Tag Archives: Physician Assistant

Procedural Complications: Residents vs Advanced Practice Providers

With the implementation of resident work hour restrictions 10 years ago, resident participation in clinical care has declined. In order to make up for this loss of clinical manpower and expertise, many hospitals have added advanced clinical providers (ACPs, nurse practitioners and physician assistants). These ACPs are being given more and more advanced responsibilities, in all clinical settings. This includes performing invasive procedures on critically ill patients.

A recent study from Carolinas Medical Center in Charlotte NC compared complication rates for invasive procedures performed by ACPs vs residents in a Level I trauma center setting.

A one year retrospective study was carried out. Here are the factoids:

  • Residents were either surgery or emergency medicine PGY2s
  • ACPs and residents underwent an orientation and animal- or simulation-based training in procedures
  • All procedures were supervised by an attending physician
  • Arterial lines, central venous lines, chest tubes, percutaneous endoscopic gastrostomy, tracheostomy, and broncho-alveolar lavage performances were studied
  • Residents performed 1020 procedures and had 21 complications (2%)
  • ACPs performed 555 procedures and had 11 complications (2%)
  • ICU and hospital length of stay, and mortality rates were no different between the groups

Bottom line: Resident and ACP performance of invasive procedures is comparable. As residents become less available for these procedures, ACPs can (and will) be hired to  take their place. Although this is great news for hospitals that need manpower to assist their surgeons and emergency physicians, it should be another wakeup call for training programs and educators to show that resident education will continue to degrade.

Reference: Comparison of procedural complications between resident physicians and advanced clinical providers. J Trauma 77(1):143-147, 2014.

PAs and NPs In Level I Trauma Centers

Trauma service staffing is important to maintaining trauma center status. Teaching centers in the US have been grappling with resident work hour rules, and non-teaching centers have always had to deal with how to adequately staff their trauma service. What is the impact of staffing a trauma center with midlevel practitioners (MLPs) such as physician assistants and nurse practitioners?

A state designated Level I trauma center in Pennsylvania retrospectively examined the effect of adding MLPs to an existing complement of residents on their trauma service. They examined the usual outcomes, including complications, lengths of stay, ED dwell times and mortality.

Here are the more interesting factoids:

  • ED dwell time decreased for trauma activations and transfers in, but it increased for trauma consults. Of note, data on dwell times suffered from inconsistent charting.
  • ICU length of stay decreased significantly
  • Hospital length of stay decreased somewhat but did not achieve significance
  • The incidence of most complications stayed the same, but urinary tract infection decreased significantly
  • There was no change in mortality

Bottom line: There is a growing body of literature showing the benefits of employing midlevel providers in trauma programs. Whereas residents may have a variable interest in the trauma service based on their career goals, MLPs are professionally dedicated to this task. This study demonstrates a creative and safe solution for managing daily clinical activity on a busy trauma service.

Reference: Utilization of PAs and NPs at a level I trauma center: effects on outcomes. J Amer Acad Physician Assts, July 2011.

PAs and NPs In Level I Trauma Centers

Trauma service staffing is important to maintaining trauma center status. Teaching centers in the US have been grappling with resident work hour rules, and non-teaching centers have always had to deal with how to adequately staff their trauma service. What is the impact of staffing a trauma center with midlevel practitioners (MLPs) such as physician assistants and nurse practitioners?

A state designated Level I trauma center in Pennsylvania retrospectively examined the effect of adding MLPs to an existing complement of residents on their trauma service. They examined the usual outcomes, including complications, lengths of stay, ED dwell times and mortality. 

Here are the more interesting factoids:

  • ED dwell time decreased for trauma activations and transfers in, but it increased for trauma consults. Of note, data on dwell times suffered from inconsistent charting.
  • ICU length of stay decreased significantly
  • Hospital length of stay decreased somewhat but did not achieve significance
  • The incidence of most complications stayed the same, but urinary tract infection decreased significantly
  • There was no change in mortality

Bottom line: There is a growing body of literature showing the benefits of employing midlevel providers in trauma programs. Whereas residents may have a variable interest in the trauma service based on their career goals, MLPs are professionally dedicated to this task. This study demonstrates a creative and safe solution for managing daily clinical activity on a busy trauma service.

Reference: Utilization of PAs and NPs at a level I trauma center: effects on outcomes. J Amer Acad Physician Assts, July 2011.

Physician Assistants And Nurse Practitioners In US Trauma Centers

The number of physician assistants (PAs) and nurse practioners (NPs) moving out of primary care to work in specialty areas in US healthcare is rising. Trauma programs in teaching hospitals have been affected by the work hour restrictions put into place 10 years ago. Non-teaching programs have been adding these midlevel providers to help balance workloads.

How common is the use of midlevel providers in trauma care? Nine-item surveys were sent to 464 designated or ACS verified trauma centers across the US. 

Here are the factoids:

  • The response rate was 53%, which is very good
  • It’s too bad that Level III and IV centers were excluded. There would have been some good data there.
  • About half were ACS verified trauma centers. Also, roughly half were Level I and half were Level II.
  • 35% used PAs, 33% used NPs, and 54% used residents. There was overlap in use.
  • ACS verified centers used midlevels more frequently than non-ACS centers (62% vs 41%)
  • Level I centers used them more than Level IIs (73% vs 53%)
  • Trauma centers with residents used midlevels more often than those without (66% vs 41%)
  • Midlevels were utilized for the traditional tasks of a surgical provider (H&P, discharge summary, rounds, trauma resuscitation, surgical assistant)
  • A third performed procedures like chest tubes, arterial and central lines
  • 19% of hospitals that did not use midlevels planned to start soon

Bottom line: Midlevel providers such as PAs and NPs are being used more and more frequently in trauma care. If you look at the graph, the inflection point happened just around the time of the new work hour rules. We use them at our trauma center, and they are very prevalent at the centers I have visited. These providers are valuable clinicians and their contributions to patient care should be embraced!

As a side note (opinion), the amount of trauma slowly grows with the population. And the number of “trauma hours” spent to take care of these patients is a zero sum game. This means that resident exposure to trauma must be decreasing as midlevel provider involvement increases. Physician training in trauma (and all other disciplines as well) is shrinking, but at least they’re not tired!

Related post:

Reference: Acceptance of physician assistants and nurse practitioners in trauma centers. JAAPA 23(1):35-41, 2010.

PAs and NPs In Level I Trauma Centers

Trauma service staffing is important to maintaining trauma center status. Teaching centers in the US have been grappling with resident work hour rules, and non-teaching centers have always had to deal with how to adequately staff their trauma service. What is the impact of staffing a trauma center with midlevel practitioners (MLPs) such as physician assistants and nurse practitioners?

A state designated Level I trauma center in Pennsylvania retrospectively examined the effect of adding MLPs to an existing complement of residents on their trauma service. They examined the usual outcomes, including complications, lengths of stay, ED dwell times and mortality. 

Here are the more interesting results:

  • ED dwell time decreased for trauma activations and transfers in, but it increased for trauma consults. Of note, data on dwell times suffered from inconsistent charting.
  • ICU length of stay decreased significantly
  • Hospital length of stay decreased somewhat but did not achieve significance
  • The incidence of most complications stayed the same, but urinary tract infection decreased significantly
  • There was no change in mortality

Bottom line: There is a growing body of literature showing the benefits of employing midlevel providers in trauma programs. Whereas residents may have a variable interest in the trauma service based on their career goals, MLPs are professionally dedicated to this task. This study demonstrates a creative and safe solution for managing daily clinical activity on a busy trauma service.

Reference: Utilization of PAs and NPs at a level I trauma center: effects on outcomes. J Amer Acad Physician Assts, July 2011.