Advanced Practice Providers Research Articles

Background: High-quality cardiopulmonary resuscitation (CPR) is critical for survival after pediatric cardiac arrest, yet adherence to guideline metrics and timely utilization of equipment remain inconsistent. CPR coaches have been described to improve CPR quality; however, a standardized training approach has not been defined. We sought to develop and implement a streamlined CPR coach training program using multimedia education and rapid cycle deliberate practice simulations to enhance adherence to resuscitation guidelines and CPR quality. Concurrently, a dedicated bedside CPR Cart was introduced to improve resuscitation ergonomics and efficiency. Objectives: To evaluate the impact of CPR coach training on provider knowledge and perceptions of pediatric resuscitation efficiency using the CPR Cart compared to a traditional pediatric crash cart. Methods: A cross-sectional survey was distributed to frontline physicians, advanced practice providers, nurses, and respiratory therapists at a large, tertiary pediatric hospital. The survey assessed demographics, CPR knowledge, and perceptions of the CPR coach and CPR Cart. Respondents were categorized as CPR coach-trained or non-trained. Mann-Whitney U and McNemar tests were applied where appropriate to compare knowledge scores, preparedness as the role of CPR coach, and perceptions of the CPR Cart versus a traditional pediatric crash cart. Results: Among 226 responses, 56 (25%) had participated in dedicated CPR coach training. CPR coach-trained individuals scored higher on knowledge of key CPR principles compared to non-trained individuals (median 93% vs 64%, p < 0.001). Trained staff reported higher preparedness (range 0-100) to assume the role of CPR coach than those who had not been trained (median 87 vs 25, p <0.001). Among those who had experience with both the CPR Cart and the traditional pediatric crash cart (n = 119), the CPR Cart was preferred over the traditional pediatric crash cart (p < 0.001), with respondents rating it higher for rapid equipment access, positioning, and workflow efficiency during CPR (Figure 1). Conclusions: A structured CPR Coach training program improves provider CPR knowledge and enhances perceptions of resuscitation effectiveness. The streamlined bedside CPR Cart further optimizes the reported efficiency of pediatric resuscitations. Future research should explore the longitudinal impact of these interventions on real-time clinical performance and survival outcomes.

Background: Chest pain is a common presenting symptom in the emergency departments (EDs). Safe and timely outpatient evaluation is reasonable for some patients without acute coronary syndrome. This study aimed to evaluate the safety of an expedited outpatient diagnostic pathway for patients with chest pain at moderate risk of adverse cardiac events. Methods: A multidisciplinary team designed a pathway consisting of a stress ECG within 5 days, and a cardiology visit with an advanced practice provider within 7 days, of ED discharge. Patients presenting with chest pain were eligible if they had non-critical high-sensitivity troponins (< 35 ng/L for men, <17 ng/L for women), were at least moderate risk of adverse cardiac events (HEART score ≥4), were able to complete exercise stress ECG testing, and had insurance coverage for outpatient care. Data on patient compliance with the pathway, stress ECG results, and 30-day ED returns, were collected from 12/1/2023 to 11/30/2024. Results: Over twelve months, 55 patients met pathway criteria and were discharged from ED. Of these, 52 patients (95%) either completed the pathway or elected to follow-up with an established cardiology provider: 38 had outpatient stress ECG, 4 had coronary computed tomography angiogram (CCTA) per ED, and 10 followed up with established providers. There were 3 patients lost to follow-up. Of the 38 stress ECGs, 4 were abnormal (10%) and led to more imaging with three being negative for obstructive coronary artery disease (CAD) and one showing obstructive CAD, leading to invasive coronary angiography and stenting. One patient with a positive stress ECG was sent to ED from diagnostic lab for additional testing, which turned out negative. No patients re-presented to the ED with acute coronary syndrome within 30 days. Conclusion: A novel expedited outpatient pathway for evaluation of patients with chest pain showed a high completion rate, low rates of abnormal stress testing, and no acute coronary syndrome ED visits within 30 days. Pathways allowing for expedited outpatient evaluation of chest pain especially for patients without established cardiology care may reduce ED length of stay and avoid observation stays for stress testing while maintaining high standards of patient care. Future research should focus on evaluating long-term outcomes and assessing opportunities to implement similar pathways for other patient populations to optimize resource utilization while enhancing the patient experience.

Design and Implementation of a Primary Palliative Care Education Program for Hematology-Oncology Advanced Practice Providers: Insights From a Three-Year Cohort.

"A Different World": A Qualitative Exploration of the Learning Environment for Residents on Pediatric Surgery Rotations.

A National Survey of Nursing Home Clinicians to Explain Increased Valproate Prescribing.

This article reviews the changing dynamics of advanced practice provider supervision in the United States, including state regulations, types of agreements, and compensation models. It distinguishes between supervision and employment agreements, discusses common payment structures such as flat fees and hourly rates, and outlines billing practices for nurse practitioners and physician assistants. The article also notes the importance of aligning agreements with legal requirements and ensuring fair compensation for supervision roles.

To enhance National Provider Identifier (NPI) and specialty information available in Medicare Advantage (MA) encounter data and use the enhanced data to evaluate methods for retrospective attribution of the patient's usual clinician, comparing results across MA and Traditional Medicare (TM) populations. We fill in missing clinician identifiers and specialty codes in MA encounter data using Centers for Medicare and Medicaid Services (CMS) and publicly available provider datasets. We attributed patients to the usual clinician using 16 methodological options, comparing the performance of these attribution methods in MA and TM. We used a 20% sample of MA encounter data and TM claims data for 2016-2022, incorporating information from CMS's Medicare Data on Provider Practice and Specialty, archived data from the National Plan and Provider Enumeration System, and specialty-taxonomy crosswalks derived from CMS publications. For MA, we identified individual NPIs for 83% of medical claims in 2016, improving to 89% in 2022. Among MA medical claims billed by physicians and advanced practice providers, 95% of NPIs were for individual clinicians by 2022. In total, we identified individual or organization NPIs and specialty codes for over 99% of medical encounters in both TM and MA in all years. Rates of patient attribution were stable over time, and most methods had similar performance in MA and TM. We recommend a hierarchical attribution method that resulted in the highest fraction attributed with good consistency of attributed clinician year over year. Published reference files and SAS code make these NPI identification and patient attribution methods accessible. Our methods allow researchers to identify provider NPIs that can be matched to external clinician data, used to attribute patients to a usual source of care, or to fit clinician fixed effects in studies of MA and TM.

OBJECTIVES The Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury (CSI) clinical prediction rule (CPR) was developed to reduce unnecessary imaging in pediatric trauma patients while ensuring accurate diagnosis. This study aimed to identify barriers and facilitators to future implementation of this rule in diverse emergency department settings. METHODS We conducted 40 interviews with 48 clinicians, including emergency department physicians, surgeons, nurses, and advanced practice providers at 21 healthcare facilities across the United States. Semi-structured interviews explored determinants impacting implementation, guided by the Tailored Implementation for Chronic Diseases (TICD) framework. We conducted a deductive thematic analysis using the TICD domains as a priori codes. Three researchers independently coded the transcripts and identified key themes aligned with the TICD framework. RESULTS Barriers included limited guideline accessibility, workflow disruptions, and inconsistent integration with electronic health records. Clinicians’ concerns regarding the applicability and adherence to guidelines were also significant. Facilitators identified included institutional support, stakeholder engagement, and targeted education that addressed knowledge gaps. Implementation strategies varied by context, with suggestions for electronic health record-based decision tools in resource-equipped facilities and external aids, such as pocket cards, in lower-resource settings. Addressing legal concerns, clinician resistance, and workflow alignment emerged as critical priorities. CONCLUSIONS Implementing the PECARN CSI clinical prediction rule requires addressing contextual barriers such as workflow challenges, clinician adherence, and technology integration. Context-sensitive strategies are essential for successful adoption and improved decision-making in pediatric trauma care. Future research should evaluate the impact of these strategies on clinician behavior and patient outcomes.

A Pulse Check: Evolution of the Pediatric Cardiac ICU Advanced Practice Provider Education, Training, and Practice.

Patients receiving glucocorticoids for acute graft versus host disease (GVHD) after allogeneic hematopoietic stem cell transplant (HSCT) are at risk for developing hyperglycemia and subsequent complications. The primary purpose of this project was to reduce time to medical intervention for steroid-induced hyperglycemia through the implementation of a tailored tool kit for HSCT clinicians. An interdisciplinary team conducted a four-phase project: (1) a baseline chart audit and survey of advanced practice providers (APPs), (2) development of a tool kit and educational materials, (3) education of the HSCT team, and (4) post tool kit implementation chart audit and APP surveys. Patients at baseline (N = 15) and post tool kit implementation (N = 8) were diagnosed with acute GVHD with ≥ 0.5mg/kg/day prednisone and subsequent steroid-induced hyperglycemia. The average number of days to medical intervention was 46 at baseline, reduced to 10days at 3months and 9days at 6months post tool kit implementation. Metrics used to evaluate changes in APP practice noted an increase in hemoglobin A1c and glucose monitoring from baseline to post tool kit implementation. There was no change in APP confidence scores pre and post tool kit (N = 29). The tool kit designed in this study is an evidence-based resource created by an interdisciplinary team that led to earlier intervention to improve glycemic control in HSCT patients. Due to the complex nature of HSCT patients, a proactive and stepwise approach to managing hyperglycemia is critical to monitoring patients at risk and initiating treatment early to mitigate symptoms.

To describe the approach to, accuracy, and variability of neuro-prognostication for patients with severe traumatic brain injury (TBI) among clinicians caring for these patients. Data were collected via an anonymous electronic survey. The survey was emailed to all clinicians who care for patients with TBI at a Level 1 Trauma Center. In this observational survey study, respondents were provided vignettes of 3 real patients with TBI and asked to predict 2-year Glasgow Outcome Scale-Extended (GOS-E) scores and 6-month risk of mortality and unfavorable outcome (GOS-E <4). Medical management decisions and approach to goals of care discussions were queried. Results were collected anonymously. Primary outcome measure was prognostic variability. Secondary outcome measures included overall prognostic accuracy and incidence of management recommendations overall and by clinical role. Of the 55 respondents, 16 (29%) were attending physicians, 19 (35%) residents or fellows, 6 (11%) advanced practice providers, and 14 (25%) nurses. The accuracy of prognostication based on initial patient presentation was 15%. The range of responses for predicted outcome for each patient spanned all GOS-E scores (1-8), and responses for predicted probability of 6-month mortality ranged from 0% to 99% for each patient. Prognostication accuracy was low, and predictions were highly variable, including all possible neurologic outcomes and mortality ranges. Decreasing the variability in neuro-prognostication for patients with severe TBI is critical.

Abstract Background and Aims In March 2020, responding to the COVID-19 pandemic, federal emergency waivers in the United States enabled kidney care providers (nephrologists and advanced practice providers) to substitute face-to-face in-center hemodialysis visits with telemedicine encounters. We examined whether the frequency of kidney care provider visits and hospitalizations were associated with telemedicine use in hemodialysis care. Method We used Medicare claims to identify US patients receiving in-center hemodialysis during the first 16 months of the COVID-19 pandemic. We examined the association between telemedicine use during in-center hemodialysis, the frequency with which kidney care providers visited patients at dialysis four-or-more times per month, and hospitalizations. We also examined whether the association between telemedicine use and visit frequency varied at facilities located in more remote areas. Multivariable regression models adjusted for patient, physician, geographic and dialysis facility characteristics along with the frequency with which kidney care providers saw patients at each facility before the pandemic. We focused on kidney care providers who demonstrated knowledge of how to bill for telemedicine visits by using the telemedicine modifier on prior claims. Results We identified 1,881 providers who saw patients between 3/2020–6/2021 and were definitively using telemedicine. In the adjusted model, a 35% absolute higher use of telemedicine at a facility (representing one standard deviation difference) was associated with a 1.4% higher rate of four-or-more visits (Incidence Rate Ratio (IRR) 1.014; 95% Confidence Interval 1.007–1.022). The association between telemedicine use and visit frequency was stronger where travel distances to facilities were farther (interaction P = 0.01). There was no significant association between telemedicine use and hospitalizations. Conclusion The use of telemedicine to care for patients receiving in-center hemodialysis was associated with a slightly higher frequency of four-or-more visits per month but not with hospitalizations; the association with visit frequency was more pronounced in areas where providers had to travel longer distances to see patients in-person.

In response to the national primary care physician shortage, states are increasingly turning to legislation that expands the scope of practice for advanced practice providers (APPs), such as nurse practitioners (NPs) and physician assistants (PAs) to practice independently without physician oversight. While the effects of these laws will be multi-faceted, little is known regarding how these laws will affect states' future abilities to attract and recruit physicians to practice within their state. This study explores medical students' (MSs) attitudes toward APP independence legislation, focusing on their perceptions of equivalency of care, the potential impact of these laws on their future practice choices, and their views on professional collaboration. An anonymous survey was administered to MSs across all 4 years of schooling at a Midwestern medical school. This survey had a 21% (109/518) response rate. 86% of MSs expressed disagreement that APP care is comparable to physician care. In addition, 59% of respondents reported they would be less likely to practice in states allowing APP independence, a figure rising to 71% among those interested in pursuing primary care. The majority of MSs do not view APP-driven care as equivalent to care delivered by a physician. Further, states that enact APP independence laws may struggle to attract future physicians as the majority of MSs in this study consider the legislative landscape of the state they practice in. States considering APP independence laws should consider the results of these studies when attempting to address their physician shortage.

This pilot study assesses diagnostic agreement between correctional advanced practice providers (APPs) and physicians in interpreting 12-lead ECG results for STEMI diagnosis, with the aim of determining whether APPs offer comparable care to adult correctional populations that decreases ED burden. This study compared the diagnostic accuracy of APPs with that of physicians in identifying STEMI through an online 12-lead ECG assessment based on current guideline criteria. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for each profession. Unadjusted odds ratio (OR) with 95% CI were used to compare groups. Of the 37 total completed submissions, no statistically significant difference was observed in overall 12-lead ECG STEMI diagnostic accuracy among the groups. Correctional APPs and physicians had comparable accuracy in using 12-lead ECGs to identify STEMI, and evaluation by an APP in the correctional setting does not increase the likelihood of ED evaluation. However, a quality improvement study entailing use of larger sample sizes and proctor-controlled assessments is needed to accurately determine APP 12-lead ECG STEMI competency.

Post-Intensive Care Syndrome Awareness and Communication: Surveys of ICU Providers and Patients.

ConstiPatED: Evaluation in the pediatric ED - practice pattern and trends amongst provider types.

The "July Effect" refers to the potential increase in adverse outcomes associated with the annual turnover of medical trainees, though its impact on surgical fields remains uncertain. Additionally, few studies have examined whether the operative day of the week and subsequent flap monitoring during the weekend affect time to reoperation or flap salvage. This study investigated whether academic quarter and operative day influence reoperation rates, flap salvage, or flap failure in microvascular free flap procedures. A retrospective review was conducted on 769 free flaps performed between June 2011 and November 2023. Multivariate analyses adjusted for patient demographics, comorbidities, flap type, and recipient region. Flaps were categorized by academic quarter and operative day, excluding weekends due to limited sample size. Primary outcomes included reoperation rates for vascular compromise, time to reoperation, and flap salvage. No significant differences in reoperation rates for vascular compromise were observed across academic quarters. While procedure duration trended longer in the first three quarters compared to the fourth, these differences were not statistically significant. Additionally, operative day did not impact reoperation rates, flap salvage, or time to reoperation. Flaps were predominantly indicated for head and neck reconstruction (74.4%) and had an overall flap loss rate of 3.0%. We found no evidence of a "July Effect" in microvascular surgery or that operative day affects free flap outcomes. Institutional factors, such as structured flap monitoring, attending oversight, and advanced practice provider support, likely mitigate risks associated with trainee turnover and shift-based staffing fluctuations.

Clinical reasoning skills are required for safe care, yet they are not consistently taught to advanced practice providers (APPs). In hospital medicine, where APPs work semi-independently, gaps in clinical reasoning can increase the likelihood of error. To address this, we developed a module that uses diagnostic root cause analysis (RCA) to teach clinical reasoning skills to hospital medicine APP fellows. The curriculum was delivered from July 2021 to March 2025. Fellows selected real-world diagnostic errors encountered during clinical rotations, created cognitive fishbone diagrams, and presented their analysis in small-group. Twenty-seven fellows completed the module and pre-post assessment surveys. Statistically significant improvements were observed across all six domains of knowledge and confidence related to identifying error contributors, analyzing cases, and setting goals. Free-text responses highlighted the module's emotional safety, peer learning value, and normalization of diagnostic reflection. Two learners published their projects as academic posters, and one graduate now co-facilitates the sessions. This module offers a scalable, time-efficient approach to clinical reasoning education that is adaptable across learner levels and specialties. Its peer-led design fosters psychological safety, reflective practice, and creates a natural pathway for APPs to engage in microscholarship-addressing a critical gap in both education and academic inclusion.

Pain is a common postpartum complaint, yet data suggest that approaches to postpartum pain management vary widely. Given the goal of improving quality and equity in postpartum pain management, we aimed to examine whether and how clinicians' perspectives on postpartum pain management differed by clinician roles.This is a qualitative study at a large, tertiary, and academic medical center. From November 2021 to June 2022, obstetric clinicians, including attending physicians, trainee physicians, and advanced practice providers (APPs), were recruited to complete in-depth interviews regarding their clinical experience managing postpartum pain using a semi-structured interview guide. Participants were asked to reflect both on their own role and that of the other clinician types. Purposive sampling was used to enroll a cohort representative of the institutional workforce in terms of clinician type and demographics. Data were analyzed using the constant comparative method.Of 46 participants, 47.8% (n = 22) were attending physicians, and 91% (n = 42) were female. Emergent themes were both self-reflected and externally directed. Data demonstrated that postpartum pain management differs by clinician type and level of experience. Themes related to the role of attending physicians included responsibilities as teachers for trainees, supervisory roles, and perceptions that attendings have greater comfort with prescribing opioids. Themes related to the role of trainee physicians included the impact of patient load on trainees' management, limitations of morning rounds, familiarity with emerging data, and perceptions of hesitancy to prescribe opioids. Themes related to the role of APPs included less reliance on opioids for postpartum pain management and emphasis on nonpharmacological approaches.Perspectives on postpartum pain management vary by clinician role. Consideration of these differences and the interplay between roles is essential when examining opioid prescribing patterns and developing interventions to improve postpartum pain management. · Pain management differs by role and experience.. · Attendings have more comfort with opioid prescriptions.. · Trainees are perceived as more hesitant to prescribe opioids.. · APPs rely more on nonopioid management strategies..

IMPORTANCE:Excessive cognitive load impairs task performance and contributes to burnout, but studies of cognitive load in pediatric critical care medicine (PCCM) settings are limited.OBJECTIVES:To better understand cognitive load in an academic PCCM setting and how cognitive load differs based on experience, role, task type, and task frequency.DESIGN, SETTINGS, AND PARTICIPANTS:Prospective two-part survey at a quaternary children’s hospital PCCM department. Part 1 (February to March 2022) assessed routine role-specific tasks; part 2 (June to August 2022) evaluated acute resuscitation. Participants were registered nurses (RNs), respiratory therapists (RTs), and physicians + advanced practice providers (APPs).MAIN OUTCOMES AND MEASURES:Raw cognitive load (1–9 Paas scale), net cognitive load (Paas × task frequency), and NASA-Task Load Index (NASA-TLX) subdomain scores (0–100) for acute resuscitation. Role was the primary exposure; between-group differences were analyzed using analysis of variance with pairwise comparisons.RESULTS:There were 109—part 1 and 79—part 2 survey respondents. Across all tasks, mean raw Paas scores were highest for physicians + APPs (5.2 ± 1.1), followed by RNs (4.8 ± 1.0) and RTs (4.0 ± 1.4; p = 0.004). In the three highest-load shared tasks—acute resuscitation, rescuing a decompensating patient, and managing advanced life-support devices—RNs reported significantly higher raw load than physicians + APPs and RTs. For bedside patient assessment, RNs had higher net cognitive load (25.0 ± 8.7) than physicians + APPs (20.3 ± 7.0; p = 0.01) and RTs (18.9 ± 8.9; p = 0.01). Nursing experience correlated with overall net cognitive load (r = 0.30; p = 0.02). During resuscitation, RNs reported higher NASA-TLX scores than other providers in all but two subdomains.CONCLUSIONS AND RELEVANCE:Cognitive load in PCCM varies significantly by role and task type. Nurses experience high raw cognitive load from critical events and net cognitive load from bedside patient assessment, suggesting opportunities for role-specific workflow redesign and cognitive load reduction strategies to benefit staff and patients.