Okay, I have no relevant financial relationships to disclose. So the objectives for today's talk are for you to all become familiar with the benefits of integrating APPs with residents in the ICU, to identify barriers to ensuring cohesion between rotating residents and critical care APPs, and to identify strategies that create positive working relationships to ultimately optimize workflow, efficiency, learning, and overall job and rotation satisfaction. To start off, I'd like to mention how we got to where we are today. In 2003, the Accreditation Council for Graduate Medical Education, or the ACGME, enforced work hour restrictions that significantly affected many hospital services that relied on the resident work pool for a majority of patient care. With this loss of manpower and the increasing physician shortage in the US, the advanced practice provider became more heavily utilized in the ICUs of academic medical centers. However, the role of the APP goes beyond filling the void of our physician trainees. Since the increasing utilization of APPs, we have learned that a majority of academic medical centers believe that APPs positively affect patients' access to care, safety, and quality, while also reducing length of stay and improving care. These two tables highlight two different perspectives, that of the Critical Care Fellowship Program Director on the left, and that of general surgery residents from various ACGME accredited programs on the right, both looking at the impact of APPs in critical care. As you can see, the perceived impact is mostly positive. However, I found it interesting that there were two areas that scored less than 50%, which are enhanced communication with providers and fill coverage gaps, which are two topics we can talk a little bit more about later when discussing things to be mindful of when we attempt to build our integrated teams. Utilizing the APP in the ICU can be done in one of two ways. By assigning APPs and residents to two separate teams in the same unit, or by having APPs work alongside our physician trainees on the same team in the same unit, having each learn from each other's strengths with overlapping responsibilities. And while both approaches absolutely have their benefits and perks, I'm gonna make the case for the mixed team today, as the combined approach has been shown to improve daily operations and workflow efficiency, and collaboration with the multidisciplinary team. And that we have learned that mixed provider teams have similar to improved quality outcomes when compared to resident staffing models, or resident only teams. And lastly, we cannot overlook the impact our APPs can have on our physician trainees. That providing a positive and supportive experience during what can be a very overwhelming and stressful rotation can have a positive impact on both parties. In 2015, Foster et al conducted a review of 21 articles describing ICU team structure and outcome. In addition to finding accumulating evidence on the impact of APPs on quality outcomes, they also found these four articles, shown here, that showed the impact of APPs on resident and fellow education. And yes, while quality outcomes like length of stay, duration of mechanical ventilation, and compliance with clinical practice guidelines was similar to improved in the mixed provider team, we cannot overlook that not all experiences were positive. Kahn et al found that 31% of general surgery residents from around the country who participated in their surgery reported a detrimental effect of APPs on their overall ICU experience. I was not surprised when I read that the regression analysis showed that these residents tended to have less favorable perceptions of APPs when they also reported that nurses preferentially contacted APPs with their patient care concerns. They found that this, in combination with a perceived competition over bedside procedures, created a scenario where residents were excluded from key portions of care, decreasing their educational experience. It is understandable and expected that there are going to be barriers to ensuring cohesion when we build an integrated team. Unclear roles with overlapping responsibilities can lead to tension and hinder collaboration. Unclear lines of communication can create a blurred sense of ownership over patient tasks, as well as procedures. And as said before, in combination with this perceived competition over bedside procedures, can create division and ultimately destroy mutual respect. And teamwork. But unity is strength, and overcoming these barriers to achieve unity has significant benefits. Because when individuals are a part of a well-functioning, cohesive team, they feel more connected to their work. They feel more supported at the end of a really stressful shift, and they feel a shared sense of achievement in working towards a common goal. All things that also benefit our patients. Because well-functioning, cohesive teams provide better patient care. And I'm sure you're all thinking that this sounds great, but how do we actually make it happen? And most of what I'm about to share here is what I have learned in my experience as the lead for my team, but also in my experience before I was the lead, when I was a, when I first joined my team, which was a new-ish integrated team of APPs and residents. At that time, I was told that the CTICU, which is the unit I work in, was the residents' least favorite rotation. And I was not surprised. It's a highly complex, highly acute unit. There's a lot of devices, there's a lot of drips, and at that time, there was a lot of very sparse staffing. And our residents were describing their experience rotating through our unit as traumatic. But with a lot of feedback and thoughtful collaboration, and now an expanded team of 11 APPs rotating alongside those three rotating residents, I have discovered a few important tenets of a successful integrated team. First, set early expectations. Maybe this means you send out an email before your residents come in, and you just really outline the workflow expectations of them while they're rotating with you. So tell them up front, how do you divide up patients? How do you divide up procedures? How do you divide up admissions? What are the lines of communication for them? And who can they call on for support if needed? Really drill home what is expected of them and ensure role clarity early. We also immediately state to these residents coming in that for the next four weeks of their rotation, the APP team is going to consider them part of our team, that we're going to look at them as if they're one of our own teammates, and we're gonna look out for them and we expect the exact same thing in return. I think it's also important to mention here that if there are any differences in the role of the APP and resident in your unit, it's really important to highlight those differences early. And I also think that if there are differences, I would encourage you to every so often consider why those differences exist and if they're best for patient care. And then next is adopt a supporting staffing model, which I will acknowledge is not an easy thing to do and it's not a quick fix, but it should not be overlooked. If possible, build a staffing model that builds around the residents. The ICU is a scary place for many learners that come through, so if you create a model that provides layers of support to give cushion for learning as well as patient care. In our unit, we get a great deal of admissions right around the time of handoff between the day team and the night team, and we have been fortunate to make the case for a swing shift provider, so someone who comes in between 10 a.m. and 10 p.m. and they are mainly responsible for helping out with any tasks, high acuity, and then they just admit all the new patients coming into the unit. This creates a little bit of cushion for our day team as they're trying to handoff and sign out and for our night team who's coming in and trying to learn all these new patients, but it also provides a layer of protection for our patients as we know that handoffs are extremely vulnerable times for patient care. And then be mindful of what we learned from Khan et al and what many of you have probably learned from experience, which is that nurses sometimes do preferentially go to the familiar face of their APP colleagues with their concerns instead of to the resident who is providing care for the patient that day, but that by allowing for this to happen creates tension and cuts the resident out of the loop and can also have patient care setbacks. We all know that the same thing doesn't just happen with nurses, but also can happen with conversations between attendings and consulting services. If you Google characteristics of high-performing teams, you will find listed that high-performing teams are built on high levels of trust and clarity of purpose and vision. Trusting one another's expertise will discourage encroachment and the need to constantly monitor, but this is really hard to do. However, we must be there to support and not to micromanage. Our residents are learning so much on these rotations and they should be building rapport with all members of the care team, so let's not rob them of that experience. Oops, I was not supposed to advance. Yes, please. Okay, and in terms of procedures, which is also an area that we should be mindful of, you must do what works best for your team and your unit. We have found in our unit in the CTICU what works best for us is clean lines of ownership over the patient care. So if it is your patient that day that ends up needing the line, you're responsible for putting it in if you're credentialed to do so. If a new hire APP or a critical care APP fellow or any other learner is in the unit who needs experience with lines, we just encourage a direct conversation between the learner and the provider, APP or resident who's providing care to the patient that day. Many times lines are offered to those who need the exposure, but they are never delegated in any other way to avoid tension with adjudication. And then break down barriers and find common ground. One of my amazing teammates had the idea to send out interviews to the residents before they come through the unit. So she just has a saved email that she sends out where she asks the residents where they're from, what their hobbies are outside of the residency, what they're most nervous about in their upcoming rotation through the CTICU, and then she asks them what they think the APP team can do to help them and to ensure that they have a worthwhile rotation. She then prints these out with a small picture of each resident and she hangs them in the break room and then she hangs them in the APP office. And this immediately builds a foundation for camaraderie. And lastly, model mutual respect. Residents who feel that APPs respect them and are open to their perspective and from learning from their areas of expertise are more likely to lean on APPs for advice and guidance when needed, which I think we can all agree is also a really good thing for patient care. We cannot teach our physician trainees to be respectful of APPs by giving them a lecture about how skillful and awesome APPs are and then have them rotate through our unit and have them watch the APPs field nursing and attending concerns on their patients, cutting them out of the loop. The resident that is not appreciative of an APP may actually be the resident who doesn't feel seen and respected themselves. Respect and appreciation is often a two-way street, so one must feel it in order to be able to show it. These are all just the small nuances of a cohesive team. APP leaders and unit leaders must be invested in maintaining a culture of mutual respect. These physician trainees will go on to be our attendings, whether on consulting services, our surgeons, or even our very own intensivists. So let us have the goal to make their initial exposure to critical care and critical care APPs a positive one and show them that together we can learn from each other and provide quality patient care. Thank you all and I look forward to taking any questions later.

advanced practice providers

intensive care unit

patient care

workflow efficiency

communication