of the soul, I think, of our department and the workforce. It sort of might sound like soft things, but they're critically important.  And I think drive a lot of the success we've had around engaging our APPs, low turnover rates, our ability to recruit even in a competitive marketplace.  So if you have structures like this, congratulations. I think it's well worth the investment. And if you don't, I would urge you to think a little bit about how to connect your APPs  as professional groups around kind of some of these shared activities. And I'll close with, I sort of nodded to this on the last slide, and this will be my last slide.  I'll just share a little bit of data with you. So all of that that I just showed you obviously occurred over many, many years with a lot of effort. None of it was easy.  It was all about timing and strategy and taking advantage of opportunities and all the things that you guys already know.  So put that on top of some significant growth that we've had in our workplace. So we've grown about 250% in the past five years at Penn.  It's probably going to continue because we're continuing to grow. And despite that, we've made really significant reductions in our turnover,  which in our marketplaces is a pretty nice accomplishment because we are surrounded by very well-renowned, very competitive, very prestigious medical centers.  So it's not like we're the only game in town. But we've seen, you can see here that in five years, we've taken our turnover from just under 14% to about 6%.  That carries a significant return on investment. There's estimations out there, depending on the calculator that you use,  that advanced practice turnover is about 1 1⁄2 times an APP's salary wages and benefits.  So that number will look different depending on where you are and what your salaries look like. But for us, that's quite significant.  In fact, when we annualized that out for the first time, we realized we were losing millions of dollars a year in turnover, even with relatively conservative turnover numbers.  And at our organization, if we can keep the turnover for every 1%, we keep it below national benchmarks, we have a cost avoidance of about $1.7 million  because our numbers are so large. So if you haven't done that math, I would encourage you to think about it.  It's a really great way to think about making a case for resources or structure or infrastructure, and I included some kind of national benchmarks for turnover there as well.  So I just encourage you to think about turnover as a cost avoidance strategy. And with that, I am going to turn it over to Rob.  Thank you. Well, it's a pleasure being with you this morning. And it's a lot of fun and actually thrilling for me to see the explosion that Corinna has already talked to you about.  Just a smidge of history, some of you might have heard this. So I graduated from PA school, I couldn't find a job. This was in, well, let's just say a long time ago.  So I couldn't find a job, so I went back to the Pulmonary Function Lab where I was before I went to school.  I knew I wanted to do critical care, that wasn't the issue, I wanted to do critical care. Thankfully, I was in a Monday night basketball league, and one of the guys  in the league had a friend who had a father-in-law who had another friend who was looking for a PA to work in the ICU, and that's how I got my first job in the ICU.  And now you know the rest of the story. But it's thrilling to see that APPs are being pursued now for the unit and structured and having tremendous benefit.  So with that, we'll just move into this. So we're going to talk about, you want a team? You got to train them. How are you going to do that? I don't have any disclosures.  What I will tell you is today's talk is going to be an 80,000-foot view. We're not going to get down into the specifics of training,  but I'm going to give you an overview of two programs. One is an OJT program, and one is a residency program.  So how to impart this critical care knowledge to your APPs that are coming on? Well, the traditional method, of course, is the OJT unit-driven orientation.  The second approach, and a little more contemporary, although some of them are quite old. I think the Montefiore surgical program was early 70s,  and there was also a primary care nurse practitioner program in the early 70s as well. They're alternatively called residencies and fellowships. We won't discuss those terms today.  Those are best discussed over maybe one, maybe two beers. And it's a philosophical argument, so we'll skip over that. But you have these people coming on. You're worried.  You've got to get them up to speed. How are you going to train them? And the older I get, the more I identify with this movie, Fiddler on the Roof.  Tevi here is complaining that his traditions, which were so important to him, have completely been upset by the Russian Revolution and the coming of the communists in that country.  And so without our traditions, our lives would be as shaky as a fiddler on the roof. And I think sometimes when people look at educating APPs, they have that mentality.  And so the first thing they do is they go to the Tried and True, the on-the-job training program. So there are advantages. It's sort of ready-made. It's informal. It's flexible.  It's much less complicated to set up than a post-grad program. It works kind of with your inherent costs of running this, and it is indigenously specific.  So if you're going to train a nurse practitioner to work in the cardiothoracic ICU, then you're going to say, this is, you know, Dr. Jones' patient.  And oh, by the way, every time he gives 20, every time he gives a liter of lactated ringers, he wants to follow that with 20 milligrams of Lasix.  So you get the idiosyncratic advantages of the unit itself, which as a newbie, it's part of your survival. But what I want to do is give you an example here, and this is one  of the best on-the-job training programs I've seen. This was published in the Journal of the American Academy of Physicians Assistant in 2015 by Gina Luckyow.  You see that the third author there is Lewis Kaplan, our new president for the society. Lew has had interest in using PAs and NPs for many years, so it's kind of neat to see that.  I'll give you a program overview. It oriented APPs for an adult surgical ICU. It was a dual program. And as we surveyed the landscape, more of these programs are incorporating nurse  practitioners and PAs together. Both in on-the-job training and residency programs. This particular program trained one training at a time and had goals.  And that's one of the things I really want to point out in here if you're going to do an OJT method, there's some key points here.  The first goal was to have your resident up to the level of a support role in three months. So it was a six-month training program. But in the first three months,  it was simply to be a support role. Of course, at the end of the six months, it was an autonomous provider. There was procedural competency that was taught and evaluated.  And there were scheduled progress evaluations.  This is a chart that I sort of handcrafted from some of their stuff. I'd encourage you to go back in the article and look at it. It's an important article.  The thing here is the didactic topics. And starting in the left-hand column, you have a weekly scheduled process for lectures. If you look, here we are.  We go out 12 weeks, roughly three months. And if you remember the previous slide, that was getting to be the helper in the unit. And what this teaching thing does is it repeats,  it recycles every three months. So in the second three months, you get the same lectures again. But just reinforcing what you learned during the first three months.  This benchmark slide is cool for a number of reasons. I think the thing that gets me most excited about this is, looking at it from an educational standpoint,  is that left-hand column, cognitive domains, procedural competency, and administrative duties. If you're thinking about doing an OJT program, setting one up, be specific.  It's not enough to just throw stuff out there. You know, three articles, a lab coat, and a stethoscope, and all of a sudden, you're newbies on Thursday night from 7P to 7A.  It's not enough. You've got to have this training program and targets. And here again, it talks about the three-month and the six-month schedule.  So in the first three months, just take for instance, you'd have basic understanding of organ system function and assessment. And by the end of six months, you would have been able  to handle organ failure. And you can go down and look at this. In the interest of time, I won't go through all of it. But you could just see the progress as you go from left  to right on the screen. And I think these educational goals and targets are extremely important. Even if you're not going to have a really formal training program.  There are some challenges to the on-the-job orientation issue. You need to have staff to train and mentor. This is very difficult.  And it's quite frankly, it's part of the residency thing too. But we're all short-staffed in our units. People are doing well just to get their notes done,  their lines in, their consults written.  But you need dedicated staff to train, even in an OJT thing. You need some sort of subjective. Most of the time, it's subjective evaluation.  So it's not organized as we'll see in a few minutes. And it's a he said, she said kind of situation. You need something much more objective, including numbers  to evaluate these individuals. Ongoing evaluation is absolutely essential. And sometimes that can get lost in the mix with just the daily grind of life.  Again, if you're not organized. Knowledge base, typically in these OJT things, are limited to specific units. So you orient them to cardiothoracic. You orient them to neuro.  But they lack a wide-based knowledge of critical care. And finally, there are no national standards for OJT. Talk a little here about clinical post-graduate  education and the advantages. One of which is it provides a programmatic pathway for learning. You have a director or co-directors. You have an opportunity for multiple trainees  as they go through the classes. There's a system of systematized evaluation. There's multiple perspective educational exposure, which means that your, let's just call them trainees.  Your trainees rotate through many ICUs, which was interesting. When I was program director, I looked at our folks as they went through. When Heather and I set this up,  we wanted that broad-based critical care knowledge. And we saw it in a few classes coming through. And because our graduates would come to us and say, well I did this.  Say they were working in a cardiothoracic. They did a neuro exam and detected stroke. Their neuro exam skills were much better than mine.  Because I've done cardiothoracic all these years. So it's a great idea to have this multi-unit exposure. The other key piece is that these programs have protected educational  experience time. These people are there to learn. They come into the unit. They are introduced to the unit that they are. And never use the word student. That's an anathema.  Okay. Never, ever use the word student. They are trainees that are there to learn. They're not for support staff. They're not for, whoops.  We got an opening on Friday night at 11 o'clock. Can you please supply somebody? No. They're there solely to learn. Now they'll do their share of nights and these kinds of things.  But it's only in a learning environment. It'll take full advantage of institutional resources. If you work for a teaching institution, Penn, Emory,  other places, you can take full advantage of those resources. And there are national standards that are created. And we'll go over that in a minute.  So by example, I used to work in this program with Heather. Amy Abide has now taken my slot doing a great job. But just by example, this is one year in length.  We give them a syllabus which gives all the nitty-gritty of what needs to happen. Sort of a, just an introduction as to what you're going to be doing, these kinds of things.  Currently, the program uses virtual critical care rounds, a product of the society, for reading in the early part of the program, and that's advanced.  Articles are given toward the latter end of the program. At the front end, we do, we still, forgive me if I slip into the we thing, but boot camp, great experience for them.  Take them, hi, how are you, how was the move? And then, okay, let's talk about PEEP. And we start with these basic concepts of critical care, chest x-ray reading, and other things.  Core competency days, we'll talk about that in just a minute. Simulation lab experience. This was, I think, one of the most popular pieces that we put out there.  I didn't know how it was going to go. I've never been a resuscitante kind of person. I like working with patients, but the plastic kind of freaked me out and stuff.  But the technical aspects of the simulation lab really appealed to the generations that are coming forward, and it's been a great experience. And as I've already said,  there was multidisciplinary ICU clinical exposure to give that great background. Just a short dive into core competency days, two days per month for the entire year.  The trainee is completely released from clinical duties at that point. These are eight-hour days, an hour for lunch, these kinds of things.  There are scheduled standardized lectures, simulation lab time, the program has testing at the end of each rotation, so there are rotational exams  that they can take during this period. Various presentations that were required of them at the end of the year, we required them to give a senior project.  And so if the individual was going to the CCU, they might do something on LVADs and teach us about LVADs and present that.  And one of the things that we just discovered as we sat there and talked to folks, you know, your lecturer is going to show up late or something, you've got about 15 minutes,  great time for feedback time. Listen to your people. Our residents really helped us refine the process. So they gave us good feedback, and we valued that.  Also, the residency program provided evaluation, a solid form of evaluation. We used for the trainee to evaluate his or her training, modified 360 evaluation form.  Now, modified 360, you're probably familiar with a 360. I think most institutions use it for their medical residents and so on and so forth.  We actually modified the 360 in conjunction with our colleagues at Johns Hopkins. We changed it from sort of the soft science things to some things that were more direct.  Is this trainee recognizing a patient in distress? Is he doing the right thing? Is she ordering the right tests? All these kinds of things.  So we modified that form using a Likert scale and used that. The program director had routine meetings with attendings and mentors.  We did, we were able to observe them in the simulation lab, which was a real eye-opener at times. Even though it's a synthetic environment, it was very, very interesting.  And we were able to pick up on their weaknesses. One that we noticed in particular was about three, four months out, they were still struggling to get,  to wean patients from ventilators. And so we sat them down at the table with a mechanical lung, and we showed them the changes in volume and so on and so forth  and what that did, and it really helped them be able to effectively wean patients from ventilators. Written exams, they were given a pretest.  As I said, we had that, we had the boot camp, and one of the, really in the first few hours, took a 75-question multiple-choice pretest  on critical care, broad-based critical care medicine. I included some pictures of pneumothoraces. And these were just broad, general things. So they'd have an x-ray that maybe had  like a 60% pneumo on one side, and we'd ask them, what do you think, do you see anything wrong with this x-ray? And the scores were traditionally very low when they came in.  It's interesting, we gave the same test, exactly the same test a year later, and saw a significant increase in knowledge.  And so, you could really sort of evaluate your teaching that way. We also gave rotation-specific exams at the end of the rotation. I mentioned in the core competency days,  you take a 50-question rotation exam. So if you're in the MICU, there'd be questions there on PEEP, peak inspiratory pressure, ARDS, et cetera.  It's also important to evaluate the program, and I put in parentheses here, real-time and reflective. So you want to evaluate the program literally on a day-to-day  or a week-to-week manner, because your program needs to be strengthened and adapt. So that's absolutely necessary. You also need a reflective time.  We interviewed the residents when they finished, they took their final exam. They're completely separated from us. No strings attached. Heather and I'd sit them down,  and we'd ask them questions directly about the program. Got a tremendous amount of feedback that way, where they were free from any kind of parental authority from the co-directors.  So got frank answers. Let's see. Yeah. So from the trainees, the mentors, of course, would feed back to us. And also our director observations in the sim lab.  There are some challenges, foundational issues. Establishing a program can be complicated with the institution. Costs and funding, administrative needs.  They are somewhat resource-dependent. Now, not everybody works at an academic institution, but you'd be surprised what resources you can come  up with when you explain these programs to interested parties. And the other challenge is multiple perspectives. Now, if you're astute and semi-awake,  you recognize that this was brought out actually as a good portion of these residency programs, of multiple exposure.  But you'll get a lot of feedback from your trainees about, well, you know, in the MICU, they wanted to know what the normal potassium was, where the surgeon would bite your head off  if you told them there was a normal potassium. Just wanted the bad part. So there's a little bit of complaining there, but it's just part of the learning process.  I'm going to refer you in the next couple of slides to some organizations that engage in these. First, the Association of Postgraduate PA Programs and their email address there.  And then the Association of Postgraduate APRN Programs.  I told you that there were national standards for these programs, and these are the ones for nurse practitioners. You'll see there are three of them. Yeah, okay.  Three of them there. And I won't bother to read them to you in the interest of time, but we can just reference those. There's one accrediting body for all PA programs.  I've been part of the subcommission that is forming the postgraduate accreditation process there. We are going to run our pilot studies this spring,  and then hopefully by mid-2020, the general public will be able to apply for accreditation through the RPA. So no matter what you do, whether you decide to go  with on-the-job or clinical postgrad, you've got to have some stuff, some must-haves. So institutional support, absolutely. It's their money.  Physician leadership, physician has to tie in. When you get into the hard place, you need a physician champion. You need consistency in curriculum. You need team building.  You need dedicated educators. Even in an OJT, there's got to be a point person. And finally, feedback and continued evaluation is absolutely necessary to assess.  So there are some sources within the, resources within the society. First of all, membership. We encourage everyone to join, network, and grow together,  even as, you know, a trainee. There is an APP resource committee. Many in this room I can see serve on that committee. It was from that committee that the books came  that Corrina mentioned. There are publications that you know about the journals, certainly. But there are other publications like exam books  that you can look at and get some test questions for your people, these kinds of things. Virtual critical care rounds is the online modular instruction. There are two levels.  There's an individual level that you can buy, and there's a director edition level, which allows the director to look in and see how the trainees are doing.  And so it, that's a valuable piece to see if they need to speed it up a little bit, read more, or do something like that. And then, of course, we have clinically focused webinars  and podcasts. This is a picture of the book, the books. So we mentioned the one from 2012 in the background and the foreground, the newest one that came out last year.  Now that you have your people all trained, everybody's happy. This lady in the front with the red vest is coming off a week, two years of nights only, and the guy  with the beard is coming off weekends and nights. So everybody's happy. Your trainees are happy because you've given them good background. Your patients are getting great care.  Thank you. Thank you, Rob and Karina. That was excellent. We now have time for questions. So please, if you guys could come to,  there's a microphone here and here if you have any questions. I actually was thinking of a question that we were recently were discussing why people make  their way to the microphones. So do you guys believe in a formalized training, a mentorship or preceptor program? And if so, have you, as somebody that assigns mentors  or assigns preceptors, there's always that one that's like you can't put them with this person. Do those, can those people change  with a formalized mentorship program, a mentee program?  It's difficult. I think you got to look at the program overall. One of the things that we learned when we started this, when Heather and I started putting this together is,  you know, we wanted contact with our mentors and all these kinds of things and we're getting all this feedback. And one of the things we learned is you have to listen  to all sides in all this because otherwise it's a he said, she said and it's very complicated and messy. I don't know that you can ever get away from the human aspect of this.  But I think as leaders and either on the job or the organized program, you have to have the wisdom to stand up and say we've got to work these things out.  So, there are times certainly when people have to be separated because it is just bad. But other times it's a challenge to your leadership to keep that going and united. So. Okay.  Let's take the first question. Hello. My name is Pedro Lambert. I'm an intensivist from Delaware Bay Health. I work with nurse practitioners and PAs.  I have a question about family nurse practitioners and acute care. We had a hard time in the hospital credentialing family  nurse practitioners because they are supposed to be inpatient and even the director of the program, when we sent the letter, she says I do not recommend because she's outpatient.  So, what is your take on family versus acute care nurse practitioners? And also, what about CNS working at the ICU as a mid-level provider? So, you've hit on a pretty touchy topic.  And when that's, you know, so the recommendation is that in an acute care setting, like a critical care unit, that you hire acute care nurse practitioners  because they have the training, the education, the licensure, and the certification to function at that level.  I know that out there across the country, people do all kinds of different things for all kinds of different reasons. You know, there are some states  where there aren't acute care programs. And so, they bridge family nurse practitioners or sometimes primary care nurse practitioners with some additional training.  But truly, in an ICU environment, it needs to be an acute care nurse practitioner or a physician assistant who's been trained specifically  to practice in that environment with those skills, with those procedural competencies, who has the certification that supports that. In Delaware, you're close to us.  There are a lot of good programs regionally. So, you know, you could look towards transitioning those family nurse practitioners with different bridge programs.  University of Pennsylvania has one where you could get them acute care certified. So, I would encourage you to think about that.  There has started to become litigation across the country for places that aren't using acute care certified nurse practitioners in ICUs when malpractice cases occur.  So, it's just, it's something to think about. We don't, we only use acute care nurse practitioners and PAs in our ICUs. Great question. Take it from you.  So, I want to thank you both for your great presentations. And one thing that was really striking with the first presentation is how wonderful it is  to be working in a hospital where you have leadership at the top recognizing advanced practice providers, supporting that, recognizing the value of that.  What advice do you have for people working in smaller institutions or in institutions where the mentality is just hire some more advanced practice providers, figure it out?  I have a colleague who leads a team of nurse practitioners in function, but was told by some of the leadership that your role in leading is just kind  of like a charge nurse function. It varies based on the day. It's not really something that should be recognized as a leadership role.  And so, I'm wondering, and everybody can't be University of Pennsylvania or Emory, what advice do you have for people who are interested in advancing that, the role  and the leadership and the value of it when some of the things that you've talked about, like looking at quality, have just kind of been like, great,  we love that about you, but thanks. No, I mean, it's a terrific question, and anybody in here can participate in answering this.  To be perfectly honest, that's how we all started out, too. I mean, you know, that was University of Pennsylvania 15 years ago as well. And so, it kind of grew up organically  as a grassroots effort where there were enough people that they wanted an unofficial leader, and then that unofficial leader did some things.  It became official, and structures started, and numbers started. I think, I guess a couple of pieces of advice, and I'm sure, you know, Rob has plenty of wisdom here as well.  I would say start by solving a local problem. Look for a challenge that hasn't been solved, and think about how APPs could contribute to solving that,  and then create some visibility around that in the right way, not visibility about, hey, look at us, we're terrific, but visibility associated  with solving a complex problem meeting an organizational need. And then, if you can, value it somehow. Put metrics around it. Put dollars around it. Put impact around it.  You have to start to live in the space where you speak the language that the people you're making your cases speak. And it's tricky because for us  in a clinical environment we speak clinical talk, and we think in terms of clinical urgency. And in administrative forums and executive suites talking  to non-clinical leaders, that's not what they speak. They're making choices a lot of times about resources and investments and people and directions.  And so, you have to start to bridge the gap between the clinical world and the leadership world. And the only way to do that is through creating a value proposition  around whatever case you're trying to make. The only thing I'd add, and that's very good, the only thing I'd add to that is it is a team effort.  And I think finding a physician champion is absolutely key. I mean, I think if you can get the champion and then support the decision with what Karina just mentioned,  I think that's terrific. And once the administrators see that people are leaving the unit quicker, they're getting off ventilators earlier, you know, all of this,  then it's sort of, it is a self-sell from there. Karina's absolutely right. We were all there, and it was very hard in the beginning. But if you really care about patients,  and it's not getting them off the ventilator because it's dollar effective. It's getting them off the ventilator because they need  to get off the ventilator before they get pneumonia and these things. And you care about your patients. You move, you know, it'll self-sell from there.  But you need somebody with political weight to help you. I would just also add to that, and maybe create a council. Maybe you just don't have enough providers within the ICU,  and you could look out for other providers. I recently switched to a smaller organization, and it all started with the council, which is really nice.  I think we have enough time for two more questions, so I'll take you from here, and then we'll end with you. So, yeah, thanks again for the presentation. It was really helpful.  But, and kind of piggybacking on that, like in our institution, we just started having a formal kind of leadership structure for APPs. That's just started.  And then, but going back into kind of the training for new APPs. I think it's, I guess, is there any evidence to say that, oh, well, we need to get our people into this,  some kind of residency program? Or, and because that, just like y'all said, it's an uphill battle to bring in resources and money  to actually do this of, you know, dedicated educators and things like that. Versus, is there any benefit, proven benefit of somebody who's been trained through a residency program,  or trained on the job, which is better? Like, yeah, who would be the better, like? There was an abstract presented, I can't remember, was it Sunday?  Sunday or Monday, that talked a little bit about that. And it compared a resident with six months in a residency versus an OJT person with six months of training OJT.  And what was the difference? And they took the same exams, so it was a measure of knowledge. And they also looked at sort of a confidence standard.  Both showed great uptick in confidence. The knowledge piece belonged more to the residency program than it did to the OJT. So, to be perfectly frank, the number was small.  So, there were like 25 and 25 in each group. So, a very small number. But the residency program had a slight edge over that. But it was mainly in the knowledge group,  not so much in the confidence. Thanks. So, there's a forgotten group when we talk about APPs, and that's the clinical nurse specialist.  And in particular, the clinical nurse specialist who's not like a direct patient provider. The one who mainly works with the nurses and, you know,  works with system change and whatnot to focus on health outcomes and improving health outcomes. But we're not directly managing patients per se as that provider.  We are finding a challenge at our organization of finding. They're building, you know, robust orientation and onboarding process with a direct provider one  with competencies and whatnot. But there's that forgotten group that's down there. Are you familiar with any kind of onboarding or any kind  of programs that are for that type of APP? Not specifically and not formally. I could potentially put you in contact with someone, though. You know, it's an interesting point.  And you made me realize I didn't address the question specifically about CNSs and ICUs, which is a state to state regulatory decision.  And in some states, they have kind of scopes of practice that look more similar to traditional nurse practitioner scopes of practice. And so, they work in direct provider roles.  But the piece you're talking about is we don't forget them. They're very much a part of our clinical unit-based clinical leadership team.  So, they work really closely with the nurses, with the advanced practice providers, with the physicians, with the pharmacists, with the whole team.  In terms of orientation and onboarding specifically, I really just don't know. But if you connect with me, I'll put you in touch with someone  who I think will be able to help direct you in a way that might connect you to some resources. I am, actually. And on that, we've lost most of the group to the luncheon.  Rob and I both have to go staff a table. So, thank you all very much. This was wonderful. Have a good rest of Congress.

Video Summary

The speakers discussed the importance of advanced practice providers (APPs) in critical care and the value they bring to healthcare. They emphasized the need for a comprehensive infrastructure to support APPs and highlighted examples of successful APP models in ICUs. The speakers also discussed the different approaches to training APPs, including on-the-job training and formal residency programs. They provided insights into the challenges and benefits of each approach and highlighted the importance of ongoing evaluation and feedback in the training process. The speakers also addressed questions about the role of family nurse practitioners in acute care settings and the need for physician champions to support the integration of APPs. They encouraged healthcare organizations to recognize the value of APPs and to invest in their training and development.

Asset Subtitle

Administration, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Make a financial case for adding advanced practice providers (APPs) to ICU services
Recognize what types of infrastructure lead to successful APP models of care
Describe a successful orientation program
Analyze the pros and cons of a formal postgraduate transition to a practice program

Show Me the Money: Why Invest in APPs?

Corinna Sicoutris

Bridging the Gap: Orientations and Fellowships

Rob Grabenkort

Panel Discussion

Corinna Sicoutris
Rob Grabenkort

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Economics

Tag APP Administration

Year 2020

Keywords

advanced practice providers

critical care

healthcare

comprehensive infrastructure

successful APP models

training APPs

evaluation and feedback

family nurse practitioners

acute care settings

physician champions

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