W. Robert Grabenkort, PA, MMSc, FCCM
Historically a variety of caregivers and teams have been used to provide treatment for patients in cardiothoracic intensive care units (CT-ICU). In academic centers, medical coverage usually consisted of rounds most frequently occurring in the morning and late afternoon with residents and attendings. A resident either present in the ICU or available by telephone or pager elsewhere in the hospital--most often in the operating room--covered the periods of time between rounds. Night coverage was usually provided by in-house residents. In private practice, rounds were made by the attending surgeon, with problems between rounds communicated via pager. Emergencies such as intubations or cardiopulmonary arrests were attended by an in-house emergency room physician or anesthesiologist until the surgeon was available.
Outside Challenges
Today these types of practices are being challenged by several powerful outside influences. The Leapfrog Group, for example, is asking for 24/7, in-house medical coverage of the ICU by a qualified individual: either a physician or designee, who should be FCCS trained. Cardiothoracic surgery residents and fellows now have restricted hours and therefore restricted in-hospital time. Few institutions have adequate numbers of house staff to provide this level of care for all their ICUs. At the same time, ICU nurses are facing increased pressures and time demands because of staffing shortages and older patients with more complicated disease states. Clearly alternatives need to be established to meet these demands for medical supervision to eliminate gaps in patient care and to increase patient safety.
Physician’s Assistants (PAs) are viable alternatives to traditional physician ICU coverage. The PA profession has evolved since its inception in the late 1960s from primary care to most all clinical specialties. PAs are trained in accredited programs which have a physician as the medical director of the program and are taught by physicians during their training, particularly during the clinical phase. Within the scope of state law, policies of the institution, and delegation from the supervising physician, the PA is allowed to perform diagnostic and therapeutic interventions in the absence of the physician, who is available by pager or phone.
The mission of the PA in the CT-ICU is specifically to provide continuity of care for the patient. The PA acts as a liaison between primary physicians, consultants, house staff and the nursing staff to ensure the necessary communication between these groups and the implementation of coordinated patient care. The PAs in the CT-ICU work under the direction of a certified intensivist or a physician with equivalent qualifications and experience in surgical critical care such as an anesthesiologist or surgeon.
The Emory Experience
Approximately 25 years ago, the Department of Anesthesiology at Emory University Hospital (EUH) established a critical care service for the purpose of providing coverage of an 18-bed CT-ICU. The mission of this service, consisting of a team of two PAs and a varying number of anesthesiology residents, was to give close care and supervision to “open heart” and postoperative patients, thus allowing the surgical team to focus their efforts in the operating room. The critical care medicine (CCM) team would follow patients from admission to discharge from the ICU. Over the years this team has become an established entity as a reliable resource for continuity of care, and has been the model for other CCM teams in the Emory system.
Some initial resistance from the nursing staff was encountered, but in a short time this dissipated as nurses realized that PAs were not “competitors” and did not interfere with the nurse-physician or nurse-patient relationship. It was readily observed that PA presence provided an additional professional layer of responsibility to enhance patient care with a collegial relationship. This RN – PA relationship has been strengthened in most recent years with staff nursing and resident shortages compounded by a CT patient population that is elderly and pathophysiologically more complex than in the past, forcing all to work harder and more efficiently.
As a means of expediting efficient and therefore safer care, the PAs have been assigned the following clinical duties:
- - Participation in morning and afternoon rounds with attendings, house staff and pharmacy
- - Orientation of medical students and residents to explain protocols and procedures in the ICU
- - Airway management including intubation/extubation
- - Weaning patients from mechanical respiratory support
- - Placement of arterial, central venous and pulmonary artery catheters
- - Guiding pharmacologic management including inotropes, vasodilators, sedatives, antibiotics and others
- - Thoracentesis, chest tube placement
- - Intra-aortic balloon pump management including placement and removal
- - Placement of transvenous pacemakers
- - Cardioversion
- - Post-pyloric feeding tube placement
- - Establishing nutrition modalities
Practitioner Communication
Integral to the assurance of high-quality care in the ICU is communication among practitioner groups. As the CT surgical patient is, in general, older and has more co-morbidities than in the past, consultation with other subspecialty groups is often necessary. The CCM team is the common thread in the unit and the PAs, because of their daily presence, are useful in conveying information so that all groups have a unified plan for the best care of the ICU patient. This communication not only increases efficiency of patient care but decreases the problems of conflicting care plans which could jeopardize patient safety. This approach has been very effective in the CT-ICUs at EUH, providing a similar environment to the “closed” ICU concept.
This continuity of care must also be conveyed to the families of ICU patients. While this responsibility lies primarily with the CT surgeon and other attendings, the PAs are in an excellent position to offer frequent “bedside chats” with these families for updates in their relative’s condition. Again, accessibility, this time from the family’s viewpoint, is key to the perception of high-quality care and safety.
Using PAs in the CT-ICU offers potential cost containment for the hospital. Efficiency of care performed by experienced personnel decreases costs. PAs can be used to ensure efficiency by the implementation of protocols such as spontaneous breathing trials and daily removal from sedation at the correct time in the patient’s course. Because of the PA’s daily presence, transfers from the ICU are accomplished expeditiously or delayed for re-assessment preventing a possible return, based on a real-time clinical assessment.
Medicine, particularly critical care medicine, is facing many new challenges in the 21st century. Shortages of physicians and nurses present difficult problems with no immediate solution. At the same time, the public is demanding an increased level of staffing. The PA provides a viable, proven alternative to physician/house-staff intensive care models.