Advanced Practice Providers Help Expand Care at SHC

In the past 20 years, the number of Advanced Practice Providers (APPs) at Stanford Hospital & Clinics has skyrocketed, from just four in 1992, to more than 200 today. In 2012 alone, SHC brought on 40 to 50 additional APPs. "Today, 42 different specialty areas at SHC use APPs to treat, diagnose, prescribe and perform surgical procedures," says Nicholas M. Perrino, MS, MPH, MSN, RN, FNP-BC, NE-BC, director of Advanced Practice.

"APPs are no longer just physician extenders," adds Nancy Lee, MSN, RN, vice president for Patient Care Services and Chief Nursing Officer. "They are working to the full extent of their education and functioning independently with minimal oversight in a number of areas throughout the hospital and clinics."

Much of this expansion of APPs can be attributed to resident work hour restrictions and clinical quality initiatives. But another prevailing reason for the increase is the realization that APPs can perform much of the same work as residents, and they can do so independently because they are not trainees.

"There's an increasing demand for providers who can diagnose, treat and prescribe," says Perrino who joined Stanford 18 month ago to oversee and standardize the APP program. "Advanced Practice Providers have the advanced education to do just that." APPs are trained to take care of the majority of common health problems. In most areas of the hospital, residents oversee patient care. But these residents are still in training, and require supervision by an attending. They also rotate services each month, which gives little consistency on the floor for patients or the nursing staff.

"APPs provide continuity of care to patients," says Laura Zitella, NP, lead advanced practice provider/nurse practitioner, Inpatient Hematology and Oncology. APPs have expert knowledge of the disease process, treatment and side effects, which helps them anticipate and respond to the patient's needs. Patients experience better symptom management, reduced re-admissions and increased satisfaction, Zitella adds, primarily because they have greater access to their provider and understand their care plan better.

"APPs know the Stanford environment, they know our medical record, they know the patient population and they know the physicians and surgeons," says Perrino. They can step into a new role and free up physicians who have competing responsibilities between inpatient care, outpatient care and research. "Physicians need protected time to do academic work," adds Zitella. "Many of them rely on us to ensure their patients get good clinical care when they can't be there."

What are APPs?

Advance Practice Providers consist of nurse practitioners, physician assistants, clinical nurse specialists, nurse anesthetists and nurse midwives. The NP and PA professions were each founded in 1965, and APPs have been used extensively in the East for the past 30 years. But the trend has just been picking up steam at Stanford in the past five to ten years.

Today, APPs provide care in nearly every area in the hospital and clinics. In some areas, like the Med 9 Hematology-Oncology Service or in the Emergency Department's Observation Unit, they are the lead practitioners, working independently to care for patients.

Beginning in September of this year, the Med 9 Hematology-Oncology Service has been staffed by three APPs during the week, and two on weekends. These APPs work collaboratively with hematologists/oncologists to care for their inpatients and independently perform procedures needed by patients such as bone marrow biopsies, lumbar puncture and administering intrathecal chemotherapy. Patients who come in for routine cycles of chemotherapy each month now see the same group of providers and they like the continuity of care, says Linda Boxer, MD, professor of medicine in Hematology. Before, patients would see a new fellow, intern or resident each visit.

"As our patient population in the Cancer Center continues to grow and trainee work hour restrictions limit their availability, we had to start thinking about how we are going to take care of patients," she says. At the Cancer Center, we decided some of the high-end subspecialty areas would need care provided by APPs. "Our APPs have been specially trained in hematology/oncology so they can do a lot of the procedures that were previously done by the attending."

In the Emergency Department (ED), APPs are running the Clinical Decision Unit (CDU), the ED Observation Unit, which cares for ED patients who need extra time to continue their workup and monitoring or to evaluate their response to a particular treatment. APPs closely monitor these patients, coordinate their transitions of care and communicate with family members and other members of the care team. The APPs can make clinical decisions based on the patient's responses and plan of care, says Garrett Chan, PhD, NP, CNS, lead advanced practice provider & associate clinical director, Emergency Department/CDU. And they collaborate with the attending physician if the patient is not progressing or if the patient's condition unexpectedly changes.

"Since we started using APPs in the Clinical Observation Unit, we have seen high levels of patient satisfaction and improved patient outcomes," says Matt Strehlow, MD, clinical associate professor, Surgery-Emergency Medicine. "Patients are being cared for in a timely manner." A large percentage of the APPs working in the CDU have been on staff for four to six years. "They are consistently improving and their practice is consistently evolving," he adds. "That's an advantage over having a resident perform the same function because each new group of residents is at the same level each year."

Initially, physicians in the ED were very hands-on with the APPs in the CDU, recalls Strehlow. But that has changed. Today, the attending physician is available for medical decision-making, but the majority of the care is being coordinated by the APP. If something comes up with a patient, the APP and physician discuss it as a team.

In Interventional Radiology, APPs are helping to manage patient care and flow in the Cath Lab, increasing efficiency and improving on-time start percentages. APPs in this department start vascular access lines, conduct histories and physicals, track labs, write orders and ensure that blood products are ordered. "They are the air traffic controllers in our area," says Nishita Kothary, MD, assistant professor, Radiology. "APPs greatly increase the efficiency of this service, which frees me up to take on more complex cases." That's a huge advantage, she adds. Trainees can't do these procedures on their own without supervision.

Before joining Stanford in 2006, Kothary had worked extensively with APPs and was surprised at how few were on staff at Stanford when she arrived. There's a cultural difference between the east and west coasts, she points out. But the west is beginning to catch up with the national trend.

"I think we'll see a wider and wider role in the usage of APPs," says Boxer. "And that will be good."

By Grace Hammerstrom