Advanced Practice Perspectives
In this column, we will hear from an increasingly represented and crucial
component of hematology/oncology care: advanced practice professionals/
advanced practitioners. In this edition, Laura J. Zitella, MS, RN, ACNP-BC,
AOCN, discusses opportunities for APPs in the inpatient setting.
A Collaborative Inpatient Model
of Hematology Care
The integration of advanced practice
providers (APPs) – physician assistants
(PAs) and nurse practitioners (NPs) –
into academic and private hematology
and oncology practices is a decades-old
and well-recognized model of care.
APP integration began in the outpatient setting, where APPs help to deliver
guideline-consistent cancer prevention
and screening services and guidelineconsistent therapy to cancer patients.1
Now – due in part to the shortage of
physicians training in hematology and
oncology programs and coupled with
the limitations on resident and fellow
training hours – there is a growing opportunity for APPs in the United States
to deliver that same quality care in the
inpatient setting.
Inpatient APP care teams were developed to help ease increasing demand in
hematology and oncology services. Models of integrative inpatient care teams
differ depending on the institution; some
integrate APPs into house-staff teams,
while others use APPs in separate teams
or even separate units altogether.2,3
Below I’ll describe the inpatient APP
cancer care team at our center – along
with the challenges and successes we
have seen in the three years since developing our APP inpatient team.
Integrating APPs into Inpatient
Cancer Care
At our center, Stanford Health Care, we
developed an inpatient APP cancer care
team separate from the house-staff teams.
We work directly with an attending physician to provide care to an average of 15
acutely ill cancer patients. Later this year,
we plan to increase that number to 20 patients. Our APP inpatient team consists
of nine APPs who provide care seven
days a week, 12 hours a day. During the
12 overnight hours, patient care is signed
out to a hospital nocturnist team.
Approximately half of our team transitioned from careers as APP outpatient
care providers, and half were hired as
new APP graduates from acute care
training programs. As we were a leading
team in developing such a model, we
have helped shape a path forward for
the expanding role of inpatient APPs in
other medical and surgical divisions at
our center.
There is little doubt that the transition from a provider of outpatient cancer
care to a provider of inpatient care for
acutely ill cancer patients involves a steep
learning curve. The transition can be
daunting for many reasons, including
knowledge deficits, high expectations,
and the pressures of being responsible for
time-sensitive, high-impact decisions in
patients with complex medical diagnoses.
Transitioning and Training
Twenty-five years ago, Dreyfus and Dreyfus postulated a model of professional
expertise that suggested that individuals
progress through a series of five levels:
novice, advanced beginner, competent,
Due to the shortage of physicians
training in hematology and
oncology programs and limitations
on resident and fellow training
hours, there is now a growing
opportunity for U.S. APPs to deliver
quality care in the inpatient setting.
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ASH Clinical News
proficient, and expert.4,5 That model has
been adopted by both medicine and
nursing to describe the acquisition of
clinical skills.6,7
The majority of APPs need 12 to 24
months to be competent in hematology/oncology.8 Some centers, including
the MD Anderson Cancer Center at
the University of Texas and The James
Cancer Center at Ohio State University,
now offer 12-month fellowship programs
for APPs.8-10
However, since fellowships are not
available for most APPs, the American
Society of Hematology (ASH) and The
Association of Physician Assistants in
Oncology (APAO) are collaborating with
the Oncology Nursing Society (ONS) to
create an online course for new APPs in
hematology. Each topic in the course is
authored by an expert hematology APP
and a hematologist. The course is undergoing final editing and is expected to be
released by the end of 2015 by ONS.
Another avenue for continued education is the newly launched Advanced
Practitioner Society for Hematology and
Oncology, a professional organization
specifically for APPs that offers an annual
conference, JADPRO Live, and publishes
the Journal for Advanced Practitioners in
Oncology.
At our center, development of an APP
fellowship is one of our future goals. Until then, we require a three-month oneon-one preceptorship orientation that
includes didactic teaching, procedural
training, and advanced training in medical decision-making. This includes training with sub-specialty inpatient teams
such as infectious disease and palliative
care, as well as rotations in hematology
and oncology clinics.
The orientation is broad-based to
foster working relationships with consultants and to facilitate effective communication between the primary outpatient
teams and the inpatient care team. At
three to six months into orientation, the
APP assumes a reduced patient load of
three to four patients a day; this increases
to a full patient load after completing the
entire six-month orientation.
Successes and Challenges
To be sure, we have faced some challenges in implementing the inpatient
APP team. There was a general lack of
understanding by physicians about the
required six-month-long orientation.
Guidelines regarding an APP’s patient
load are not available. And, when our
APP inpatient team was created, some
referring physicians felt our team should
not provide care to patients with complex
medical diagnoses and conditions.
Over time, though, our team has
gained the confidence of these physicians
and now provides care for newly diagnosed acute leukemia patients, as well as
for other cancer patients with complex
diagnoses. We have reached a point
where the acuity and breadth of diagnoses on the APP team parallels that of the
house-st fb