Advanced practice providers versus medical residents as leaders of rapid response teams:A 12-month retrospective analysis

Purpose In a time of worldwide physician shortages, the advanced practice providers (APPs) might be a good alternative for physicians as the leaders of a rapid response team. This retrospective analysis aimed to establish whether the performance of APP-led rapid response teams is comparable to the performance of rapid response teams led by a medical resident of the ICU. Material and methods In a retrospective single-center cohort study, the electronic medical record of a tertiary hospital was queried during a 12-months period to identify patients who had been visited by our rapid response team. Patient- and process-related outcomes of interventions of rapid response teams led by an APP were compared with those of teams led by a medical resident using various parameters, including the MAELOR tool, which measures the performance of a rapid response team. Results In total, 179 responses of the APP-led teams were analyzed, versus 275 responses of the teams led by a resident. Per APP, twice as many calls were handled than per resident. Interventions of teams led by APPs, and residents did not differ in number of admissions (p = 0.87), mortality (p = 0.8), early warning scores (p = 0.2) or MAELOR tool triggering (p = 0.19). Both groups scored equally on time to admission (p = 0.67) or time until any performed intervention. Conclusion This retrospective analysis showed that the quality of APP-led rapid response teams was similar to the quality of teams led by a resident. These findings need to be confirmed by prospective studies with balanced outcome parameters

Impact of the advanced practice provider in adult critical care: a systematic review and meta-analysis

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

Evaluation and Clinical Application of the Enterotest® for the Determination of Human Biliary Porphyrin Composition

Peer Reviewe

Non-invasive liver iron concentration measurement by MRI:Comparison of two validated protocols

In the non-invasive determination of the liver iron concentration several validated MRI methods are available, two of which are compared in this study. Twenty-eight patients were examined by MRI and evaluated by the methods of Kreeftenberg et al. [Kreeftenberg Jr HG, Mcoyaart EL, Huizenga JR, Sluiter WJ, Kreeftenberg Sr HG. Quantification of liver iron concentration with magnetic resonance imaging by combining T1-, T2-weighted spin echo sequences and a gradient echo sequence. Neth J Med 2000;56:133-7] and Gandon et al. [Gandon Y, Olivie D, Guyader D, et al. Non-invasive assessment of hepatic iron stores by MRI. Lancet 2004;363:357-62]. It is concluded that the latter shows a better inter- and intra-observer correlation and is more accurate because of the automated preselection of one of five sequences most sensitive in the estimated liver iron concentration range. In the Kreeftenberg method combining the results of three suboptimal sequences, leads to underestimation of the liver iron concentration. (C) 2008 Elsevier Ireland Ltd. All rights reserved

Correlation between serum ferritin levels and liver iron concentration determined by MR imaging:impact of hematologic disease and inflammation

Liver iron concentration was determined in 28 patients by magnetic resonance imaging using the method of Gandon et al. (Non-invasive assessment of hepatic iron stores by MRI. Lancet 2004;363:357-362). The result showed a significant correlation with blood plasma ferritin content (Spearman's r = .66; P <.001) and a slightly improving correlation coefficient when limited to those patients not known to have inflammation (r = .82; n = 17; P <.001). Zooming in on patients with hematologic disease also had a beneficial effect on the correlation between liver iron content and plasma ferritin level (r = .79; n = 13; P = .001). It is concluded that in patients without inflammation and in patients with hematologic disease, the content of ferritin in blood is a better predictor of liver iron content than in other patient categories. (c) 2007 Elsevier Inc. All rights reserved

Procedures Performed by Advanced Practice Providers Compared With Medical Residents in the ICU: A Prospective Observational Study.

To assess the frequency and safety of procedures performed by advanced practice providers and medical residents in a mixed-bed ICU. Design: A prospective observational study where consecutive invasive procedures were studied over a period of 1 year and 8 months. The interventions were registered anonymously in an online database. Endpoints were success rate at first attempt, number of attempts, complications, level of supervision, and teamwork. Setting: A 33-bedded mixed ICU. Subjects: Advanced practice providers and medical residents. Interventions: Registration of the performance of tracheal intubation, central venous and arterial access, tube thoracostomies, interhospital transportation, and electrical cardioversion. Measurement and main results: A full-time advanced practice provider performed an average of 168 procedures and a medical resident an average of 68. The advanced practice provider inserted significant more radial, brachial, and femoral artery catheters (66% vs 74%, p = 0.17; 15% vs 12%, p = 0.14; 18% vs 14%, p = 0.14, respectively). The median number of attempts needed to successfully insert an arterial catheter was lower, and the success rate at first attempt was higher in the group treated by advanced practice providers (1.30 [interquartile range, 1-1.82] vs 1.53 [interquartile range, 1-2.27], p < 0.0001; and 71% vs 54%, p < 0.0001). The advanced practice providers inserted more central venous catheters (247 vs 177) with a lower median number of attempts (1.20 [interquartile range, 1-1.71] vs 1.33 [interquartile range, 1-1.86]) and a higher success rate at first attempt (81% vs 70%; p < 0.005). The number of intubations by advanced practice providers was 143 and by medical residents was 115 with more supervision by the advanced practice provider (10% vs 0%; p = 0.01). Team performance, as reported by nursing staff, was higher during advanced practice provider procedures compared with medical resident procedures (median, 4.85 [interquartile range, 4.85-5] vs 4.73 [interquartile range, 4.22-5]). Other procedures were also more often performed by advanced practice providers. The complication rate in the advanced practice provider-treated patient group was lower than that in the medical resident group. Conclusions: Advanced practice providers in critical care performed procedures safe and effectively when compared with medical residents. Advanced practice providers appear to be a valuable addition to the professional staff in critical care when it comes to invasive procedures

Procedures Performed by Advanced Practice Providers Compared With Medical Residents in the ICU: A Prospective Observational Study.

To assess the frequency and safety of procedures performed by advanced practice providers and medical residents in a mixed-bed ICU. Design: A prospective observational study where consecutive invasive procedures were studied over a period of 1 year and 8 months. The interventions were registered anonymously in an online database. Endpoints were success rate at first attempt, number of attempts, complications, level of supervision, and teamwork. Setting: A 33-bedded mixed ICU. Subjects: Advanced practice providers and medical residents. Interventions: Registration of the performance of tracheal intubation, central venous and arterial access, tube thoracostomies, interhospital transportation, and electrical cardioversion. Measurement and main results: A full-time advanced practice provider performed an average of 168 procedures and a medical resident an average of 68. The advanced practice provider inserted significant more radial, brachial, and femoral artery catheters (66% vs 74%, p = 0.17; 15% vs 12%, p = 0.14; 18% vs 14%, p = 0.14, respectively). The median number of attempts needed to successfully insert an arterial catheter was lower, and the success rate at first attempt was higher in the group treated by advanced practice providers (1.30 [interquartile range, 1-1.82] vs 1.53 [interquartile range, 1-2.27], p < 0.0001; and 71% vs 54%, p < 0.0001). The advanced practice providers inserted more central venous catheters (247 vs 177) with a lower median number of attempts (1.20 [interquartile range, 1-1.71] vs 1.33 [interquartile range, 1-1.86]) and a higher success rate at first attempt (81% vs 70%; p < 0.005). The number of intubations by advanced practice providers was 143 and by medical residents was 115 with more supervision by the advanced practice provider (10% vs 0%; p = 0.01). Team performance, as reported by nursing staff, was higher during advanced practice provider procedures compared with medical resident procedures (median, 4.85 [interquartile range, 4.85-5] vs 4.73 [interquartile range, 4.22-5]). Other procedures were also more often performed by advanced practice providers. The complication rate in the advanced practice provider-treated patient group was lower than that in the medical resident group. Conclusions: Advanced practice providers in critical care performed procedures safe and effectively when compared with medical residents. Advanced practice providers appear to be a valuable addition to the professional staff in critical care when it comes to invasive procedures

Advanced Practice Providers as Leaders of a Rapid Response Team: A Prospective Cohort Study

In view of the shortage of medical staff, the quality and continuity of care may be improved by employing advanced practice providers (APPs). This study aims to assess the quality of these APPs in critical care. In a large teaching hospital, rapid response team (RRT) interventions led by APPs were assessed by independent observers and intensivists and compared to those led by medical residents MRs. In addition to mortality, the MAELOR tool (assessment of RRT intervention), time from RRT call until arrival at the scene and time until completion of clinical investigations were assessed. Process outcomes were assessed with the crisis management skills checklist, the Ottawa global rating scale and the Mayo high-performance teamwork scale. The intensivists assessed performance with the handoff CEX recipient scale. Mortality, MAELOR tool, time until arrival and clinical investigation in both groups were the same. Process outcomes and performance observer scores were also equal. The CEX recipient scores, however, showed differences between MRs and APPs that increased with experience. Experienced APPs had significantly better situational awareness, better organization, better evaluations and better judgment than MRs with equal experience (p < 0.05). This study shows that APPs perform well in leading an RRT and may provide added quality over a resident. RRTs should seriously consider the deployment of APPs instead of junior clinicians