Advanced Practice Nurse (APN) Intensivists: A Model for Generating Potential Revenues and Cost-Effective Healthcare Delivery in the ICU

Background:  Intensive Care Units (ICUs) account for over 10 percent of all US hospital beds, have over 4.4 million patient admissions yearly, and account for close to 30% of acute care hospital costs.  ICUs that use a physician intensivist model of care have improved patient outcomes, less resource use, and lower mortality rates (up to a 40% reduction), large reduction in in-hospital mortality following trauma, particularly in the elderly and may help save almost 54,000 Americans in the U.S. each year.  The need for critical care services has continued to grow due to an increased aging population and medical advances that have extended life expectancy.  This increased demand for ICU services has resulted in efforts to improve patient outcomes, optimize financial performance, and implement models of care in ICUs that will enhance the quality of care and reduce health care costs.  By the year 2020 an estimated 22% shortage of intensivists is expected as a result of the aging population and a growing demand for intensivists.  This will have increased to an approximate 35% shortage of intensivists by 2030.  Over 5 billion dollars in healthcare costs could be saved annually by implementing changes in physician staffing just in non-rural U.S. hospitals.  The compounded effect of this projected shortage of physician intensivists and physicians practicing in critical care in smaller hospitals may be larger.  This shortage will negatively impact small hospitals and rural communities putting more at risk certain vulnerable populations.  In contrast to the shortage of intensivist physicians and critical care trained physicians, Advanced Practice Nurses (APNs), sometimes referred to as mid-level practitioners or non-physician providers, are increasing in acute care both in the United States and globally.  In the U.S., APNs have increased in numbers and expanded their roles over the past decades, becoming an important link in healthcare systems and organizations.  The largest group of APNs is nurse practitioners.  Some APNs function as Acute Care Nurse Practitioners (ACNPs) in hospitals and in ICUs.  In spite of this increased visibility and participation in the healthcare arena, healthcare providers and potential employers are still unfamiliar with the scope of practice of APNs.  Since the early 1980s, the role of APNs in providing high quality care and low cost has been documented.  Care provided by APNs in acute care has been documented in numerous studies examining quality of care, morbidity, and mortality.  Results of these studies have indicated that the quality of care provided by APNs is equal to that of physicians as well as being cost efficient.  However, studies in the ICU documenting the role of APNs in reducing the costs of care on specific patient outcomes are very limited.  In ICUs, the role of APNs has been evolving to replace physicians (input substitution) and support patient care rather than providing traditional nursing care.  APNs function as members of multidisciplinary teams in closed (intensivist lead) or semi-closed (intensivist shared lead) ICUs.  Collaborative practice rather than individual or autonomous practice is the norm in both instances.  However, APNs have continued to enjoy autonomy in decision making and treatment modalities as permitted by the scope of their respective collaborative agreements.  The APN Intensivist is a healthcare provider with a high level of independence and specialization in the management of critically ill patients in critical care settings.  Very little has been published on this relatively new sub-specialty role of APNs.  The lack of literature to explain the role of APNs as intensivists and of research to evaluate the effectiveness of this APN role made the need clear for research to examine the role economically and for its effect on quality of care and patient outcomes.  The empirical evidence of the effects of APN Intensivists on patient outcomes and healthcare costs remains scarce compared to the well documented effects of APNs in other areas and models of healthcare delivery.  In light of this dearth of the literature examining the effects of APN Intensivists on patient outcomes and healthcare costs, research is needed to fill this gap in our knowledge.

Objective:  The purpose of this study, using a retrospective chart review of 816 randomly selected patients during the 3-year study period, was to examine the dose effect of APN Intensivists in a surgical intensive care unit (SICU) on healthcare revenues generated by APN Intensivists services for the unit when the SICU was staffed by differing APN Intensivist staffing levels.  The study also explored different procedures performed by these providers.

Method:  The sample consisted of post-operative patients admitted to a teaching hospital SICU during a 3-year period.  Of approximately 1,000 charts meting the study criteria 816 were randomly selected for the 4-time periods of the study (204 charts T1-T4).  Each of the four time-periods represented a different level of APN Intensivist staffing.  Power was calculated with a total N of 204 for the research question.  A t-test analysis with a sample of 200 per group, medium effect size and alpha of 0.05 provided > 85% power.  The charges for APN Intensivists’ services were obtained from a financial report generated by the hospital Financial Office on SICU APN Intensivists’ charges.  These amounts reflected charges attributed to SICU APN Intensivists from the inception of billing for services in the SICU to the date of the report generated.  The report tallied the number of units (procedures) paired with corresponding charges for each billing period.  It was not possible to obtain data on APN Intensivists’ charges for procedures for individual patients.

Results:  Study findings indicated no statistically significant difference in the SICU length of stay among the time-periods (M= 3.27, SD = 3.32), t (202) = 1.02, p= .31.  Charges for APN services (generated revenues) increased over the 4 time periods from $11,268 at T1 to $51,727 at T4 when a system to capture APN billing was put into place.  For each of the four study time-periods (T1, T2, T3, and T4), total healthcare charges for APN Intensivists’ services for the sample were $90,478.  Study revealed potential areas for revenue generation and the implications for practice advancement.  Study also documented various procedures associated to APN Intensivist practice in the SICU.

Discussion:  Study results suggest a dose effect of APN Intensivists on important patient health outcomes and on the number of APNs initiatives to prevent health complications in the SICU.  Study also suggests potential of APN Intensivists in generating revenues through performance of procedures related to their skills and competencies.