BACKGROUND: Little information is available on the practice of acute care nurse practitioners and physician assistants in acute care settings. OBJECTIVES: To compare the care activities performed by acute care nurse practitioners and physician assistants and the outcomes of their patients with the care activities and patients' outcomes of resident physicians. METHODS: Sixteen acute care nurse practitioners and physician assistants and a matched group of resident physicians were studied during a 14-month period. Data on the subjects' daily activities and on patients' outcomes were collected 4 times. RESULTS: Compared with the acute care nurse practitioners and physician assistants, residents cared for patients who were older and sicker, cared for more patients, worked more hours, took a more active role in patient rounds, and spent more time in lectures and conferences. The nurse practitioners and physician assistants were more likely than the residents to discuss patients with bedside nurses and to interact with patients' families. They also spent more time in research and administrative activities. Few of the acute care nurse practitioners and physician assistants performed invasive procedures on a regular basis. Outcomes were assessed for 187 patients treated by the acute care nurse practitioners and physician assistants and for 202 patients treated by the resident physicians. Outcomes did not differ markedly for patients treated by either group. The acute care nurse practitioners and physician assistants were more likely than the residents to include patients' social history in the admission notes. CONCLUSIONS: The tasks and activities performed by acute care nurse practitioners and physician assistants are similar to those performed by resident physicians. However, residents treat patients who are sicker and older than those treated by acute care nurse practitioners and physician assistants. Patients' outcomes are similar for both groups of subjects.

BACKGROUND: Intracranial hypertension occurs in response to routine procedures such as endotracheal suctioning in patients with severe head injuries. In some patients, the intracranial pressure does not immediately return to baseline levels. OBJECTIVES: To examine the effect of drug administration on cerebrovascular response to endotracheal suctioning in adults with severe head injuries. METHODS: Seventy-one subjects were divided into 3 groups: those who received no drugs, those treated with opiates only (morphine sulfate and fentanyl citrate), and those treated with a neuromuscular blocking agent (vecuronium bromide) plus opiates. A controlled protocol involving 2 sequences of endotracheal suctioning that included hyperoxygenation, hyperinflation, and suctioning was used for all subjects. Two-way repeated-measures analyses of variance were done with type of drug as the between-subject factor and phase of suctioning as the within-subject factor. Survival analysis was used to compare the return of intracranial pressure to baseline levels among the 3 groups. RESULTS: Changes in intracranial pressure were significantly smaller in subjects who received a neuromuscular blocking agent plus opiates than in subjects who did not receive any drugs or received opiates only. The greatest increase in intracranial pressure from baseline was in the first and second phases of suctioning. The 3 groups showed no significant difference in the return of intracranial pressure to baseline level. CONCLUSIONS: Neuromuscular blockers attenuate the increases in intracranial pressure that occur with endotracheal suctioning. It is not known whether control of procedurally induced elevations in intracranial pressure affects long-term outcomes in adults with severe head injuries.

Curriculum development for preparation of acute care nurse practitioners requires a comprehensive process. To develop a program for their preparation at a large university, the faculty examined needs of the target patient population and care delivery system; scope of acute care nurse practitioner practice; current guidelines for the education of primary care nurse practitioners; evolving guidelines for the didactic and clinical education of acute care nurse practitioners; educational requirements of governing or licensing and certifying bodies; and placement of this new role within the existing healthcare team structure. A curriculum was then developed using a collaborative, multidisciplinary approach.

Critical care, as a specialty in both nursing and medicine, is well recognized and the number of people requiring hospitalization for critical illnesses continues to increase. The purpose of this paper is to examine the future and the changes that lie ahead in critical care. New and expanding roles for nurses are projected along with a continued refinement and expansion of the critical care medicine subspecialty for physicians. A variety of changes in critical care are anticipated that reflect our increasing abilities in biotechnology, basic and clinical research, and data management. These changes are viewed for their obvious impact on cost, ethical controversies, and patient care and outcome.