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Perspectives |
1 From the Division of Abdominal Imaging, Department of Radiology, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322. Received March 28, 2007; final version accepted April 25. Address correspondence to W.C.S. (e-mail: wsmall{at}emory.edu).
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INTRODUCTION |
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 TOP INTRODUCTION BACKGROUND THE SOLUTIONHURDLES ALONG THE WAY...CONCLUSION References |
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Nonphysician providers, including nurse practitioners (NPs) physician assistants, and—more recently—radiology assistants, represent an important new resource for providing patient care. The presence of these individuals in our department has provided a great degree of added competency and consistency in areas of high contact with patients. Our cumulative experience and satisfaction with the value these professionals bring have grown in direct proportion to the ever-expanded role that they fill. This perspective describes the experience at Emory University over a 5-year period of nonphysician provider contribution to our practice, including the history of nonphysician provider participation in our department and the scope of involvement that has evolved.
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BACKGROUND |
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TOPINTRODUCTIONBACKGROUND THE SOLUTIONHURDLES ALONG THE WAY...CONCLUSION References |
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In the initial development of a job description for nonphysician providers, the goal was to create a more senior and semi-independent capability to permit more consistent patient care. This need was appreciated as a result of a variety of factors. First, during the late 1990s as part of a national trend (4), radiology staff shortages became severe, and this led to difficulty covering even routine tasks, such as image interpretation, and staffing interventional procedures. Little time was available for other necessary tasks, such as obtaining patient informed consent, performing physical examinations, providing patient education and consultation, and performing both short- and long-term patient follow-up. These trends were exacerbated by the more specific shortage in interventional radiology physician staff when the number of procedures was rapidly increasing owing to the advent of new image-guided techniques. Although there is often an abundance of manpower in the form of residents and fellows in an academic center, these individuals rapidly rotate their responsibilities, leading to inconsistency and confusion. Thus, this was not an adequate solution in our institution.
A second trend that emerged was the rapid growth of a subset of procedures that were still invasive but were relatively repetitive and could be easily mastered. These procedures included image-guided liver biopsy, thoracentesis, paracentesis, and venous access. Although resident and fellow trainees must master the skills needed to perform these procedures, the number of trainees far exceeded the need for adequate participation in even a large program such as ours with 57 residents and multiple fellows.
A third trend, which may be less predictable, occurred in the setting of a more sophisticated but growing area of intervention—that of a busy radiofrequency ablation service. This subset of our interventional practice magnified many of the existing needs for coordination with referring physicians who may be a long distance from our hospital; long-term follow-up for a growing number of patients, many of whom come to our institution from a distance; and brief but intense periods of patient care and family interaction.
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THE SOLUTION |
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TOPINTRODUCTIONBACKGROUND THE SOLUTIONHURDLES ALONG THE WAY...CONCLUSION References |
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Both national and state (in this case, Georgia) resources regarding accrediting boards and state licensure are available (5,6). The NP functions under his or her own license and usually carries his or her own liability insurance or is covered by the practice's malpractice policy. Each state defines what NPs can do and what level of supervision is required as a part of the State Nurse Practice Act for that specific state. Furthermore, within the individual facility where the NP is employed, there is a credentialing and certification process in which the NP must demonstrate the ability to perform procedures and display competence. Individual facility requirements for NP credentialing vary. This process is similar to the medical credentialing that occurs for physicians. The hospital cannot provide credentialing for procedures that are at a higher level of complexity than that allowed by the state. In most instances, the NPs can perform a variety of tasks independently under mutually agreed-on protocols. The protocols are agreed on and approved by the sponsoring physician and must be approved by the institution where care is provided. In our case, the NPs must perform each procedure under supervision 10 times before they are allowed to perform the procedure independently with the sponsoring physician available for assistance as needed. The function of physician assistants is somewhat different, as they do not practice under their own license but rather under the license and direction of the sponsoring physician.
Nonphysician provider roles, as defined and credentialed in primary care specialty areas such as family practice, women's health, cardiology, geriatrics, or acute care, are established, growing, and accepted by the public as a means to increase patient access and improve care while controlling cost. However, when we first considered incorporating these providers to fill our recognized needs within radiology, there was no real model and no pool of candidates with experience in patient care specific to radiology. Developing job descriptions, lines of reporting, and appropriate credentialing has been an ongoing effort, as has been described in other reports (7). Similarly, finding individuals with excellent clinical experience and gradually adapting and applying these skills to benefit the clinical needs in our department have required continual thought.
The use of nonphysician providers at Emory University has been divided into two functionally different skill sets. These roles have largely evolved according to the area of practice. In the interventional department, the procedural duties of the three NPs and the physician assistant are centered in a peripherally inserted central catheter line service, which has led to a decreased wait time for this procedure (from several days to 24 hours in most cases). In patient care, interventional service providers also assist in the outpatient setting by seeing patients before and after they undergo a procedure. They also interact with referring services to make sure that patients are ready to undergo a procedure. This includes obtaining informed consent from patients, making sure that laboratory work-up results are within acceptable limits, reviewing patients' medication, and pointing out any other problems that must be identified before beginning a procedure.
The initial role of the NP (M.A.B.) in the abdominal division was similar. Getting patients "procedure ready" included interacting with the radiology nursing staff and technologists to prioritize procedures, contacting the referring service and pathology department to make sure that appropriate testing and evaluation were performed for each patient, and ensuring that postprocedure patient follow-up was appropriate.
The consistency of the nonphysician provider's presence in both the interventional and the abdominal divisions allows continuity and consistency of clinical care. The attending physicians rotate daily; the residents, every 4 weeks; and the fellows, every 5 weeks. The stability of nonphysician provider staffing allows clinicians from referring services to have a ready and reliable conduit for communication to schedule examinations, troubleshoot problems, and be a consistent point of facilitation of radiology services. This single point of contact has enabled the referring services to better understand how tasks are prioritized and accomplished.
One of the authors (M.A.B.) has developed an expanded role as a primary provider of a growing subset of interventional services within the abdominal division, with hospital credentials enabling him to perform procedures such as liver biopsy, thoracentesis, and paracentesis. In such circumstances, he works under the supervision of a sponsoring physician, with assistance from the physician only if needed; billing is done independently or in the physician's name, depending on the patient's insurance coverage.
Although this role in providing communication support and direct patient care both in the procedure room and in the pre- and postprocedural settings has proved vital, other enhancements not originally included in the initial job description have become indispensable. Such situations are largely the result of providing consistency of presence and a central conduit of information and a desire to overcome disconnects in coordinating services. This is best exemplified by the development of a database for follow-up of patients who undergo radiofrequency ablation. The database is a resource to remind the referring services when to schedule follow-up imaging studies and appointments. On a weekly basis, the NP (M.A.B.) queries to find patients who are due or potentially overdue for follow-up imaging, and he alerts the ablation service within our department and the referring physician of the need for follow-up imaging.
In our department, all pre– and post–radiofrequency ablation imaging studies are double read by radiologists who are skilled in performing ablations. In these team-based review sessions, final decisions are made with regard to residual disease, if present; accessibility of lesions to treatment; modality used for image guidance; method of treatment, including type of probe and likely number of required treatment sessions; and, based on each patient, the potential need for anesthesia support. The first author (M.A.B.) is a direct participant in the evaluation of images to determine if the patient is a candidate for radiofrequency ablation with several derived benefits to the overall ablation service. First, since the first author (M.A.B.) maintains the database, the accuracy and detail of information are maximized. Second, decisions made as a result of these review sessions allow accurate planning of either initial or repeat treatments and enhance the role of the nonphysician provider as an intermediary for communicating with the referring clinician, scheduling and planning treatment, and educating the patient and his or her family. A third benefit has been the first author's professional development as a result of such a team approach to patient care in this highly specialized area. This type of interaction has fostered growth in this author's knowledge of not only imaging interpretation but also ablative techniques and the related literature, reputation among clinicians both within and beyond radiology, interactions with vendors and radiologists outside Emory University, and participation in meetings both as an attendee and as a speaker.
The previously mentioned types of interaction as part of the ablation service have helped improve the overall execution of all types of procedures within the abdominal division. A chronic problem that plagued us in the past was poor communication of procedures approved and planned by one radiologist but ultimately performed by a colleague. The NP (M.A.B.) has developed a simple preprocedure scheduling template that captures information regarding the exact procedure requested, all prior imaging examinations, image numbers containing disease on prior imaging to direct attention to the proper area of interest, documentation of all tissue tests desired (cytology, histopathology, special stains, research projects, etc), and anesthesia needs, even to the extent of patient positioning.
An additional benefit of NP activity on one of our other campuses has been improved quality assurance. All interventional procedures are tracked on a physician-specific spreadsheet that includes patient information, procedure performed, outcome, and complications. This documentation has allowed long-term trends to be identified and corrected if they are adverse. This has resulted in policies that have allowed staff re-education, better coordination between referring clinicians and the pathology department, better evaluation of biopsy devices, and evidence-based choices of new or replacement interventional equipment.
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HURDLES ALONG THE WAY |
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TOPINTRODUCTIONBACKGROUND THE SOLUTIONHURDLES ALONG THE WAY...CONCLUSION References |
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Historically, nurses in the radiology department (and in other departments as well) have a certain set of duties and responsibilities that are almost cultural. They are also always in short supply. The combination of these facts and the fact that the term nurse practitioner begins with "nurse" initially led to misunderstandings. There was a strong initial desire to pull NPs to cover patient monitoring or sedation when there was a shortage of nurses. The NP's responsibilities are defined as a scope of activity and responsibility separate from that of staff radiology nurses, and this degree of separation has at times required clarification to protect and prevent dilution of the added skills and independent function they possess.
Another issue that requires a degree of vigilance is related to the area of procedure performance. As discussed previously, there is great value in nonphysician provider performance of a variety of relatively low-difficulty often-performed procedures, such as vascular access procedures and ultrasonography-guided liver biopsy, thoracentesis, or paracentesis. There is a tendency to allow an ever-increasing number of these procedures to be performed by proficient individuals and to not take the time to allow junior residents to perform a satisfactory number of procedures so that they become proficient themselves. In our practice, as the number of diagnostic imaging studies each resident sees and dictates grows, there is a trend for some of the junior residents to shy away from procedures. This has necessitated an intentional policy of requiring a portion of these procedures to be performed by residents under the supervision of an attending physician. Although this may be less efficient, to do otherwise would compromise resident education. Certainly, nonphysician provider assistance in a large number of such procedures allows more flexibility and time for attending physicians to teach and supervise more challenging cases. The incorporation of nonphysician providers into a practice brings a host of considerations to any site. In an academic center, there are additional challenges and opportunities to balance the capabilities of new resources with both educational and patient care responsibilities (8).
Billing practices require careful attention to detail to avoid errors. Some carriers recognize and offer reimbursement if nonphysician providers perform procedures independently, whereas some providers do not. In our practice, when the lead author (M.A.B.) is scheduled to perform an interventional procedure, patient insurance is reviewed to confirm what billing is appropriate to the policies of the carrier. In situations where the carrier does not recognize nonphysician providers performing independent interventions, the NP performs and dictates the procedure in a fashion similar to the resident, with supervision by and billing under the name of the attending physician, per the contract with the commercial or managed care insurance company. Alternatively, if the carrier recognizes NP independence, the NP bills under his or her own name. In some cases, there may be a modest reduction in reimbursement. (Medicare will reimburse at 85% of the physician fee schedule.) The issue of billing requires care to ensure compliance at a local level, and it will engender increasing discussion of staffing and reimbursement at a national level as nonphysician provider patient care inevitably grows (9).
A final potential hurdle is financial in nature. In our academic environment, a comparison of nonphysician provider compensation with that available in the private practice or community hospital setting is inevitable and unfortunately reveals a negative disparity. Turnover in nonphysician providers within our own practice is not unusual, and inferior compensation is a contributory factor. The primary author's (M.A.B.) situation has been more stable, and there have been a number of negotiations to recognize his contributions, some of which have been described. Certainly, the opportunity to make a substantial contribution to the excellence of patient care as part of a team and with unique recognition is a source of satisfaction; however, a competitive salary is also necessary.
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CONCLUSION |
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TOPINTRODUCTIONBACKGROUND THE SOLUTIONHURDLES ALONG THE WAY...CONCLUSION References |
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FOOTNOTES |
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References |
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TOPINTRODUCTIONBACKGROUND THE SOLUTIONHURDLES ALONG THE WAY...CONCLUSION References |
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