Editorial Comment: Advanced practitioners in the cardiothoracic intensive care unit

Abstract

In this month’s journal, Skinner et al. [1] present a study that seeks to demonstrate that specifically trained advanced nurse practitioners can safely and efficiently provide sole resident cover within a cardiac surgical intensive care unit (ICU), without the need for additional resident middle grade medical staff. They have utilized outcome measures such as mortality, cost and surgical training time to attempt to quantify the impact of this staffing innovation. The critical care workload within the UK continues to rise on a yearly basis. Within cardiothoracic ICUs, the age and comorbidities of the patients also rise each year, and the complexity of many procedures increases, with a resultant increase in the clinical workload. Cardiothoracic ICUs within the UK have traditionally employed a varying combination of junior/middle grade anaesthetic and surgical medical staff to provide 24 h cover. As the authors state, the challenges of continuing to provide this level of skilled medical cover are increasing. In response to these shortfalls in manpower, many ICUs across the UK in recent years have sought to introduce new roles or have extended the scope of practice of existing ICU nursing staff, as is the case with the Nurse Practitioners in Nottingham. Within the UK, the demand for these types of advanced roles has culminated in the development of the advanced critical care practitioner (ACCP) role. The ACCP role is a new way of working for health professionals in critical care. The role crosses the professional boundaries of many functions within critical care, including medicine, nursing, technical, physiotherapy and clinical pharmacology. Recruitment to the ACCP role is not limited to nursing staff, but rather to any suitably qualified and academically able health care professional, with at least 2 years recent experience working within critical care at a senior level; this includes nursing staff, physiotherapists, pharmacists and Operating Department Assistants. The ACCP programme in the UK is an ongoing project under the auspices of the Faculty of Intensive Care Medicine at the Royal College of Anaesthetists. It is a development of the initial ACCP pilot scheme that subsequently led to the publication of the National Education and Competence Framework for ACCPs document by the Department of Health in March 2008. This document provided a basic training framework from which several hospital trusts within the UK designed tailor-made ACCP programmes in conjunction with local Higher Education Institutions (HEI). The FICM is now in the process of utilizing the knowledge and experience gained within these initial training centres, in order to produce a comprehensive national training curriculum together with an accredited exit examination. ACCP training will consist of a full-time 2-year Master’s-level qualification that is taught and assessed in conjunction with local HEIs. The majority of the teaching is delivered within the clinical arena and is augmented by the nationally accredited non-medical prescribing qualification (this enables the ACCPs to prescribe independently of medical staff ). The ultimate aim is to develop a network of ACCP training sites around the UK, delivering a common, highintensity training programme, resulting in the award of a nationally recognized and transferable qualification. As of June 2012, there were already at least 25 fully qualified ACCPs working at the four existing training sites within the UK. Although the exact nature of their role differs slightly from trust to trust, most are already being utilized to provide 24-h resident cover for the ICU, having been embedded within existing medical rotas. Close attention continues to be paid to patient safety and outcome measures, but the initial feedback and data analysis has been very positive. Skinner et al.’s study was conducted within the dedicated cardiac surgical ICU in Nottingham, with 700 major cardiac cases per year. It is widely perceived that the role of the ACCP may be particularly well suited to cardiothoracic ICUs. In comparison with a general ICU, the workload is more predictable, more repetitive, more amenable to employing protocol-led care and generally presents less primary diagnostic difficulty. Patient turnover is higher and the potential impact of introducing ACCPs in terms of throughput, speed of recovery and discharge, cost savings and enhanced patient satisfaction, may be more easily demonstrable. Within any critical care environment, a transition from resident medical cover to only non-medical personnel being resident must be predicated on the basis that patient safety is not compromised. Continuous detailed monitoring of patient outcomes is essential when introducing any new clinical role into the ICU environment. Morbidity, mortality, length of stay, readmission rates, cost savings, etc. can all be utilized to assess the impact of these new roles. The ability to perform immediate chest re-opening in patients post-cardiac surgery has traditionally been considered one of the primary reasons to maintain resident surgical cover on