Pros and cons, and an analysis of the current literature on staffing models
I work at a center that provides 24 hour cardiac surgery physician assistant coverage. During the day, one of a group of 4 or 5 intensivists (not exclusive to cardiac surgery) rotate through, a week at a time. The surgeon on call makes rounds in the morning in the ICU, and in the afternoon on the step down unit. Other than that, we are a consistent group of 14 physician assistants, and one nurse practitioner that is always here. At night, everyone else goes home, yet we remain. Whether it be with advance practice providers, intensivists, surgeons, house staff, or a combination of all these groups, I think many practices are heading in the direction of 24 hour coverage, in order to provide full time care for our patients. There are several pros and cons associated with running a CVT service with non-physician providers and, unfortunately, a study of the associated literature doesn’t provide the guidance our field wants on what the best staffing model may be.
Since this is the life I live, I know many of these pros and cons first hand. In having 24 hour coverage, there is a provider immediately at the bedside to deal with emergencies. I have been in several scenarios where I’m sure that if the patient had to wait for someone to arrive from home, he or she wouldn’t have made it. In addition, being at the bedside throughout the night allows patients to be progressed even in the overnight hours. This improves ICU hours, and cuts down on length of stay. The advantages specific to using PAs and NPs for this coverage means there is, often, more consistent staff. Residents and house staff rotate through services, and may not become experts in the way that stationary providers will. We all know that consistent staff adhere to consistent procedures and protocols, such as hand off practices. Better hand off practices, in turn, decrease errors in patient care.
Although there are many benefits to providing 24 hour coverage, there are associated cons to this model, many of which relate to staffing itself. Obviously, if a service requires PAs and NPs to be in house all the time, many more practitioners are needed to provide adequate staffing. When a facility uses this model over house staff, it does come at an increased cost to the hospital. We cost significantly more than residents and medical students, although we would argue that we come with much more practice and knowledge of the field of cardiac surgery than someone in training. Along these lines, proponents of a model using physicians, residents, and medical students, sometimes argue that since PAs and NPs have less schooling, we have less training on how to provide potential differential diagnoses when there is a patient problem. We can’t deny the fact that we have less training, although we combat that at my facility with good resource utilization. There is always someone to call to get extra guidance. Perhaps one of the most important things to look at is physician assistant burnout. We provide a great service to our patients by being experts in our field. At the same time, being in a fast paced ICU, where extremely sick patients are the norm, there is often little thanks, little recognition of the stress we are constantly under to perform, or any outlet for the horrible things we frequently witness.
In preparing this piece, I did a lot of research to determine what the literature says is the best staffing model. I read pieces on medical ICUs, and cardiac ICUs. I found a lot of conflicting data. Several papers say that 24 hour coverage intensivist coverage provides better outcomes. I read several other papers stating that it didn’t make a difference. The American Thoracic Society just released a paper saying that over night intensivist coverage did not reduce ICU patient mortality, although, many of the studies in this meta-analysis were observational. There is also a lot of discussion regarding open versus closed units. Again, some papers say a closed unit provides better outcomes, while other papers say it makes no difference. The surgeons that started our practice almost 40 years ago believed in the physician assistant model, and our program has functioned that way ever since. Granted, we have adapted as times have changed, and now share some responsibility with our intensivists. Optimally, we function in conjunction with them, offering our surgical experience, and excellence in resuscitating those in cardiogenic shock, while they offer more detailed knowledge of things like ventilator weaning, and appropriate antibiotics. Pros and cons aside, perhaps in time, research will show that a hybrid of intensivists and experienced PAs, or NPs will provide optimal care for an increasingly sick and complex patient population.