In the wake of Ebola, other emerging infectious diseases, common HAIs and an ever expanding array of reporting requirements and regulations, infection preventionists and their infectious disease colleagues are too often short-staffed and stretched to the breaking point.
For example, the Association for Professionals in Infection Control and Epidemiology (APIC) surveyed infection preventionists last year, finding that one in two hospitals had only one or less than one full-time IP on staff. The survey found that hospitals nationwide are understaffed in infection control and prevention, particularly if they need surge capacity to handle a major infectious disease event like Ebola or pandemic flu.1
Doc shortage looming
In addition, the Annals of Family Medicine projects a physician shortage that will require at least 52,000 additional primary care physicians by 2025.2 Shortages in primary care and internal medicine impact the subspecialty of infectious diseases, which has been attracting fewer residents in recent years.
“Some institutions are not meeting their match in [infectious disease] fellows, so there are not as many fellows coming into training programs,” says Jim Raper, DSN, CRNP, JD, nurse practitioner and director of the University of Alabama 1917 HIV outpatient, dental and research clinic in Birmingham.
“When you can’t fill all your slots, somebody has to do the work,” he adds.
‘An intriguing solution’
Since turning around this trend by educating more physicians is a long-term and logistically difficult solution, many states and hospitals have sought solutions that include nurse practitioners or physician assistants, Raper notes.
“It’s incredibly difficult to recruit physicians and get them credentialed, so having a nurse practitioner work with the infection control team is an intriguing solution to hiring more infectious disease doctors,” he says.
The Institute of Medicine (IOM) in Washington, DC, has suggested that the Affordable Care Act’s expansion of health care access will require a fundamental rethinking of the roles of nurses and other health care professionals.
“The IOM states that nurses should be able to practice to the full extent of their education,” Raper says.
Expanded roles in infection control?
This includes giving nurse practitioners expanded roles on hospital infection control and prevention teams, he adds.
The chief obstacle has been national regulations and state laws, which traditionally have limited nurse practitioners’ autonomy when it comes to prescribing medication and performing procedures independent of a physician’s supervision. For example, federal laws forbid Medicare from reimbursing home health care ordered by nurse practitioners, Raper says.
But the recent passage of New York’s Nurse Practitioner Modernization Act, which went into effect Jan. 1, 2015, suggests the tide is turning. The new law says that nurse practitioners with more than 3,600 hours of clinical practice no longer are required to have a written collaborative agreement with a physician and they are no longer required to submit patient charts to a physician for review. The bill notes that NPs will continue to collaborate with physicians.
There are 19 states that do not require nurse practitioners to have a signed written practice agreement with a physician, says Stephen A. Ferrara, DNP, FNP-BC, FAANP, associate dean of clinical affairs, Columbia University School of Medicine in New York, NY.
All nurse practitioners are registered nurses first, and in New York they must complete approved training appropriate to their practice, including infection control and barrier precautions. A minimal four-hour IC course must be completed every four years, Ferrara says.
“While we don’t encourage the terminology of ‘physician extenders,’ nurse practitioners can and do practice in collaboration with infectious disease specialists within those departments,” he adds.
Most of the 19 states that no longer require NPs to have a written practice agreement with doctors are located in the West or New England. The addition of New York -- a large and populous state will help the issue gain attention, Raper says.
One of the organizations pushing for greater NP autonomy is the HIV Medicine Association (HIVMA).
“Across the U.S., it’s the nurse practitioner or physician assistant who is providing HIV care, so HIVMA wanted to make this policy statement in support of what we do,” explains Raper, who was co-chair of the Ryan White Medical Providers Coalition at HIVMA.
In addition to working as ID clinicians, nurse practitioners with greater autonomy can expedite patient care, helping to prevent catheter associated urinary tract infection (CAUTI) and other infections, Raper says.
“Nurse practitioners could expedite the care of the patient in an informed way, preventing CAUTIs,” he says. “A nurse practitioner can be educated and develop the competencies to manage most of these issues in a much timelier manner than it takes us to educate a physician, and there are plenty of nurses who want to invest the additional two to three years in school to become a nurse practitioner.”
Getting catheters out
In New York, NPs already could sign orders for catheter removal – prior to the new law, but they can do so now without having a written collaborative agreement with a physician, Ferrara says.
“As hospital-acquired infections are very problematic and preventable, I believe implementation of evidence-based protocols must happen,” he says. “These protocols should include utilizing all providers to utmost capabilities.”
This may mean NPs and other clinicians will fill non-traditional roles to help fight these infections, he adds.
- APIC. APIC Ebola Readiness Poll: Results of an online poll of infection preventionists. 2014: http://bit.ly/17MNE6N
- Petterson SM, Liaw WR, Phillips RL, et al. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10(6):503-509.