Background

While people of all ages receive emergency and critical care services across the world, the elderly population continues to exhaust a greater proportion of these services [1]. The complexity and acuity of care have heightened with greater prevalence of chronic illness and multimorbidity among older adults [2]. Correspondingly, the demand for emergency and critical care services has increased [1], alongside a concomitant increase in the forecasted workforce requirements for such services [3]. The Accreditation Council for Graduate Medical Education regulations in 2006 in the United States of America (USA) recommends a high-intensity model of care involving 24-h physician coverage [3, 4]. This implementation accentuates inadequacies of the healthcare workforce to provide emergent and critical care services. In the USA, it is predicted that, compared to healthcare system’s demands, there will be a 22% shortfall of critical care physicians by 2020 and a subsequent 35% shortfall by 2030 [1].

With the impending rise in demand for health services, an effective utilization of the workforce is paramount to ensure high-quality yet cost-effective health service delivery [5]. Across some countries, healthcare workers’ wages account for approximately 50% of the total healthcare expenditure [6].DQ1 Cost-effectiveness of APN Essay.  Hence, cost containment strategies will inevitably involve the workforce [7]. Efforts are underway for measures to enhance productivity through increasing the capacity of the workforce.

One potential measure is a greater utilization of nurses in advance practice. The global annual growth of the nurse practitioner (NP) workforce has been estimated to be between three to nine times greater compared to physicians; therefore, of interest to health policymakers is the utilization of NPs and advanced practice nurses (APNs) [8, 9]. The nomenclature varies internationally. The “NP” title is used in Australia, Belgium, Canada, Sweden, the United Kingdom (UK), and the USA whereas the “APN” title is used in Switzerland, Singapore, and South Korea [10]. Nonetheless, NPs and APNs (NP/APNs) are registered nurses “who acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice” ([4], p. 26) and enter the workforce with a master’s degree [11].

This advanced practice role was first introduced in the 1960s as a solution to the lack of primary care physicians, to meet the primary care needs of the rural and underserved populations [12]. Primary care has first contact with patients and, subsequently, provides continuity of care within the healthcare system through the coordination of care according to patients’ needs [13]. Studies to evaluate the quality of primary care provided by NP/APNs have been shown to be comparable to that of physicians in terms of effectiveness and safety [14]. To fulfill primary care needs, NP/APNs in this setting are trained generalists who have a breadth of knowledge to render a wide scope of care.

Since the inception of advanced nursing practice in primary care, its role has extended to other healthcare settings such as the acute care. Acute care provides short-term restorative stabilization to patients in unstable chronic conditions and with complex acute and critical illnesses. Acute care encompasses emergency and critical care [15]. DQ1 Cost-effectiveness of APN Essay. Emergency and primary care advanced nursing practice do share similarities in that they serve as first-contact access to healthcare, but the acuity of the patient manifestations delineates the two. Unlike in primary care NP/APNs, emergency NP/APNs are trained to manage patients with acute life- or limb-threatening conditions [15]. In the past decade, greater practice autonomy has been given to NP/APNs in emergency and critical care. This expanded practice allows nurses to assume some medical tasks typically performed by physicians, aiming at not only increasing the access to healthcare and service efficiency but also eventually mitigating the cost of health services.

The development of advanced nursing practice contributed to a service model aiming to respond flexibly to the ever-changing needs of patients [16]. Systematic reviews of studies on the effectiveness and safety of NP/APN-led primary care have reported positive effects of NP/APN service on clinical outcomes, patient satisfaction, and costs [14, 17] These reviews focused on the primary care setting, it may be inappropriate to extrapolate their findings to the emergency and critical care settings since the patient acuity and clinical needs differ among settings.

Nonetheless, reviews evaluating NP services in the emergency and critical care settings exist. However, they have three shortcomings, the first of which concerns their generalizability. Over the past decade, studies have evaluated whether the delegation of medical tasks to NP/APNs in the emergency and critical care settings was feasible and safe. A review of 31 studies on the impact of NPs and physician assistants in such settings reported that their practice was safe and, in some cases, the quality of care was higher than that of physicians [18].DQ1 Cost-effectiveness of APN Essay.  However, only two of the studies were randomized controlled trials (RCTs) [19, 20] whereas the rest had small sample sizes and questionable study methodology; these limit the generalizability of the review. A more recent review [21] also reported that NPs do have a positive impact on the quality of care. Nonetheless, the reviews included both NPs and non-nursing healthcare providers, thereby introducing heterogeneity in the synthesis of evidence, making it difficult to assess the true effect of NPs in the intensive care settings [18, 21].

The second shortcoming centers on the inconclusiveness of the reviews. One review suggested although NP services in the emergency setting did reduce waiting time and provide care comparable to that of a midgrade physician, the cost of NP services was higher than that of resident physicians [22]. In contrast, another review concluded that the use of NPs reduced the cost of emergency and intensive care services. Further complicating the picture is a recent systematic review that reported an inadequacy of evidence to determine the cost-effectiveness of NP services in emergency departments (EDs) [23]. Consequently, the cost-effectiveness of advanced nursing practice in the emergency and critical care settings has remained inconclusive. Lastly, all existing reviews [18, 21–23] elucidating advanced nursing practice in the emergency and critical care settings included only studies published before January 2013, which may be dated.

Considering the existing literature, it is of interest to undertake an updated systematic review on the latest evidence to determine whether advanced practice nursing in emergency and critical care have an impact on the quality of care, clinical outcomes, patient satisfaction, and cost savings. If NP/APNs can indeed provide competent and safe care in these settings, greater access to emergency and critical care services will be available, thereby strengthening the workforce to fulfill the escalating healthcare demands. DQ1 Cost-effectiveness of APN Essay.

Therefore, the main objective of this systematic review is to present, critically appraise, and synthesize the best available evidence on the impact of advanced nursing practice on patients’ length of stay, time to treatment or consult, mortality, patient satisfaction, and cost in emergency and critical care settings.

Methodology

Study eligibility

This review included RCTs, quasi-experimental studies, prospective and retrospective cohort studies. Cross-sectional studies and studies without comparison groups were excluded.

The PICO (Population-Intervention-Comparison-Outcome) framework guided the selection process [25]. This review considered studies that included the following:

• Patients: at least 16 years of age, presenting in EDs, trauma centers, intensive care unit (ICU), or high dependency units, requiring emergency or critical care

• Nurses: registered nurses in advanced practice role, i.e., APNs or NPs

• Physicians: emergency physicians, intensivists, residents, medical officers, hospitalists, or house officers in the ED or ICU or high dependency units

Excluded from the review were studies that examined both adult and pediatric patients requiring emergency or critical care services. DQ1 Cost-effectiveness of APN Essay. Excluded from the review were also studies that examined services provided by physician assistants. This review included studies with interventions which compared the outcomes of the APN-/NP-directed emergency or critical care services with those of the physician-directed care. This review also included studies with interventions which compared the physician-only model of care with APN-physician or NP-physician collaborative model of care.

Studies that had the following outcome measures were included:

• Patients’ length of stay in the emergency or critical care setting

• Patient mortality

• Time to consultation or treatment

• Patients’ satisfaction

• Cost of care

The selection of studies was done independently by two of the authors (BW and JL) based on the eligibility criteria. Disagreement during selection was resolved by discussion with a third-party arbiter (WT). The selection process is illustrated in the flow diagram in Fig. 1.

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Fig. 1

Systematic review search flow diagram

Results