Advanced Practice Providers in the Post Work Hour Era: Perceptions, Reality, and Future Directions*

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The Society of Critical Care Medicine convened the first task force on models of critical care in 2001 and has emphasized the value of strong multidisciplinary teams (1, 2). These team structures have adapted to changing workforce pressures. In 2002, the Accreditation Council for Graduate Medical Education (ACGME) issued new standards for trainee duty hours including the 80-hour work week and required rest periods (3). The ACGME work group acknowledged that the inevitable void of hours covered by trainees warranted new strategies of staffing and teaching. Growth in the fields of advanced practice providers (APPs) including nurse practitioner and physician assistants has occurred in parallel to the reduction in trainee coverage. One survey of adult ICUs found APPs provided care in 72% of units. Of pediatric nurse practitioners surveyed, the most frequent area of practice was in critical care units and has grown from 27.5% in 2009 to 35% in 2014 (4, 5). The implications of changing complements of medical providers in the PICU for patient care and education are not fully understood.
In this issue of Pediatric Critical Care Medicine, Foster et al (6) report a comprehensive review of the literature on ICU staffing models and strove to describe the impact of APPs on patient outcomes and on trainees’ experience. Although Foster et al (6) aim to address the pediatric audience, their review encompasses both adult and pediatric data. Their review captures publications after 2002 in the era of ACGME limited trainee hours and shiftwork. We commend the authors for this thorough review as the rapidly changing landscape of ICU care necessitates improved understanding of the impact of our staffing decisions.
The authors described the impact of mixed staffing models of APPs and physician trainees on patient care, education, and trainee experiences. It appears that the addition of APPs to ICUs leads to similar or improved patient outcomes. Readmission rates, mortality, and ventilator days are unchanged, whereas some studies demonstrated decreased lengths of stay. Physicians, nurses, and APPs perceived improvements in daily operations and effective teamwork. Physicians have reported reduced workload with the addition of APPs. These findings reassure us that increasing complexity and diversity of staffing does not worsen patient care and may in fact improve patient care. Concerns of competition between disciplines of APPs and physician trainees do not bear out and indeed are countered by improved workload distribution.
However, the addition of APPs is not always rosy. On the contrary, one study found that the addition of nurse practitioners did not lead to a perception of improved doctor and nurse collaboration (7). This nuance may suggest that although collaboration is improved at the APP to physician level, relationships with frontline nursing staff are less influenced by APPs than hoped. Educational needs of APPs and trainees are also ripe for improvement. Although the addition of APPs may allow more time for trainee education, some data were concerning in that APPs actually interfered in trainee education (8). Not only may APPs suppress trainee education but also APPs similarly reported unmet educational need (9). Foster et al (6) focused on the impact of the introduction of APPs to physician trainee education, but as we onboard more and more APPs in pediatric critical care, their career development needs must also be met. Training institutions will need to bridge the silos of physician and nursing education toward a common goal of training competent critical care practitioners.
The most surprising finding was in the perceptions of an APP’s level of competency and contribution to education.

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