INTRODUCTION
Advanced practice providers (APPs) – nurse practitioners (NPs) and physician assistants (PAs) – are increasingly involved in the care of critically ill patients in the US. Their presence in US emergency departments has grown1 and one study across 22 US hospitals reported their availability in 72.4% of 29 intensive care units (ICUs) in 2010.2 However, laws that regulate APPs scope of practice vary by state, with some states having full practice environments (i.e., evaluate, diagnose, order, interpret, initiate, manage and prescribe without a supervising physician) and others with reduced or restricted practice environments.3,4 In fact, the National Academy of Medicine currently recommends full practice authority for APPs and in turn, there has been steady growth in full scope of practice legislation in the U.S.5 With more legislative support combined, record high graduation rates of NPs6 and PAs7, and ICU staffing shortages accelerated by the COVID-19 pandemic, the number of APPs practicing in ICUs in the United States is likely to grow.
Research has documented the benefits of NPs and PAs in contributing to high quality care delivery in the ICU. Medical or mixed medical-surgical ICUs staffed with APPs have shown similar patient outcomes (e.g., mortality, readmission rates, infection rates) to those staffed by physicians alone.2,8 When examining care led by an NP team in a medical ICU, one study showed a significant reduction in hospital length of stay compared to patients cared for by medical resident teams.9 Other studies have identified better patient, clinician, and family satisfaction when APPs are involved in ICU care.8,10,11 Despite the benefits of APP staffing in ICUs, there is a paucity of data about how APPs have been employed recently in ICUs and, particularly, in ICUs that also have physicians-in-training. More specifically, it is unclear to what extent APPs may serve as replacements for physicians in ICUs, function in conjunction with physicians in providing care or some other combination; it is also unknown whether their function in ICUs differs by scope of practice legislation in each state.
Therefore, understanding how APPs are currently utilized in ICUs can inform workforce planning, optimize their deployment, and augment investments in physician staffing. Therefore, we sought to describe recent staffing models across US ICUs with the dual aims of understanding how APPs are employed, including in the context of physicians-in-training, and whether state-level regulations on APP scope of practice influence that deployment.
METHODS
We conducted a descriptive analysis of existing interprofessional staffing survey data from a national cohort of US ICUs. Our aims were to describe utilization of APPs (NPs and PAs) and physicians-in-training (interns, residents, and fellows) across the US, evaluate state-level differences in deployment, and investigate whether state-level APP scope of practice regulations correlated with utilization in the ICUs. As is common in the literature,8,12,13 APPs were considered together given the relative similarity of NPs’ and PAs’ roles in the ICU setting.
Data Sources
The survey has been described in detail elsewhere (see full survey in Appendix).14 In brief, ICU clinicians (targeting nurse managers and physician directors) were queried in spring 2022-winter 2023 about interprofessional staffing and unit characteristics of their ICUs prior to the COVID-19 pandemic (to obtain steady-state estimates not influenced by COVID-19-related surges). Responses were solicited by direct telephone outreach to all 3,664 acute hospitals with at least one adult critical care bed in the 2020 American Hospital Association (AHA) survey, and via emails/website postings to membership lists of four US critical care societies (the American Association of Critical Care Nurses, the Society of Critical Care Anesthesiologists, the Society of Critical Care Medicine, and the Critical Care Network of the American College of Chest Physicians); because of the second sampling strategy, the number of potential respondents is not known. ICU survey responses were matched to 2020 AHA annual survey data to characterize hospitals in which surveyed ICUs resided; matching was performed manually by a single investigator (HBG) using hospital name, city, and state. For this study, we focused on survey questions pertaining to staffing of APPs (NPs and PAs) and physicians (intensivist and physicians-in-training [interns, residents, critical care fellows, and non-critical care fellows]) and restricted our cohort to ICUs caring for adult patients and for which data on APP and physician-in-training staffing was non-missing.
We used information available on the websites from the American Association of Nurse Practitioners and the American Academy of Physician Associates on January 4, 2024 to assess state-by-state scope of APP practice authority (Figure S3). Full practice for NPs is defined, in line with state licensure laws, as the ability to “evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances”;3 for PAs, optimal allowance is defined as “practice to the full extent of their medical education, training, and experience” without any “additional administrative requirements… mandated in state law and/or regulation.”4 We categorized scope of practice as: 1) full scope (as above, “full” for NPs and “optimal” for PAs) and 2) not full scope (any reduced or restricted practice authority for both NPs and PAs).
Analysis
We categorized ICUs by staffing model into four groups, those employing: 1) both APPs and physicians-in-training; 2) APPs only; 3) physicians-in-training only; or 4) neither APPs nor physicians-in-training. We used standard summary statistics to describe the cohort, using Chi-square and Wilcoxon rank sum testing as appropriate to compare characteristics across staffing models. Post hoc, we compared unit characteristics (including staffing models) by hospital environment (metropolitan vs not) due to differences observed in the initial descriptive analysis.
To evaluate the association of state-level regulations for APP scope of practice, we created a multivariable logistic regression models (dependent variable: deployment of either NPs or PAs in the ICU; exposure independent variable: state-level APP scope of practice in state ICU is within); covariables included: ICU type (single specialty, medical, surgical, mixed medical-surgical); intensivist presence (yes/no); availability of telemedicine in the ICU (not used, overnight only, 24 hours/day, other); ICU size (number of beds); hospital environment (metropolitan vs not); hospital geography by AHA region (1, 2, and 3; 4 and 7; 5 and 6; 8 and 9); hospital size (<100, 100–250, >250 beds); teaching hospital; and hospital type (not for profit, for profit, government).
All analyses were performed using STATA/MP 18 (StataCorp, College Station, Texas) and Microsoft Excel (Microsoft, Redmond, Washington). P-values <0.05 were considered significant; no adjustment was made for multiple comparisons in this descriptive analysis. The Institutional Review Board at the University of Miami Miller School of Medicine approved the study (#20201473) which was carried out in accordance with the ethical standards set forth in the Helsinki Declaration.
RESULTS
We received survey data from 588 unique ICUs caring for adult patients for which information about APPs and physicians-in-training (fellows and residents/interns) was non-missing (Figure S4); 571 (97.1%) were able to be matched to 2020 AHA annual survey data. Of the 588, 460 (78.2%) reported having APPs; 314 (53.4%) fellows; 374 (63.6%) residents or interns; and 55 (9.4%) neither (Figure 1). APP deployment, either alone or in conjunction with physicians-in-training, varied across the US (Figure 2). Among the 460 ICUs with APPs, 154 (33.5%) had only NPs, 47 (10.2%) had only PAs, and 259 (56.3%) had both. APPs, fellows, and residents/interns were all present in 228 (38.8%) ICUs.
Figure 1.
Overlap of Non-Intensivist Provider Staffing.*
* Includes 588 intensive care units that do not care exclusively for neonatal and/or pediatric patients and which provided information about both advanced practice providers and physicians-in-training availability.
Figure 2.
Advanced Practice Provider Availability in Intensive Care Units Across the United States.*
APP: advanced practice provider
* Includes 590 (99.0%) of 596 intensive care units that have data available on APP deployment (whether or not data was available for physicians-in-training); gray = no data available (Idaho); data from only 1 intensive care unit in each of Alaska, Iowa, Oklahoma, Vermont, and Wyoming
APP Deployment in the Context of Physicians-in-Training
A majority of ICUs that completed the survey had both APPs and physicians-in-training (n=336, 57.1%); 124 (21.1%) had APPs only and 73 (12.4%) had physicians-in-training only (Table 1). Units with both APPs and physicians-in-training were more commonly surgical (17.6% vs ≤9.6% for other staffing groups) and units with physicians-in-training only were more commonly medical (20.5% vs ≤9.8%; p<0.001). Units with neither APPs nor physicians-in-training were nearly universally mixed ICUs (98.2%), and only 80.0% had intensivists (versus ≥91.9% for all other staffing models, p=0.001). These ICUs also tended to be smaller (median [interquartile range]: 14 [7,20] vs 18–20 [12–15,22–28] for other staffing types, p<0.001) and more commonly in smaller, non-teaching, for-profit hospitals in non-metropolitan environments in the western US. Metropolitan ICUs were more commonly staffed by both APPs and physicians-in-training (60.2% vs 25.0%) and less often had APPs alone (18.8% vs 43.2%, p<0.001; Table 2).
Table 1.
Cohort Characteristics Stratified by Non-Intensivist Provider Availability.*
| Neither | Advanced practice providers only | Physicians-in-training only | Both | |
|---|---|---|---|---|
| # of ICUs, N (row %) | 55 (9.4) | 124 (21.1) | 73 (12.4) | 336 (57.1) |
| ICU Characteristics | ||||
| ICU type | ||||
| Single specialty | 0 (0.0) | 11 (8.9) | 6 (8.2) | 40 (11.9) |
| Medical | 1 (1.8) | 5 (4.0) | 15 (20.5) | 33 (9.8) |
| Surgical | 0 (0.0) | 4 (3.2) | 7 (9.6) | 59 (17.6) |
| Mixed | 54 (98.2) | 104 (83.9) | 45 (61.6) | 204 (60.7) |
| Intensivist available | 44 (80.0) | 114 (91.9) | 71 (97.3) | 317 (94.3) |
| Telemedicine in the ICU | ||||
| Not used | 36 (65.5) | 80 (64.5) | 56 (76.7) | 234 (69.6) |
| Overnight only | 7 (12.7) | 15 (12.1) | 5 (6.8) | 11 (3.3) |
| 24 hours/day | 6 (10.9) | 18 (14.5) | 8 (11.0) | 84 (25.0) |
| Other | 6 (10.9) | 11 (8.9) | 4 (5.5) | 7 (2.1) |
| ICU bed #, median (IQR) | 14 (7,20) | 18 (12,24) | 18 (12,22) | 20 (15,28) |
| Hospital Characteristics † | ||||
| Metropolitan environment | 41 (74.5) | 99 (79.8) | 70 (95.9) | 317 (94.3) |
| Geographic region‡ | ||||
| Northeast/Mid-Atlantic | 11 (20.0) | 49 (39.5) | 26 (35.6) | 124 (36.9) |
| South/Southeast | 8 (14.5) | 33 (26.6) | 13 (17.8) | 63 (18.8) |
| Midwest | 5 (9.1) | 22 (17.7) | 18 (24.7) | 84 (25.0) |
| Mountain/West | 29 (52.7) | 14 (11.3) | 15 (20.5) | 57 (17.0) |
| Hospital bed # | ||||
| <100 | 16 (29.1) | 17 (13.7) | 2 (2.7) | 19 (5.7) |
| 100–250 | 19 (34.5) | 32 (25.8) | 8 (11.0) | 49 (14.6) |
| >250 | 18 (32.7) | 69 (55.6) | 62 (84.9) | 260 (77.4) |
| Teaching hospital§ | 20 (36.4) | 51 (41.1) | 56 (76.7) | 222 (66.1) |
| Hospital type | ||||
| Not for profit | 33 (60.0) | 94 (75.8) | 54 (74.0) | 231 (68.8) |
| For profit | 10 (18.2) | 11 (8.9) | 1 (1.4) | 26 (7.7) |
| Government | 10 (18.2) | 13 (10.5) | 17 (23.3) | 71 (21.1) |
AHA: American Hospital Association; ICU: intensive care unit; IQR: interquartile range
p-values for all comparisons (by Chi-square and Kruskal-Wallis testing as appropriate) were significant at p<0.05; p-values: ICU type <0.001; Intensivist available = 0.001; Telemedicine <0.001; ICU bed # <0.001; Metropolitan environment <0.001; Geographic region <0.001; Hospital bed # <0.001; Teaching hospital <0.001; and Hospital type = 0.004
evaluated among 571 (97.1%) of 588 ICUs which were in hospitals that could be matched to hospitals in the American Hospital Association survey
geographic regions determined by groupings of American Hospital Association (AHA) regions: Northeast/Mid-Atlantic (AHA regions: 1, 2, 3) = Connecticut, Maine Massachusetts, New Hampshire, Rhode Island, Vermont, New Jersey, New York, Pennsylvania, Delaware, Kentucky, Maryland, North Carolina, Virginia, West Virginia, District of Columbia; South/Southeast (AHA regions: 4, 7) = Arkansas, Louisiana, Oklahoma, Texas, Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee; Midwest (AHA regions: 5, 6) = Illinois, Michigan, Indiana, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota; Mountain/West (AHA regions: 8, 9): Arizona, Colorado, Idaho, Montana, New Mexico, Utah, Wyoming, Alaska, California, Hawaii, Nevada, Oregon, Washington
defined as hospitals reporting the presence of any full-time equivalent residents in the American Hospital Association survey (8); thus, does not fully align with staffing survey responses for presence of physicians-in-training in the ICU
Table 2.
Characteristics of Metropolitan Versus Non-Metropolitan Intensive Care Units.*
| Metropolitan | Non-Metropolitan | |
|---|---|---|
| # of ICUs†, N (row %) | 527 (92.3) | 44 (7.7) |
| Non-intensivist providers | ||
| None | 41 (7.8) | 12 (27.3) |
| APPs only | 99 (18.8) | 19 (43.2) |
| Physicians-in-training only | 70 (13.3) | 2 (4.5) |
| Both APPs & physicians-in-training | 317 (60.2) | 11 (25.0) |
| ICU Characteristics | ||
| ICU type | ||
| Single specialty | 56 (10.6) | 0 (0.0) |
| Medical | 50 (9.5) | 4 (9.1) |
| Surgical | 68 (12.9) | 0 (0.0) |
| Mixed | 353 (67.0) | 40 (90.9) |
| Intensivist available | 499 (94.7) | 31 (70.5) |
| Telemedicine in the ICU | ||
| Not used | 374 (71.0) | 21 (47.7) |
| Overnight only | 32 (6.1) | 5 (11.4) |
| 24 hours/day | 98 (18.6) | 14 (31.8) |
| Other | 23 (4.4) | 4 (9.1) |
| ICU bed #, median (IQR) | 20 (14,26) | 9 (6,13) |
| Hospital Characteristics | ||
| Hospital bed # | ||
| <100 | 32 (6.1) | 22 (50.0) |
| 100–250 | 90 (17.1) | 18 (40.9) |
| >250 | 405 (76.9) | 4 (9.1) |
| Teaching hospital‡ | 339 (64.3) | 10 (22.7) |
| Hospital type | ||
| Not for profit | 386 (73.2) | 26 (59.1) |
| For profit | 44 (8.3) | 4 (9.1) |
| Government | 97 (18.4) | 14 (31.8) |
ICU: intensive care unit; IQR: interquartile range
p-values for all comparisons (by Chi-square and Kruskal-Wallis testing as appropriate) were significant at p<0.05 except for Hospital type with p=0.086; other p-values: Non-intensivist providers <0.001; ICU type =0.003; Intensivist available <0.001; Telemedicine = 0.015; ICU bed # <0.001; Hospital bed # <0.001; and Teaching hospital <0.001
evaluated among 571 (97.1%) of 588 ICUs which were in hospitals that could be matched to hospitals in the American Hospital Association survey
defined as hospitals reporting the presence of any full-time equivalent residents in the American Hospital Association survey (8)
APP Deployment in the Context of State-Level Scope of Practice Regulations
Approximately one-third of ICUs (225 [38.3%]) were in states with full scope of practice regulations for APPs, most of which were in the northeast, mountain, and western US (Figure e1). Staffing of non-intensivist providers varied with APP scope of practice regulations: when full scope was allowed, deployment of APPs alone was less common (16.9% vs 23.7%) but deployment in combination with physicians-in-training was more common (63.6% vs 53.2%; p=0.033); no other ICU or hospital characteristics differed significantly (Table 3). After adjustment for ICU and hospital characteristics, the odds of employing APPs were higher among ICUs in states with full scope of practice regulations, yet this result did not reach statistical significance (odds-ratio [95% confidence interval]: 1.59 [0.99,2.56], p=0.06, Table S3).
Table 3.
Characteristics of Intensive Care Units in States with Restricted Versus Full Scopes of Advanced Practice Provider Practice.
| Restricted Scope | Full Scope | P-Value | |
|---|---|---|---|
| # of ICUs, N (row %) | 363 (61.7) | 225 (38.3) | |
| Non-intensivist providers | 0.033 | ||
| None | 32 (8.8) | 23 (10.2) | |
| APPs only* | 86 (23.7) | 38 (16.9) | |
| Physicians-in-training only | 52 (14.3) | 21 (9.3) | |
| Both APPs & physicians-in-training* | 193 (53.2) | 143 (63.6) | |
| ICU Characteristics | |||
| ICU type | 0.99 | ||
| Single specialty | 35 (9.6) | 22 (9.8) | |
| Medical | 34 (9.4) | 20 (8.9) | |
| Surgical | 42 (11.6) | 28 (12.4) | |
| Mixed | 252 (69.4) | 155 (68.9) | |
| Intensivist available | 336 (92.6) | 210 (93.3) | 0.72 |
| Telemedicine in the ICU | 0.41 | ||
| Not used | 245 (67.5) | 161 (71.6) | |
| Overnight only | 27 (7.4) | 11 (4.9) | |
| 24 hours/day | 71 (19.6) | 45 (20.0) | |
| Other | 20 (5.5) | 8 (3.6) | |
| ICU bed #, median(IQR) | 20 (12,25) | 19 (12,25) | 0.55 |
| Hospital Characteristics † | |||
| Metropolitan environment | 329 (92.4) | 198 (92.1) | 0.89 |
| Hospital bed # | 0.91 | ||
| <100 | 35 (9.8) | 19 (8.8) | |
| 100–250 | 68 (19.1) | 40 (18.6) | |
| >250 | 253 (71.1) | 156 (72.6) | |
| Teaching hospital‡ | 209 (58.7) | 140 (65.1) | 0.13 |
| Hospital type | 0.31 | ||
| Not for profit | 252 (70.8) | 160 (74.4) | |
| For profit | 28 (7.9) | 20 (9.3) | |
| Government | 76 (21.3) | 35 (16.3) |
ICU: intensive care unit; IQR: interquartile range; n/a: not applicable
279 (76.9% of 363) ICUs in states with restricted scope had APPs (with or without physicians-in-training) compared to 181 (80.4% of 225) in states with full scope; p=0.31 for APPs (with or without physicians-in-training) versus no APPs
evaluated among 571 (97.1%) of 588 ICUs which were in hospitals that could be matched to hospitals in the American Hospital Association survey
defined as hospitals reporting the presence of any full-time equivalent residents in the American Hospital Association survey (8)
DISCUSSION
We found variability in the deployment of APPs and physicians-in-training across US adult ICUs. Notably, while one in five cohort ICUs deployed APPs alone and one in eight deployed only physicians-in-training, a majority employed both provider types. Less than 10% of ICUs functioned without APPs or physicians-in-training and, perhaps unsurprisingly, these tended to be smaller units in smaller, non-academic, for-profit hospitals outside of metropolitan environments, although a causal relation between these factors and APP deployment cannot be established. Interestingly, although our finding did not reach statistical significance, there is a suggestion that state-level allowance of full scope of practice for APPs may be independently associated with an increased odds of their availability in ICUs.
Epidemiologic data on modern APP staffing in US adult ICUs are sparse. Studies suggest that APPs have been an essential presence in US neonatal ICUs for decades (primarily in the form of NPs).15 Recent studies demonstrate that APPs are also commonly deployed in modern US pediatric critical care: 70% (28 of 40 surveyed ICUs) of general units across nine states,16 and the vast majority of pediatric cardiac ICUs nationally (88% [52 of 59 surveyed ICUs] employed NPs and 34% [20 of 59] PAs).17 In adult critical care, APPs have recently been noted to participate in US tele-ICU programs,18 yet other evidence suggested their integration into adult critical care has been minimal (they comprise <5% of broad US ICU clinician survey respondents19,20 and participate in multidisciplinary rounds in ≤15% of military treatment facilities21). Our findings of their presence in nearly four out of five of our US adult ICUs suggest their deployment in adult critical care may be more common than previously appreciated and demonstrate their important role across ICUs caring for patients of all ages.
Much evidence has accrued over the past decades about the relative safety and effectiveness of employing APPs in the adult ICU setting;8,22 yet, much of this work has studied APPs as a replacement for physicians-in-training. Our data suggest a more complex staffing approach may exist. APPs may serve as replacements for physicians-in-training—either on certain shifts, to supplement lower numbers of house officers, or in the care of a subset of patients. It is also possible, however, that the two provider types are being employed together intentionally (perhaps, on the same ICU teams) given their different and potentially complimentary school- and experience-based educations, as well as the practiced procedural skills and unit-specific knowledge that fulltime ICU APPs provide. While not fully consistent, most existing literature suggests that physicians-in-training value the presence of APPs in the adult ICU setting—both as colleagues who assist in patient care and to improve their educational experience.23–25 Exploring how ICUs are utilizing APPs and physicians-in-training when both are available was outside of the scope of this survey, but will be important to explore in future studies given the frequency of this staffing model.
After adjustment for ICU and hospital characteristics, we found that state-level APP scope of practice regulations may be associated with APP availability in adult ICUs, suggesting that state regulations may impact ICU staffing choices. Currently, more than 50% of states have full practice authority for NPs or optimal practice authority for PAs. However, the remaining states have reduced or restricted scope of practice; this mean that APPs are limited in their ability to diagnose, treat, prescribe and must work with a collaborating or supervising physician in some capacity.5 Moreover, Gigli and colleagues found that organizational restrictions on practice can exceed those imposed by the state for pediatric ICU NPs.26 They also demonstrated that patient care responsibilities did not differ in states with full or limited NP practice authority; however, pediatric ICU NPs were less likely to bill for care and more likely to report to advanced practice managers in states with more restricted NP authority.27 In the adult context, APPs are more available in non-acute care settings in states with fuller scope of practice allowances.28,29 As APPs often work on ICU teams with an intensivist or other attending physician readily available, it is perhaps overlooked that differences in state-level practice authority regulations may impact APP presence in critical care settings. Whether such a scope of practice-based difference is driven by APPs’ desire to work where they are afforded more authority, as is known in the outpatient setting,30 or decisions by the ICU or hospital is unknown. Regardless, this reality may limit the opportunity for all ICUs across the country to realize their optimal staffing model.
The strengths of our study stem from its relatively large sample inclusive of a geographically diverse set of ICUs and our tackling of a topic for which current data are sparse. Our study has important limitations, however. First, the parent survey was potentially limited by generalizability (as responses from professional organization-accessed respondents skewed towards academic centers), recall bias (as respondents were asked about conditions prior to the COVID-19 pandemic), and our lack of knowledge of the total number of ICUs in the U.S. and per hospital (which limited our ability to understand whether we comprehensively sampled all ICUs within a given hospital, for example).14 We were also unable to assess the specific roles and responsibilities of APPs and physicians-in-training in individual ICUs. Lastly, the association we identified between state-level scope of practice regulations and APP availability may remain confounded by unmeasured differences in states with and without restrictions and may be impacted by misclassification bias if state-level restrictions present in 2024 differ from those present at the time of the staffing reported in the survey. Moreover, our study design precludes an assessment of causality regarding whether state level practice allowances for APPs drive the differences in employment of APPs in ICUs or whether such regulations may differently impact PAs and NPs.
CONCLUSIONS
APPs are common in US adult ICUs, both with and without the co-availability of physicians-in-training. Non-modifiable factors such as ICU or hospital size and hospital location differ between ICUs using different provider staffing models. We found that state-level regulations pertaining to APP scope of practice, which are modifiable, may be associated with APP availability in US adult ICUs. Further work is needed to understand if such laws cause APPs to be deployed less frequently. In the post-pandemic era of ICU workforce shortages and rising burnout,31,32 any barriers to ensuring access to qualified ICU providers should be eliminated.
Supplementary Material
Figure S3. Advanced Practice Provider Scope of Practice Restrictions Across the United States.*
* Data obtained from the American Association of Nurse Practitioners (State Practice Environment. Accessed April 30, 2024. https://www.aanp.org/advocacy/state/state-practice-environment) and the American Academy of Physician Associates (PA State Practice Environment. Accessed April 30, 2024. https://www.aapa.org/advocacy-central/state-advocacy/state-maps/pa-state-practice-environment/)
Figure S4. Cohort flow diagram.
AHA: American Hospital Association; APP: advanced practice provider; ICU: intensive care unit
Contributor Information
Deena Kelly Costa, Yale School of Nursing, West Haven, Connecticut, and Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut..
Danny Lizano, Fort Lauderdale Dr Pallavi Patel College of Health Care Sciences Health Professions Division, Nova Southeastern University, Fort Lauderdale, Florida..
Allan Garland, Department of Medicine and Community Health Sciences, University of Manitoba, and an adjunct scientist, Manitoba Centre for Health Policy, Winnipeg, Manitoba, Canada..
Robert Fowler, Interdepartmental Division of Critical Care Medicine, University of Toronto, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, and Tory Trauma Program, Sunnybrook Hospital, Toronto, Ontario, Canada..
Vincent Liu, Division of Research, Kaiser Permanente, Pleasanton, California..
Damon C. Scales, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada..
Hannah Wunsch, Department of Anesthesiology, Weill Cornell Medical College, New York, New York, Sunnybrook Research Institute, Toronto, and Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada..
Hayley B. Gershengorn, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida, and Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York..
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S3. Advanced Practice Provider Scope of Practice Restrictions Across the United States.*
* Data obtained from the American Association of Nurse Practitioners (State Practice Environment. Accessed April 30, 2024. https://www.aanp.org/advocacy/state/state-practice-environment) and the American Academy of Physician Associates (PA State Practice Environment. Accessed April 30, 2024. https://www.aapa.org/advocacy-central/state-advocacy/state-maps/pa-state-practice-environment/)
Figure S4. Cohort flow diagram.
AHA: American Hospital Association; APP: advanced practice provider; ICU: intensive care unit