Category Archives: Critical Care Units

The intention was to select individuals who have had adequate exposure to inpatient care and were familiar with hospital-based medical care. Second, prior experience in a hospital setting is desirable. The PAs employed in this study had experience in surgical, anesthesia or cardiology services and were capable of recognizing emergencies and dealing with them. Third, formal training in the delivery of intensive care should be offered. This is best accomplished by inviting the PAs to participate in rounds in an intensive care unit under the supervision of qualified physicians. After a period of observation, they may be assigned patient care duties, starting with simple histories, physical examinations and chart reviews and gradually increasing to performance of invasive procedures under direct supervision. (more…)

Discussion In the past two decades, PAs have functioned under supervision at newly developed satellite health centers in rural areas of the nation. These health providers were accepted by the physicians and their patients, and their performance was good. Studies comparing their aptitude to that of medical students showed minimal if any differences. In addition to their traditional role in primary care, PAs now are being utilized in place of house officers in surgical, medical, pediatric and emergency room departments. For example, in 1981, Perry et al reported that out of 522 surgical departments surveyed, 165 employed at least one PA. Thirty-three percent of department chairs felt that PAs had improved surgical patient care. (more…)

Guidelines for the management of critically ill patients were determined by the affiliated university program. Consequently, no major changes in approaches to patient care were implemented during the study period. The following factors were evaluated: (a) number of monthly admissions, (b) occupancy, (c) APACHE II score as an index of intensity of disease, (d) duration of stay, (e) mortality, (f) number of invasive procedures, (g) number of complications, (h) utilization of laboratory resources, and (i) quality of charting. These factors were obtained on a monthly basis. Differences between the two periods were compared using the Wilcoxin rank sum nonparametric test with a p<0.05 considered statistically significant. (more…)

8.    Communicating with the next of ldn of patients to obtain relevant historical information, signed consents for invasive procedures, or simply to update the families on the progress of their patients. 9.    Recordkeeping and dictation of admission notes, progress notes and discharge summaries also were done by the PAs. All such notes and orders were countersigned by the rounding physician. (more…)

4.    Management of patients in shock requiring hemodynamic monitoring and vasopressors. The PAs inserted central lines and assisted the physician in floating Swan-Ganz catheters. They wrote orders for fluid resuscitation and vasoactive medications after consultation with the physician. They also analyzed hemodynamic data and initiated changes in therapy accordingly. 5.    Reversal of life-threatening episodes of arrhythmia. The PAs administered antiarrhythmic medications in accordance with protocols developed in our unit. Following that, immediate consultation with the physician was obtained. (more…)

The duties assigned to the PAs were identical to those of housestaff physicians normally appointed to medical intensive care units. Specifically, they included: 1.    Writing stat and routine orders in the medical record after consultation with the rounding physician. Since all orders were preapproved by the physician, they were unrestricted and were carried out promptly by the nursing staff. 2.    Managing patients admitted for observation, as well as patients admitted for intensive therapy. In both situations, the PAs performed the initial physical examination, initiated therapy including administration of fluids, oxygen, antibiotics, blood or other emergency medications and completed the paperwork. The case was then discussed with the attending physician, the abnormalities outlined and therapeutic plan finalized, a process identical to what is normally done when house staff officers are appointed to the unit. (more…)

Draining and Privileges of Physician-Assistants All physician assistants hired had received formal college education and graduated with bachelors degrees as physician assistants. They were certified, licensed and had passed the certifying examination given by the American Board of Physician Assistants. They had several years of experience in managing in-patients in acute medical and surgical settings. Following recruitment, the physician-assistants spent a period of three months rotating with fellows and residents under the supervision of certified intensivists in a university hospital. The physician-assistants received training in the techniques of obtaining history and physical examination in a critical care setting. (more…)

The spectrum of admitting diagnoses is similar to what is encountered in other medical intensive care units and includes, among others, respiratory insufficiency, hepatic failure, cardiac decompensation and shock, massive bleeding, hyperglycemic and hypoglycemic emergencies, seizure disorders, stroke, and uremia. Approximately one half of the patients are ventilator-dependent at some point during their hospitalization. No surgical or postoperative patients are normally admitted to this unit. Two physicians alternate on a monthly basis in providing medical supervision. (more…)

For these reasons, house staff officers for the primary care of inpatients may not be available in large numbers in the future. Alternative staffing will have to be implemented. Many hospitals already have hired non-physician health providers to fill the gap. Nurse practitioners and PAs, whose job was originally designed to serve outpatients in rural communities, are now being employed to perform inpatient duties on surgical and medical floors as well as in emergency rooms. Lately, new curricula in critical care education for PAs have been developed. Many PAs are being trained in the management of acutely ill patients with multiorgan failure. Hospitals, however, may be reluctant to allow physician assistants to take care of such delicate patients. In this study, we evaluated the feasibility and outcome of utilizing PAs in a medical ICU. The period of study ranged for four years, during the initial two of which only residents were assigned to the unit. During the latter two, residents were replaced by PAs. (more…)

Hospital-based health care delivery in the United States traditionally has relied on the services of physicians in training, commonly referred to as house staff or house officers. The existence of large numbers of house staff to provide inpatient care may, however, decline. The reasons for this are varied. First, the Graduate Medical Education National Advisory Report estimated that the United States will have a surplus of70,000 by the year 1990 and 145,000 by the year 2000. It recommended freezing the number of trainees in internal medicine and reducing subspecialty trainee positions by up to 20 percent and medical students by 17 percent. Based on this, many medical schools already have decreased the size of their classes and residency programs. Second, funding for house officers is becoming less readily available. (more…)