The Role of the Nurse Practitioner in the Cardiac Cath Lab

A nurse practitioner (NP) is a registered nurse with advanced academic and clinical experience, who provides health care in an expanded specialty role. Nurse practitioners fall under the umbrella term of physician extender, mid-level practitioner, or advanced-practice nurse.¹ The nurse practitioner role was first introduced in the 1960’s when pediatric care was not accessible to many in rural settings due to a shortage of primary-care physicians. This encouraged two physicians, Loretta Ford and Henry Silver, to begin the first nurse practitioner program at the University of Colorado.² The NP began providing primary care to the underserved population. In the late 1970’s, the NP role expanded to include care of the acutely ill. Dramatic changes were made in health care delivery and in graduate medical education in the 1990’s. These issues encouraged the use of NPs in the acute care setting. With the growth of managed care and changes in Medicare reimbursement, opportunities for advanced practice nurses in acute care have mushroomed. There has been a phenomenal increase in NP educational programs in the past decade, reflecting an increase implementation of the role in the acute care setting. With the increase of NPs in the acute care setting, research has shown that the care is cost effective and is promoting a high degree of patient satisfaction.³ What does the role of the NP in the acute care setting entail? Responsibilities may include admission histories and physicals, ordering and interpreting laboratory and diagnostic studies, initiating emergency measures, discharge summaries, and discharge planning. NPs perform a variety of therapeutic and diagnostic procedures that relate to their specialty area. Although most of the duties of a NP are patient care-centered, other duties could include teaching, research, department projects, quality assurance, community education with follow up, and administrative duties. How would a NP be integrated into practice? If a cath lab is considering integration of a NP into the practice setting, some questions should first be answered. Is the practice or specialty area attempting to improve continuity of existing care? Would the NP be hired to perform duties previously held by medical residents? Are research or administrative duties involved? Would a NP or another provider best meet the practice needs? The NP and employer must collaborate for a successful adaptation of the position. The guidelines of employer expectations for specific role function must be clearly stated in writing. The NP must prepare a portfolio of experience and education. It would be beneficial to the patient, employer, and other healthcare providers if the NP would help develop the position. The employer and NP must be aware of the rules and regulations governing the NP. These include the facility of the prospective employer, the supervising physician, the particular State Board of Nursing, and national governing bodies such as certification or credentialing agencies. The above sources could also be helpful in outlining a job description. A written agreement will differentiate the duties that may be performed independently and those duties needing physician collaboration.⁴ A pilot study was done in Canada regarding the implementation of the NP in the acute care setting. ⁵ The purpose of the study was to assist healthcare providers in developing strategies for integrating nurse practitioners into a specialty area. The Ontario Study, involving four tertiary hospitals, documented employer, employee, and other healthcare providers’ satisfaction with the integration of the NP’s role and barriers that were met with implementation. Greatest satisfaction occurred with the impact on patient care. After implementation of the NP role, there was enhanced continuity of care through improved communication and attentiveness to patient care issues. Barriers mentioned were lack of mentorship, knowledge of the role, and perceived lack of support from administration. Kleinpell⁶ conducted a survey of NPs in acute care settings and came to some of the same conclusions regarding satisfaction. NPs who were polled identified the impact they have on patient outcomes as giving them great satisfaction. Other positive advantages include autonomy, challenging work experiences, and providing collaborative care. An NP can be an effective team player in the cardiac cath lab. With demands placed on present-day health care delivery, an NP would be an asset in a fast-paced cardiac cath lab. An NP could be utilized for pre-procedure assessment, including history and physicals; reassessment for moderate sedation; management of cath site issues; quality assurance; research; patient education; post-procedure visits; writing discharge orders and for discharge planning. Each lab would have their own needs depending on size and type of institution, and volume of the lab. For example, a lab that had experienced a decrease in cardiology fellows could integrate the use of nurse practitioners. Su⁷ has described the inclusion of nurse practitioners as a unique feature of Mount Sinai Medical Center in New York. Mount Sinai has employed three NPs in the cardiac cath lab for the past six years. The NPs were mentored by staff cardiologists. The physicians suggested using NPs when the cardiac fellows’ hours were decreased. All three NPs divide their time between the cardiology clinic and the cath lab. Two NPs do diagnostics, including deploying closure devices, and one performs non-complex interventions. Other duties include history-taking, physical examinations, pre-cath teaching, obtaining consents, and discharging. The cath lab personnel have been very receptive to the nurse practitioner role, citing better continuity of care as a major benefit. It has been proven to be a cost-effective measure for the hospital, and there has been greater patient satisfaction with the NP implementation. The program has been so successful, that in 2005 Mount Sinai is expecting to hire two additional NPs. Many health care consumers are dissatisfied with the traditional health care delivery system. Realistically, the addition of a NP in the cardiac cath lab could make a difference. Implementation of the role would improve patient care delivery and be cost effective. Above all, patient’s satisfaction would make them eager to share their positive experience with others. This would not only be beneficial to patients, but physicians and staff as well. The author would like to thank Mary Beth Duffy RN, ANP, for her contribution. Margaret Stuppy can be contacted at: mastuppy@cox.net

1. Buppert, C. Nurse Practitioner’s Business Practice and Legal Guide. Boston: Jones and Bartlett Publishers, 2004. 2. Joel, L. Advanced Practice Nursing. Philadelphia: Davis Company, 2004. 3. Morse, C., Brown, M. Collaborative practice in the acute care setting. Critical Care Nurse Quarterly 1999; 21(4): 31-36. 4. Madgdic K, Rosenzweig, M. Integrating the Acute Care Nurse Practitioner into Clinical Practice: Strategies for Success. Dimensions of Critical Care Nursing 1997; 16(4): 208-214. 5. van Soeren, M, Vaska, M. Success indicators and barriers to acute nurse practitioner role implementation in four Ontario hospitals. American Association of Critical Care Nurses 2001;12(3):424-437. 6. Kleinpell, R. Evolving role descriptions of the acute care nurse practitioner. Critical Care Nurse Quarterly 1999;21(4):9-15. 7. Su, G. Cath Lab Spotlight: Mount Sinai Medical Center. Cath Lab Digest 2004;12(7):1,6-12.