• general surgery
• practice guideline

The authors of Advancing the practice of trauma: Utilizing advanced practice providers to improve patient outcomes through a collaborative team approach deserve recognition for providing the trauma and acute care surgery community with a long overdue, well-written comprehensive review on the inclusion of advanced practice providers (APPs) as vital members of trauma teams.1

The concept of APPs was conceived nearly 60 years ago and grew out of an imbalance of physician-to-patient ratios. At that time the glaringly obvious workforce shortage was primary care in rural areas. The first nurse practitioner program was developed in 1965 by Dr. Loretta Ford and Dr. Henry Silver at the University of Colorado, and focused primarily on family health, disease prevention, and health promotion.2 The first physician assistant program was established at Duke University in 1965 by Dr. Eugene A Stead with the first class made up of four Navy corpsmen with vast prior experience.3 Dr. Stead’s program was designed to build on their students’ prior training and existing knowledge. Today, most physician assistant programs require their applicants to have completed a minimum of 1000 hours of direct patient care or healthcare experience.4

There is no question that during the past two decades APPs have become an essential part of our acute care surgery workforce, that also grew out of an imbalance of provider-to-patient ratios. In 2003 the specialty of acute care surgery was branded. In the same year, the ACGME restrictions on resident work hours were instituted. Many trauma medical directors, division chiefs, and surgical chairs felt this represented the perfect storm, creating workforce challenges for many academic trauma centers. For trauma centers without resident support, many had already discovered the value of the trauma surgeon/physician assistant team model several years earlier. We began employing physician assistants in 1996 at our Level II trauma center at Poudre Valley Hospital in Fort Collins, Colorado. Several experienced nurses completed a 2-year physician assistant program and returned to join our team to help address the rapidly growing volume of non-operative work that began to consume the surgeon’s time. The physician assistants also served as first assistants in the operating room, further improving our efficiency. In 1998, the group at Hurley Medical Center, also a community Level II trauma center, reported their use of physician assistants was associated with more timely throughput with a 43% decrease in transfer time to the operating room, 51% decrease in transfer time to the intensive care unit, a 20% decrease in transfer time to the floor, and an overall length of stay decreased by 13%.5 Findings similar to those reported in the contemporary literature are reviewed by Lasinski et al.

The role and function of APPs can be quite variable based on their training and experience. Physician assistants being trained under a medical model, and nurse practitioners being trained under a bio-psycho-social model, each group brings unique and valuable skills to our teams. We found that a new graduate from a physician assistant program that had minimal prior healthcare or bedside experience often required a year-long orientation before being able to function independently in their role. Our new graduate nurse practitioners often required significant additional procedural training. This realization prompted the development of the UCHealth APP surgical fellowship program to better prepare the graduates for a successful transition to the workforce. This has resulted in a significant reduction in the duration of orientation. APP postgraduate programs have continued to grow. The second article, Trauma advanced practice provider education: The current state of trauma APP fellowships in the US, covers the status of a subspecialty APP fellowship in trauma.6 Our efforts must go beyond APP fellowship training. Institutions must invest in the continued professional and academic development of their APPs in a fashion unlike what is done for attending surgeons and residents, ensuring the inclusion of APPs in all departmental educational events.

APPs as members of the trauma and acute care surgical team decrease the length of stay, increase continuity of care, result in cost reduction, promote quality and safety, increase team cohesion, and improve patient satisfaction. They are truly the glue that keeps our service together.