So, I'm going to introduce our next speaker, who is going to speak to us on the utilization of advanced practice providers in the neuro ICU. Mr. Robert Blessing, or Dr. Robert Blessing, graduated from the Duke University School of Nursing and received his MSN from Duke's acute care NP program in 1997. He serves as lead nurse practitioner within the advanced practice nursing department, and more recently, the Department of Neurology. Dr. Blessing is responsible for providing leadership for the APPs at Duke. He has spoken at numerous national and international conferences. Please welcome Dr. Blessing. Thank you for that introduction, and thank you for the opportunity to speak today and talk about the expanding role of acute care nurse practitioners. And I want to talk not only about the expanding roles, but what our current role is and the role development that led to these current roles. I have been at Duke now, started my career at Duke in 1992, and as I look out in the audience, I bet some of you probably weren't even born in 92. So we've seen a lot of changes in our roles and development over time. So I want you to think about your first job, or maybe the current role that you're in, and just think about this, and you don't have to answer out loud or raise your hands, but how many of you actually understood what kind of role you were getting into? When you started your position, what would you do on a day-to-day basis? And I would bet initially you would be like me, you didn't really have a roadmap, there was a lot of uncertainty in your role, and you didn't really know what you would be doing on a day-to-day basis. That role developed over time. And now think about that role, and think about what others thought about that role, like your managers, your physicians that you're working with, your surgeons, and did they have that same expectation of your roles as you did? I mean, I'd bet they probably didn't. So I want to talk a little bit in importance of role clarity. We were fortunate at the beginning of our practice at Duke that we had some really great leaders. We had one of the founding fathers of neurocritical care, Cecil Burrell, who came to Duke in 1990s from John Hopkins and started the neurocritical care unit. He was charged with starting a world-renowned neurocritical care unit in the neuroanesthesia department. Along with him was Dr. Joanne Hickey, who was an expert on education. Many of you may have recognized the name. She's written many textbooks on neuroscience nursing, as well as Dr. Graf and Nino, who trained with Dr. Burrell. The three of those realized that we needed coverage, and we needed to provide 24-hour coverage, and that's what we were charged with. How do we provide 24-hour coverage seven days a week? We knew we didn't have the resources to do that. We didn't really understand our role, but the good thing is nobody else did either. When we started back in the 90s, we really didn't have critical care, a team of critical care providers at Duke and many other institutions across the country. So we didn't know our roles. Other people didn't know our roles. We kind of learned our roles together. This was a problem in many instances. We were an eight-bed neurocritical care unit at the time, and I was on call. I was in charge of taking care of those eight patients at night, independently, kind of on my own. And I remember getting a phone call from microbiology, and they said, hey, I need to talk to a physician in charge. I need to give a positive blood culture. And I'm like, well, I'm the MP. I'm in charge of taking care of these patients. And they said, no, I can't give you that result. It has to be a physician. And so that really hindered the care that we could provide, but after about two or three times calling the attending at home at 2 o'clock, it didn't take long for these changes to happen. So we survived 20 years of practice. I think from the beginning, one of our biggest challenges would be learning from our experiences, adapting to a changing environment, not only a changing environment at Duke as we're expanding and growing the number of critical care beds that we would provide, but also the influences and the changing landscape of critical care. We had new evidence that showed that a care team provided by a subspecialty practice 24 hours a day or 24 hours a day, seven days a week would actually improve outcomes. So we used this literature and this changing landscape to help develop our roles. We continue to adopt our changes in attempts to provide the biggest impact to make a change on not only patient care, but also our professions as we expand our roles. The importance of role clarity is underestimated in the literature. But as we have more and more literature coming out, I think that it has shown to be one of the most important determinants of successful integration and success of APP programs. I also teach for the acute care nurse practitioner program at Duke and have been involved with that education for about the last 15 years, teaching the critical care component of that. And so a lot of the practice that we see at Duke involve nurse practitioners we have, but our positions are open to both MPs and PAs. But this role clarity has a big impact on educational programs. So again, the PA, the formal educational programs like the PA program or MP programs. Also on fellowship programs, and as we have increasing number of fellowship programs throughout the country, that role clarity will have a big impact on that. And then less formal educational programs, such as how we train and onboard our APPs in critical care. Next is it has a big implication on direction of legislation. Not just legislation on a national level, but also on a state level. It has implications for credentialing and certification. Also how we need to be supervised or the degree of collaboration depends on what kind of role we provide in the ICU or anywhere. And it has a big impact on reimbursement, and I'll talk about reimbursement throughout this talk because I think that's really important for the sustainability of APP practice. Next it sets standards, and it sets standards for patient care activities as well as practical skills such as the procedures that we're going to be doing. And defines the operational function and how we work with other teams and how we collaborate with other teams, where often our roles may overlap. And then lastly, permits for evaluation. Without evaluation, we really can't determine where our roles should expand to or how those roles should look. So there's a lot of drivers in role development. And I'll spend a little bit of time about this because I think, again, role development is really important to the success of the integration of APPs in your practice. So like many other places, Duke, we had a shortage of providers. Not only just with resident cutbacks on our restrictions for residents and interns, but also on the number of providers actually providing the critical care as far as attendings go that had that specialized critical care skills. We know that our patient population is getting older. Central did a good job of describing that, as well as getting sicker. Most of those patients come in with multiple comorbidities or sicker than they used to. So that really drives what we need to do as far as how we function in the ICU. We're having emerging literature that shows that we can, as APPs, provide effective and safe care. That wasn't true when I started my practice, and often when, even with role clarity, that you see that you have some resistance among other entities, such as physicians and reimbursement programs, and I'll talk a little bit about that. We know that hospital costs continue to go up. We need to decrease those costs while still providing effective, safe care. And then we also look at hospital and department needs and what are the needs of those as we develop our roles in outside emerging agencies, such as looking at outcomes, for example. So when you're thinking about role development, it's really important to understand who the key stakeholders are going to be. They can be bodies that help make up our certification, and they can be some of our physician champions, administration, finances. And so all of those are going to be really important to gather together as we develop our role, think about those drivers of change. And then what are the resources involved in developing these roles? Do we have resources to help with education and evaluation? Do we understand what the management of these positions are going to look like? Do they need to be managers from the physician side as well as the APP side? And probably so. So you need to make sure you include all those key stakeholders when you're developing these roles. Education, you want to make sure all these key stakeholders understand what that education should be and agree on that, because there's a lot of disagreements in stakeholders that make role transition difficult. And lastly, the evaluation. How are you going to evaluate these roles, and how can you get better? So I want to talk a little bit about the importance of role clarity as it pertains to a project that I was involved with. So I've been involved with developing roles in critical care, both nationally and internationally. And this is a program that we developed in Germany. Germany had a lot of the same drivers we had. They had lack of physicians. Many of the German physicians, after they finished their education, they left Germany because they had hour restrictions placed on them, which decreased their ability to increase their revenue. And it left a shortage, which gave them more responsibilities. And this was a program that we developed in one of the largest private hospital systems with over 100 hospitals in Germany. The goal was to develop this program in a cardiothoracic ICU and then start with a small population size or a small sample size of maybe 5 or 10 APPs. And then we used experienced nurses at this time for this project, and then implement this program within the institution and hopefully across multiple ICUs and then across their whole hospital system. Now again, the drivers were very similar. Many of these patients, the attending physicians, had to have dedicated time in their ICU to be able to recover these patients. And they didn't. They didn't have enough of these physicians. So many of their patients were stuck in the operating suite and recovered in the OR. And that led to increased dissatisfaction. So they were familiar with our educational program, and they were familiar with the services we provide in our neuro-ICU. So we contracted with Germany and developed this program for them, thinking we, and certainly we planned and got, we thought we had all the stakeholders together. And one of the things we learned is that there was a big discrepancy between what their nurses can do compared to what ours could do. Our nurses, I think, in the U.S. function at a little higher level. And so when we trained these nurses, we thought we had a pretty clear idea of what their role would be. It would be similar to what we do in our ICU or what we do at Duke in our cardiothoracic ICU. And we failed to think about that bridging, that distance between what they are able to do and the autonomy and the independence that they would gain after this program. And so we lost some of our initial class, our initial cohort, and we've really had a hard time in struggling with the integration because of that lack of role clarity and understanding what that role could be. So next I want to transition a little bit about what we're doing at Duke. So we've defined our roles, and we spent a lot of time thinking about how we would define our roles. And I was part of that initial cohort at Duke, working with these great mentors and now friends of mine, and really experts in the field. You really need a good champion when you think about how to develop your roles. We knew we would start and try to practice to the top of our level. We know that if, as APPs, we're able to practice with as little restriction as we can, that it can improve outcomes, it can improve satisfaction, as well as it can improve revenue. Next the integration of our practice, I think, went fairly smoothly, except for within our ICU group, I feel like it went fairly smoothly, but it took a long time for the hospital and other disciplines to understand what we were doing. I think also when we're thinking about roles, it's really important to talk about investing in our APPs. And this is really important, especially with a new program. We have a strong onboarding program, and that helps with investment. We continue education. We send our APPs out to conferences. We encourage publications. We promote the team, and that's going to be really important. And then last, evaluating the team. So I'm sure most of you are aware of the roles we do as a provider in the ICU. A lot of these roles encompass that of what we do as providers. This is taking care of the patients. This is the things we do every day. And I'll talk a little bit about how that role breaks up. We are also coordinators of care. We spend a lot of time coordinating care. We are educators, and I think our role as educators are expanding. We are involved with research, and I heard earlier today they're giving grants out for those APPs doing research, even within AANS. I'm a little ashamed to say that after 25 years of practicing, this is my first time coming to AANS. I usually go to the Society of Critical Care, European Society of Critical Care Medicine, Neurocritical Care, but I'm impressed by the involvement of APPs in AANS. We also serve as mentors, so we're trying to help bring up younger APPs, and then the time we spend in administration, which varies depending on your position. So a lot of hats that we play every day when we're working. We are split-funded in our ICU, and it's a requirement to determine, a hospital requirement, to determine how you split your day. So we split our time between, and we're split-funded between the hospital. Primarily we're funded by the Department of Neurology. That's 51% of our funding, and 51% of that funding we're able to bill for. These are physician-type duties that we provide, and then the other 49% of our funding comes from the hospital. This funding structure is very helpful in when we're talking about sustainability and how we get reimbursed for what we do. So I want to talk in this slide kind of on the hospital side of what we do, and most of what we do on the hospital side of our role is providing education, providing education to our patients and families, and in an ICU we spend a lot of time with family teaching and family conferencing, as well as education for our staff and colleagues. The 20% part of what we do in a hospital is taking care of non-ICU patients. Now these are patients who do not meet criteria for billing in critical care, but these are patients who still need ICU, and these are often our post-operative patients. They are bundled in our global fee, so we do not bill for those unless they have a lot of other comorbidities that we're taking care of, but we're still familiar and we're still involved with their care, and we work really closely with our neurosurgery counterparts in delivering that care. And that's part of our hospital side. Next, the provider side of our practice, which is 51%, again, this is what we bill for, and we do directly get reimbursed for the services that we provide as APPs. And this is the things you would think about as a provider. This is taking care of patients, obtaining a history and physical documentation, which I feel like that's 100% of what I do some days, procedures, and I'll talk a little bit about the procedures that we're doing in our ICU, providing consults or obtaining consults from other services, evaluating our patients and reviewing our results, and we're expected to be able to read CT scans, MRIs, any studies that we're, any neurologic studies that we're providing for our patients. We're responsible for reviewing those and knowing how to interpret those. This is just a big list of procedures that we do at Duke in our ICU. Some of these procedures we can directly bill from, some of them we can't. Probably the biggest volume of procedures we do here are central lines and placement of dialysis catheters, arterial lines, which we do frequently, a lot more punctures we do frequently, managing airways, intubation, PA catheters I left up here, although I don't know, I really can't remember the last time I placed a PA catheter, and I say that as our roles have changed, we have better ways or less invasive ways of monitoring hemodynamics now in the ICU, but I will say early on when we were still managing our subarachnoid hemorrhage patients with triple H therapy, we would place PA catheters in every patient, whether they were a Hunt-Hess 2 or whether they were a 4, it didn't matter. We placed a PA catheter, and often there would be days I'd place two or three PA catheters. But we still are doing a lot of these procedures. We manage all of our codes, we manage all of our RRTs in the ICU as well as out on our intermediate floors for neurosurgery and neurology patients. Next I want to talk a little bit about our routine, kind of what our daily pattern looks like and what we do day-to-day, and talk a little bit about these teams because I think as I talk about the teams, you'll kind of have a better understanding of our role. So we are a 24-bed ICU. We are a closed ICU, meaning that any patient admitted to our ICU is admitted to our service. We are the first overflow for trauma in general ICU, so we may get trauma patients even if they don't have a head injury or any neurologic problems, and we're second overflow for MICU. So any patients that are admitted to our unit are admitted to our service, with the exception of neurosurgery. And neurosurgery admits their own patients to their service, but we co-manage those patients. That has a lot of implications on my role because not only do I have to be familiar with how to manage neurosurgical patients or neurology patients, but I also have to be versed in managing all critical care patients as we may get anything from a GI bleed to a TBI to a postpartum patient with a platelet count of five. So really it's important to understand your role in the patient population that you may be taking care of. So we have 10 intensivists, 8 are neurologists. One is a neurology and anesthesia trained attending, and one is anesthesia critical care. So 10 intensivists, they rotate two at a time in our ICU, and we have 12 APPs. We have a couple fellows, usually one fellow in the unit at a time, and we have neurosurgery interns and occasionally neurosurgery residents and neurology interns. So we break our 24-bed ICU into three teams. One team will be managed by the most senior APP, along with a fellow. And many of our fellows, especially our neurology fellows, they don't have critical care training. They're board of neurologists, but they really lack critical care skills. So we do a lot of education with them. So we round as a team, and then the other two attendings will round with either an MP that's less senior or a resident or intern. And we start our morning with handouts like you typically would. We do 24-hour shifts in our ICU, and we've tried different patterns of scheduling. And I think most of our APPs enjoy the 24-hour shifts, and it does improve patient continuity from day to day. And so then we have teaching rounds, and we spend a lot of time teaching. We have many learners in our teams. It could be MPs. It could be medical students, interns, residents, and other disciplines. And we have multidisciplinary rounds, including respiratory therapy, pharmacy, and like I said, many learners. And we round, and our rounds, again, we spend a lot of time educating. It takes us about three hours, sometimes a little longer, depending on how many times we're interrupted for codes or for admissions. But we could be rounding until noon, and then after that, we admit patients. Most of the time after rounds, the attendings are free to go do other things. We have a very independent practice. We work very autonomously. So most of the time after rounds, the attendings will go take care of non-clinical kind of activities, such as administration work and research. And then usually we're it. So we're the APP on for the night. Again, we have two usually APPs on with a resident or intern, and we help provide care for that site as well, especially for the more high-acuity patients. So that's what we do, and that's our role in the ICU. But I think it's really important to think about, do we make a difference in those roles? And so measuring the value of practice of APPs is really important, especially when you're thinking about how do you expand these roles and what's the impact of our roles? And we look at competency outcome metrics, our role as an educator, as well as process improvements and cost reduction. Most of these outcomes are more reflective of what we do as a practice team, not necessarily an individual provider, but we do have provider outcomes such as competency metrics, and we look at these competency metrics. This is a joint commission requirement with focused and ongoing professional practice evaluation, and we evaluate both when they're onboarding or if there's a particular trigger that would have led us up to more remediation. And we also look at maintaining competencies, such as the example I gave with the PA catheter. We don't do that very often, and it could be a high-risk procedure with a low volume. So we look at how do we maintain those competencies. And then we look at hospital outcomes, patient safety. First, the goal we were set out to do 20 years ago was can we provide 24-hour care seven days a week, and we've certainly done that for 20 years. We look at patient satisfaction and process improvements. And one example of that process improvement, we have APP involved with these processes all the time, and one of them actually looked at the routine use of CT scan after TPA in stroke patients. And we looked at outcomes and did that routine CT scan make a difference in not only just outcomes, but it did make a difference in how we manage that patient. And after doing this process improvement project, we found out that it really did make a difference, so we stopped doing routine CT scans. Now, obviously, if a patient had an acute event or deterioration, we were going to get that CT scanning anyway. So that's just an example of how we can improve, kind of process improvements, and actually creates a cost reduction. Next is the usual patient outcomes, which most of you are familiar with, which is length of stay, mortality, complication rates, and return visits. This looks like a busy slide and it kind of is, but this is looking at triggers that we use to evaluate competency and performance. And we look at patient outcomes, practice patterns, documentation, and procedures. And we look for triggers that may lead itself to some decreased performance in these areas, and we do that by chart review, care conference teams, and direct observation and peer evaluation. And if we find a trigger or a performance measure that we can improve on, we have tools to help with that, either through education, and we use a lot of simulation in our unit. Next I want to talk about clinical outcomes. So we look at more than just our outcomes at Duke. We look at national trends and international trends. And from the beginning, we've seen increasing evidence of at least equivalent, if not improved, outcome measurements from having a team that's utilizing APPs. And these are just some examples of these. And we're looking at, does this care optimize critical care using APPs optimize outcomes? And you can see this literature is growing and growing. This is actually a systemic review looking at 31 research papers looking at the impact of APPs, not just in critical care, but through the emergency department as well. And again, they found the same thing looking at these 31 studies is that we have an impact on length of stay, time to treatment, as well as increased satisfaction and decreased cost. And this is comparing traditional teams with physicians and residents, as well as teams that are NP directed only, and teams that involve a collaborative practice. Next I want to talk about the impact of our role as an educator. Now, we spend a lot of time educating, like I said, patients and families. And we know that leads to increased patient and family satisfaction, as well as improved outcomes. These outcomes are seen by way of improved compliance and decreased readmission rates. But again, we spend a lot of time with staff education. We know our nurses have increased turnover, not only at Duke, but nationally as nurses are going back to receive additional degrees. So we know that keeping staff engaged in education is really important. It leads to increased satisfaction as well. And some of the opportunities that we're doing for education involve daily rounds, pre-sectorships. We have one of our APPs started a NICU journal club, initially just for our critical care group, but it's expanded beyond our ICU group and involved neurosurgery, as well as regional institutions, and then most recently now inviting international and national researchers to join this journal club, all run by one of our APPs. We're involved with formal lectures, workshops. We do a lot of simulation and M&M conference. We know our role as a collaborator of care and our role as improving communication and teamwork is vital. It leads to a lot of safety issues. So one of the things I want to talk about is how we've increased our transition between cares and try to make that seamless. We're doing work on face-to-face handoffs and some of that work is involving using a checklist from, especially in our neurosurgery population, when we get handoffs from the OR. So that's often a busy time, managing multiple patients, and we get a patient rollback. So we make sure we have the right people there, anesthesia, neurosurgery, as well as a critical care team, where we're giving face-to-face handoffs using this checklist. And that seems to improve care from the OR to the ICU. We're increasing our collaboration between teams. Like I said, we've always worked really well with neurosurgery, so that really hasn't been as big of an issue as maybe with other teams. So we get a neurology patient, and so we're the primary team for them, and we have to collaborate with the team that's going to be taking care of them. We have had to increase our communication related to discharge. Occasionally we'll take a patient who comes to the ICU and discharge them to a skilled nursing facility, or recently we're sending them home from the ICU after TPA or a thrombectomy, for example. And how do we arrange that care and help with that transition of care from the ICU to that patient going home? And that's something that I have not had a lot of experience with. I'm used to my training has been taking care of patients who are really sick that are on multiple pressers, and so it's changed my role a little bit in thinking about, okay, well, how do I get this patient safely home, and how do I keep them home and not coming back? So we are now working with our stroke team. An example of that is we're working with our stroke team and actually talking to the APP involved with outpatient stroke and helping arrange them to have a follow-up appointment, and then making sure we give a good handoff to them, talking about the etiology of the stroke, the workup, and what is needed when they go home. Other considerations of research. So not only do we look at clinical outcomes, but we're all involved with research. We are all screening for potential research in critical care patients, but we also are involved with enrolling. We had one particular project that I was involved with looking at statins and subarachnoid hemorrhage and how their effects on ethyl nitric oxide synthase and the inflammatory response, and we started off with a murine model in the lab and transitioned it to the patient care area, and the APPs were involved in that project, along with our champion and one of our translational researchers. We're also involved with unit-based initiatives and departmental hospital projects, such as developing new protocols, looking at the literature and changing our protocols that we have. Let's talk a little bit about the financial impact of our role. So again, we're always trying to improve outcomes, and we know that some of these outcomes are linked directly to financial reimbursement. So most of those are in terms of some of the complications or the no-ever events, such as CAUTI or catheter-associated UTI or catheter-related bloodstream infection related to a central line placement. We also look at length of stay, ventilator days, and looking to see if we're adhering to policies and guidelines, such as our stroke guidelines. All these are leading to improved safety and access to care. We know that if we grow our roles and our positions and grow independence and autonomy, that that gives our physicians a chance to do other things, and they don't have to be there providing the care because we are there. So that increases their physician productivity. Like I said, we directly reimburse for the physician side of our practice, which is through critical care time, evaluation and management, procedures and consults. And again, I think it's important to have a practice where you can follow that direct reimbursement and change your roles based on that. So if you're not involved with critical care billing, it could be a big portion of our revenue stream. So this all came out of CMS fee schedules in 2018. So the first hour of critical care is about $226, and this will vary based on your region and what kind of institution you practice at. And if you do that for 24 patients, you can see that that would add up. Now, this is all CMS data, so if you're getting reimbursed from a third-party payer, that could be much higher. Second hour of critical care is about $110, and then if there are patients that we're following that do not, they don't get billed on critical care because they don't meet those criteria, then we're usually billing those for evaluation and management. And that's time and acuity-based, and you can see those volumes are much less. These are just a list of some of the common procedures that we're doing and the reimbursement rate for those. Next is how do we take this data and how do we change our practice based on that? So this is just an idea of kind of how we keep up with our volumes and are we doing a good job in decreasing our complication rates with education and with enough procedures. So you can see in the first chart over on your left, this is five years' worth of data. And the last column on the right, you can see the procedure is down, but that doesn't capture all the data that we're doing. But I think overall, at least from the last 20 years, our procedures are down. Our amount of invasive procedures such as central line placement and PA catheters are down because we can now place PICC lines instead. And we have other non-invasive ways of monitoring hemodynamics. This is a list of some of the non-billable procedures, and these are things we do frequently as well. We don't bill for these procedures, but they're accounted for in our critical care time. And for the last little bit, I want to talk about the future directions and kind of where we take this data and how do we move forward. So we know these clinical roles are evolving, and that image on the bottom right is something that one of our residents is experimenting with and trying to develop new ways of doing procedures such as placing an AVD. We look at our educational roles again and how we develop those, our clinical opportunities, looking at outcomes, as well as our extended areas. Do we have any gaps in the service that we're providing? And interprofessional education is becoming more and more part of the role that I provide as well as other APPs. I also teach for fourth year medical students at Duke University, and we're involving those medical students as well as other disciplines that come and learn with us in the ICU setting. And we know that impact of IPEs improves collaboration, and this is a way we're going to practice anyway, so we might as well learn that way. It improves processes and then can improve patient outcomes. We do a lot of IPE with our nursing staff, so again, it improves satisfaction, and we really are trying to engage our nursing staff, especially our senior nursing staff, so they can continue educating. And we do that. We have APPs within our group that part of their role is to making sure that we provide that education for them. And again, we use a lot of simulation. One of our metrics looking at process measurements is our metrics on inpatient stroke codes. We know that nationally if you have a stroke in an inpatient setting that those metrics are not even as good as if you come from home and go through the ED, where they're much more versed in seeing stroke, recognizing stroke, and they have a nice process to make sure that you reduce the time from onset to therapies, whether that's TPA or whether that's thrombectomy. So what we did is we took a mannequin, went to a room, and went to the nurse and said, I'm concerned this patient may be having a stroke as a family member, and see how that process breaks down and see what ways we can improve that, whether it's educational or through a process. And then last, acute deterioration. So if we don't see codes very often, then I'll bring up the mannequin, hit the code button, and see what happens, and see how that team works together and see how we can improve. Another thing we're doing as far as education is developing fellowships. And this is a fellowship that we developed at Duke in neurology, and we plugged them into our already existing neuroresidency program and providing education. And we know that this fellowship programs, which are growing nationally, certainly every time I look for registries, I see them increasing every month. And we know that fellowship program gives specific training, helps with satisfaction, helps with retention, is important for, I think, our practice. Next is, how do we use clinical outcomes in evidence-based medicine? Well, we do this looking at ICU complications. We look at thrombotic events. We know our patient population has one of the biggest risks of having PEs and DVTs. We know that our patient population has a big risk of infections and acute decline. And how do we look at that data and how do we provide, one, how do we diagnose it and how do we evaluate that? And then, how do we provide effective and timely therapies? So again, our patient population, and this is neurosurgery patient population, has a 20-fold time higher incidence of developing a PE or DVT. And often, these are the things that we see in our ICU every day. So we look at these complications, and as the provider in the ICU, I'll order a, I have some idea that they may be having either a PE from either decreased oxygenation or increased work of breathing. So we'll order the appropriate studies and do lower extremity ultrasounds or we'll order a spiral chest CT, PE protocol. But that takes time. So one of the things we're doing in our ICU is doing point-of-care ultrasounds. So we decided as a group of APPs that we would learn ultrasonography, a point-of-care ultrasonography in our ICU. And this is a good example of what we would do in our ICU. And this is a common femoral vein. And you can see the area on the second arrow, this hyperchoic material in the vein, and it lacks decompressibility. So you can see as we decompress on the veins around it, there's lack of compression in that one area. So this looks like a DVT. We're doing that for point-of-care ultrasonography for your echo as well. So we're doing echocardiogram. And we can look at function. This is an example of McCullen's sign. And you can see the right ventricle is dilated. You have bowing of that midseptum. And this has a very high sensitivity for PE, for large PE. So these are some of the ways that we're developing our roles in the ICU. Another thing we're doing is bronchoscopy in the ICU. As the APPs, we can use bronchoscopy not only for diagnosis of infection, but also as therapeutic means in cleaning out the lungs. And then the last thing I want to talk about is kind of how we expand our role beyond the ICU. And this is something that we're doing with having a roving APP position. We know that some of our patients, as we are full in the ICU, some of our patients, our critical care patients, are outside of our ICU, outside of the walls of our unit. And these are often our neurosurgery patients. These patients may have, say, the night in the PACU. And they don't have that specialized neuro ICU care that they need. So we have a roving APP position that will go manage these patients. The goals were to improve NICU bed flow. So occasionally we'll have a patient who's just on the border. Should they leave the ICU or do they need to stay in another day? Well, we feel confident in letting them go out early because they'll have this position following them. And then provide critical care again outside the ICU and provide support. And next is the evaluation process. And I think this is kind of where we're at now. This role's been in place for six months. And we need to get the whole stakeholder group together and figure out if this makes a difference. And are the goals being met? Do we need to add more APP roving positions as we expand our service? So again, I think as you're thinking about the roles, the goal isn't can we just provide a successful practice, but really how do you make your biggest impact and how do you strive for excellence? So that is it. Thank you. Any questions? Yes. Thank you for your talk. That was great. I have a question regarding your privileging. You talked about doing procedural care. Do you hold the same standard as the physician providers for the number of cases that you need to do to be competent? And how do you measure ongoing competence? Yeah, good question. So the question was how do we measure ongoing competency in the ICU with our APPs? And do we hold ourselves to the same standards as physicians? And the answer's absolutely yes. We keep up with our numbers of procedures that we're doing and our complication rate. And as you see that one slide, we fall below that trigger, that threshold, the benchmark for complications. And if we measure these quarterly, and one of the criteria for joint commission is you have to have some standard to measure competency for ongoing professional practice evaluation. And they recommend doing that more than twice a year. So we do this quarterly. We do this through evaluations of records. We do this through monitoring our QI data. And if we see triggers, then we have, like I said, we have tools in place to help improve performance that go back on a focused practice, a professional practice evaluation where we monitor them more frequently. Once we maintain, once we ensure competency, then we go back to that ongoing competency. So how many of you are in academic practice? How many of you are in private practice or non-academic? And so are your roles defined? Are your, you know, your credentials, your privileging, who establishes that for you? These are really important questions that, you know, when you go back, make sure that you have someone who's evaluating the skills that you have so that, especially with the payers now, you know, as APPs become more and more intertwined in the surgical subspecialties, you really need to know, are they billing for you? How are they doing it? You know, who's looking out for your productivity? So these are all really important questions. It's kind of built into the big academic centers that have had APPs for a long time. But some of the smaller hospitals where you may be new to neurosurgery that they've never had an APP before, you need to have a champion who's looking out for you. It's really important. And it actually helps improve your service and gives you bonuses, like going to extra conferences. As we show we can generate revenue, that's how we've increased our number of CME dollars that we get to our department. So it's really important to keep up with that, I think, as individuals. All right, thank you. Thank you.

Dr. Robert Blessing

neuro ICU

APP roles

role clarity

Duke University

challenges

high-quality patient care

financial aspect