Transcription
Acute Care Nurse Practitioner:An Advanced Practice RoLefor RN First AssistantsJANICE L SCHROEDER, RN, MSN, CRNFA, ARNP, ACNPPerioperati\'e nurses and RN firstassistants (RNFAs) have long beenfamiliar with the advanced practice roles of the certified RN anesthetist(CRNA), certified nurse midwife (CNM),clinical nurse specialist (CNS) as clinicaleducator, and the family nurse practitioner (FNP) as a primary care provider.An advanced practice role that perioperative nurses and RNFAs may not be asfamiliar with is the acute care nursepractitioner (ACNP). Acute care nursepractitioners are educationally preparedto provide advanced nursing care topatients with complex acute, critical, andchronic illnesses. TTiis role is ideally suited to perioperative nurses and RNFAswho want to take on an advanced practice role but do not want to leave thehands-on, acute care setting of the perioperative arena.ADVANCED PRAcncE ROLESAND SCOPE OF PRAcncEThe scope of practice defined by eachstate determines the type of patients thatNPs can treat, where they can practice,and under what circumstances they maydo so. In the past, some perioperativenurses and RNFAs may have been hesitant about pursuing an advanced practice role, believing that the only nursepractitioner (NP) option was the FNPI ole. The FNP course of study and scopeof practice would likely take them out ofthe acute care setting they enjoy and aremost comfortable in and move theminto the outpatient primary care settingof a clinic or health department. FamilyNPs are trained for care of the familyunit from newborns and the postpartumwoman to older adults, and they areeducationally prepared to provide directpatient care aimed at health promotion.ri AORN, Inc, 2008health protection, and disease prevention.' Other NP specialties ological,women's health, andacute care.An advanced practice opportunity forperioperative nurses who are interestedin OR education, practice and policydevelopment, research, or managementis the clinical nurse specialist (CNS) role;employment in private practice for a surgeon or other specialist also is an optionin some states. In defining the CNS role,the National Association of ClinicalNurse Specialists says that a CNSindependently provides theory andresearch-based care to clients in facilitating attainment of health goals,works with nurses to advance nursingABSTRACTACUTE CARE NURSE PRACTITIONERS (ACNPs)are advanced practice RNs who are educationallyprepared to provide advanced nursing care topatients with complex acute, critical, and chronicillness.THE EDUCATION of advanced practice nursesshould prepare them for the setting in which theypractice; ACNPs are well prepared for hospital andspecialty practice, particularly if they have experience as RN first assistants (RNEAs).THIS ARTICLE PROVIDES a brief overview of theACNP opportunity for RNFAs and the importanceof additional training for ACNPs without OR experience who may be first assisting. AORN J 87 (June2008) 1205-1215. AORN, Inc, 2008.JUNE 2008, VOL 87, NO 6 AClRN lOURNAt 1 2 0 5
JUNE 2008, VOL 87, NO 6practice to improve outcomes cost-effectively,and/or provides clinical expertise to affectsystem-wide changes in organizations toimprove programs ofcare. Schroederprepared to focus specifically on the perioperative patient population through policy andpatient care protocols and ensuring that mandated quality care initiatives are implemented.The perioperative ACNP is educationally prepared to make medical diagnoses collaboratively with a surgeon for individual patients, prescribe treatments for those medical diagnoses,and follow patients throughout their perioperative experience, including post-hospital discharge care.' A survey of 158 CNSs and 77ACNPs supports the scope of practice describedfor each role. The ACNP respondents indicatedthat individual patient care accounted for 74%of their practice time, whereas the CNS respondents indicated that 26% oftheir practice time was spenton individual patient care."it is important to check the scope of practicefor CNSs in the state in which the nurse willpractice. In some states, the CNS is considered anadvanced RN practitioner (ARNP), but not inother states. States that do not recognize the CNSas an ARNP limit the CNS's scope of practice inareas of prescriptive authority, practice options,and reimbursement from Medicare and otherthird-party payers.' In addition, state legislaturespass regulations that change the scope of nursingpractice. For example, effectiveJuly 1,2007, the Nebraska StateLegislature signed into law anew definition of ARNP thatincludes CNSs, CRNAs, andDEVELOPMENT OFCNMs. Before July 1,2007, inTHE ACNP ROLEThe acute care nurseNebraska, "ARNP" referredIn the 1970s, the first ACNPonly to the NP roles. This legpractitioner role is anrole evolved from the pediislative action also allows licenatric NP role. A combinationsure for CNSs.'advanced practice role of cutbacks in the number ofAnother advanced practicepediatric residents and inrole that perioperative nursescreasing acuity and complexithat allows for moreand RNFAs can pursue is thety of surviving neonatal paACNP role, which allows fortients prompted the develophands-on patient caremore hands-on patient carement of the neonatal NP role.'than the CNS role. Acute carethan the clinical nurse A similar scenario then ocNPs provide advanced nurscurred in the adult population,ing care to patients with comand primary care NPs beganspecialist role.plex acute, critical, and chronicaccepting positions and addiillnesses. Practice settingstional training for hospitalinclude acute and subacutebased practice.' The need forhospital departments such aseducationally prepared ACNPsthe intensive care, bum, emergency, trauma,became apparent, and the first graduate-level,dialysis, or medical-surgical units, as well asadult ACNP programs emerged in tlie latespecialty office and rehabilitative settings.1980s, with the first national certification examiAcute care NPs are often the mid-level provider nation by the American Nurses Credentialingof choice in specialty practice, such as pulCenter being offered in 1995. monology, cardiology, oncology, nephrology,Also in 1995, AORN recognized and definedneurology, and any of the surgical specialties.the role of the perioperative advanced practiceThe ACNP scope of practice is determined bynurse with an official statement of practice apeach individual state's laws and is outlined inproved by the AORN House of Delegates. Thisthe Nurse Practice Act. statement was revised in 2006 to indicate that aTypically, both the CNS and ACNP practicehallmark of NP skill is autonomy and experhse inprimarily in acute care or specialty practice setassessing, diagnosing, and prescribing pharmacotings. Tlie perioperative CNS is educationallylogical and treatment modalities in the care of the1206.AORN lOURNAL
JUNE 2008. VOL 87, NO 6surgical patient." This is a descriptive statementthat is not used as a form of credentialing ortitling by any state board of nursing, and it isapplicable to either a CNS or NR'In 2003, the Accreditation Council for Graduate Medica! Education mandated restrictingresident physicians to working 80 hours perweek.'" Teaching institutions that traditionallyrelied on surgical residents for first assistantservices have begun using the surgically trainedNP or physician assistant (PA) to fill the void incare created by the decrease in resident hours."As Medicare and other third-party reimbursements continue to decline, demand forACNPs is increasing. Surgeons are faced withincreasing demands on their time and arelooking for ways to maximize their practiceresources without compromising patient careoutcomes.'- A surgeon functioning as a firstassistant is allowed to bill Medicare \6% of thesurgeon's Medicare allowable charge. AnARNP, CNS, or PA may bill 13.6% for the sameservice." Reimbursement from commercialinsurance for first assistant services is dependent on the individual company policy; somepayers allow 20"/ or 25% of the surgeon'sallowable fee. The ACNP as first assistant iscost-effective for the patient, insurance provider, and surgeon. When the simplicity of asurgical procedure does not warrant an assistant, the ACNP's time and skills may be usedto monitor, assess, educate, and treat inpatients or outpatients, optimizing patient careand efficiency for the surgeon.THE IMPACT OF NP CARE ON PATIENT OUTCOMESSeveral research studies have shown that inaddition to being cost-effective, the use of NPsand ACNPs in patient care leads to positivepatient outcomes. Brooten et al" analyzed 333interaction logs created by NPs during fiverandomized controlled trials that included very low birth weight infants, women who underwent unplanned cesarean birth, women with a high-risk pregnancy, women who underwent hysterectomy, and older adults with cardiac medical and surgical diagnoses.Each group was monitored for total amount of1 2 0 8 AORNJOURMAI.SchroederAs Medicare and other third partyreimbursements continue to decline,demand for acute care nursepractitioners is increasing.NP time, number of contacts per patient, andmean length of time per NP contact. Thegroups with greater mean NP time and contacts per patient had greater improvements inpatients' outcomes and greater health care costsavings.' Hysterectomy and cardiac surgicaldiagnoses were included in this study; it is reasonable to expect similar findings of improvedpatient outcomes and cost savings when anACNP is part of the team for other surgicalspecialties as well.Researchers for the randomized controlledtrial Study of Nursing Intervention in Practiceassigned 339 consenhng patients scheduled forelective cardiac catheterizations to receive preprocedure teaching and preparation by either anNP or a junior medical staff member." Tlie cardiologist's evaluation of patient preparation wasacceptable in both groups, with both groupshaving nearly equal scores: 983% in the NPgroup and 98.8 % in the junior medical staffmember group. No adverse events occurred inpatients in the NP group and adverse eventsoccurred for two of 161 patients (1.2%) in thejunior medical staff member group. Patient satisfaction questionnaires indicated greater satisfaction in the NP group (P .04), and the median duration of the preadmission visit was lowerin the NP group (ie, 165 minutes in the NPgroup versus 185 minutes in the junior medicalstaff member group). The researchers concludedthat an appropriately traiJied NP can safely prepare patients for diagnostic cardiac catheterization." This study indicates that ACNPs are wellsuited to provide preprocedure patient teaching.In a 31-month study by Hoffman et al'" in ateaching institution, researchers compared
Sohrot'derpatient outcomes in a subacute intensive careunit {ICU) as managed by two teams: anACNP and attending physician team and acritical care fellow or pulmonary fellow andattending physician team, The results showedthat the duration of mechanical ventilation,length of stay, readmission rates, and mortality did not differ between the two management teams, indicating that an ACNP andattending physician team can safely managechronically critically ill patients. Both theACNP and the critical care/pulmonary fellows demonstrated similar efficiency profilesrelated to time spent in patient management.The ACNP spent 44% of the time on careactivities compared with 40% for the fellows.The researchers concluded that an ACNP/attending physician team can competentlyassume responsibility for the management ofchronically and critically ill patients.'" Theconcept of using ACNP/physician teams isapplicable to the care of surgical patients.THE ACNP ROLE IN A SURGICAL PRACTICEIn addition to first assisting during surgery,preoperative and postoperative responsibilitiesof the ACNP in a surgical practice may include,but are not limited to, taking histories and conducting physicalexaminations, working coilaboratively to manage inpatients, providing patient education, performing postoperative discharge planning, and teaching.Performing outpatient foUow-up care and minorprocedures (eg, inserting arterial lines, thoracostomy tubes, or chest tubes; performing woundrepair; excising skin lesions) and consultingwith referring physicians all may be part of acollaborative surgical practice.' "" Although thetraining for all NPs includes the basic NP skillsof taking histories and conducting physicalexaminations, ACNP education also includes afocus on stabilizing acute problems, preventingand managing complications in the hospital setting, and providing comprehensive management of injury or iUness. The ACNP who firstassists during surgery has a unique perspectiveJUNE 2008, VOL 87, NO 5from which to manage the acute episode of thesurgical patient and work coilaboratively withthe surgeon, OR staff members, perioperativeCNS or educator, hospital surgical unit staffmembers, and office staff members to achievethe best possible outcomes for each patient.An ACNP with an RNFA background isuniquely qualified to evaluate patients preoperatively for potential intraoperative or postoperative complications. For example, anRNFA will know that electrolyte imbalancesmay precipitate cardiac dysrhythmias and thata hypertensive crisis or an unsafe level of anticoagulation may warrant postponement of thesurgery. An ACNP without experience in theOR may lack some of the essential knowledgefor a first assistant. Awareness of physiologicalconditions that may impair wound healing,such as diabetes, chemotherapy, steroid use, ormalnutrition, will aid the ACNP and surgeonin proper wound closure techniques andchoice of antimicrobial therapy to avoid postoperative complications. Patient medications,age, nutrition status, body habitus, woundclassification, and intraoperative events all factor into decisions regarding suture selection,drains, and length of time sutures or staplesshould remain in place. Preoperative medication administration, intraoperative use ofantibiotics, and postoperative management areguided by evidence-based research and tailored to a patient's individual needs.After surgery, daily rounding on patientsallows the ACNP to monitor patient progress,collaborate with the surgeon and staff members regarding best practice management, andidentify patient education needs. Continuity ofcare for the patients and a consistent personfor staff members to contact with patient concerns also is an important aspect of ACNPpatient rounds, particularly in a teaching facility where surgical residents change frequently.THE NEED FOR ADEQUATE TRAININGSurgeons expect a competent first assistant tobe familiar with the steps of the surgical procedure and to be acutely knowledgeable regardingthe anatomic location of critical structures, physiologic consequences of tissue handling, andhow to anticipate these consequences withoutAORN OLiRNAl 1 2 0 9
JUNE 2008, VOL 87, NO 6needing continual instruction or direction. Theability to identify and avoid damage to nervousand vascular structures, as well as knowingwhere electrosurgery or clamping can be safelyapplied, is only one difference between an ORnaive assistant and an experienced assistant.Experienced RNFAs know the conseciuences oftissue handling and are able to aiiticipate thesteps of the surgical procedure.'"Rothrock and colleagues sought to determine the pre-existing level of competence infundamental perioperative nursing careamong a cohort of 16 NPs enrolled in theDelaware County Community College'sRNFA program.'" A self-rating instrument tomeasure fundamental perioperative nursingcompetencies was used. Of the 16 NPs, nonehad RNFA experience, six had prior OR experience, and 10 had no OR experience. The NPswith OR experience indicated they knewmany of the basic principles of perioperativecare but lacked confidence in interpreting laboratory values and radiologic studies, using various means of achieving hemostasis in the surgical field, identifying referral services, and identifying fluid and electrolyte imbalancesand replacement therapies.''*Nurses in the NP group without OR experience self-identified areas of deficiency in establishing intraoperative nursing diagnoses and patient outcomes; developing an intraoperative plan of care,including knowing instrumentation, supplies, and equipment needed; safe patient positioning for the surgicalintervention; creating and maintaining a sterile field; anticipating requirements of the surgery; performing counts to prevent the risk ofinjury from a retained foreign body; participating in use of surgical medications; calculating blood loss; monitoring and controlling the surgicalenvironment, including traffic patterns,electrical safety, thermoreguiation, andenvironmental sanitation; exercising safe judgment and decision-makingbased on past experience; and1210.AORN [OURNALSchroeder evaluating desired patient outcomes for theintraoperative period.'"This survey showed that several self-identifiedgaps in knowledge and skill existed for theNPs surveyed before starting an RNFA program. This finding could raise issues of concern for patient safety if an ACNP accepts theresponsibility of first assisting without previously obtaining adequate training.Patient safety is of utmost concern in the surgical setting. The Joint Commission now sets annual National Patient Safety Goals, one of which isreducing surgical site infections. " If an ACNPpracticing in the role of first assistant is unfamiliar with the essentials of creating and maintaining a sterile field or of environmental sanitationin the OR, as noted in the self-report analysis byRothrock,'" the risk of surgical site infectionwould increase rather than decrease. Safe patientpositioning also is a constant concern in the OR.The first assistant frequently assumes responsibility for patient positioning before the surgeon'sarrival. Permanent nerve or vascular damage canoccur as a result of improper positioning or inadequate protection of vulnerable areas.These examples illustrate the importance ofadditional training for the OR-naive ACNP.From a medical-legal perspective, the ACNPwho accepts the responsibility of first assistingshould be able to demonstrate educationalpreparation and experience that qualifies him orher to function in the role of first assistant." Intoday's litigious society, additional credentialingas a graduate from an RNFA program adds tothe credibility that the ACNP is practicing within his or her scope of practice. When NPs practice outside the scope of practice for whichthey have been trained and have experience,significant liability issues arise."TRAINING FOR ACNPSCertification for NPs specifically trained inacute care started in 1995. As scope of practicelaws change with this relatively new ACNPoption, hospital administrators are looking moreclosely at the educational background and experience of the NPs in their facilities. Competenciesguiding the educational preparation of theACNP are spelled out in the Acute Care NursePractitioner Competettcies developed by the
JUNE 2008. VOL 87, NO 6SchroederTABLE 1RNFA Programs'The following RN first assistant (IWFA) programs have met specific criteria and are accepted by theCompetency & Credentialing Institute (CCI) as acceptable programs for certified RN first assistant(CRNFA) eligibility. The program acceptance plan began in June 1998. Any formal RNFA programs takenbefore that date will be allowed for CRNFA eligibility.None of the programs below are affiliated with CCI, so they may have separate eligibility requirementsfor enrollment. Please note that the following list is subject to change without notice. Web site addresseshave been provided where available.The * denotes those programs that are affiliated with an accredited school of nursing. If you need moreinformation on their accreditation status, please contact the school directly.Alabama University of Alabama at Birmingham,School of Nursing(205)934-0610California*School of Nursing, University of Californiaat Los Angeles-Extension(310) ef /depa rtmentalpages/ii idex.cfm&departme} tt /lieatthsci/index.cfniColorado*NIFA Distance Learning RNFAProgram,DenverAffiliated with Community College ofSouthern Nevada(800) 922-7747littp://wwu'. rnfa.net/FloridaProfessional Assistants PRN, NaplesAffiliated with Southwest Florida Collegein e Community College, tege.edu/futurestudents/progiwnsoffereddetail.asp ? ProgramNamelD Registered%2ONurse%20First%20AssistantKansas*Elite School of Surgical First Assisting, Topeka(877) 224-0133E-mail: info@essfa.netMaryland*Anne Anmdel Community College, Arnold(410) etts"Northeastern University, SchtKil of Professional andContinuing Studies, sional/rnfa2*Lawrence Memorial/Regis College, University of South Rorida,College of Nursing, Tampa(813) 974-4392Michigan*O ikwood Hospital Heritage Center, TaylorAffiliated with Wayne County Community College(313) 295-5400/; t tp://wiinv.hsc.usf.edu/nocms/n ursing/index.htmlhttp://www. oakioood.org/Locations/locationsdetail.asNational Panel for Acute Care Nurse PractitionerCompetencies.- All NPs are trained in a core setof competencies; additional training providedfor ACNPs includes assessment of tbe acutely illpatient, electrocardiogram and x-ray interpretation, acute care respiratory support, arterial lineand chest tube insertions, hemodynamic monitoring, and acute and critical care pharmacologi1212- AORNJOURNALcal interventions, as well as additional training inthe clinical setting specific to a chosen practicearea. Additional skills mastered and proceduresperformed by the ACNP are influenced by thepatient population or specialty area in which theACNP is practicing, as well as individual abilities, motivations, and personality traits.'-'Nurse practitioners without formal acute care
SchroederJUNE 2008, VOL 87, NO 6TABLE 1RNFA Programs (continued)'MissouriNorth Carolina*St Charles Community College,St Peters(636) 922-8284http://www.stdias.edu/*Moses Cone Health System and North CarolinaAgricultumI & Technical State University, Greensboro(336) 832-2575*St Louis Communitv :/Auww.mosescone.com/careercenter.cfni?id 1365*Columbus State Community' College(614)287-2487http://wunv.cscc.eiiu/New Mexico*Professional Nursing Seminars,Taos Ski ValleyAffiliated with Northern New MexicoCommunity College(505) 776-5989}iftp://wwu .rnfirstassistant.coni/New York*SUNY Upstate Medical University,College of Nursing, Syracuse(315) 464-4276http://unvuiiipAtnte.ciiu/con/*University of BuffaloSchool of /*University of Rochester,School of Nursing/CommunityNursing Center(585) 273-5456httirj/wivw. edvan tagehealth.com/*Lakeland Community College, Kirtland(440) 525-7016http://iiRvio. lakeland.cc.oh.us/*Loraiii County Community College, Elyria(800) 995-5222, ext. 7159http://www.lorainccc.edu/E-mail: psedlak@lorainccc.eduPennsylvania Delaware County Community College, Media(610) 359-5286http:/Avww.dccc.edu/*Luzerne County Community College, ex.jspCanadaBritish Columbia Institute of Technology-SpecialtyNursing, Burnaby(800) 663-6542 - local 7079http://www.bcit.ca/health/mirsing/7. RNFA programs. Compctcucij & Credentialing Institute. http://www.cc-institute.org/certj:rnf prep rnfa.aspx.Accessed January 8, 2008.All web sites accessed January 8. 2008.Adapted with permission fmm tite Competency & Credentialing institute, Denver, Colorado.training who want to pursue an ACNP role canacquire clinical competence in several ways; through preceptorships and mentoring by acollaborating physician, attending a formal post-master's ACNPprogram, attending conference sessior\s focusing onacute care skills, orI obtaining certification through advancedcourse work such as the Society of CriticalCare Medicine's Fundamentals of CriticalCare Support course. Acute care NPs new to the surgical arena canacquire the basic skills of first assisting from oneof the RNFA programs that have iiicorporatedNP competencies into the curriculum (Table 1).AORN JOURNAL* 1 2 1 3
JUNE 2008, VOL 87, NO 6Many RNFA programs have special considerations for advanced practice nurses regardingtheir admission policy. Some programs addressthe specific needs of the advanced practicenurse without OR experience by adding extraclinical and didactic time to the curriculum.-' Ifattending a formal RNFA program is not anoption for the ACNP, the perioperative CNS oreducator can teach the ACNP basic intraoperative skills to enhance patient safety before he orshe begins learning the first assistant role. Shortseminars in suturing also are available in someof the RNFA programs.Perioperative nurses and RNFAs can accessNP graduate studies intended specifically forthe acute care setting from one of the manyACNP graduate programs across the nation.Kleinpell et af outlined contact information for70 schools offering the ACNP option to graduateand post-graduate students in their article "Educational options for acute care nurse practitionerpractice." Some, but not all, graduate programsrequire critical care experience m an ICU oremergency room before accepting an applicantinto the ACNP track. Perioperative nurses andRNFAs without critical care experience may beable to obtain the minimum experience requiredfor admission by working part time in an ICUwhile attending graduate school.Schroedei*atric, and Women's Health. Washington, DC: USDepartment of Health and Human Services, HeaithResources and Services Administration; April 2002.http://www.nonpf.com/finalaug2002.pdf. Accessed January 1, 2008.2. Model rules and regulations for CNS title protection and scope of practice. National Association ofClinical Nurse Specialists. March 9, 2004. http://www.nacns.org/model language.pdf. AccessedJanuary 1,2008.3. Phillips SJ. A comprehensive look at the legislative issues affecting advanced nursing practice.Nurse Pract. 2007;32(l):14-]7.4. Hravnak M, Kleinpell R, Magdic K, Guttendorf J.The acute care nurse practitioner. In: Hamric AB,Spross JA, Hanson CM, eds. Advanced Practice Nursiii;i: A}i lnte;:;rative Approach. 3rd ed. St Louis, MO:Elsevier/Saunders; 2005:475-514.5. Kieinpell RM, Perez DF, McLaughlin R. Educational options for acute care nurse practitioner practice. / Aw Aciid Nurse Pract. 2005;17(ll):460-471.6. Becker D, Kaplow R, Muenzen PM, Hartigan C.Activities performed by acute and critical careadvanced practice nurses: American Association ofCritical-Care Nurses Study of Practice. Am } CritCrtrc. 2006;15(2):130-148.7. Barber J, Burke M. Advanced practice nursing inmanaged care. In: Mezey MD, McGivern DO, eds.Nurses, Nurse Prnctitioiicrs: Evolution to AdvancedPractice. New York, NY: Springer Publishing Co;1999:203-218.8. Giordano BP. Dues increase, unlicensed assistivepersonnel, advanced practice top issues this yearAORN}. 1995;61{6):947-958.9. Position statement: Perioperative advanced practice nurse. In: Stovdards, Recommended Practices, andAN IDEAL ROLE FOR RNFASThe ACNP role developed out of a need foradvanced practice nursing care in the acute caresetting. Blending the roles of ACNP and RNFAoffers optimai benefits to patients and surgeonsby incorporatiiig the knowledge and skills ofboth roles into a collaborative surgical practice.As scope of practice laws are refined to reflect theexpected standard of care, however, it is becoming more important to ensure that ARNPs practice within the scope of practice of their specialty.The introduction of ACNP graduate programsprovide RNFAs and perioperative nurses with anopportunity for advanced practice education thatprepares them to take on an advanced practicerole in an acute care setting. REFERENCES1. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Primary Care Competenciesin Specialty Areas: Adult, Family, Gerontological, Pedi1 2 1 4 AORN JOURNALGuidelines. Denver, CO: AORN; 2007:403. Statements/Position AdvancedPracticeNurse/.Accessed January 1, 2008.10. Common program requirements. iV. Residentduty hours in the learning and working environment. Accreditation Council for Graduate MedicalEducation. February 2007. http://www.acgme.org/acWebsite/dutyHours/dh ComlVogrRequirmentsDutyHours0707.pdf. Accessed January 4, 2008.11. Franko FP. Providers of first assisting services.AORN j. 2004;79(6):13n-1318.12. Burke M. Billing Medicare for the services ofNP's & PA'S. Physician's News Digest. April ke.html. Accessed January 1, 2008.13. Payment Changes Are Needed for Assistants-atSiirgery. Washington, E)C: US General AccountingOffice; January 2004. ht:tp://www.gao.gov/new.items/dO497.pdf. Accessed January 1, 2008.14. Brooten D, Youngblut JM, Deatrick J, Naylor M,York R. Patient problems, advanced practice nurse(APN) interventions, time and contacts among fivepatient groups. / Nurs Scholarsh. 20a3;35(l):73-79.
Schroeder15. Stables RH, Booth J, Welstand J, Wright A,Ormerod OJ, Hodgson WR. A randomised controlled trial to compare a nurse practitioner to medictil staff in the preparation of patients for diagnostic airdiac catheterisation: the Study of NursingIntervention in Practice (SNIP). Eur j CardiovascNi/r s, 2004;3{l):53-59.16. Hoffman LA, Tasota FJ, Zullo TG, ScharfenbergC, Donahoe MP Outcomes of care managed by anacute care nurse practitioner/attending physicianteam in a subacute medical intensive care unit. Am jCrit Care. 2005;14(2):12]-130.17. Fox VJ, Schira M, Wadlund D. The pioneer spirit in perioperative advanced practice—two pract
(CRNA), certified nurse midwife (CNM), clinical nurse specialist (CNS) as clinical educator, and the family nurse practi-tioner (FNP) as a primary care provider. An advanced practice role that perioper-ative nurses and RNFAs may not be as familiar with is the acute care nurse practitioner (ACNP). Acute care nurse practitioners are educationally .
