Download The role of physician-assistants in critical care units

The role of physician-assistants in critical care
units
BA Dubaybo, MK Samson and RW Carlson
Chest 1991;99;89-91
DOI 10.1378/chest.99.1.89
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The Role of Physician-Assistants in Critical
Care Units*
Basim A. Dubuybo, M.D.;t Michael K. Samson, Af.D.;t and
Richard W Carlson, M.D., Ph.D., F.C.C.P.§
We evaluated the feasibility of utilizing physician assistants
as providers of primary care in a medical ICU. After a
three-month period of rigorous training, two PAs were
assigned to the ICU. Their performance as well as the
operation of the ICU over a two-year period was evaluated
and compared to two preceding years when it was operated
by house officers. There were no changes in occupancy,
mortality or the rate of complications. Evidence for more
careful evaluation of patients prior to admission and dis
charge, manifesting as slightly fewer admissions and slightly
longer duration of hospitalization, was also documented.
We conclude that properly trained PAs may have a role in
providing health care in intensive care settings.
TTTospital-based
health care delivery in the United
•¿*--*States traditionally has relied on the services of
ing for foreign graduates is more difficult to obtain and
Medicare funds to programs hiring FMGs may be
cut.5
physicians in training, commonly referred to as house
staff or house officers. The existence of large numbers
of house staff to provide inpatient care may, however,
decline. The reasons for this are varied. First, the
Graduate Medical Education National Advisory Re
port estimated that the United States will have a
surplus of 70,000 by the year 1990 and 145,000 by the
year 2000.' It recommended
freezing the number of
trainees in internal medicine and reducing subspecialty trainee positions by up to 20 percent and medical
students by 17 percent. Based on this, many medical
schools already have decreased the size of their classes
and residency programs. Second, funding for house
officers is becoming less readily available. Congres
sional committees are considering budget cuts for
postgraduate medical training. Congress recently en
acted the Consolidated Omnibus Budget Reconcilia
tion Act of 1986 in which Medicare reimbursement
for the indirect costs of medical education were
reduced.2 Many hospitals are now relying on revenues
from patient care to compensate for these losses.
However, with the implementation
of the DRGs in
1983, this source of revenue may be curtailed. Finally,
the supply of FMGs willing to fill the gap left by the
decreasing number of US trainees may decline. Fund-
*From the Department
of Medicine, Veterans Administration
Medical Center, Allen Park, MI; and Wayne State University
School of Medicine, Detroit.
tAssistant Professor of Medicine.
t Professor of Medicine, Chief, Medical Service, Veterans Admin
istration Medical Center, Allen Park, MI.
§Professor of Medicine, Chief, Division of Pulmonary/Critical
Care,
Wayne State University School of Medicine, Detroit.
Manuscript received April 2; revision accepted June 26.
Reprint requests: Dr. Dubuybo, Medical Service (I IIA), VA Medical
Center, Allen Park, Ml 48101.
(Chest 1991; 99:89-91)
ICU = intensive care unit; DRGs = diagnosis-related
groups;
FMGs = foreign medical graduates; PAs = physician assistants
For these reasons, house staff officers for the primary
care of inpatients may not be available in large
numbers in the future. Alternative staffing will have
to be implemented. Many hospitals already have hired
non-physician health providers to fill the gap. Nurse
practitioners and PAs, whose job was originally de
signed to serve outpatients in rural communities,4 are
now being employed to perform inpatient duties on
surgical and medical floors as well as in emergency
rooms.5 Lately, new curricula in critical care education
for PAs have been developed. Many PAs are being
trained in the management of acutely ill patients with
multiorgan failure. Hospitals, however, may be reluc
tant to allow physician assistants to take care of such
delicate patients. In this study, we evaluated the
feasibility and outcome of utilizing PAs in a medical
ICU. The period of study ranged for four years, during
the initial two of which only residents were assigned
to the unit. During the latter two, residents were
replaced by PAs.
MATERIALSAND METHODS
TheMedicalIntensiveCareUnit
The medical intensive care unit at this hospital consists of eight
fully monitored beds. The patient population is derived from direct
admissions through the emergency department
or from transfers
from other medical inpatient floors. The spectrum of admitting
diagnoses is similar to what is encountered in other medical intensive
care units and includes, among others, respirator)' insufficiency,
hepatic failure, cardiac decompensation
and shock, massive bleed
ing, hyperglycemic and hypoglycfinic emergencies, seizure disor
ders, stroke, and uremia. Approximately one hall of the patients are
ventilator-dependent
at some point during their hospitalization. No
surgical or postoperative
patients are normally admitted to this
unit. Two physicians alternate on a monthly basis in providing
CHEST / 99 / 1 / JANUARY 1991
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Copyright © 1991 by American College of Chest Physicians
89
medical supervision. The nursing staff consist of 24 nurses who
provide continuous coverage on the basis of three separate shifts.
The number of nurses per shift varies with the number of patients
admitted, but is never less than two. During the study period, a
total of four physician-assistants
were assigned to the unit, two at a
time. Both physician-assistants
were available during the day time,
while night coverage was provided by on-call physicians. Patient
workup and charting, however, remained the responsibility of the
physician-assistants,
even in the case of patients admitted at night.
Training and Privileges of Physician-Assistants
All physician assistants hired had received formal college educa
tion and graduated with bachelors degrees as physician assistants.
They were certified, licensed and had passed the certifying exami
nation given by the American Board of Physician Assistants. They
had several years of experience in managing in-patients in acute
medical and surgical settings. Following recruitment, the physicianassistants spent a period of three months rotating with fellows and
residents under the supervision
of certified intensivists
in a
university hospital. The physician-assistants
received training in
the techniques of obtaining history and physical examination in a
critical care setting. They also were instructed in the performance
of numerous invasive procedures, record keeping and family and
patient counseling. At the end of this period of training, the
physician-assistants
were certified and allowed to take primary care
of patients under the supervision of staff physicians. The physicians
actually were present in the unit and visually supervised the PAs
when invasive procedures were being conducted. In other situa
tions, physicians could be outside the unit (but within the hospital
complex) and provide supervision via telephone consultations. The
duties assigned to the PAs were identical to those of housestaff
physicians normally appointed to medical intensive care units.
Specifically, they included:
1. Writing stat and routine orders in the medical record after
consultation with the rounding physician. Since all orders were
preapproved by the physician, they were unrestricted
and were
carried out promptly by the nursing staff.
2. Managing patients admitted for observation, as well as patients
admitted for intensive therapy. In both situations, the PAs performed
the initial physical examination, initiated therapy including admin
istration of fluids, oxygen, antibiotics, blood or other emergency
medications and completed the paperwork. The case was then
discussed with the attending physician, the abnormalities outlined
and therapeutic plan finalized, a process identical to what is normally
done when house staff officers are appointed to the unit.
3. Initiation of cardiopulmonary
resuscitation and administration
of vasopressors, fluids, antiarrhythmic
agents and other lifesaving
medications in the case of an emergency. Endotracheal intubation,
whether elective or emergency, is usually performed by anesthetists
who are readily available.
4. Management
of patients in shock requiring hemodynamic
monitoring and vasopressors. The PAs inserted central lines and
assisted the physician in floating Swan-Ganz catheters. They wrote
orders for fluid
consultation with
data and initiated
5. Reversal of
resuscitation
and vasoactive medications after
the physician. They also analyzed hemodynamic
changes in therapy accordingly.
life-threatening
episodes of arrhythmia. The PAs
administered antiarrhythmic
medications in accordance with pro
tocols developed in our unit. Following that, immediate consultation
with the physician was obtained.
6. The task of weaning patients from mechanical ventilation was
performed jointly by the physician, who set the global plan (mode
of ventilation, oxygen concentration, pressure support, etc) and the
PA who periodically followed the patients progress, made fine
adjustments, checked the patient clinically, measured arterial blood
gas values or transcutaneous
oxygen saturation, or both, and
90
reported changes to the physician for final approval or modification.
7. Performance of invasive procedures
including insertion of
arterial lines, central venous catheters, pleura! taps, peritoneocentesis, lumbar puncture and others under direct supervision. In this
case, physician supervision
meant the actual presence of the
physician inside the intensive care unit. In other situations, such as
writing orders or initiating therapy, the ability of the PA to
communicate via telephone with a physician who is physically in
the building but not necessarily in the intensive care unit was
considered sufficient supervision.
8. Communicating
with the next of kin of patients to obtain
relevant historical information, signed consents for invasive proce
dures, or simply to update the families on the progress of their
patients.
9. Recordkeeping
and dictation of admission notes, progress
notes and discharge summaries also were done by the PAs. All such
notes and orders were countersigned by the rounding physician.
Feasibility Studies
To determine the feasibility of assigning a PA to the medical ICU,
not only should they be qualified, but also they should be accepted
by hospital personnel,
patients and patient families. This was
determined by interviewing all the physicians, nurses and techni
cians interacting with the medical ICU patients as well as numerous
patients and their relatives. Responses were uniformly positive.
Data Collection
Data collection and analysis were performed by individuals not
involved in this study or in patient management in the medical
ICU. The following two periods of time were reviewed: Period 1,
ranging from July 1984 to June 1986, during which house officers
were assigned to the unit. Period 2, ranging from July 1986 to June
1988, during which PAs were assigned to the same unit. There was
no change in the physical plant, organizational
structure and
monitoring equipment of the unit during this period. Guidelines
for the management of critically ill patients were determined by
the affiliated university program. Consequently, no major changes
in approaches to patient care were implemented during the study
period. The following factors were evaluated: (a) number of monthly
admissions, (b) occupancy, (c) APACHE II score as an index of
intensity of disease, (d) duration of stay, (e) mortality, (f) number of
invasive procedures, (g) number of complications, (h) utilization of
laboratory resources, and (i) quality of charting.
These factors were obtained on a monthly basis. Differences
between the two periods were compared using the Wilcoxin rank
sum nonparametric
test with a p<0.05 considered statistically
significant."
RESULTS
As shown in Table 1, since the introduction
of PAs
Table 1—VitalStatistics
FactorsAdmissions
8.9*4.62
+
monthDurationper
±5.73.96
(days)Monthly
of stay
±0.9241.8±15.270.2 ±1.91*41.2±13.376.7
(%)Monthly
mortality
(%)APACHE
occupancy
±9.615.2
±13.016.3±7.22.8
±6.52.1±0.2621.2±6.87.1±1.20.22
scoreProcedures
II
patientComplications
per
±0.9531.6±10.3*6.4
yr)Blood
(2
patientCultures
studies per
patientIncomplete
per
±1.80.18
±0.02* charts (%)Residents37.0
±0.01PAs30.4
= p<0.05.
Physician-Assistants
in Critical Care Units (Dubaybo, Samson, Carlson)
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Copyright © 1991 by American College of Chest Physicians
into the medical ICU, there has been a slight reduction
in the number of patients admitted and a slight
increase in the duration of their stay. However, the
occupancy rate, the mortality, the number of compli
cations and the adequacy of charting remained un
changed. Although the utilization of laboratory studies
was increased, the total number of studies requested
remained within the acceptable averages for patients
in an intensive care setting.
DISCUSSION
In the past two decades, PAs have functioned under
supervision at newly developed satellite health centers
in rural areas of the nation.4 These health providers
were accepted by the physicians and their patients,
and their performance was good.7 Studies comparing
their aptitude to that of medical students showed
minimal if any differences.8 In addition to their tradi
tional role in primary care, PAs now are being utilized
in place of house officers in surgical, medical, pediatric
and emergency room departments.9"13 For example, in
1981, Perry et al9 reported that out of 522 surgical
departments
Thirty-three
surveyed, 165 employed at least one PA.
percent of department
chairs felt that
PAs had improved surgical patient care.
In this study, we demonstrated
the feasibility of
utilizing non-physician health care providers for the
delivery of medical care in an intensive care setting.
Specifically, we have shown that the concept is ac
ceptable to the medical and nursing establishment
and that care of critically ill patients will not be
compromised.
Successful utilization of PAs in an
intensive care setting, however, depends on a number
of factors. First, highly qualified individuals should be
sought. In this study, we utilized only PAs with formal
university-based
education and college degrees. The
intention was to select individuals who have had
adequate exposure to inpatient care and were familiar
with hospital-based medical care. Second, prior ex
perience in a hospital setting is desirable. The PAs
employed in this study had experience in surgical,
anesthesia or cardiology services and were capable of
recognizing
emergencies
and dealing with them.
Third, formal training in the delivery of intensive care
should be offered. This is best accomplished
by
inviting the PAs to participate in rounds in an intensive
care unit under the supervision of qualified physicians.
After a period of observation, they may be assigned
patient care duties, starting with simple histories,
physical examinations and chart reviews and gradually
increasing to performance
of invasive procedures
under direct supervision.
As shown in Table 1, some reduction in the number
of admissions and a slight increase in the duration of
stay may occur. In our study, these alterations re
mained within what is expected in an intensive care
setting. In any case, the results indicate that the
supervising physicians were being more cautious in
admitting and discharging patients. Such caution is
probably among the more favorable outcomes of util
izing PAs in the medical intensive care unit.
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CHEST / 99 / 1 / JANUARY 1991
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91
The role of physician-assistants in critical care units
BA Dubaybo, MK Samson and RW Carlson
Chest 1991;99;89-91
DOI 10.1378/chest.99.1.89
This information is current as of March 24, 2008
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