Outline. Advanced Practice Providers in the Intensive Care Unit. Why utilize APPs in the ICU? 5/30/2013

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1 Outline Advanced Practice Providers in the Intensive Care Unit Thomas Farley MS, NP Assistant Clinical Professor UCSF School of Nursing Why utilize APPs in the ICU Recent publications General review of NP practice requirements Our NP experience at UCSF and SFGH General review of billing for APP critical care services Why utilize APPs in the ICU? Imbalance in the supply of and the demand for intensivists Team based approach to care delivery It is taking place in the USA, Canada, and the UK already The literature shows it is safe, effective, and more human than a robot Garland A, Gershengorn HB. Staffing in the ICUs: physicians and alternative staffing models. Chest; 2013; 143(1): Kapu AN, Thomson-Smith C, Jones P. NPs in the ICU: the Vanderbilt initiative. Nurse Pract. 2012; 37(8): Butler KL, Calabrese R, Tandon M. Optimizing advanced practitioner charge capture in high acuity surgical intensive care units. Arch Surg. 2011; 146(5): Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36(10): Gracias VH, Sicoutris CP, Stawicki SP, et al. Critical care nurse practitioners improve compliance with clinical practice guidelines in "semiclosed" surgical intensive care unit. J Nurs Care Qual. 2008;23(4): Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006;26(1):9-17. Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med. 2003;31(12):

2 Recently published Gershengorn HB, Wunsch H, Wahab R, et al. Impact of non-physician staffing on outcomes in a medical intensive care unit. Chest. 2011; 139(6): Columbia Presbyterian Medical Center Retrospective review of two ICUs Patients managed by NP/PA team had no worse outcomes NPs in Critical Care or Trauma Memorial Sloan Kettering Cancer Center Columbia University Henry Ford Hospital Detroit Cleveland Clinic UC Davis California Pacific Medical Center UCSF/SFGH Medical Centers Oregon Health Sciences University Nurse Practitioners RN with Masters or Doctoral degree National certification exam required CA mandates use of standardized procedures Independent licensure Eligible for DEA schedule 2-5 prescribing NPI for medicare/private billing NP Species Focus of education and national certification Acute Care: generally inpatient care Adult and Family: primary care Current recommendation by National Council of State Boards of Nursing is to restrict intensive care roles to acute care nurse practitioners 2

3 Our experience at UCSF Farley, TL, Latham, G. Evolution of a critical care nurse practitioner role within a US academic medical center. ICU Director. 2011; 2(1-2): Evolution of a NP practice At UCSF 76 adult critical care beds Limited amount of housestaff Goal of providing immediate critical care consultation 24 hours a day 4 NPs added in 2005 Currently15 NPs covering 4 ICUs At times no residents on team Evolution of a NP practice At SFGH level 1 trauma center Recognized need for quality control and improvement Added 4 NPs to service in 2001 Current environment of limited housestaff and work hour reductions Now 12 NPs in trauma/general surgery At times no interns on teams Experience at UCSF and SFGH Employed by hospital not by MD group Medicare part A not part B No independent billing performed Close contact with the UCSF SON 3

4 UCSF Critical Care ICU Attending MD ICU Fellow MD Resident MD Nurse Practitioner SFGH Surgery Surgical Attending Surgical PGY4/5 Surgical Intern Nurse Practitioner NP responsibilities Follow and teach standard ICU practices and protocols Quality standards and improvement Intervene and direct or provide appropriate initial therapy First call at UCSF and SFGH Overnight shifts at UCSF and SFGH 4

5 Critical Care NP Duties History taking and physical exams Entering admission histories and physical in to the EMR Entering daily progress notes into the EMR Writing admission orders and routine orders Independently performing procedures Rounding with the critical care team and presenting patients Implementing proven care bundles (sepsis, early mobilization, DVT prophylaxis) Critical Care NP Duties Consultative role to admitting services Consultative role to bedside RNs Guidance of house staff Responding to code blue activations Assisting with rapid response consultations Serving on hospital wide multidisciplinary committees Precepting acute care nurse practitioner students Attending morning teaching and monthly morbidity and mortality conferences NP Procedures Central venous catheter insertion PICC insertion Arterial catheter insertion Chest tube insertion Lumbar puncture Suture and drain removal Airway intubation RN First Assist for OR role Why it works It is essential to have appropriate conduits for collaboration and supervision Supportive attending MDs Buy-in from the ICU RNs NPs have experience as ICU RNs SON provides excellent job candidates Dedicated and professional group of NPs 5

6 NPP Billing in Critical Care Reference CMS transmittal #1548 nloads/r1548cp.pdf Services may be provided by qualified NPPs and reported for payment Unlike outpatients no incident to or shared visits allowed Billing in surgical critical care Painter, JR. Critical care in the surgical global period. Chest 2013;143(3): Trauma and burn patients are unique Medicare allows separate payment to surgeon for post op critical care during global period Billing in Critical Care Only one provider per day can bill for CPT 99291critical care eval and mgt 30-74min Follow-up after first 74min of services billable by MD or NPP using CPT each additional 30min of critical care That time must be spent at the bedside or elsewhere on the floor as long as the provider is immediately available Billing in Critical Care May be continuous clock time or intermittent time increments and aggregated Only one provider can bill for critical care services within an actual time period even if more than one provider involved More than one provider can provide critical care at another time and be paid 6

7 NP Billing in Critical Care For Medicare NP billing as hospital employees (part A) not allowed To bill Medicare NPs must be employed by clinical departments or groups For Medicare, reimbursement is 85% of published MD fee schedule NPs may be credentialed by private payor Private payors may reimburse up to 100% 7

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