Describing advanced practice provider roles within critical care teams with Tele-ICUs: Exemplars from seven US health systems.

Telehealth is an acknowledged strategy to meet patient healthcare needs. In critical care settings, Tele-ICU's are expanding to deliver clinical services across a diverse spectrum of critically ill patients. The expansion of telehealth provides increased opportunities for advanced practice providers including advanced practice nurses and physician assistants; however, limited information on roles and models of care for advanced practice providers in telehealth exist. This article reviews current and evolving roles for advanced practice providers in telehealth in acute and critical care settings across 7 healthcare systems in the United States. The health system exemplars described in this article identify the important role of advanced practice providers in providing patient care oversight and in improving outcomes for acute and critically ill patients. As telehealth continues to expand, additional opportunities will lead to novel roles for advanced practice providers in the field of telehealth to assist with patient care management for subacute, acute, and critically ill patients.

Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018.

OBJECTIVES: To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings. DATA SOURCES: Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018. STUDY SELECTION: Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting. DATA EXTRACTION: Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice. DATA SYNTHESIS: Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes. CONCLUSIONS: Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

Evolving the practitioner-teacher role to enhance practice-academic partnerships: a literature review.

AIMS AND OBJECTIVES: The purpose of this article was to review the development of the practitioner-teacher model and its use in advancing clinical nursing. BACKGROUND: The practitioner-teacher role, or the unification model, incorporates clinical practice, teaching, consultation and research responsibilities for nurses serving in advanced clinical roles or as nursing faculty as part of professional nursing practice. The practitioner-teacher role facilitates a practice-academic partnership that can serve as a beneficial way to advance clinical nursing care. DESIGN: An exploratory literature review was conducted combined with review of practitioner-teacher and practice-academic exemplars. METHODS: A descriptive review of the practitioner-teacher model of nursing practice reveals that activities of the role include clinical nursing care, serving as a preceptor for nursing students in a focused area of expertise, consulting on patient care issues, presenting in-services and course lectures, and serving as a member of faculty and nursing division committees. RESULTS: The practitioner-teacher role lends itself to promoting practice-academic partnerships that combine clinical nursing care with professional nursing activities. CONCLUSIONS: The model of practice, education, consultation and research of the practitioner-teacher position advances practice-academic partnerships. RELEVANCE TO CLINICAL PRACTICE: The practitioner-teacher model serves to optimise the way nursing practice and academic work together to integrate knowledge, scholarship, service and learning and to advance the profession and the discipline of nursing. This article discusses aspects of the unique practice-academic partnership using the practitioner-teacher model, how the role evolved, and how it can improve clinical nursing care globally.

Philanthropy as a source of funding for nursing initiatives.

Nurse leaders are challenged with ensuring that research and evidence-based practices are being integrated into clinical care. Initiatives such as the Magnet Recognition Program have helped reinforce the importance of advancing nursing practices to integrate best practices, conduct quality improvement initiatives, improve performance metrics, and involve bedside nurses in conducting research and evidence-based practice projects. While seeking research funding is an option for some initiatives, other strategies such as seeking funding from grateful patients or from philanthropic resources are becoming important options for nurse leaders to pursue, as the availability of funding from traditional sources such as professional organizations or federal funding becomes more limited. In addition, more institutions are seeking and applying for funding, increasing the pool of candidates who are vying for existing funding. Seeking alternative sources of funding, such as through philanthropy, becomes a viable option. This article reviews important considerations in seeking funding from philanthropic sources for nursing initiatives. Examples from a multiyear project that focused on promoting a healthy work environment and improving nursing morale are used to highlight strategies that were used to solicit, obtain, and secure extension funding from private foundation funding to support the initiative.

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

OBJECTIVE: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations. RESULTS: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

Infection control in the intensive care unit: expert consensus statements for SARS-CoV-2 using a Delphi method.

During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

OBJECTIVES: The Accreditation Council for Graduate Medical Education recently released new standards for supervision and duty hours for residency programs. These new standards, which will affect over 100,000 residents, take effect in July 2011. In response to these new guidelines, the Society of Critical Care Medicine convened a task force to develop a white paper on the impact of changes in resident duty hours on the critical care workforce and staffing of intensive care units. PARTICIPANTS: A multidisciplinary group of professionals with expertise in critical care education and clinical practice. DATA SOURCES AND SYNTHESIS: Relevant medical literature was accessed through a systematic MEDLINE search and by requesting references from all task force members. Material published by the Accreditation Council for Graduate Medical Education and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force corresponded by electronic mail and held several conference calls to finalize this report. MAIN RESULTS: The new rules mandate that all first-year residents work no more than 16 hrs continuously, preserving the 80-hr limit on the resident workweek and 10-hr period between duty periods. More senior trainees may work a maximum of 24 hrs continuously, with an additional 4 hrs permitted for handoffs. Strategic napping is strongly suggested for trainees working longer shifts. CONCLUSIONS: Compliance with the new Accreditation Council for Graduate Medical Education duty-hour standards will compel workflow restructuring in intensive care units, which depend on residents to provide a substantial portion of care. Potential solutions include expanded utilization of nurse practitioners and physician assistants, telemedicine, offering critical care training positions to emergency medicine residents, and partnerships with hospitalists. Additional research will be necessary to evaluate the impact of the new standards on patient safety, continuity of care, resident learning, and staffing in the intensive care unit.

How the COVID-19 pandemic will change the future of critical care.

Coronavirus disease 19 (COVID-19) has posed unprecedented healthcare system challenges, some of which will lead to transformative change. It is obvious to healthcare workers and policymakers alike that an effective critical care surge response must be nested within the overall care delivery model. The COVID-19 pandemic has highlighted key elements of emergency preparedness. These include having national or regional strategic reserves of personal protective equipment, intensive care unit (ICU) devices, consumables and pharmaceuticals, as well as effective supply chains and efficient utilization protocols. ICUs must also be prepared to accommodate surges of patients and ICU staffing models should allow for fluctuations in demand. Pre-existing ICU triage and end-of-life care principles should be established, implemented and updated. Daily workflow processes should be restructured to include remote connection with multidisciplinary healthcare workers and frequent communication with relatives. The pandemic has also demonstrated the benefits of digital transformation and the value of remote monitoring technologies, such as wireless monitoring. Finally, the pandemic has highlighted the value of pre-existing epidemiological registries and agile randomized controlled platform trials in generating fast, reliable data. The COVID-19 pandemic is a reminder that besides our duty to care, we are committed to improve. By meeting these challenges today, we will be able to provide better care to future patients.

Promoting research in clinical practice: strategies for implementing research initiatives.

Promoting the use and conduct of research in clinical practice is an essential component in ensuring best practices and promoting positive outcomes for patients. Yet, it is often difficult for nurses in clinical practice to devote time to research activities because the daily demands of practice often take precedence. This article reviews key strategies for implementing research in clinical practice. Examples of ongoing initiatives being conducted at a variety of clinical settings are highlighted to showcase strategies for implementing clinically focused research projects.

Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review.

BACKGROUND: Advanced practitioners including nurse practitioners and physician assistants are contributing to care for critically ill patients in the intensive care unit through their participation on the multidisciplinary team and in collaborative physician practice roles. However, the impact of nurse practitioners and physician assistants in the intensive care unit setting is not well known. OBJECTIVES: To identify published literature on the role of nurse practitioners and physician assistants in acute and critical care settings; to review the literature using nonquantitative methods and provide a summary of the results to date incorporating studies assessing the impact and outcomes of nurse practitioner and physician assistant providers in the intensive care unit; and to identify implications for critical care practice. METHODS: We conducted a systematic search of the English-language literature of publications on nurse practitioners and physician assistants utilizing Ovid MEDLINE, PubMed, and the Cumulative Index of Nursing and Allied Health Literature databases from 1996 through August 2007. INTERVENTIONS: None. RESULTS: Over 145 articles were reviewed on the role of the nurse practitioner and physician assistant in acute and critical care settings. A total of 31 research studies focused on the role and impact of these practitioners in the care of acute and critically ill patients. Of those, 20 were focused on nurse practitioner care, six focused on both nurse practitioner and physician assistant care, and five were focused on physician assistant care in acute and critical care settings. Fourteen focused on intensive care unit care, and 17 focused on acute care including emergency room, trauma, and management of patients with specific acute care conditions such as stroke, pneumonia, and congestive heart failure. Most studies used retrospective or prospective study designs and nonprobability sampling techniques. Only two randomized control trials were identified. The majority examined the impact of care on patient care management (n = 17), six focused on comparisons of care with physician care, five examined the impact of models of care including multidisciplinary and outcomes management models, and three assessed involvement and impact on reinforcement of practice guidelines, education, research, and quality improvement. CONCLUSIONS: Although existing research supports the use of nurse practitioners and physician assistants in acute and critical care settings, a low level of evidence was found with only two randomized control trials assessing the impact of nurse practitioner care. Further research that explores the impact of nurse practitioners and physician assistants in the intensive care unit setting on patient outcomes, including financial aspects of care is needed. In addition, information on successful multidisciplinary models of care is needed to promote optimal use of nurse practitioners and physician assistants in acute and critical care settings.

Developing an advanced practice nursing credentialing model for acute care facilities.

Credentialing of advanced practice registered nurses (APRNs) in acute care settings is an essential practice, but care must be taken to ensure that full utilization of the scope of practice and capacity of APRNs is attained. The process of credentialing and privileging involves the verification of required education, licensure, and certification to practice as an APRN along with the recognition of the scope of the individual APRN's practice based on training, education, and practice setting. Nursing administrators are challenged with ensuring that APRNs are credentialed and privileged and that appropriate mechanisms exist within the institution for promoting recognition of the scope of practice of APRNs. This article reviews concepts related to the process of credentialing and privileging for APRNs, with special considerations to acute care settings. Important considerations are highlighted to ensure that the credentialing process for APRNs promotes practice within their scope of practice.

Reducing Unnecessary Testing in the Intensive Care Unit by Choosing Wisely.

Overuse of laboratory and X-ray testing is common in the intensive care unit (ICU). This review highlights focused strategies for critical care clinicians as outlined by the Critical Care Societies Collaborative (CCSC) as part of the American Board of Internal Medicine Foundation's Choosing Wisely® campaign. The campaign aims to promote the use of judicious testing and decrease unnecessary treatment measures in the ICU. The CCSC outlines five specific recommendations for reducing unnecessary testing in the ICU. First, reduce the use of daily or regular interval diagnostic testing. Second, do not transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dl. Third, do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of ICU stay. Fourth, do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. Finally, do not continue life support for patients at high risk of death without offering patients and their families the alternative of comfort focused care. A number of strategies can be used to reduce unnecessary testing in the ICU, including educational campaigns, audit and feedback, and implementing prompts in the electronic ordering system to allow only acceptable indications when ordering routine testing. Greater awareness of the lack of outcome benefit and associated costs can prompt clinicians to be more mindful of ordering tests and procedures in order to reduce unnecessary testing in the ICU.

Integrating telehealth as a strategy for patient management after discharge for cardiac surgery: results of a pilot study.

Advances in telecommunication technologies have improved access and availability of telehealth for use in healthcare. In cardiac care, telehealth has predominantly been used to manage patients with heart failure. The use of telehealth as a strategy for patient management after discharge for cardiac surgery can be beneficial in monitoring postoperative status and in the early detection of complications. This article provides an overview of the use of telehealth and telemanagement in cardiac patients and discusses the results of a pilot study as an example of an application of the use of telehealth for elderly cardiac surgery patients at high risk of postoperative complications.

APNs: invisible champions?

On a daily basis, advanced practice nurses in acute and critical care settings impact outcomes for patients, families, and evidence-based practice.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.