Physician extenders on surgical services: a systematic review

Abstract

Background: With the introduction of resident duty hour restrictions and the resulting in-house trainee shortages, a long-term solution to ensure safe and efficient patient care is needed. One solution is the integration of nurse practitioners (NPs) and physician assistants (PAs) in a variety of health care settings. We sought to examine the use of NPs and PAs on surgical/trauma services and their effect on patient outcomes and resident workload. Methods:We performed a systematic review of EMBASE, Medline, CINAHL, and the Cochrane Central Register of Controlled Trials. We included studies (all designs) examining the use of NPs and PAs on adult surgical and trauma services that reported the following outcomes: complications, length of stay, readmission rates, patient satisfaction and perceived quality of care, resident workload, resident work hours, resident sleep hours, resident satisfaction, resident perceived quality of care, other health care worker satisfaction and perceived quality of care, and economic impact assessments. We excluded studies assessing nonsurgical/trauma services or pediatrics and review articles.Results: Twenty-nine articles met the inclusion criteria. With the addition of NPs and PAs, patient length of stay decreased, and morbidity and mortality were unchanged. In addition, resident workload decreased, sleep time increased, and operating time improved. Patient and health care worker satisfaction rates were high. Several studies reported cost savings after the addition of NPs/PAs. Conclusion:The addition of NPs and PAs to surgical/trauma services appears to be a safe, cost-effective method to manage some of the challenges arising because of resident duty hour restrictions. More high-quality research is needed to confirm these findings and to further assess the economic impact of adding NPs and PAs to the surgical team.Contexte : Compte tenu de la réduction du nombre d'heures de travail des médecins résidents et de la pénurie de stagiaires qui en a résulté, une solution à long terme s'impose pour assurer la sécurité et l'efficacité des soins aux patients. Une solution consiste à intégrer des infirmières praticiennes (IP) et des adjoints aux médecins (AM) dans divers contextes de soins de santé. Nous avons voulu examiner l'incidence du recours aux IP et aux AM dans des services de chirurgie et de traumatologie et son effet sur la santé des patients et sur la charge de travail des médecins résidents.

The role of physician associates in secondary care: the PA-SCER mixed-methods study

“…Evidence from North America suggests that similar factors have supported the inclusion of PAs in acute medical/surgical teams. 133,152,153 As part of an innovation and change process, 154 many participants within the hospitals identified the benefit of having clinical leadership, ongoing clinical champions for PAs and visible executive-level support (see Chapters 4, 7 and 9). This has previously been described in relation to one acute hospital unit in England.…”

Risks and Rewards of Advanced Practice Providers in Cardiothoracic Surgery Training: National Survey

“…12,13 Other studies quantifying the effects of APPs in field found APPs increase the efficiency of attending surgeons. [14][15][16][17] The investigation of the impact of APPs on resident education, particularly surgical resident education, has been limited. Surveys of both surgical faculty and residents have acknowledged that APPs offer benefits in managing the clinical workload while posing a potential threat to resident education.…”

“…Furthermore, faculty face constant pressure to be clinically productive, and APPs have been demonstrated to improve surgeon efficiency in multiple studies. [14][15][16][17] APPs, residents, and faculty is the next critical step in this process. Assessing, and then periodically reassessing, the team dynamic as well as satisfaction with the responsibilities of the team members ensures continued satisfaction with these roles over time.…”

Comparison of the Outcome of Patient Management with Physician Extenders Only and with both Residents and Extenders

“…One study found that patients in ICUs with nurse practitioners and physician assistants had lower mean acute physiology scores and mechanical ventilation rates [5]. Another study examining the use of nurse practitioners and physician assistants on adult surgical and trauma services also found that LOS decreased but found that mortality and morbidity were unchanged [6]. With some research showing that extenders had a positive effect when introduced in certain hospital settings, it is worthwhile to determine if there a significant treatment outcome between physician extenders only and both residents and extenders.…”