Physician assistant on the ic is not inferior to physician assistant

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Physician assistant on the ic is not inferior to physician assistant

Catharina Hospital/Jarno Verhoef

Intensivist Herman Kreeftenberg already saw the potential of the physician assistant (PA) in the ICU years ago. That is why in 2016 he started researching their quality and employability in the IC of ‘his’ hospital – the Catharina Hospital in Tilburg. A group of PAs was already working there at that time.

On 24 March he will receive his doctorate for this research at Tilburg University. Title of his dissertation: Organizational aspects of Critical Care: the Advanced Practice Provider. To clarify: because of the different designations in the literature for the PA, he uses the collective term Advanced Practice Provider for this professional group in his dissertation.

At the start of his research, there was no clarity about employability and the range of tasks that a PA could perform, says Kreeftenberg. It turned out to be a rather underexposed topic in the scientific literature. And there are still only a few countries that use PAs on the IC: some states in the US, England, Australia and the Netherlands, which is at the forefront in that respect.

The results of Kreeftenberg’s research now form the basis of a ‘consensus document’ describing task reallocation in the intensive care unit, which has been endorsed by the Dutch Association for Intensive Care and the Dutch Association of Physician Assistants. It states what the status of the PA on the ICU is, what they can and cannot do in practice, and what steps they have to go through before they can actually perform small surgical procedures independently, such as the insertion of central lines, insertion of arterial lines and intubation.

Because PAs can do a lot, as he shows. The quality of care they provide is on par with that of other clinicians and is sometimes even slightly better. Yet it turned out not to be easy to prove that. Based on length of hospitalization and mortality, Kreeftenberg shows through a meta-analysis that they are at least as good as physician assistants. But, he puts things into perspective, you don’t actually measure accurately enough. ‘On the IC you work in a team. These two robust outcome measures are therefore subject to too much bias, they do not represent the contribution of the individual team members accurately enough. So you actually need other parameters, especially in a high-quality health system such as in the Netherlands. We searched for such validated outcome measures. We thought of the so-called Maelor tool, which you can use to measure whether the performance of an intervention team is within acceptable limits. But we didn’t do well. The question remained: what makes it impossible for us to properly measure the value of the deployment of PAs, while we do have that firm impression? We concluded that it had to be about things like decisiveness, communication, overview, assessment, organization. An important determining factor is experience. PAs stay longer than residents – they know the team from facility services to intensivist through and through, also because they often worked as intensive care nurses before. In short: they offer continuity, quality, efficiency and speed – all of which are important in an IC where it is increasingly important to use the available resources efficiently. It makes them anchor points in the team.’

Incidentally, Kreeftenberg adds, that is precisely why the position of PA is a great way to retain the experience of ICU nurses. ‘They often leave because they want to develop further; it is precisely by giving them the opportunity to further develop their skills as a PA that you retain them.’

The importance of experience came into focus thanks to a simulation. Kreeftenberg explains: ‘In it we presented acutely ill patients. As PAs became more experienced, they appeared to be better able to lead a group and adequately solve problems of a critically ill patient. Experienced clinicians, whom we asked to complete a rating, were found to rate the PAs’ assessments of the clinical situation as better than those of a resident physician. PAs, for example, grabbed an oxygen mask just a little faster and put it on a patient. While an assistant delegates that: after all, it is a practical act that he does not do himself.’

A minority of Dutch ICs now use PAs, especially the larger hospitals. Kreeftenberg: ‘They are then often fully deployed as physician assistants with all the daily tasks that can be done in an IC, including invasive interventions and quality assurance through long-term support from the intensivist.’ However, some ICs, Kreeftenberg knows, still limit the tasks of the PA due to unfamiliarity with their capabilities, or do not use them at all for that reason. So, he says, there is still room for improvement.

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