ABSTRACT
Objective: This study analyzes the impact of midlevel practitioners (MLPs) on patient care and resource utilization at a level I trauma center.
Methods: A retrospective review of trauma patients admitted during two periods was performed: PRE-MLP, during which limited MLP coverage was available; and POST-MLP, when MLP coverage was expanded. Demographics, injury severity scores (ISS), and preexisting medical conditions (PEC) were recorded. Trauma service activity was measured by daily admissions, inpatient census, and daily discharges. Outcome variables included hospital mortality, total length of stay (HLOS), ICU length of stay (ICU-LOS), and incidence of the three most prevalent complications: deep vein thrombosis (DVT), major arrhythmia (MA), urinary tract infection (UTI).
Results: PRE-MLP and POST-MLP groups were similar with respect to age, gender, and ISS. Mean daily admissions were 3.05 during the PRE-MLP period and 4.01 during the POST-MLP period (P = .0001). Reduced incidence of UTI was demonstrated in the POST-MLP period: 0.9% versus 2.6% (P = .0001). Incidence of DVT and MA were unchanged. HLOS decreased from 5.09 days to 4.84 days (P = .092). ICU-LOS was reduced from 4.08 days to 3.28 days (P = .019).
Conclusion: Use of MLPs led to a significant reduction in ICU-LOS with no increased incidence of complications. MLPs offer a clinically effective and resource-efficient alternative to residents on a trauma service.
Trauma center staffing has become an important issue in any discussion of contemporary trauma systems. Optimal management of severely injured patients requires around-the-clock commitment of health care providers. Recently published studies from the Institute of Medicine clearly document the significant challenges to emergency medicine with regard to staffing at all levels.
1 Smaller community hospitals are frequently unable to provide necessary care for injured patients. As a result, the inpatient census on many contemporary trauma services includes patients with minor and moderate injuries who have been transferred to the trauma center. Limitations on resident work hours, imposed in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), have created an additional staffing dilemma for trauma centers. Traditionally, trauma services have relied heavily on residents for their participation in trauma resuscitation, surgical procedures, inpatient management, and discharge planning.
Physician assistants (PAs) are health care providers who provide medical care under physician supervision to expedite the physician's ability to manage more patients. Training programs for PAs were initiated in the 1960s based on a predicted shortage of physicians, particularly in more rural regions. Over time, the scope of practice for PAs has expanded to include subspecialties (eg, neurosurgery, emergency medicine, and trauma), which has shifted the focus for these professionals to include hospital-based practice.2 The nurse practitioner (NP) profession also developed in response to physician shortages. NPs—nurses with advanced training at a master's degree level—can provide medical services and may prescribe medications.2,3 Most NPs work in collaborative practice with physicians, but changes in licensing regulations in some states permit NPs to practice independently.
The trauma service at St. Luke's Hospital in Bethlehem, Pennsylvania, is staffed by full-time attending trauma surgeons. This service manages all aspects of trauma patient care, including the intensive care unit (ICU) and the general care unit. The hospital has accredited residencies in general surgery and emergency medicine; both programs provide residents to the trauma service on a rotating basis. Since the designation of the trauma program in 1999, the trauma service has employed NPs to assist in patient care. As the program has evolved, trauma volume has increased by approximately 15% annually, with a commensurate increase in ICU volume. In 2004, as a result of this increase in volume and the ACGME mandates, administration approved the hiring of three additional NPs and PAs. A distinct position, trauma midlevel practitioner (MLP) with a specific job description, was created (Table 1). No differentiation was made between NPs and PAs with regard to roles and responsibilities.
The purpose of this study was to analyze the impact of trauma MLPs on patient care and resource utilization at a level I trauma center. We hypothesize that the quality of trauma care can be maintained when midlevel practitioners are incorporated into an established trauma practice.