AcuteCareNurse Practitioners in Oncologic Critical Care: The Memorial Sloan-Kettering Cancer Center Experience

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1 AcuteCareNurse Practitioners in Oncologic Critical Care: The Memorial Sloan-Kettering Cancer Center Experience Rhonda D Agostino, ACNP-BC a,b, *, Neil A. Halpern, MD c,d KEYWORDS Acute care nurse practitioner Nurse practitioner Intensive care Critical care Oncologic intensive care Physician alternative Reductions in the number of residency positions, restrictions on residency work hours, expansion of an aging population, and requirements to meet the Leapfrog critical care medicine (CCM) criteria have highlighted a deficit in CCM physician staffing. 1 7 Nurse practitioners (NPs) and physician assistants (PAs) are being used to fill the intensivist void in the intensive care unit (ICU). 4,8 11 NP and PA programs were originally developed in the 1960s to provide outpatient primary care and pediatric services. 10 Subsequently, in the early 1990s, the role of these nonphysician or midlevel providers was expanded to include inpatient care in the ICU and non-icu settings. 12 The predominance of the medical literature shows that the NP and PA groups have had a positive impact on patient care and outcomes, throughput, implementation of care guidelines, and cost control in each environment a Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C1179, New York, NY 10065, USA b Critical Care Nurse Practitioner Program, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C1179, New York, NY 10065, USA c Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C1179, New York, NY 10065, USA d Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA * Corresponding author. Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C1179, New York, NY address: bruynr@mskcc.org (R. D Agostino). Crit Care Clin 26 (2010) doi: /j.ccc criticalcare.theclinics.com /09/$ see front matter ª 2010 Elsevier Inc. All rights reserved.

2 208 D Agostino & Halpern where they have practiced, including the ICU. 4,13,14 There is no consensus, however, on how to incorporate the NPs or PAs into the multidisciplinary CCM team or on how to provide the enhanced training that these groups require to provide care in the ICU. 4,15 In this article, we describe the development and function of our CCM NP program in the 20-bed, closed, mixed medical-surgical adult ICU of the Memorial Sloan-Kettering Cancer Center, a 435-bed, tertiary care oncology center in New York City. Currently, CCM NPs, in addition to house staff trainees and CCM fellows, provide full-time comprehensive ICU patient care as well as consultative and rapid response team (RRT) services outside the ICU (Box 1). The NPs function as physician alternatives in collaboration and under the direction of the CCM attending physician group. 12 Box 1 CCM NP responsibilities Patient care Obtaining histories Performing physical examinations Participating in daily clinical rounds Ordering and interpreting diagnostic tests Prescribing and adjusting medications Performing/supervising invasive procedures Managing mechanical ventilation Documenting procedures and progress notes Assessing patients for changes in clinical status Stabilizing new ICU admissions Formulating plans of care with CCM attending Participating in multidisciplinary rounds Coordinating services with other teams Communicating with patients and families Consultative and RRT Providing critical care consultation and follow-up First responders for the institution s RRT Participate as a team member in medical codes Coordinate ICU admissions and discharges Teaching Provide support and education to clinical nursing staff Precept students (NP and medical) Data control, quality improvement, and research Maintain and update the CCM census database Record patient data on daily CCM care bundles Perform and participate in quality or performance improvement activities and clinical research

3 Critical Care Nurse Practitioner Program 209 CONCEPTION, DESIGN, AND IMPLEMENTATION OF THE CCM NP PROGRAM Historically, our ICU patients were cared for by anesthesiology and internal medicine house staff with CCM fellow and attending supervision. During the planning steps for our ICU expansion from 12 to 20 beds it became apparent that additional house staff or physician alternatives would be required. However, additional house staff were not available or necessarily wanted, thus the physician alternative model with NPs and PAs was explored. We recruited both NPs and PAs but elected the NP, rather than the PA, approach for 3 reasons. First, the NP program was far larger and more developed in our hospital. Second, we thought that NPs who had already worked in the critical care setting as registered nurses (RNs) would not only be more experienced than PAs but would also be easier to train and more attuned to the nuances of CCM practice. Third, the NPs were willing to work nights and weekends, whereas the PAs were not so inclined. As we considered governance paradigms, it was evident that the existing nursing organizational structure in our institution where NPs report directly to nursing leadership would be incompatible with our goals of a direct expansion of the CCM physician team We felt that the fostering of a close and direct collaborative relationship between the CCM physicians and NPs would be inhibited by the existence of separate and potentially conflicting obligations to the nursing department. In addition, we felt that nurse managers, although well experienced in addressing staff nurse issues, were not suited to develop the educational programs for the new NPs or to evaluate their medical decision-making skills. 8,16 Therefore, we devised a joint governance model where the Department of Anesthesiology and Critical Care Medicine would direct the education, training, clinical supervision, scheduling, and discipline of the new CCM NPs, and the Department of Nursing would govern financing, administrative supervision, and credentialing (Fig. 1). RECRUITMENT In the fall of 2006, recruitment efforts commenced with the goal of establishing an NPstaffed CCM team (11 NPs) by April 2007 when the new and larger ICU would open. Fig. 1. CCM NP reporting structure. The CCM NP Coordinator directly reports to the Service Chief of CCM and the NP Clinical Program Director. The NP Coordinator also collaborates with the Department of Nursing through the Director of CCM Nursing. The CCM NP Coordinator functions within the nursing governance at the same level of a nurse manager.

4 210 D Agostino & Halpern Prior critical care (ICU, PACU, ED, Step-down) experience as either an RN or an NP was considered a prerequisite for employment as well as (Fig. 2) a master s degree in nursing, specialty certification from a national NP certifying body (ANCC, American Nurse Credentialing Center; AANP, American Academy of Nurse Practitioners; and AACN, American Association of Critical Care Nurses), and New York State licensure. Although there are many NP educational tracks (acute care, adult primary care, psychology/mental health, family, gerontological, pediatric, and neonatal), we sought NPs who were ACNP (acute care nurse practitioner) trained because of their concentrated exposure to didactic and clinical critical care medicine. 4,11,14,19,20 We looked for a pioneering mindset among the applicants that would indicate a willingness to take a chance on a job opportunity within an uncharted role and practice environment. Candidates who were self-directed, resourceful, and ambitious or who had demonstrated leadership qualities were hired. We recognized that this new program would have growing pains, and therefore, would need hardy, resilient individuals equal to the task. Interviews were conducted by 2 CCM attendings and the NP Clinical Program Director. Despite pessimism about the feasibility of finding 11 qualified candidates even within 1 year, 10 NPs were hired within 6 months. This indicated to us that there was a pool of NPs eager to step forward into CCM. Subsequently, an additional 10 NPs were hired and a program coordinator selected, as further responsibilities were placed on the CCM team and the house staff complement continued to diminish. TRAINING The new NPs underwent a custom designed 3-month CCM formal educational training program (Box 2). Daytime and evening lectures were conducted by a CCM attending to accommodate all NP shifts. On rounds, the CCM attendings focused on developing NPs case presentation skills and helped them learn to organize and prioritize the care Fig. 2. Different career tracks starting from RN to NP. Our preference (bold arrows) is ACNPs with prior ICU nursing experience. Alternatively, if the applicant had NP experience we preferred NPs with ICU experience; however there are few such candidates.

5 Critical Care Nurse Practitioner Program 211 Box 2 CCM NP training course curriculum Admissions and discharges Admission process Distinguishing medical and surgical problems and needs Order writing by protocol Discharge process Critical care medicine consults Clinical Chest radiograph interpretation ECG interpretation Ventilator management Noninvasive positive pressure ventilation Fluid resuscitation Antibiotics selection Multiorgan failure Continuous renal replacement therapy Shock states and vasopressors Prophylactic regimens Acute coronary syndromes and arrhythmias Sedation regimens Delirium management Common ICU emergencies Postoperative care and common surgical procedures Devices Venous and arterial catheters Airways Chest tubes and drainage systems What to do when devices fail CCM information systems Data-tracking program Hand-offs between teams and shifts Care bundles: ventilator-associated pneumonia, central venous catheter CCM template notes Consultation/RRT notes Daily progress notes Procedure notes

6 212 D Agostino & Halpern of patients with complex and multiple active medical and/or surgical problems. Mannequins (Fig. 3) were acquired to teach insertion techniques for central venous and arterial cannulation. When proficient in the simulation classroom, the NPs were directly supervised in catheter insertion by CCM fellows and attendings. Airway skills and ventilator management were likewise taught using mannequins (Fig. 4) and through biweekly hands-on ventilator workshops. The CCM NPs were sent to the operating rooms to enhance their intubation experience in real life. While in the operating suites, the NPs were also assigned to observe designated types of surgical procedures typical of ICU admissions and to recognize the potential postoperative problems associated with them. Being in the operating rooms had the added benefit of developing collegial relationships with the anesthesiology and surgical teams. Advanced training modules in imaging (ultrasonography and computed tomography) and electrocardiogram (ECG) interpretation were offered to experienced NPs. Multiple educational approaches were used for this intensive NP training regimen. These included the traditional didactic lecture format, interactive small group sessions and role-playing, and advanced media tools, such as the SMART board (SMART Technologies ULC, Calgary, Alberta, Canada). A multimedia critical care web site with various self-directed learning options was developed. The web site includes podcasts of daytime lectures, a repository of required reading articles, and links to other educational web sites. All NPs took the Fundamental Critical Care Support (FCCS) course offered by the Society of Critical Care Medicine. This course teaches basic critical care principles for the non-intensivist health care provider. NPs also attended formal simulation training in a local simulation center with a focus on code management, emergency airway skills and team building. DIVISION OF LABOR The CCM service functions daily with 3 teams: house staff, NP, and consultative/rrt (Fig. 5). No distinctions are made between house staff and NP ICU admitting teams when triaging ICU admissions, although our original intent was to select patients with Fig. 3. Central venous catheter (CVC) insertion. (A) Using a mannequin and full sterile preparation, NPs learn to insert a CVC. Arterial catheter insertion is similarly taught. The mannequin has different color fluids in its vessels and arterial pulsation to differentiate between central venous and arterial structures. (B) Once the NP is comfortable with the technical aspects of catheter insertion, they are taught how to use ultrasonographic guidance.

7 Critical Care Nurse Practitioner Program 213 Fig. 4. Airway (A) Intubation training on an airway mannequin. (B) Direct observation of the airway tree and lungs for manually insufflating air after correct ET placement. lower acuity for placement on the NP service We strove to maintain an equal census between the 2 admitting teams. Hence, the CCM NP service is usually responsible for 10 beds, and each NP manages 3 to 4 patients. Because the house staff allocation continued to decrease, NPs were integrated into the house staff team to supplement coverage. The CCM NP role inside the ICU includes presenting in morning and evening rounds, managing complex critical patients, performing and supervising procedures (arterial and central venous catheters, intubation, and thoracentesis), and meeting with families (see Box 1). NPs also staff the CCM consultative/rrt service around-the-clock in conjunction with a CCM fellow. The consultative/rrt service evaluates new consults for ICU admission, follows up ICU discharges and rejections, and handles ventilator management outside the ICU. The NPs of this service serve as first-responders to RRT and code calls, determine in consultation with the CCM fellow if the RRT call must be elevated to a CCM consultation, and work with cardiology in handling acute coronary syndrome cases. Fig. 5. Pathways of the CCM service. The CCM service cares for patients inside the ICU (house staff and NP teams) and outside the ICU. The house staff team is staffed with anesthesiology interns, NPs, and a CCM fellow. Fellows periodically rotate on the NP team. The consultative and RRT work is divided between the CCM fellows and NPs. A CCM attending directs each of the 3 teams.

8 214 D Agostino & Halpern REPORTING STRUCTURE AND MANAGEMENT The NP team is managed by an NP Coordinator who reports directly to the CCM Service Chief (see Fig. 1). The NP coordinator is at similar rank to nurse managers, attends nursing administrative meetings and serves as a liaison between the CCM NP group and the Department of Nursing via a direct reporting relationship with the hospital s NP Clinical Program Director. Similar to physicians with administrative duties in our hospital, the NP Coordinator continues to have clinical responsibilities. TRANSITIONING Our NPs faced personal challenges when transitioning from previous roles as bedside nurses or nurse practitioners to CCM NPs. 21,22 Day to day activities including formal rounds presentations, rapid review and assimilation of extensive medical records, and performing procedures were foreign to the incoming NPs. Additionally, the change from being a facilitator of care to becoming an independent CCM provider and thinker fostered insecurities with their clinical practice, role development, and autonomy. Similarly, the shift from being primarily a source of comfort and support at family meetings to becoming an active clinical contributor was a major role adjustment. There was also occasional resistance from the bedside nursing staff to comply with NP orders. Our nursing and physician teams were not accustomed to dealing with CCM NPs. The CCM physicians were also concerned about the NPs knowledge and clinical capabilities and were uncertain about the NPs skill set in dealing with patients and family members and addressing end of life care. 19,23 28 Fortunately, with extensive training and time, as well as increasing familiarity and trust, these issues have largely resolved. For the NP transition to be successful, the CCM program must recognize that the CCM NPs are not doctors. NP schooling is much shorter and less comprehensive than physician education and training. NP approaches to critical thinking and problem solving are also different then those of doctors. Thus, the onus is upon the CCM program to create the environment and educational curriculum for the NPs to thrive. COMMUNICATION Excellent communication skills are crucial for working successfully in the ICU environment. The CCM NP must deal with diverse circumstances, including coordination of care between multiple teams, speaking with the families of ICU patients, and addressing EOL issues. 29 CCM NPs in their coordinator of care-roles 30 in the ICU constantly interact with admitting and consultative services. When all parties are in agreement with the diagnosis and care plan, this task is straightforward; however, when conflicts in diagnosis or management emerge, interactions may become frustrating and difficult. Disagreements between the ICU and admitting services may be legitimate and develop because of differences in opinion. Alternatively, disputes may be secondary to uncommunicated deviations from the agreed-upon care plan, loss of order writing control by the primary team within the closed ICU environment, and disappointment in unanticipated complications and poor outcomes. Regardless of the cause, it is essential that the CCM NPs maintain decorum and equilibrium in navigating these situations and foster a unified health care team approach to treatment, patients, and their families. The physician-patient relationship may be even more important for oncology patients than other patients because of the insidious nature of cancer and the fear

9 Critical Care Nurse Practitioner Program 215 associated with cancer and its therapies. Thus, patients with cancer and their families usually develop a bond with their primary oncologists or oncologic surgeons. This relationship becomes even more pronounced when the patient suddenly and unexpectedly becomes critically ill. Thus, CCM practitioners, including NPs, are challenged to quickly develop a close connection with the family members. In the oncologic setting in particular, families and providers may feel compelled to keep going even when the cause seems futile. This circumstance occurs especially if the patient is young and has received aggressive care in hope of a cancer cure or extension of life. Training the CCM NPs to recognize denial on the part of the clinician or family and to interact in complicated family dynamics requires extensive preparation and most of all, experience. The NPs must learn to deal with unrealistic expectations on the part of family members and admitting physicians. 31,32 Sometimes, even having EOL discussions may be discouraged by the admitting teams or the families, 33 thus presenting an ethical quandary to the CCM NPs who may feel that an inappropriately high level of care is being rendered. We provide the NPs with enhanced communication training through their mandatory attendance in a formalized communication skill workshop managed by the Department of Psychiatry where EOL discussion skills are developed and refined. NPs participate in videotaped simulation sessions with professional actors playing family members or other physicians. These interactions are then analyzed, and constructive suggestions are offered for a host of common EOL scenarios that range from giving bad news, to initiating and completing EOL discussions, and arranging palliative care and withdrawal of life-supportive therapy. EMOTIONAL SUPPORT Working in an oncologic ICU may be more emotionally draining than working in a standard ICU setting. Cancer mortality among the young is common. NPs are also faced with moral distress in recognizing that health care proxies often do not uphold advanced directives limiting care. 32 Thus, it is critical that the ICU and hospital provide psychological support to the NPs to prevent burn out. FUTURE DIRECTIONS We are now exploring billing for NP services (procedures and RRT calls) that are not currently billed by the CCM attendings. We are also developing a job description for charge NPs for each shift with responsibilities for oversight and direction of the junior NPs, scheduling, and advancing cohesiveness of the team. Finally, we are looking to create a post-np CCM fellowship training program. 4 SUMMARY Relatively little information exists about NP practice models in the adult ICU, let alone in an oncologic ICU setting. Our collaborative physician-np practice model governed primarily through critical care, provides a well-trained, highly functional NP team. The growth and transformation of this program has brought to light the challenges that may well be faced by other institutions seeking to cultivate their own CCM NP teams. It is our hope that this descriptive article of the development of our CCM NP group will allow others pursuing the same path to benefit from our experience.

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