Physician extenders on surgical services: a systematic review

Background: With the introduction of resident duty hour restrictions and the resulting in-house trainee shortages, a long-term solution to ensure safe and efficient patient care is needed. One solution is the integration of nurse practitioners (NPs) and physician assistants (PAs) in a variety of health care settings. We sought to examine the use of NPs and PAs on surgical/trauma services and their effect on patient outcomes and resident workload. Methods: We performed a systematic review of EMBASE, Medline, CINAHL, and the Cochrane Central Register of Controlled Trials. We included studies (all designs) examining the use of NPs and PAs on adult surgical and trauma services that reported the following outcomes: complications, length of stay, readmission rates, patient satisfaction and perceived quality of care, resident workload, resident work hours, resident sleep hours, resident satisfaction, resident perceived quality of care, other health care worker satisfaction and perceived quality of care, and economic impact assessments. We excluded studies assessing nonsurgical/trauma services or pediatrics and review articles. Results: Twenty-nine articles met the inclusion criteria. With the addition of NPs and PAs, patient length of stay decreased, and morbidity and mortality were unchanged. In addition, resident workload decreased, sleep time increased, and operating time improved. Patient and health care worker satisfaction rates were high. Several studies reported cost savings after the addition of NPs/PAs. Conclusion: The addition of NPs and PAs to surgical/trauma services appears to be a safe, cost-effective method to manage some of the challenges arising because of resident duty hour restrictions. More high-quality research is needed to confirm these findings and to further assess the economic impact of adding NPs and PAs to the surgical team.