In large and small trauma centers, APPs are on the front lines

Advanced practice providers (APPs) became an essential part of most adult and pediatric trauma teams when resident hours were restricted a decade ago. Since then, studies have shown that the presence of APPs leads to decreased length of hospital stay, reduced costs and increased patient satisfaction. The benefits are seen at all levels of trauma care, although the roles of nurse practitioners (NPs) and physician assistants (PAs) can vary considerably, depending on trauma center resources.

"When a trauma patient comes in, there is always a need for immediate assessment and decision-making, and APPs play a key role in that," says Kyle W. Satterblom, P.A.-C., a physician assistant at Mayo Clinic's campus in Rochester, Minnesota. "In our division, about one-third of an APP's time is spent on the trauma service. There are so many residents and surgeons in the ED that APPs mainly take on a hospitalist role, managing day-to-day care of patients after they've been admitted. We also do acute wound care, oversee transfers to a skilled nursing facility or rehab center — a wide range of things that may not be typical of APPs in other trauma centers in our area."

In low-volume centers, on the other hand, where staffing is mostly APPs, a nurse practitioner or physician assistant may be the main emergency department (ED) provider, deciding whether patients can be treated there or need immediate transfer to definitive care.

"At Level III and Level IV centers, providers do a quick assessment to get a sense of what's going on and what they need to do to stabilize the patient using the resources they have," Satterblom says. "If a patient's injuries exceed available resources, they arrange a transfer to a higher level of care. It's very different from the Level I center, where the team leader is usually a resident or staff surgeon and the APP serves in the role of assessing provider."

Performance improvement

Satterblom says performance improvement (PI) is one area where advanced practice providers are on an equal footing with physicians. "APPs do PI the same way doctors do. We participate in the same morbidity and mortality conferences; we review practice management guidelines, perform chart reviews and evaluate whether protocols have been followed," he explains.

Advanced practice providers are, increasingly, also involved in practice management guideline development — performing literature searches to make sure current guidelines are up to date and evidence based, tracking registry data, and helping determine why goals aren't being met.

Making performance improvement easier across the board are the Southern Minnesota Regional Trauma Advisory Committee (SMRTAC) trauma team activation criteria that went into effect in 2014.

"We all use the same criteria now; that's been one of the big things," Satterblom says. "Everybody's on board and trying to learn from each other. Mayo is the only Level I Trauma Center in the region, and there are a lot of Level III and Level IV centers, but in SMRTAC, everyone has equal say. It's not a matter of 'What can I teach you;' it's a matter of what we can learn from each other."

In that same spirit, Mayo Clinic recently began offering an Emergency Medicine Fellowship for APPs. One of the goals of the program is to prepare nurse practitioners and physician assistants to staff emergency departments at Level III and Level IV centers in southern Minnesota.

For more information

New TTA criteria help ensure optimal care for injured patients. Mayo Clinic Trauma Physician Update e-Edition. May 2014.