Impact of the Advanced Practice Provider in Adult Critical Care: A Systematic Review and Meta-Analysis*

Abstract

Objectives: To evaluate the effects on quality and efficiency of implementation of the advanced practice provider in critical care. Data Sources: PubMed, Embase, The Cochrane Library, and CINAHL were used to extract articles regarding advanced practice providers in critical care. Study Selection: Articles were selected when reporting a comparison between advanced practice providers and physician resident/fellows regarding the outcome measures of mortality, length of stay, or specific tasks. Descriptive studies without comparison were excluded. The methodological quality of the included studies was rated using the Newcastle-Ottawa scale. The agreement between the reviewers was assessed with Cohen’s kappa. A meta-analysis was constructed on mortality and length of stay. Data Extraction and Synthesis: One-hundred fifty-six studies were assessed by full text. Thirty comparative cohort studies were selected and analyzed. These compared advanced practice providers with physician resident/fellows. All studies comprised adult intensive care. Most of the included studies showed a moderate to good quality. Over time, the study designs advanced from retrospective designs to include prospective and comparative designs. Data Synthesis: Four random effects meta-analyses on length of stay and mortality were constructed from the available studies. These meta-analyses showed no significant difference between performance of advanced practice providers on the ICU and physician residents/fellows on the ICU, suggesting the quality of care of both groups was equal. Mean difference for length of stay on the ICU was 0.34 (95% CI, –0.31 to 1.00; I 2 = 99%) and for in hospital length of stay 0.02 (95% CI, –0.85 to 0.89; I 2 = 91%); whereas the odds ratio for ICU mortality was 0.98 (95% CI, 0.81–1.19; I 2 = 37.3%) and for hospital mortality 0.92 (95% CI, 0.79–1.07; I 2 = 28%). Conclusions: This review and meta-analysis shows no differences between acute care given by advanced practice providers compared with physician resident/fellows measured as length of stay or mortality. However, advanced practice providers might add value to care in several other ways, but this needs further study.

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

“…One systematic review of 18 studies of APPs in acute care (15), a systematic review of 15 studies of advanced practice nursing roles in emergency and critical care settings (16), a systematic review of 29 studies of APP care on surgical services (17), a systematic review of 14 studies of NP impact on cost, quality of care, satisfaction and wait times in ED settings (18), a literature review of 47 studies on NP care on critical care services (19), a narrative review of 29 studies related to PA satisfaction (20), a literature review of 12 studies on NP use and intensivist staffing (21), a literature review of five studies focused on APP care for ICU patients (22), a systematic review of 30 studies on the impact of APP care for adult critical care patients with a meta-analysis of eight studies (23), and 44 individual studies were identified. The studies addressed a variety of APP models of care including 24/7 ICU coverage (24), and specialty practice roles including cardiovascular surgery (25–28), neuroscience (29, 30), trauma care (31–39), pediatric critical care (40–44), oncology care (45, 46), surgical services (17, 47), ED settings (16, 19), orthopedics (48), stroke care (30), heart failure care (49), burn care (15), aneurysmal subarachnoid hemorrhage care (50), and palliative care (51), among other areas of specialty care.…”

Advanced practice providers in critical care improve team performances. A post-hoc analysis of the BASIC trial

“…Recent research on APPs in critical care often focused on the evaluation of clinical patient-related outcomes and performances of these APPs in conjunction with a coordinating medical specialist. (2)(3)(4) In this study the non-technical skills of APPs and residents as leaders of a RRT were assessed without this additional consultation. APPs performed better than residents in several subcategories and omitted overall less predefined critical steps.…”

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey

“…Literature reviews that comprise more recent studies on APP impact emphasize improvement in the patient care experience and outcomes rather than performing tasks to ease resident workload as motivating factors for their inclusion in the acute care staffing model. 11,12,14,22 The survey question regarding APP participation in research or QI suggests a potential missed opportunity. The split in responses may be institution specific where some centers have a robust APP research and quality initiative and others have yet to optimize the APP role in this way.…”