Editorials 6. NQF Endorses Additional Infectious Disease Measures. Available at: http://www.qualityforum.org/News_And_Resources/Press_ Releases/2013/NQF_Endorses_AdditionalJnfectious_Disease_ Measures.aspx. Accessed September 20, 2013 7. Kumar A, Haery C, Paladugu B, et al: The duration of hypotension before the initiation of antibiotic treatment is a critical determinant of survival in a murine model of Escherichia coli septic shock: Association with serum lactate and inflammatory cytokine levels. J Infect Dis 2006; 193:251-258 8. Puskarich MA, Trzeciak S, Shapiro NI, et al; Emergency Medicine Shock Research Network (EMSHOCKNET): Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Crit Care Med 2011; 39:2066-2071
9. Gaieski DF, Mikkelsen ME, Band RA, et al: Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010; 38:1045-1053 10. Drake DE, Cohen A, Cohn J: National hospital antibiotic timing measures for pneumonia and antibiotic overuse. Qua/ Manag Health Care 2007; 16:113-122 11. Kumar A, Roberts D, Wood KE, et al: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care /Wed 2006; 34:1589-1596 12. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N EngI J Med 2001; 345:1368-1377
Central Venous Catheter Insertion by Advanced Practice Nurses: Another Demonstrated Competency* Janna S. Landsperger, MSN, RN, ACNP-BC Arthur P. Wheeler, MD, FCCP Division of Allergy, Pulmonary, and Critical Care Medicine Department of Medicine Vanderbilt University Medical Center Nashville, TN
E
fforts to decrease adverse events associated with central venous catheters (CVCs), particularly rates of bloodstream infections, are at the forefront of many hospital initiatives (1). A proceduralist's experience is one factor associated with fewer complications, but over time several influences have eroded operator competency (2). Eor example, fewer patients now receive pulmonary artery and CVCs as the value of these monitoring devices has been questioned (3, 4). In addition, because of their perceived safety and ease of insertion, peripherally inserted central catheters (PICCs) placed by teams of nurses have increasingly supplanted CVCs. It is also well documented that the supply of critical care physicians who traditionally inserted CVCs has not kept pace with workload (5, 6). Additionally, in teaching hospitals, trainees have less time to learn and do procedures as the workday is compressed 'See also p. 536. Key Words: advanced practice nurses; central venous catheter; nurse practitioner Dr. Wheeler is a consultant to Cumberland Pharmaceuticals, provided expert testimony for ad hoc legal consulting, received royalties from Williams and Wilkens, and has stock with Cumberland Pharmaceuticals. Their institution received grant support from the National Institutes of Health. Ms. Landsperger has disclosed that she does not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01 .ccm.0000435683.06554.b0
Critical Care Medicine
by duty hour requirements. Furthermore, there is a decline in the in the number of noncritical care physicians who are capable and willing to do invasive procedures as competence is not expected for internal medicine board certification and is no longer demanded by many training programs. Advanced practice nurses (APNs) are increasingly being used to offset critical care physician shortages, and with time, the range of their responsibilities has grown (7). APN's ability to augment traditional staffing models in teaching hospitals has been demonstrated (8) as has their ability to care for patients independent of physician trainees (9), including performance of procedures in the ICU, and leadership of rapid response teams. Given the complex interplay of priorities and pressures, it is innovative to consider the possibility that ICUbased APNs could safely insert CVCs around the clock, offloading work from physicians while simultaneously decreasing the rate of complications and generating revenue. In this issue of Critical Care Medicine, Alexandrou et al (10) report procedural characteristics and outcomes from a CVC placement service operated by APNs. This highly trained ICU-based service provided elective placement of nearly 5,000 nonemergent catheters over a period of 13 years (about 1 catheter/d) to patients in general wards of an 850-bed tertiary care university hospital. In line with observed practice trends, slightly more than half of the lines inserted were CVCs, whereas 45% were PICCs. The most common reason for insertion was administration of antibiotics, followed by administration of chemotherapy. Complications rates including catheter-related infections (0.01%), pneumothorax (0.4%), and arterial puncture were low (1.3%) and were equal to or better than previously published rates (2). The limitations of this study are obvious and acknowledged by the authors. Specifically, there is no contemporaneous comparator group against which to judge safety, and the number and outcomes of catheters not
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inserted by this group is unknown. In addition, this service places a relatively small number of catheters electively, and the success and safety of high volume or emergent placement by such a group is unknown. Furthermore, there are no data about financial aspects of the program. Although this single-center investigation may not be generalizable to all institutions, it is clear that with proper training and initially supervised experience, insertion of CVCs by APNs is safe and feasible and may provide several benefits. First, as previously reported by Taylor and Palagiri (11), increased experience with CVC placement has been shown to improve patientrelated outcomes and decrease complication rates. In addition, as long the activity does not detract from ICU responsibilities, APNs could provide catheter placement services continuously unlike dedicated "PICC teams" which in many places are only available during business hours. Placement of catheters (in and outside the ICU) by APNs would allow physicians to focus on other tasks. Finally, unlike trainees, in many locales, certified and credentialed APNs can bill for placement of CVCs, which likely would help to support the costs of ICU-based APNs. The growing use of APNs in many ICUs demonstrates that when APNs undergo rigorous training, they can provide many services including placement of CVCs, care of critically ill patients, and leadership of rapid response teams. Ultimately, use of APNs has proven to be part of the solution to solving the critical shortage of intensivists while improving care.
REFERENCES 1. Berenholtz SM, Pronovost PJ, Lipsetf PA, ef al: Eliminating catheferrelated bloodstream infections in fhe intensive care unit. Crit Care Med 2004; 32;2014-2220 2. McGee D, Gould M: Preventing complications of cenfral venous catheterizafion. New EngI J Med 2003; 348:11 23-1133 3. The National Heart, Lung, and Blood Institute Acufe Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Pulmonary-artery versus cenfral venous catheter to guide treatment of acute lung injury. New EnglJ Med 2006; 354:2213-2224 4. Marik PE, Baram M, Vahid B; Does central venous pressure predict fluid responsiveness? Cftesf 2008; 134;172-178 5. Ward N, Afessa B, Kleinpetl R, et al; Intensivist/patienf ratios in closed ICUs: A statement from the Society of Critical Care Medicine faskforce on ICU staffing. Crit Care Med 2013; 41 ;638-645 6. Krell K: Critical care workforoe. Crit Care Med 2008; 36;1350-1353 7 Howie-Esquivel J, Fontaine D; The evolving role of the acute care nurse pracfifioner in critical care. Curr Cpin Crit Care 2006; 12;609-613 8. Gershegorn HB, Wunsch H, Wahab R, et al; Impact on non-physician staffing on outcomes in a medical ICU. Chest 2011 ; 139: 1347-1353 9. Landsperger JS, Williams KJ, Hellervik SM, et al: Implementation of a medical intensive care unit acute-care nurse practitioner service. Hosp Pract 2011 ; 39;32-39 10. Alexandrou E, Spencer TR, Frost SA, ef al: Central Venous Cafhefer Placement by Advanced Practice Nurses Demonstrates Low Procedural Complication and Infection Rates—A Report From 13 Years of Service. Crit Care Med 2014; 42;536-543 11. Taylor R, Palagiri A: Cenfral venous cafheterization. Crit Care Med 2007; 35;1390-1396
ICU Scoring Systems: After 30 Years of Reinventing the Wheel, Isn't It Tinfie to Build the Cart?* Laurent G. Glance, MD Department of Anesthesiology University cf Rochester School of Medicine Rochester, NY Andrew W. Dick, PhD RAND Health, RAND Boston, MA
*See also p. 544. Key Words: Acute Physiology and Chronic Health Evaluation; intensive care units; quality assurance; risk adjustment Supported, in part, by Department of Anesfhesiology af the University of Rochester School of Medicine. The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and Lippincoft Williams & Wilkins DOI: 10.1097/01 .ccm.0000435695.23586.04 732
wvv/w.ccmjournal.org
Turner M. Osier, M D Department of Surgery University of Vermont College of Medicine Burlington, VT
M
ore than five million patients a year are admitted to ICU in the United States (1), costing over 80 billion dollars annually and accounting for 4% of national health expenditures (2). Each year, nearly 500,000 people die in ICUs (3). The mortality rate for patients admitted to the ICU, which ranges between 8% and 19%, is greater than for any other condition other than myocardial infarction (4). There is wide variation in risk-adjusted mortality, and perhaps quality, across ICUs (5). Quality measurement is the cornerstone of quality improvement. Benchmarking cannot be performed without accounting for differences in case mix and severity-of-disease. At the risk of oversimplification, performance benchmarking is simply a comparison of an ICU's observed and expected mortality rate (EMR)—where the EMR is calculated using a risk-adjustment March 2014 • Volume 42 • Number 3
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
9. Gaieski DF, Mikkelsen ME, Band RA, et al: Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010; 38:1045-1053 10. Drake DE, Cohen A, Cohn J: National hospital antibiotic timing measures for pneumonia and antibiotic overuse. Qua/ Manag Health Care 2007; 16:113-122 11. Kumar A, Roberts D, Wood KE, et al: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care /Wed 2006; 34:1589-1596 12. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N EngI J Med 2001; 345:1368-1377
Central Venous Catheter Insertion by Advanced Practice Nurses: Another Demonstrated Competency* Janna S. Landsperger, MSN, RN, ACNP-BC Arthur P. Wheeler, MD, FCCP Division of Allergy, Pulmonary, and Critical Care Medicine Department of Medicine Vanderbilt University Medical Center Nashville, TN
E
fforts to decrease adverse events associated with central venous catheters (CVCs), particularly rates of bloodstream infections, are at the forefront of many hospital initiatives (1). A proceduralist's experience is one factor associated with fewer complications, but over time several influences have eroded operator competency (2). Eor example, fewer patients now receive pulmonary artery and CVCs as the value of these monitoring devices has been questioned (3, 4). In addition, because of their perceived safety and ease of insertion, peripherally inserted central catheters (PICCs) placed by teams of nurses have increasingly supplanted CVCs. It is also well documented that the supply of critical care physicians who traditionally inserted CVCs has not kept pace with workload (5, 6). Additionally, in teaching hospitals, trainees have less time to learn and do procedures as the workday is compressed 'See also p. 536. Key Words: advanced practice nurses; central venous catheter; nurse practitioner Dr. Wheeler is a consultant to Cumberland Pharmaceuticals, provided expert testimony for ad hoc legal consulting, received royalties from Williams and Wilkens, and has stock with Cumberland Pharmaceuticals. Their institution received grant support from the National Institutes of Health. Ms. Landsperger has disclosed that she does not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01 .ccm.0000435683.06554.b0
Critical Care Medicine
by duty hour requirements. Furthermore, there is a decline in the in the number of noncritical care physicians who are capable and willing to do invasive procedures as competence is not expected for internal medicine board certification and is no longer demanded by many training programs. Advanced practice nurses (APNs) are increasingly being used to offset critical care physician shortages, and with time, the range of their responsibilities has grown (7). APN's ability to augment traditional staffing models in teaching hospitals has been demonstrated (8) as has their ability to care for patients independent of physician trainees (9), including performance of procedures in the ICU, and leadership of rapid response teams. Given the complex interplay of priorities and pressures, it is innovative to consider the possibility that ICUbased APNs could safely insert CVCs around the clock, offloading work from physicians while simultaneously decreasing the rate of complications and generating revenue. In this issue of Critical Care Medicine, Alexandrou et al (10) report procedural characteristics and outcomes from a CVC placement service operated by APNs. This highly trained ICU-based service provided elective placement of nearly 5,000 nonemergent catheters over a period of 13 years (about 1 catheter/d) to patients in general wards of an 850-bed tertiary care university hospital. In line with observed practice trends, slightly more than half of the lines inserted were CVCs, whereas 45% were PICCs. The most common reason for insertion was administration of antibiotics, followed by administration of chemotherapy. Complications rates including catheter-related infections (0.01%), pneumothorax (0.4%), and arterial puncture were low (1.3%) and were equal to or better than previously published rates (2). The limitations of this study are obvious and acknowledged by the authors. Specifically, there is no contemporaneous comparator group against which to judge safety, and the number and outcomes of catheters not
vwvw.ccnnjournal.org
731
Editorials
inserted by this group is unknown. In addition, this service places a relatively small number of catheters electively, and the success and safety of high volume or emergent placement by such a group is unknown. Furthermore, there are no data about financial aspects of the program. Although this single-center investigation may not be generalizable to all institutions, it is clear that with proper training and initially supervised experience, insertion of CVCs by APNs is safe and feasible and may provide several benefits. First, as previously reported by Taylor and Palagiri (11), increased experience with CVC placement has been shown to improve patientrelated outcomes and decrease complication rates. In addition, as long the activity does not detract from ICU responsibilities, APNs could provide catheter placement services continuously unlike dedicated "PICC teams" which in many places are only available during business hours. Placement of catheters (in and outside the ICU) by APNs would allow physicians to focus on other tasks. Finally, unlike trainees, in many locales, certified and credentialed APNs can bill for placement of CVCs, which likely would help to support the costs of ICU-based APNs. The growing use of APNs in many ICUs demonstrates that when APNs undergo rigorous training, they can provide many services including placement of CVCs, care of critically ill patients, and leadership of rapid response teams. Ultimately, use of APNs has proven to be part of the solution to solving the critical shortage of intensivists while improving care.
REFERENCES 1. Berenholtz SM, Pronovost PJ, Lipsetf PA, ef al: Eliminating catheferrelated bloodstream infections in fhe intensive care unit. Crit Care Med 2004; 32;2014-2220 2. McGee D, Gould M: Preventing complications of cenfral venous catheterizafion. New EngI J Med 2003; 348:11 23-1133 3. The National Heart, Lung, and Blood Institute Acufe Respiratory Distress Syndrome (ARDS) Clinical Trials Network; Pulmonary-artery versus cenfral venous catheter to guide treatment of acute lung injury. New EnglJ Med 2006; 354:2213-2224 4. Marik PE, Baram M, Vahid B; Does central venous pressure predict fluid responsiveness? Cftesf 2008; 134;172-178 5. Ward N, Afessa B, Kleinpetl R, et al; Intensivist/patienf ratios in closed ICUs: A statement from the Society of Critical Care Medicine faskforce on ICU staffing. Crit Care Med 2013; 41 ;638-645 6. Krell K: Critical care workforoe. Crit Care Med 2008; 36;1350-1353 7 Howie-Esquivel J, Fontaine D; The evolving role of the acute care nurse pracfifioner in critical care. Curr Cpin Crit Care 2006; 12;609-613 8. Gershegorn HB, Wunsch H, Wahab R, et al; Impact on non-physician staffing on outcomes in a medical ICU. Chest 2011 ; 139: 1347-1353 9. Landsperger JS, Williams KJ, Hellervik SM, et al: Implementation of a medical intensive care unit acute-care nurse practitioner service. Hosp Pract 2011 ; 39;32-39 10. Alexandrou E, Spencer TR, Frost SA, ef al: Central Venous Cafhefer Placement by Advanced Practice Nurses Demonstrates Low Procedural Complication and Infection Rates—A Report From 13 Years of Service. Crit Care Med 2014; 42;536-543 11. Taylor R, Palagiri A: Cenfral venous cafheterization. Crit Care Med 2007; 35;1390-1396
ICU Scoring Systems: After 30 Years of Reinventing the Wheel, Isn't It Tinfie to Build the Cart?* Laurent G. Glance, MD Department of Anesthesiology University cf Rochester School of Medicine Rochester, NY Andrew W. Dick, PhD RAND Health, RAND Boston, MA
*See also p. 544. Key Words: Acute Physiology and Chronic Health Evaluation; intensive care units; quality assurance; risk adjustment Supported, in part, by Department of Anesfhesiology af the University of Rochester School of Medicine. The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2013 by the Society of Critical Care Medicine and Lippincoft Williams & Wilkins DOI: 10.1097/01 .ccm.0000435695.23586.04 732
wvv/w.ccmjournal.org
Turner M. Osier, M D Department of Surgery University of Vermont College of Medicine Burlington, VT
M
ore than five million patients a year are admitted to ICU in the United States (1), costing over 80 billion dollars annually and accounting for 4% of national health expenditures (2). Each year, nearly 500,000 people die in ICUs (3). The mortality rate for patients admitted to the ICU, which ranges between 8% and 19%, is greater than for any other condition other than myocardial infarction (4). There is wide variation in risk-adjusted mortality, and perhaps quality, across ICUs (5). Quality measurement is the cornerstone of quality improvement. Benchmarking cannot be performed without accounting for differences in case mix and severity-of-disease. At the risk of oversimplification, performance benchmarking is simply a comparison of an ICU's observed and expected mortality rate (EMR)—where the EMR is calculated using a risk-adjustment March 2014 • Volume 42 • Number 3
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
