NAPLES, FLA. – Complication rates are similar for advanced clinical practitioners and resident physicians performing key routine procedures in the ICU or trauma setting, a retrospective study found.
Advanced clinical practitioners (ACPs) performed 555 procedures with 11 complications (2%), while resident physicians (RPs) performed 1,020 procedures with 20 complications (2%).
Ms. Massanu Sirleaf
Procedures consisted of arterial lines, central venous lines, bronchoalveolar lavage, thoracotomy tubes, percutaneous endoscopic gastrostomy (PEG), and tracheostomies, Massanu Sirleaf, a board-certified acute care nurse practitioner, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
No differences were observed between the ACP and RP groups in mean ICU length of stay (3.7 days vs. 3.9 days) or hospital stay (13.3 days vs. 12.2 days).
Mortality rates were also similar for ACPs and RPs (9.7% vs. 11%; P = .07), despite significantly higher age (mean 54.5 years vs. 49.9 years; P less than .05) and APACHE III scores for the ACP group (mean 47.7 vs. 40.8; P less than .05).
"Our results demonstrate that ACPs have become a very important part of our health care team and substantiate the safety of ACPs in performing surgical procedures in critically ill patients," Ms. Sirleaf said.
Restrictions in resident work hours have imposed workload challenges on trauma centers, leading some to recruit nurse practitioners and physician assistants to care for critically ill patients in the ICU and to perform invasive procedures previously done exclusively by physicians, she observed. Very few studies, however, have addressed ACPs’ procedural competence and complication rates.
The retrospective study included all procedures performed from January to December 2011 in the trauma and surgical ICUs at the F.H. "Sammy" Ross Jr. Trauma Center, Carolinas Medical Center in Charlotte, N.C. Eight ACPs performed invasive procedures for surgical critical care patients under attending supervision, while three postgraduate year two (PGY2) surgical and emergency residents performed procedures for trauma patients.
Invited discussant Dr. Jeffrey Claridge, director of trauma, critical care, and burns at MetroHealth Medical Center in Cleveland, agreed with the study’s conclusion that complications were similar between ACPs and RPs, but went on to say that 2% is extremely low and that "something is missing or oversimplified."
In particular, he pressed Ms. Sirleaf on where the procedures were performed, the level of supervision provided to ACPs, and how extensive the review of complications was other than procedural notes. For example, did the authors look at whether chest tubes fell out within 24 hours because they were inappropriately secured, PEG or tracheostomy sites that got infected, or breaks occurred in sterile technique.
"Determining a more comprehensive complication panel would give more power to detect differences and, truthfully, more credibility to the paper," Dr. Claridge said.
Ms. Sirleaf replied that in addition to reviewing postprocedural notes, radiologists looked for complications 24 hours after chest tube placement and patients with a tracheostomy were followed for complications for 7 days by the attending.
Urgency of the procedure was not evaluated since the procedures were elective and most were performed at the bedside.
"For the ACPs with a level of competency, just like interns at the beginning, they assisted the attending and as they got better, the majority of the procedure was performed by the ACP at the bedside with the attending scrubbed in," she said.
At the time of the study, three ACPs had 1 year of experience, with up to 7 years’ experience in the remaining ACPs. Senior ACPs provided training along with the attendings, and both ACPs and RPs underwent quarterly simulation lab training on procedures. To maintain competency, Carolinas Medical Center also requires ACPs perform a set number of each type of procedure on a yearly basis and have these procedures witnessed and signed off on by an attending, said Ms. Sirleaf, now with Sharp Memorial Hospital, San Diego.
Ms. Sirleaf and her coauthors reported having no financial disclosures.