APP Joan Kinniry (second from right), who over sees patient care in the MICU, rounds with members of the unit’s patient care team.
Advanced practice providers – specifically nurse practitioners and physician assistants – have been part of the health care environment for the last 50 years, but it’s only been in the past 15 years or so that their presence – and numbers – have dramatically shifted. Several key factors combined to create this upsurge. According to the Association of American Medical Colleges, the nation will face a shortage of between 46,000-90,000 physicians by 2025. And the Accreditation Council for Graduate Medical Education limited the hours a resident can practice within a 24-hour period. Both, experts say, would lead to gaps in care. Also, the Affordable Care Act increased health-care access to millions, and the move to value-based care demanded higher quality outcomes at a lower cost.
Based on these trends – as well as changes in reimbursements, clinical program growth, and evolving models of care – Penn Medicine has been experiencing its own rapid growth in advanced practice numbers. Today, more than 1,200s APPs (which include nurse practitioners, physician assistants, nurse anesthetists and nurse midwives) treat and manage patients in nearly every service and facility, both inpatient and ambulatory.
While a need to fill gaps in patient care may have fueled this upward trend, studies showing the positive impact that APPs have on patients. For example, a review of studies evaluating the impact of advanced practice nursing in the emergency and critical care settings showed that their involvement “improves the length of stay, time to consultation/treatment, mortality, patient satisfaction, and cost savings.” Another study – focusing on the primary care setting – suggested that “the APN workforce is well-positioned to provide safe and effective primary care.”
“There is clear and compelling evidence that APPs can drive outcomes that are critical in a value-based era,” said Regina Cunningham, PhD, RN, chief executive officer at the Hospital of the University of Pennsylvania (HUP).
Throughout Penn Medicine, APPs are the front-line providers on many patient-care units. They have overseen care on both trauma intensive care units at Penn Presbyterian since Penn Medicine’s Level 1 Trauma Program moved there in 2015. At HUP, they are in the in-house clinicians for several acute care services, including hematology-oncology, medical critical care, advanced lung disease, cardiac surgery, and neurosurgery.
In addition, “nurse practitioners, physician assistants, and midwives are integral members of care teams on virtually every surgical – and many of the medical services – at Pennsylvania Hospital,” said Rhoda Sulzbach, MSN, CRNP, the hospital’s director of Advanced Practice Providers, adding that OB/GYN and Palliative Care recently expanded their APP teams to meet the growing demands and needs of the service lines and their patients.
APPs also play key roles as educators. An APP-led procedure service at HUP provides consults on many types of bedside procedures including lumbar punctures, central venous catheter placement, and para- and thoracentesis (removing fluid from the abdomen and chest cavity, respectively). “This is the only such service led by an advanced practice provider in an academic medical center,”said Joan Kinniry, MSN, ACNP-BC, AP manager in HUP’s new medical ICU who developed this service with William Schweikert, MD, the medical director of the service. In addition to providing procedural support, this team of providers participates in critical care outreach and responds to clinical emergencies across HUP overnight.
To ensure a standard level of excellence in performing bedside cardiac ultrasounds (echos) in PPMCs trauma ICUs, nurse practitioner Ng Niu, CRNP, and trauma surgeon Niels Martin, MD, developed a monthly conference to educate both APPs and fellows. At each session, an APP and fellow jointly do an echo case presentation and receive real-time feedback from a from a board-certified echo physician. “Each of us has become more confident in our echo skills,” said Jason Saucier, MSN, CRNP, manager of Surgical Critical Care Advanced Practice Providers.
One of the unique ways Penn has positioned itself to meet the growing demand for highly trained APPs was to develop a post-graduate training program in critical care. This highly competitive program is in its fourth year and admits four APPs per year who elect to spend 12 additional months rotating between all of the ICUs at HUP and Trauma’s ICU at PPMC.
Within the health system, Kinniry said the effect on patient care when APPs are included echos the research, and organizations are responding by cementing their place in the health care environment.
“Healthcare is changing right in front of us and APPs are well positioned to drive value across our organization,” said Corinna Sicoutris, MSN, CRNP, director of Advanced Practice at HUP. “In the past three years, the number of APPs at HUP alone has grown 221 percent. Any conversation we have about opening a new unit, expanding a model of care, etc., involves a dialogue about the role of APPs in that setting.”