Examining the critical role of advanced practice providers on a multidisciplinary transplant team

Abstract

It is well documented that Physician Assistants (PAs) and Nurse Practitioners (NPs), collectively known as Advanced Practice Providers (APPs), have a beneficial role beyond the field of primary care. APPs broad spectrum of knowledge make them particularly well suited for specializing in complex fields such as transplant. Variations in practice across transplant centers lead to questions regarding optimal use of APPs. Using job descriptions from transplant centers currently employing APPs, we sought to examine the critical role of transplant APPs beyond clinical care alone. In this review, we explore not only the general training of APPs and current utilization of APPs in transplant, but also safety, cost effectiveness, and comparison of APPs to other transplant providers. We aimed to highlight the importance of recruitment and retention of transplant specific trained APPs to provide continuity in transplant programs. Additionally, APPs expansion into transplant research, quality improvement, leadership, and management must be considered. We challenge transplant centers utilizing APPs to consider these important aspects when seeking ways to expand and optimize the critical role APPs provide on the transplant team. It is well documented that Physician Assistants (PAs) and Nurse Practitioners (NPs), collectively known as Advanced Practice Providers (APPs), have a beneficial role beyond the field of primary care. APPs broad spectrum of knowledge make them particularly well suited for specializing in complex fields such as transplant. Variations in practice across transplant centers lead to questions regarding optimal use of APPs. Using job descriptions from transplant centers currently employing APPs, we sought to examine the critical role of transplant APPs beyond clinical care alone. In this review, we explore not only the general training of APPs and current utilization of APPs in transplant, but also safety, cost effectiveness, and comparison of APPs to other transplant providers. We aimed to highlight the importance of recruitment and retention of transplant specific trained APPs to provide continuity in transplant programs. Additionally, APPs expansion into transplant research, quality improvement, leadership, and management must be considered. We challenge transplant centers utilizing APPs to consider these important aspects when seeking ways to expand and optimize the critical role APPs provide on the transplant team. Advanced Practice Providers (APPs) may also be referred to as Advanced Health Providers (AHP), Advanced Practice Clinicians (APC) and Advanced Transplant Providers (ATP). While the nomenclature may vary the fundamental importance surrounding the utilization of APPs in transplant is evident. The PA profession was established in 1967 with over 255 programs. They are educated at a Masters’ degree level and undergo 2000 hours of clinical rotations.1What is a PA? Learn more about the PA profession. AAPA. https://www.aapa.org/what-is-a-pa/. Accessed November 9, 2019.Google Scholar The scope of practice for PAs requires physician supervision in 47 states and is determined by the supervising/collaborating physician. Upon program completion, they are certified to provide care across all specialties. The NP profession was also established in 1967. NPs have first met the requirements to work as registered nurses and subsequently complete a Masters or Doctoral program.2American Association of Nurse Practitioners. NP Fact Sheet. https://www.aanp.org/about/all-about-nps/np-fact-sheet. Accessed November 9, 2019.Google Scholar The scope of practice for NPs varies depending on the state in which they practice. As of 2019, NPs have full practice authority in 23 states, reduced practice in 16 states, and restricted practice in 12 states.3American Association of Nurse Practitioners. State Practice Environment. https://www.aanp.org/advocacy/state/state-practice-environment. Accessed April 30, 2020.Google Scholar Education programs and certification exams require NPs to select an area of practice. These include but are not limited to pediatrics, family practice, adult primary care, gerontology, psychiatric-mental health and acute care. Broad theory-based education combined with clinical exposure provided to NPs and PAs during training allows them to function autonomously with state dictated limitations upon hire. Kleinpell et al. explored the care provided by NPs over a 5-year period, including discussing care with families, ordering and interpreting tests and labs, initiating specialty consultations, discharge planning, and tasks that promote continuity of care.4Kleinpell RM Ely EW Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review.Crit Care Med. 2008; 36 (https://doi.org/10.1097/CCM.0b013e318186ba8c): 2888-2897Crossref PubMed Scopus (197) Google Scholar These are essential functions to any area in which an APP elects to practice. Transplant as a specialty is well suited to utilize APPs as providers. Centers have seen sustained growth over time, with an increasing number of waitlisted patients and more transplants being performed.5SRTR/OPTN Annual Data Report. https://www.srtr.org/reports-tools/srtroptn-annual-data-report/. Accessed October 20, 2018.Google Scholar With a growing number of transplant patients, centers need non physician providers capable of keeping up with this demand in a way that is safe, effective, and cost efficient.6Chaney AJ Harnois DM Musto KR Nguyen JH. Role development of nurse practitioners and physician assistants in liver transplantation.Prog Transplant. 2016; 26 (https://doi.org/10.1177/1526924816632116): 75-81Crossref PubMed Scopus (8) Google Scholar, 7Chaney AJ Yataco ML. The emerging role of nurse practitioners and physician assistants in liver transplantation.Liver Transpl. 2019; 25 (https://doi.org/10.1002/lt.25474): 1105-1109Crossref PubMed Scopus (4) Google Scholar, 8McAfee JL. Developing an advanced practice nurse-led liver clinic.Gastroenterol Nurs Off J Soc Gastroenterol Nurses Assoc. 2012; 35 (https://doi.org/10.1097/SGA.0b013e31825a2786): 215-224Crossref PubMed Google Scholar Incorporating APPs in the care of transplant patients can lead to overall improvement of the patient experience and outcomes.6Chaney AJ Harnois DM Musto KR Nguyen JH. Role development of nurse practitioners and physician assistants in liver transplantation.Prog Transplant. 2016; 26 (https://doi.org/10.1177/1526924816632116): 75-81Crossref PubMed Scopus (8) Google Scholar,7Chaney AJ Yataco ML. The emerging role of nurse practitioners and physician assistants in liver transplantation.Liver Transpl. 2019; 25 (https://doi.org/10.1002/lt.25474): 1105-1109Crossref PubMed Scopus (4) Google Scholar,9Pullen LC. Building a transplantation team with advanced-practice providers.Am J Transplant. 2018; 18 (https://doi.org/10.1111/ajt.14681): 531-532Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar They provide consistent clinical care to patients across the transplant continuum. This is becoming increasingly important as hospital fees for service is becoming more intertwined with the patient experience and outcome. While the need for additional transplant providers has steadily increased at many centers, there is no universal set of roles and responsibilities of an APP. This adds to lack of clarity around optimal utilization of APPs within the specialty. A review of job descriptions from various transplant centers demonstrates just how vast the duties of APPs in transplant are (Appendix A). Although we will describe areas of practice separately, it is important to note overlap between each area of practice exists with some practicing solely in one setting and others in multiple settings. As inpatient providers, APPs are responsible for daily care of admitted patients. Hours vary but can include after-hours and weekend coverage.10Tedesco J. Acute care nurse practitioners in transplantation: adding value to your program.Progress in Transplantation. 2011; 21: 278-283Crossref PubMed Google Scholar Completing admission H&Ps, daily progress notes, and discharges are often primary responsibilities. APPs ability to adhere to pathway driven practices helps ensure care is evidence based. The Centers for Medicare and Medicaid Conditions of Participation require transplant centers provide multidisciplinary care to transplant recipients and an APP helps ensure these discussions occur daily and no discipline is excluded.11Mahmud N Halpern S Farrell R et al.An advanced practice practitioner-based program to reduce 30- and 90-day readmissions after liver transplantation.Liver Transpl. 2019; 25 (https://doi.org/10.1002/lt.25466): 901-910Crossref PubMed Scopus (7) Google Scholar As outpatient providers, APPs manage patients as part of a multidisciplinary team and serve as the primary provider typically in a clinic setting.6Chaney AJ Harnois DM Musto KR Nguyen JH. Role development of nurse practitioners and physician assistants in liver transplantation.Prog Transplant. 2016; 26 (https://doi.org/10.1177/1526924816632116): 75-81Crossref PubMed Scopus (8) Google Scholar,7Chaney AJ Yataco ML. The emerging role of nurse practitioners and physician assistants in liver transplantation.Liver Transpl. 2019; 25 (https://doi.org/10.1002/lt.25474): 1105-1109Crossref PubMed Scopus (4) Google Scholar,9Pullen LC. Building a transplantation team with advanced-practice providers.Am J Transplant. 2018; 18 (https://doi.org/10.1111/ajt.14681): 531-532Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,11Mahmud N Halpern S Farrell R et al.An advanced practice practitioner-based program to reduce 30- and 90-day readmissions after liver transplantation.Liver Transpl. 2019; 25 (https://doi.org/10.1002/lt.25466): 901-910Crossref PubMed Scopus (7) Google Scholar Early in the post-transplant course, the focus is on acute recovery from surgery with careful monitoring for organ specific complications. For instance, readmissions after liver transplantation are common with increased morbidity and cost and APPs can be effective in reducing this risk. University of Pennsylvania performed a retrospective cohort study of all liver transplant patient from 2014 to 2017. A NP based post-transplant care program and clinic were initiated in 2016. Post-discharge readmission rates were compared between the pre- and post-exposure groups while adjusting for associated risk factors. They found that there was no significance in demographics of the patients; however, they significantly decreased readmission rates in the post-exposure group at 30 days (hazard ratio 0.60, 95% confidence interval, 0.39–0.90; p = .02) and 90 days (hazard ratio 0.49, 95% confidence interval, 0.34–0.71; p ≤ .001). They felt that these results were mediated through increased NP outpatient clinics and phone calls to patients.11Mahmud N Halpern S Farrell R et al.An advanced practice practitioner-based program to reduce 30- and 90-day readmissions after liver transplantation.Liver Transpl. 2019; 25 (https://doi.org/10.1002/lt.25466): 901-910Crossref PubMed Scopus (7) Google Scholar The long term management of post-transplant patients requires knowledge of potential chronic complications related to organ transplant. A major focus is immunosuppressive management both early and late in the post-transplant phase as this requires a skilled transplant specific provider to understand each patient’s particular risk. In some transplant programs, APPs primarily function in organ procurement and practice in the operating room. Some states require NPs to also have their Registered Nurse First Assistant (RNFA) certification to function as first assist in the operating room leading to more PAs performing in this function. Certain APPs are exceptionally skilled with the surgical techniques that optimize organ recovery based on the transplant program’s requirements. APPs in the procurement operating room provide the fellows with assistance in the procedure as well as troubleshooting inevitable difficulties based on well-founded experience. APPs can also serve an important role as first assist in elective cases as the common denominator with ever-changing fellows and residents. They ensure the proper equipment is available, the patient is checked in properly, and the OR staff is aware of any changes and communication between OR rooms with simultaneous living donor and recipient surgeries. There has been controversy about the quality of care provided by APPs compared to physicians. Newhouse and colleagues’ policy paper stated outcomes of care provided by NPs in collaboration with a specialist or primary care physicians are similar to, or in some cases better than, the outcomes of care provided by a physician alone.12Kroese ME Severens JL Schulpen GJ Bessems MC Nijhuis FJ Landewé RB. Specialized rheumatology nurse substitutes for rheumatologists in the diagnostic process of fibromyalgia: a cost-consequence analysis and a randomized controlled trial.J Rheumatol. 2011; 38 (https://doi.org/10.3899/jrheum.100753): 1413-1422Crossref PubMed Scopus (7) Google Scholar The Institute of Medicine claims there is a large body of evidence that does not support the conclusion that NPs are less able than physicians to provide safe, effective, and efficient care.13Institute of Medicine (IOM)The future of nursing: Leading the change, advancing health. The National Academies Press, Washington, D.C.2011Google Scholar Safe and effective use of APPs within transplant is also documented. In a retrospective study from 1998 to 2013, Mayo examined all of the liver transplants performed at their center. In that time, there was increased MELD score from 16 to 25, suggesting that patients were sicker at time of transplantation. They implemented the use of inpatient APPs and found that even with sicker patients, the median length of stay did not increase and remained at 7 days. The median warm ischemic time did not increase but actually decreased from 33 to 30 over the study period (p < .001). Furthermore, the outcomes for patient and graft survival improved.6Chaney AJ Harnois DM Musto KR Nguyen JH. Role development of nurse practitioners and physician assistants in liver transplantation.Prog Transplant. 2016; 26 (https://doi.org/10.1177/1526924816632116): 75-81Crossref PubMed Scopus (8) Google Scholar They concluded that APPs were essential for optimal patient outcomes. A review of 287 at University compared fellows and a PA performed over a period of They both as the lead donor with fellows in 90 cases and the PA in cases The PA significantly rates compared to the fellows for graft were also significantly compared to the fellows J Physician for a Full Text Full Text PDF PubMed Google Scholar They found that a PA in donor procurement was a safe, cost effective, and to et al. performed a analysis of patients in were being seen for a primary care They care by APPs in patients with complex such as and They also that only of patients met combined which an area for improvement in the the quality of care provided by advanced practice evidence program evidence evidence program of Washington, et of NPs and PAs in and 2018; PubMed Scopus (8) Google Scholar A review of by and the of APPs to surgical in decreased length of an improvement in operating and in The morbidity and were but found rates while one study an increase in of of of the in this review specific cost outcomes with APPs compared to physicians cost the The length of stay of patients was to increase cost in while et al. similar with APPs, there was of an increase in surgical and decreased surgical J Physician on surgical a Scholar In the of an analysis of NP practice and found the cost of an NP was to that of a physician. The in between these of providers has not for 30 J Physician on surgical a Scholar are less and they work hours than however, they have APPs the of their overall S The and future use of physician in general surgery training one to the work PubMed Scopus Google Scholar et found that the use of APPs was cost effective and a to physicians in with increased work by work S The and future use of physician in general surgery training one to the work PubMed Scopus Google Scholar is and programs are to while J. and for advanced practice in organ transplantation.Prog Transplant 2011; PubMed Scopus Google Scholar Centers increasing the use of APPs are ways to APP to the and of these including progress notes, and performing The of these functions are by ways APPs value that may not but are essential functions of transplant care include or clinical research, for pre- and care, and patient APPs are well suited to by centers when education as it to transplant. There is a for and on the transplant With during their the of the of the transplant patient is The of are that they have and can provide however, they require increased and are limited to surgery and lack of exposure to transplant University centers the primary for APPs was not only to the but also to and to and quality of care.4Kleinpell RM Ely EW Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review.Crit Care Med. 2008; 36 (https://doi.org/10.1097/CCM.0b013e318186ba8c): 2888-2897Crossref PubMed Scopus (197) Google AJ Harnois DM Musto KR Nguyen JH. Role development of nurse practitioners and physician assistants in liver transplantation.Prog Transplant. 2016; 26 (https://doi.org/10.1177/1526924816632116): 75-81Crossref PubMed Scopus (8) Google Scholar,7Chaney AJ Yataco ML. The emerging role of nurse practitioners and physician assistants in liver transplantation.Liver Transpl. 2019; 25 (https://doi.org/10.1002/lt.25474): 1105-1109Crossref PubMed Scopus (4) Google Scholar,9Pullen LC. Building a transplantation team with advanced-practice providers.Am J Transplant. 2018; 18 (https://doi.org/10.1111/ajt.14681): 531-532Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, J. Acute care nurse practitioners in transplantation: adding value to your program.Progress in Transplantation. 2011; 21: 278-283Crossref PubMed Google Scholar, N Halpern S Farrell R et al.An advanced practice practitioner-based program to reduce 30- and 90-day readmissions after liver transplantation.Liver Transpl. 2019; 25 (https://doi.org/10.1002/lt.25466): 901-910Crossref PubMed Scopus (7) Google Scholar The APPs a of knowledge than a from being on the transplant Nurses are important to manage transplant patients both on the transplant and in the outpatient setting and They are at the as discharge as clinic support and as knowledge helps them to patients on a daily as well as be the for patient and family scope of practice is limited by education and Transplant centers transplant to serve in various with focus on clinical care and organ Some centers transplant APPs to serve in this the is the ability of APPs to and and and have Nurse are limited and to practice in this provider for Advanced for clinical and procurement transplant Transplant. PubMed Google Scholar Centers must be careful to have APPs serve as transplant Care must be to ensure APPs are not for their patients to undergo transplant. multidisciplinary in this risk is There are a number of that can be to and the APP for a transplant team. an program to and can be at and on such as and will also increase the of There are APP transplant programs that can also be for APPs trained in transplant. There is risk of with transplant APPs to patient and increased There is a large of when a transplant APP the The cost for for an APP is and a is typically of the however, the cost of the and can of the J. does advanced practice provider Accessed April Scholar This does not include the cost of training or a APP which can to to This is retention is is for retention and include a process or program that has general about not only the job but also the The APP can currently with the team to other roles and duties of the transplant The length of will be on experience of the APP and the roles that they will be to of both the APP and the team a and the Practice for APPs have a A transplant specific a for and adds to the transplant be as a team for both and team the APP and their need to in development and the APP for them to of communication is essential in practicing and for all to increasing APP utilization include training and scope of practice, and requirements. Advanced practice providers on the transplant team and for continuity of care, but also may be as for by the It has been that increased use of APPs in transplantation has to decreased by in the field of transplantation and have a on recruitment of physicians to the JL et in the transplantation physician Transplant. Full Text Full Text PDF PubMed Scopus Google Scholar APPs to staff education with of the for living the role of the nurse as in Transplantation. 2011; 21: PubMed Google Scholar, The role of the nurse in an and on PubMed Scopus Google Scholar, J et overall to a surgical 2008; PubMed Scopus Google Scholar APPs are trained as and as clinical of the APP into the clinical of transplantation is particularly the APP is a or from a role of of clinical of the practice provider in outpatient liver transplant In The of Transplant J A and for care advanced practice 2018; PubMed Scopus Google Scholar is as the practice include care of complex patients in to to including and the ability to function as a transplant when the of the APP role in the lack of APPs to APPs can be a challenge within transplant and to APP Additionally, a of for APPs. is fundamental for the APPs to in the field and and associated with for a PubMed Scopus Google Scholar is an area of in and cost of APPs in transplant is no of APP cost include APPs from of the of physicians and of outpatient in a from the physician. there are other that must be into et al. the of in length of stay APP staff to be in during in documented APP N N et of an advanced practice provider service on an transplant unit: on patient Transplant. 21: Full Text Full Text PDF PubMed Google Scholar et was significantly for the physician compared with the cohort of of 90 the quality of care provided by advanced practice evidence program evidence evidence program of Washington, Scholar While and associated of APP are important to consider the the are from a patient care as well as a challenge to the role of APPs in transplantation is the lack of a scope of practice across states as well as requirements. requirements of in each state as APPs require the requirements as their physician including and transplant centers often an APP to assist with but and a challenge to APP practice in transplantation. APPs are for expansion into and in transplant centers as they clinical and to the field of and can areas of the expansion of these APPs in these roles an for growth and development while reducing As APPs providers at transplant centers, in and quality improvement role and APPs have a role in many quality require a vast of policy and at a state and APP leading an area of is effective as they have a in clinical and These are to areas in need of improvement and provide to This clinical knowledge the between quality and effective of to outcomes as well as reducing the time to to programs. APPs understand the in knowledge and be in to questions and to APPs can serve in a of some as and others in in with and other of Health and Centers for Medicare and Medicaid and Medicare Conditions of for and of Transplant Centers to Accessed 2020.Google Scholar As APPs are across the transplant they are well suited to ensure transplant are manage complex and ensure education and can patients be based on of APPs are increasingly being in roles as transplant and this role may at as APPs are seen as clinical care Advanced practice in transplantation.Prog Scopus Google Scholar They have clinical and which allows them to understand and lead a multidisciplinary team that but is not limited to and They can also a program with and clinical to of the for living the role of the nurse as in Transplantation. 2011; 21: PubMed Google Scholar In the role of nurse as of for living The combined clinical with multidisciplinary APPs to centers in a patient while of the for living the role of the nurse as in Transplantation. 2011; 21: PubMed Google Scholar The increasingly complex multidisciplinary care to manage transplant patients is by APPs. practice combined with at each transplant APPs are performing a of duties across the This may lead to limited for APPs while not their In job descriptions of APPs currently in practice as a for APP we the vast clinical and roles APPs can within transplant. We transplant centers to consider and the use of APPs at their to the of these transplant providers.

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