Running head: NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 1

Impact of Nurse Practitioners in the Intensive Care Unit on Length of Stay and Mortality

Jennifer Leuzinger

University of Central Florida

NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 2

Abstract

The need for safe and effective critical care providers continues to grow in response to the aging

population, intensivist shortages, and budget constraints. An integrated literature review was

conducted in order to investigate the outcomes of intensive care unit (ICU) length of stay (LOS)

and in-hospital mortality with a nurse practitioner as an adjunct provider compared to the

facility’s standard ICU providers. Research articles were selected for review by use of the

following search engines; CINAHL, MEDLINE, The Cochrane Central Register of Controlled

Trials, and The Cochrane databases of Systematic Reviews (CDSR). Five articles were included

in the review. Four of the articles included in-hospital mortality as an outcome and four

examined ICU LOS. Two resulted in statistically significant improvements in ICU LOS with the

inclusion of an acute care nurse practitioner (ACNP) as an adjunct provider, and one resulted in a

significant decrease in in-hospital mortality when ICU care included an ACNP. Only one of the

studies did an exceptional job maintaining homogeneity between the intervention group and the

comparison group. Further research is needed in order to develop extensive orientation and

training programs for ACNPs to promote their safety and efficacy in the ICU, however at this

stage in the research there is no evidence of a drawback to adding ACNPs as adjunct providers in

the ICU.

Keywords: acute care nurse practitioner, critical care, in-hospital mortality, intensive care

unit, length of stay

NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 3

Impact of Nurse Practitioners in the Intensive Care Unit on Length of Stay and Mortality

Introduction

The Affordable Care Act (ACA) was a catalyst for restructuring the healthcare delivery

model with the goals of perpetuating efficiency and promoting fiscal responsibility. The

intensive care unit (ICU) within the hospital is responsible for almost 25% of the total budget

(Dogra & Dorman, 2016). Due to the more stringent limitations on medical residents’ hours and

the disproportionate increase in the number of critically ill patients (Gershengorn et al., 2011), a

significant deficit in critical care providers has developed.

Although there are many negative perceptions towards the ACA in regards to outcome-

based reimbursement and bundled payment plans, this act promoted systemic increased fiscal

awareness, as well as aided in the development of new health care delivery models (Dogra &

Dorman, 2016). In regards to cost-effectiveness, the ICU is responsible for a significant amount

of the hospital’s total budget. However, only about ten percent of services provided are deemed

critical care, ranging anywhere from $2000 to $3000 per day (Dogra & Dorman, 2016).

Due to the restrictions on hours by the Accreditation Council for Graduate Medical

Education (ACGME) (Costa, Wallace, Barnato, & Kahn, 2014) combined with the increasing

prevalence and costs associated with managing chronic illness (Department of Health and

Human Services, 2009) and the shortage of intensivists (Angus, Kelley, Schmitz, White, &

Popovich, 2000) there is a very high need for healthcare delivery remodeling in the critical care

environment. Thus far, there have been adequate studies demonstrating the benefits of nurse

practitioners in the acute care environment, but in regards to critical care the research available

regarding efficacy and safety is much less robust (Gershengorn et al., 2011).
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 4

A systematic review by Newhouse et al. (2011) demonstrated that advance practice

nurses (including clinical nurse specialists, clinical nurse leaders, clinical educators, and nurse

practitioners) are capable of reducing the physician deficit while providing high-quality effective

patient care. A retrospective comparative study with the primary outcome of 30-day readmission

rates done by David, Britting, and Dalton (2015) compared the cardiac ICU team with and

without an acute care nurse practitioner (ACNP) and resulted in a significant reduction in 30-day

readmission rates by more than 50%; 28.9% for the control group and 13.8% for the ACNP

group [[chi]2(1, N = 185) = 6.454, P = 0.011]. This significant outcome supports that the stable

presence of an ACNP on a high acuity unit will allow for enhanced communication between staff

members and patients and the development of relationships that will aid in facilitating the care

for these complex patients (David et al., 2015).

Due to the mounting critical care physician deficits, the advanced aging population

increasing the need for beds in the ICU, and the call for healthcare delivery remodeling, research

on the efficacy of nurse practitioners within the ICU needs to become a priority. The purpose of

this review is to evaluate in critically ill adult patients on the ICU, how does the integration of

nurse practitioners, as compared to those units that do not have nurse practitioners, impact ICU

length of stay (LOS) and in-hospital mortality?

Methods

A thorough search was conducted to find relevant research articles related to the impact

of ACNPs in the ICU. Database sources included CINAHL, MEDLINE, The Cochrane Central

Register of Controlled Trials, and The Cochrane databases of Systematic Reviews (CDSR).

The following search terms were used across all of the databases; (MH "Acute Care") OR

"acute care" OR "ICU" OR (MH "Intensive Care Units") OR (MH "Critical Care Nursing") OR
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 5

"intensive care" or "critical care" ) AND "Nurse practitioner*" OR (MH "Nurse Practitioners")

OR (MH "Acute Care Nurse Practitioners") OR (MH "Emergency Nurse Practitioners") OR

(MH "Adult Nurse Practitioners") OR (MH "Gerontologic Nurse Practitioners") OR ARNP* OR

NP*) AND "length of stay”.

Articles were included if there was a nurse practitioner involved in direct patient care in

the critical care environment with measureable outcomes of either ICU LOS or in-hospital

mortality. Only database articles written in the English language were included in this review.

Articles were excluded if the population age was stated to be less than 18 years old, the study

was conducted outside of the United States, and if it was a dissertation/thesis.

Results

Search Results

A total of 124 research articles were identified. During the review process it was found

that 75 of the articles did not satisfy all of the inclusion criteria. Of the 49 remaining articles,

fourteen only had an abstract available and ten were excluded due to significant reported

differences between the populations of the control and intervention group. Twenty-five articles

were critically appraised using these three general questions for critical appraisal recommended

by Melnyk and Fineout-Overholt (2015): What are the results, are they valid, and are they

helpful in regards to patient care?

Following the critical appraisal, five articles were deemed valid, reliable, and applicable

and were included for the purpose of this review. The articles were published between 2002 and

2016 and all five employed quantitative research methods. An evidence table (see Appendix)

was used to outline each of the articles. The levels of evidence for the primary research articles

are level IV according to the Rating System for the Hierarchy of Evidence
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 6

Intervention/Treatment Questions (Melnyk & Fineout-Overholt, 2015). A results table (see Table

1) was created to highlight the primary studies and the outcomes of interest.

Table 1 - Primary studies – outcomes of interest

Primary study Design; Characteristics of Results

level of evidence; intervention
sample N
(2014) Costa, Wallace Cohort Study Nurse practitioner integrated In-hospital mortality
Barnati, & Kahn Level IV as adjunct provider during 13.7%, (p = .10)
N = 30,254 the weekdays (not specified)
on medical and mixed
medical critical care units.
(2011) Gershengorn et Cohort Study Acute care nurse practitioner In-hospital mortality
al. Level IV integrated as an adjunct 32.1% (p = .96)
N = 302 provider following 2- 4
weeks training from 7a – 7p ICU LOS
on a medical critical care 4.22 + 2.51 days (p =.59)
unit.
(2005) Hoffman, Cohort Study Acute care nurse practitioner In-hospital mortality
Tasota, Zullo, Level IV integrated as an adjunct for 8 10.4% (p = .89)
Scharfenber, & N = 250 – 10 hours Monday – Friday
Donahoe on a subacute medical critical ICU LOS
care unit. 10 (5 – 19 IQR) (p = .42)
(2016) Landsperger et Cohort Study Acute care nurse practitioner In-hospital mortality
al. Level IV integrated as an adjunct after 10% (p < .001)
N = 2,366 10 months training for 24
hours a day on to a medical ICU LOS
critical care unit. 3.4 (3.2 – 3.5 IQR) (p < .001)
(2002) Russell, Cohort Study Acute care nurse practitioner ICU LOS
VorderBruegge, & Level IV integrated as an adjunct Displayed in bar graph –
Burns N = 402 during implementing the significant decrease
outcomes-managed model of with p < .001
care delivery for at risk
patients on a neuro-surgical
critical care unit.

Methods

Three of the five studies obtained baseline data for comparison by means of retrospective

collection via the hospital’s electronic medical record (EMR) (Costa et al., 2014; Gershengorn et

al., 2011; Russell, VorderBruegge, & Burns, 2002). The other two studies were done
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 7

prospectively and gathered data for the intervention and control group either in a repeated

measures style with seven-month blocks of time on the same unit or simultaneously (Hoffman,

Tasota, Zullo, Scharfenberg, & Donahoe, 2005; Landsperger et al., 2016). The prospective

approach used in the latter two studies decreased the risk of variability within the ICU

environments between the control group and the intervention group.

Lower acuity for the intervention group with the nurse practitioner was determined by

number of patients on vasopressors, patients requiring mechanical ventilation on ICU admission,

or by the lower Acute Physiology Score (APS); this was noted in two of the studies and has an

impact on the interpretation of the results (Costa et al., 2014; Landsperger et al., 2016). Despite

the lower acuity level seen in those two studies, one of them reported higher patient-provider

ratios (Landsperger et al., 2016) and the other study resulted in no difference being found in the

relative risk of death after being adjusted for patient covariates (adjusted relative risk, 1.10; 95%

CI, 0.92 – 1.31) (Costa et al., 2014).

Three of the studies used medical residents or critical care/pulmonary fellows as the

control group adjuncts (Gershengorn et al., 2011; Hoffman et al., 2005; Landsperger et al.,

2016). This allows for a more accurate comparison of the efficacy of nurse practitioners in the

ICU within teaching hospitals that employ residents and fellows. Four of the studies used an

ACNP in the intervention group (Gershengorn et al., 2011; Hoffman et al., 2005; Landsperger et

al., 2016; Russell et al., 2002). One of those studies involved six months of intense preparation

prior to the start of the study including didactic, procedural, simulation training, and was

followed by four months of directly supervised hands-on integration into the unit (Landsperger et

al., 2016). The methodology used by Landsperger et al. (2016) allows for direct inferences in

regards to ACNP care within the ICU and extends to 90-day survival.
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 8

Findings

ICU LOS. Four of the studies with a total of 11,118 patients reported either a primary or

secondary outcome of ICU LOS (Gershengorn et al., 2011; Hoffman et al., 2005; Landsperger et

al., 2016; Russell et al., 2002). Half of these studies used an ACNP for the intervention group

and resulted in a statistically significant decrease in ICU LOS, p < .001 (Landsperger et al.,

2016; Russell et al., 2002). However, in the other two studies, the difference in LOS was not

found to be statistically significant. The latter two included medical residents or critical

care/pulmonary fellows as adjuncts in the comparison group (Gershengorn et al., 2011; Hoffman

et al., 2005).

In-hospital mortality. In-hospital mortality was reported by four of the studies spanning

25 hospitals and 33 ICUs (Costa et al., 2014; Gershengorn et al., 2011; Hoffman et al., 2005;

Landsperger et al., 2016) Three of these studies resulted in no statistical significance in the

mortality rate between the standard hospital ICU team and the intervention group including the

nurse practitioner as an adjunct provider (Costa et al., 2014; Gershengorn et al., 2011; Hoffman

et al., 2005). However, the study done by Landsperger et al. (2016) did result in a statistically

significant decrease in mortality by the ACNP group of almost 6%, p < .001, compared to the

medical resident groups.

Limitations of the Evidence

Due to the variability in the methods and settings of these studies, generalizability of the

results should be guarded. Three of the studies included only medical ICUs (Gershengorn et al.,

2011; Hoffman et al., 2005; Landsperger et al., 2016). One study took place in a neurosurgical

ICU (Russell et al., 2002) and Costa et al. (2014) was the largest sample consisting of 29 medical

and mixed medical/surgical ICUs. None of these studies were randomized and only Landsperger
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 9

et al. (2016) had the ACNP cover the unit 24 hours a day, seven days a week. Two studies used

inexperienced nurse practitioners having just completed their programs (Gershengorn et al.,

2011; Hoffman et al., 2005) and only one of those studies provided 2 – 4 weeks training prior to

placing the nurse practitioner on the unit (Gershengorn et al., 2011). The Landsperger et al.

(2016) study reported lower acuity for the ACNP intervention group and attempted to account

for the difference in acuity level between the groups by using a multivariable and propensity

score analysis.

Discussion

The use of ACNPs continues to grow as a result of an aging population, intensivist

shortages, and budget constraints. Research on the safety and efficacy of the ACNP in the critical

care environment is an area that needs further investigation. Landsperger et al. (2016) and

Russell et al. (2002) resulted in a positive impact on ICU LOS with a significant decrease in days

for the patients managed by the ACNP group. This differs from the study done by David et al.

(2015) in which there was no statistically significant difference in ICU LOS, t183 = 0.726, p =

0.469. This study was a retrospective review evaluating the efficacy of an ACNP on a cardiac

ICU and interpreted this outcome, combined with the significant decrease in 30-day emergency

department visits and readmissions, as a success.

Since half of the studies included in this review evaluated the impact of the ACNP as an

adjunct provider in the ICU on ICU LOS resulted in fewer days spent in the ICU, it is possible

that further research into this ICU provider restructuring could expand to a reduction in ICU-

associated comorbidities and decreased hospital expenditures. In regards to in-hospital mortality,

only one of the studies resulted in a significant reduction in mortality while the other three

showed none. Overall, the inclusion of the ACNP as an adjunct provider on the ICU team did not
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 10

impact the number of critical care patients who died during their admission. The challenge with

interpreting these studies is the lack of homogeneity. However, these articles do provide

significant groundwork for future research.

The education of nurse practitioners encompasses both nursing and medicine and places

them at a greater advantage of being able to treat and manage patients through both spectrums,

allowing for the attainment of the much desired holistic approach (David et al., 2015). Although

the difference in ICU LOS was not found to be significant in the David et al. (2015) study, the

involvement of the ACNP generated other positive outcomes; perhaps through the stable

presence on the unit and the subsequent development of strong relationships promoting improved

communication. The Landsperger et al. (2016) study was very well planned out and executed; it

involved an ACNP covering for 24 hours a day/7 days a week with identical privileges to the

adjuncts in the comparison group and resulted in fewer days in the ICU, as well as a reduced

amount of patient deaths during admission.

Recommendations

Practice

Although there is a significant amount of variability between the studies’ methodologies

and settings, all of the outcomes support the inclusion of nurse practitioners as adjunct providers

in the ICU environment by either resulting in a statistically significant improvement or by

remaining unchanged. This knowledge will surely help guide future research. However, at this

time, it is safe to recommend adding nurse practitioners as ICU adjunct providers with the aim of

promoting improved collaboration and ideally over time a reduced ICU LOS and in-hospital

mortality.
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 11

Education

The authors in the Landsperger et al. (2016) study stand apart in their methodology by

including an extensive ten month orientation period for the ACNPs so that they may be

adequately prepared to work in a multi-disciplinary environment with a highly complex patient

population. Gershengorn et al. (2011) also provided ACNP training prior to integration in the

ICU, although it only lasted between 2-4 weeks. It is recommended to establish an orientation or

specialized training for ACNPs that includes both didactic and procedural components.

Healthcare Policy

Although this topic is not specifically discussed throughout the articles, the potential for

benefits with ACNPs within the critical care environment has shown to be significant. This

supports further research into Medicare reimbursement for ACNPs and the employment of

ACNPs into the appropriate clinical settings, as opposed to family nurse practitioners.

Future Research

The study that yielded the most positive results in regards to the ACNP being used as an

adjunct provider in the ICU was done by Landsperger et al. (2016). The goal for future research

should be to replicate these results. It is recommended that in future studies the ACNP privileges

and hours are equal to that of the adjuncts in the comparison group in order maintain

homogeneity between the two groups and to allow for clearer inferences in regards to the

outcomes of direct care from the ACNP (Landsperger et al., 2016).

NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 12

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patient. Current and projected workforce requirements for care of the critically ill and patients

with pulmonary disease: Can we meet the requirements of an aging population? JAMA:

Journal of the American Medical Association, 284(21), 2762-2770.

Costa, D. K., Wallace, D. J., Barnato, A. E., & Kahn, J. M. (2014). Nurse practitioner/physician

assistant staffing and critical care mortality. Chest, 146(6), 1566-1573. doi:10.1378/chest.14-

0566

David, D., Britting, L., & Dalton, J. (2015). Cardiac acute care nurse practitioner and 30-day

readmission. The Journal of Cardiovascular Nursing, 30(3), 248-255.

doi:10.1097/JCN.0000000000000147

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disease...the public health challenge of the 21st century Hyattsville, MD: National Center for

Health Statistics.

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act. Critical Care Medicine, 44(3), e168-e173. doi:10.1097/CCM.0000000000001431

Gershengorn, H., Wunsch, H., Wahab, R., Leaf, D., Brodie, D., Li, G., & ... Factor, P. (2011).

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Outcomes of care managed by an acute care nurse practitioner/attending physician team in a

subacute medical intensive care unit. American Journal of Critical Care: An Official

Publication, American Association of Critical-Care Nurses, 14(2), 121-130.

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Landsperger, J. S., Semler, M. W., Li, W., Byrne, D. W., Wheeler, A. P., & Wang, L. (2016).

Outcomes of nurse practitioner-delivered critical care: A prospective cohort

study. Chest, 149(5), 1146-1154. doi:10.1016/j.chest.2015.12.015

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing &

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NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 14

Appendix

Evidence Evaluation Table

Design/Method Major Variables Appraisal:

Data Analysis
Citation Level of Sample/Setting Studied and their Intervention Measurement Worth to
and Results
Evidence Definitions Practice
Costa, D. Cohort study; 39,541 patients IV1: ICU care team Direct patient In-hospital All analyses were I: NPs/PAs are
K., Wallace, Level IV across 29 ICUs without NP/PA (n=9,287) care from mortality is performed using Stata a safe adjunct
D. J., in 22 hospitals. NP/PA vs. calculated by 12.0 to the ICU
Barnato, A. Quantitative IV2: ICU care team Physician only percentage and t tests or χ2 tests used care team
E., & Kahn, retrospective 21 ICUs including NP as an ICU* was evaluated for comparing the
J. M. reported NP/PA adjunct (n=30,254) for discharge characteristics b/w the L:
(2014). Analyzed coverage. bias groups. Nonrandomize
Nurse reported data DV: In-hospital mortality Relative risk regression d, (APACHE
practitioner/ obtained via Medical and for mortality calculation clinical
physician Acute mixed med/surg information
assistant Physiology and ICUs *Interpret In-hospital mortality: system),
staffing and Chronic Health results as the 13.7% with NP/PA unmeasured
critical care Evaluation From 2009 – effect of group vs 14.4% without patient and
mortality. (APACHE) – 2010 staffing the ICU (P=.10) unit variables;
Chest, system with NP/PA i.e. culture of
146(6), adjuncts instead the unit
1566-1573. of “direct
doi:10.1378/ patient care”
chest.14-
0566
Gershengor Cohort study; 1,002 IV1: MICU-RES care Care on MICU In-hospital Databases management I: Acute care
n, H., Level IV admissions/590 provider team involving from NP/PA vs. mortality, ICU and statistical analyses NP/PA team
Wunsch, H., daytime usual ICU staff and MICU with mortality, ICU performed using Excel can provide
Wahab, R., Quantitative admissions medical residents as Medical LOS and and Stata 10.0 critical care to
Leaf, D., retrospective adjunct (n=288) residents hospital LOS t tests or χ2 tests used severely ill
Brodie, D., 2 12-bed (Both have are measured for comparing the patients
Li, G., & ... Analyzed two Medical ICUs IV2: MICU- NP/PA care intensivist on in percentages characteristics b/w the without
Factor, P. medical ICUs in one facility provider team involving during the day, and days groups. significant
(2011). within the same NP/PA as adjunct and intensivist respectively Multivariate logistic and differences to
Impact of facility. 1/2008- (n=302) on call at night) linear regression used to clinically
nonphysicia 12/2008 investigate the impact. relevant
n staffing on DV: in-hospital mortality outcomes
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 15

Design/Method Major Variables Appraisal:

Data Analysis
Citation Level of Sample/Setting Studied and their Intervention Measurement Worth to
and Results
Evidence Definitions Practice
outcomes in MICU-NP/PA and ICU and hospital In-hospital mortality:
a medical admits only 7a- LOS 32.1% with NP/PA L: Only
ICU. Chest, 7p while group vs 32.3% without MICU-RES
139(6), MICU-RES MICU-NP/PA received (P=.96) admitted at
1347-1353. admits 24/7 older population and Adj. night,
doi:10.1378/ higher prevalence of [0.75(0.46,1.23)P=.26)] transferring
chest.10- DNR on admission other patients
2648 ICU mortality: to MICU
No significant difference 19.5% with NP/PA NP/PA –
in illness severity or group vs 20.8% without Non-
admitting diagnosis b/w (P=.70) randomized,
the 2 units NP/PA
ICU LOS: coverage only
4.22 + 2.51 days with 7p – 7a, higher
NP/PA group vs 4.44 + risk for
3.10 days in RES group mortality due
(P=.59) to advanced
Adj. [-0.07(-0.19,0.06) age and DNR
P=.29)] admitted to
MICU-NP/PA
Hospital LOS:
14.01 + 2.92 days with Note: A
NP/PA group vs 13.74 + sensitivity
2.94 days in RES group analysis was
(P=.86) performed to
Adj. [0.07(-0.05,0.19) evaluate the
P=.19)] impact of
nighttime
admissions.
No significant
difference in
the clinical
outcomes.
Hoffman, L. Cohort study; 526 patients IV1: ICU care team with ACNP utilized ICU LOS in Baseline demographic I: A team
A., Tasota, Level IV admitted to pulmonary or critical care as an adjunct to days and medical profile data including an
F. J., Zullo, Subacute fellow as adjunct (n=276) the ICU care compared via t tests or ACNP with an
T. G., Case-control, Medical ICU provider team χ2 tests attending can
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 16

Design/Method Major Variables Appraisal:

Data Analysis
Citation Level of Sample/Setting Studied and their Intervention Measurement Worth to
and Results
Evidence Definitions Practice
Scharfenber repeated IV2: ICU care team with for 14 months LOS between the two safely manage
g, C., & measures, 6/2000 – NP as adjunct (n=250) teams was compared the care of
Donahoe, equivalent time 2/2003 using multivariate chronically
M. P. samples design Both care teams included analysis critical
(2005). an attending physician patients
Outcomes of 7 month blocks and a respiratory In-hospital mortality:
care of time was therapist. 10.4% with ACNP S:
managed by allotted for each The two care teams being group vs 7.9% with Generalizabilit
an acute team to manage compared were on the fellows group (P=.89 y due to
care nurse care, then unit for 8-10 hours and P= .25, without and similar
practitioner/ alternate. Total Monday-Friday during with treatment limitation demographics,
attending length of time their blocks of time. respectively) medical
physician per team = 14 ACNP and Critical conditions,
team in a months care/pulmonary fellows ICU LOS: and workload
subacute shared the same 12.7 (9.5) days with
medical responsibilities and ACNP group vs 11.7 L: An
intensive privileges. days in Fellows group attending
care unit. Night time management (P=.42) physician was
American was provided by medical at the disposal
Journal of resident. Weekends were of the ACNP.
Critical covered by the attending Many other
Care: An group. facilities may
Official not have this
Publication, support
American available.
Association Only 6-8
of Critical- patients to
Care manage during
Nurses, the study,
14(2), 121- results could
130. differ with
larger patient
load.
Nonrandomize
d.
Only 1 NP
used in this
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 17

Design/Method Major Variables Appraisal:

Data Analysis
Citation Level of Sample/Setting Studied and their Intervention Measurement Worth to
and Results
Evidence Definitions Practice
study

Landsperger Cohort study; 9,066 patients IV1: ICU care team with Both the ACNP In-hospital Outcomes between the I: In an adult
, J. S., Level IV admitted to a ACNP (n=2,366) team and the mortality is two teams are compared medical ICU
Semler, M. Medical ICU Resident teams calculated by using the Wilcoxon trained ACNPs
W., Li, W., IV2: ICU care team with included an percentage and rank-sum test can safely
Data collection
Byrne, D. one first-year and one attending ICU LOS is in for continuous variables manage
W., ongoing for 3 1/2011 – upper-level resident intensivist and a days and Pearson χ2 test or patients and
Wheeler, A. years. 12/2013 (n=6,700) critical care Fisher’s exact test for produce
P., & Wang, Schedules of fellow categorical variables. comparable
L. (2016). providers were DV: ICU and Hospital longer term
Outcomes of modified LOS. ICU and In-hospital ACNPs In-hospital mortality: outcomes as
nurse throughout the mortality prepared for 10 10% with ACNP group resident teams.
practitioner- months prior to vs 15.9% with residents
first two years
delivered implementation (p < .001) S: ACNP
critical care: of the data of this study. provided
A collection. Including; ICU LOS: coverage 24/7
prospective didactic, 3.4 [3.2 – 3.5] days with during the ICU
cohort procedural, and ACNP group vs 3.7 [3.6 stay for the
study. Chest simulation – 3.8] days in residents assigned
, 149(5), training, group (p < .001) patients. –
1146-1154. developing Unlike prior
doi:10.1016/ protocols and research that
j.chest.2015. lastly 4 months has overnight
12.015 of supervised or weekend
hands-on coverage by
patient care. attending
physicians or
fellows.
90 day follow-
up gives better
idea of patient
outcomes.
Large sample.
Prospective
data
collection.
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 18

Design/Method Major Variables Appraisal:

Data Analysis
Citation Level of Sample/Setting Studied and their Intervention Measurement Worth to
and Results
Evidence Definitions Practice

L: Caution
with
generalizing
the results due
to the fact that
this was a
closed adult
medical ICU
in a teaching
hospital with
ACNPs that
were trained
for 10 months
prior

Russell, D., Cohort study; 524 total IV1: ICU care team ACNP utilized ICU LOS in Variables between the Goal; improve
VorderBrue Level IV patients across without NP as adjunct as an adjunct to days two groups analyzed via clinical
gge, M., & a (n=122) the ICU care t tests outcomes
Burns, S. 14 bed provider team while
Analyzed
(2002). neuroscience IV2: ICU care team with for 6 months In-hospital mortality implementing
Effect of an retrospective ICU and a 29 the addition of an NP as 2.63% with ACNP vs a quality
outcomes- data 1 year bed an adjunct (n=402) 2.06% without (results improvement
managed prior to the neuroscience based off neurosurgical model that
approach to inclusion of an unit DV: ICU LOS unit and neuro-ICU) promotes
care of NP on the ICU efficiency,
neuroscienc care team 1/1998 – ICU LOS: efficacy, and
e patients by 12/1998 (pre- Figure 5 shows in a reduces the
acute care intervention) graph significant financial
nurse Compared to decrease in LOS for 5 of burden
practitioners the data 1/1999 - 6/1999 the 6 subgroups on the
. American gathered over (post- neuro ICU (one L:
Journal of the following 6 intervention) subgroup had no Nonrandomize
Critical months once an retrospective spinal d,
Care, 11(4), NP was added admissions to analyze) P retrospective
353-362. < .001 control group.
as an adjunct
Brief study of
NURSE PRACTITIONERS IN THE INTENSIVE CARE UNIT 19

Design/Method Major Variables Appraisal:

Data Analysis
Citation Level of Sample/Setting Studied and their Intervention Measurement Worth to
and Results
Evidence Definitions Practice
Hospital LOS: intervention (6
8 days with ACNP vs 11 months).
days without (P= .03) Specialized
(results based off ICU (neuro).
neurosurgical unit and
neuro-ICU)

Abbreviations: LOS, length of stay; ICU, intensive care unit; ACNP, acute care nurse practitioner; NP, nurse practitioner; PA, physician assistant; I, implications;
S,strengths; L, limitations; MICU, medical ICU.