title: Advanced care nurse practitioners can safely provide sole resident cover for level three patients: impact on outcomes, cost and work patterns in a cardiac surgery programme.
abstract: OBJECTIVE
  There are significant pressures on resident medical rotas on intensive care. We have evaluated the safety and feasibility of nurse practitioners (NPs) delivering first-line care on an intensive care unit with all doctors becoming non-resident. Previously, resident doctors on a 1:8 full-shift rota supported by NPs delivered first-line care to patients after cardiac surgery. Subsequently, junior doctors changed to a 1:5 non-resident rota and NPs onto a 1:7 full-shift rota provided first-line care.
  
  
  METHODS
  A single centre before-and-after service evaluation on cardiac intensive care.
  
  
  METHODS
  mortality rates, surgical trainee attendance in theatre and cost before and after the change. After-hour calls by NPs to doctors and subsequent actions were also audited after the change.
  
  
  RESULTS
  The overall mortality rates in the 12 months before the change were 2.8 and 2.2% in the 12 months after (P = 0.43). The median [range] logistic EuroSCORE was 5.3 [0.9-84] before and 5.0 [0.9-85] after the change (P = 0.16). After accounting for the risk profile, the odds ratio for death after the change relative to before was 0.83, 95% confidence interval 0.41-1.69. Before the change, a surgical trainee attended theatre 467 of 702 (68%) cases. This increased to 539 of 677 (80%) cases after the change (P < 0.001). The annual cost of staffing the junior doctor and NP programme before the change was £933 344 and £764 691 after. In the year after the change, 192 after-hour calls were made to doctors. In 57% of cases telephone advice sufficed and doctors attended in 43%.
  
  
  CONCLUSIONS
  With adequate training and appropriate support, resident NPs can provide a safe, sustainable alternative to traditional staffing models of cardiac intensive care. Training opportunities for junior surgeons increased and costs were reduced.
authors.affiliation: Trent Cardiac Centre,  Nottingham University Hospitals, Nottingham,  UK.
authors.forename: Henry
authors.initials: H
authors.lastname: Skinner
authors.forename: Julian
authors.initials: J
authors.lastname: Skoyles
authors.forename: Sue
authors.initials: S
authors.lastname: Redfearn
authors.forename: Raj
authors.initials: R
authors.lastname: Jutley
authors.forename: Ian
authors.initials: I
authors.lastname: Mitchell
authors.forename: David
authors.initials: D
authors.lastname: Richens
mesh_terms: D006348:Cardiac Surgical Procedures / Q000401:mortality / Q000592:standards* / Q000706:statistics & numerical data; D017598:Efficiency, Organizational; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000458:organization & administration / Q000592:standards; D007396:Internship and Residency / Q000592:standards / Q000706:statistics & numerical data; D009722:Nurse Practitioners / Q000592:standards* / Q000706:statistics & numerical data; D012307:Risk Factors; D016896:Treatment Outcome; D006113:United Kingdom; D000078329:Workforce