Outline Why utilize APPs in the ICU Advanced Practice Providers - PDF document

5/30/2013 Outline • Why utilize APPs in the ICU Advanced Practice Providers • Recent publications in the Intensive Care Unit • General review of NP practice requirements • Our NP experience at UCSF and SFGH • General review of billing for APP critical care Thomas Farley MS, NP services Assistant Clinical Professor UCSF School of Nursing • Garland A, Gershengorn HB. Staffing in the ICUs: physicians and Why utilize APPs in the ICU? alternative staffing models. Chest ; 2013; 143(1): 214-221. • Kapu AN, Thomson-Smith C, Jones P. NPs in the ICU: the Vanderbilt initiative. Nurse Pract . 2012; 37(8): 46-52. • Imbalance in the supply of and the • Butler KL, Calabrese R, Tandon M. Optimizing advanced practitioner charge capture in high acuity surgical intensive care units. Arch Surg . 2011; demand for intensivists 146(5): 552-555. • Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician • Team based approach to care delivery assistants in the intensive care unit: an evidence-based review. Crit Care Med . 2008;36(10):2888-2897 • It is taking place in the USA, Canada, and • Gracias VH, Sicoutris CP, Stawicki SP, et al. Critical care nurse practitioners improve compliance with clinical practice guidelines in the UK already "semiclosed" surgical intensive care unit. J Nurs Care Qual . 2008;23(4):338-344. • The literature shows it is safe, effective, • Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the and more human than a robot costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006;26(1):9-17. • Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med . 2003;31(12):2752-2763. 1

5/30/2013 Recently published NPs in Critical Care or Trauma • Gershengorn HB, Wunsch H, Wahab R, et • Memorial Sloan Kettering Cancer Center al. Impact of non-physician staffing on • Columbia University outcomes in a medical intensive care unit. • Henry Ford Hospital Detroit Chest . 2011; 139(6): 1347-1353. • Cleveland Clinic • Columbia Presbyterian Medical Center • UC Davis • Retrospective review of two ICUs • California Pacific Medical Center • Patients managed by NP/PA team had no • UCSF/SFGH Medical Centers worse outcomes • Oregon Health Sciences University Nurse Practitioners NP Species • RN with Masters or Doctoral degree • Focus of education and national certification • National certification exam required • Acute Care: generally inpatient care • CA mandates use of standardized • Adult and Family: primary care procedures • Independent licensure • Current recommendation by National Council of State Boards of Nursing is to • Eligible for DEA schedule 2-5 prescribing restrict intensive care roles to acute care • NPI for medicare/private billing nurse practitioners 2

5/30/2013 Our experience at UCSF Evolution of a NP practice • At UCSF 76 adult critical care beds • Limited amount of housestaff • Goal of providing immediate critical care consultation 24 hours a day • 4 NPs added in 2005 • Currently15 NPs covering 4 ICUs • At times no residents on team Farley, TL, Latham, G. Evolution of a critical care nurse practitioner role within a US academic medical center. ICU Director . 2011; 2(1-2): 16-19. Evolution of a NP practice Experience at UCSF and SFGH • At SFGH level 1 trauma center • Employed by hospital not by MD group • Recognized need for quality control and • Medicare part A not part B improvement • No independent billing performed • Added 4 NPs to service in 2001 • Close contact with the UCSF SON • Current environment of limited housestaff and work hour reductions • Now 12 NPs in trauma/general surgery • At times no interns on teams 3

5/30/2013 UCSF Critical Care ICU Attending MD ICU Fellow MD Resident MD Nurse Practitioner SFGH Surgery NP responsibilities • Follow and teach standard ICU practices Surgical Attending and protocols • Quality standards and improvement • Intervene and direct or provide Surgical PGY4/5 appropriate initial therapy • First call at UCSF and SFGH • Overnight shifts at UCSF and SFGH Surgical Intern Nurse Practitioner 4

5/30/2013 Critical Care NP Duties Critical Care NP Duties • History taking and physical exams • Consultative role to admitting services • Entering admission histories and physical in to the EMR • Consultative role to bedside RNs • Entering daily progress notes into the EMR • Guidance of house staff • Writing admission orders and routine orders • Responding to code blue activations • Independently performing procedures • Assisting with rapid response consultations • Rounding with the critical care team and presenting • Serving on hospital wide multidisciplinary committees patients • Precepting acute care nurse practitioner students • Implementing proven care bundles (sepsis, early • Attending morning teaching and monthly morbidity and mobilization, DVT prophylaxis) mortality conferences NP Procedures Why it works • Central venous catheter insertion • It is essential to have appropriate conduits • PICC insertion for collaboration and supervision • Arterial catheter insertion • Supportive attending MDs • Chest tube insertion • Buy-in from the ICU RNs • Lumbar puncture • NPs have experience as ICU RNs • Suture and drain removal • SON provides excellent job candidates • Airway intubation • Dedicated and professional group of NPs • RN First Assist for OR role 5

5/30/2013 NPP Billing in Critical Care Billing in surgical critical care • Reference CMS transmittal #1548 • Painter, JR. Critical care in the surgical global period. Chest 2013;143(3):851-855. • http://www.cms.hhs.gov/Transmittals/Dow • Trauma and burn patients are unique nloads/R1548CP.pdf • Services may be provided by qualified • Medicare allows separate payment to NPPs and reported for payment surgeon for post op critical care during global period • Unlike outpatients no ‘incident to’ or ‘shared’ visits allowed Billing in Critical Care Billing in Critical Care • Only one provider per day can bill for CPT • May be continuous clock time or 99291critical care eval and mgt 30-74min intermittent time increments and aggregated • Follow-up after first 74min of services • Only one provider can bill for critical care billable by MD or NPP using CPT 99292 each additional 30min of critical care services within an actual time period even • That time must be spent at the bedside or if more than one provider involved • More than one provider can provide critical elsewhere on the floor as long as the provider is immediately available care at another time and be paid 6

5/30/2013 NP Billing in Critical Care • For Medicare NP billing as hospital employees (part A) not allowed • To bill Medicare NPs must be employed by clinical departments or groups • For Medicare, reimbursement is 85% of published MD fee schedule • NPs may be credentialed by private payor • Private payors may reimburse up to 100% 7