As an acute care nurse practitioner (NP), I am often asked about the value of advanced practice in the inpatient acute and critical care settings. Although somewhat taken aback, I can empathize with this question, as the acute care NP's practice can often be deemed as "invisible" or difficult to track in terms of outcomes. Billing productivity is usually the 1st subject to come to mind, professional billing for acute care services. This is more feasible in the critical care environment, billing for critical care services, and, in the medicine, hospitalist practice, billing for general medical care. It is much more difficult to attach value to billing productivity for acute, surgical NPs as their work is usually encompassed within a global charge for the principle procedure the patient is about to undergo or has already undergone. All of this lends to a difficult task of outcomes tracking, outcomes that would substantiate the investment, supporting the employment of acute care NPs. These outcomes rise beyond direct professional billing and contribute to the quality of care the patient receives while hospitalized.

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Over the past 20 years, acute care NPs have become the fastest-growing subset of NPs in the country.1 Although primary care NPs remain the majority, acute care NPs are increasing in number because of the demand for consistency in quality patient care outcomes within the hospital setting. Studies have repeatedly shown that acute care NPs have a substantial impact on outcomes of care including the following:

* decreased hospital length of stay (LOS) and ICU LOS;

* consistency of standardized care;

* decreased adverse events;

* decreased nosocomial infections;

* decreased unexpected hospital readmissions;

* decreased ICU readmissions;

* decreased procedural complication rates;

* decreased hospital mortality related to sepsis death rates;

* improved patient/family satisfaction; and

* optimal resource utilization2-5

Acute care NPs are nurses who hold graduate degrees in nursing and have been educated, clinically trained, and board certified to care for patients who are acutely and critically ill. Acute care NPs must subspecialize in pediatric or adult gerontology care. For instance, if an acute care NP wanted to care for patients in each of these age groups, the NP would have to obtain graduate education in 2 distinct programs of study with separate board certification examinations. The specialization for NPs, as outlined in the 2008 Joint Consensus Statement, is what allows NPs to focus on a specific patient population, while pursuing their advanced nursing education.6

Acute care NPs are highly collaborative and coordinate care among members of the healthcare team. Frequently, the acute care NP is the central "coordinator" of care, decreasing risk of conflicting or multiple orders being placed for the patient in the hospital setting by the members of a multidisciplinary team, which sometimes can mean multiple consultants and specialists across disciplines. An example might be an ICU patient who has undergone complex heart surgery, now critically ill, requiring the professional services of multiple physicians such as an ICU intensivist, nephrologist, cardiologist, anesthesiologist, infectious diseases specialist, and surgeons. In addition, the patient might require services of healthcare team members such as a pharmacist, social worker, case manager, respiratory therapist, physical therapist, and dietitian. All of these services require careful, expeditious, well-coordinated care for optimal outcomes. To this, an acute care NP is educated and trained to focus on patient- and family-centered care. They actively engage with patients and families to provide updated information on the plan of care and evidence-based education regarding the different treatments recommended or underway.

In my own hospital, acute care NPs are included as important team members to many surgical, specialty, hospitalist, and critical care teams. Acute care NPs not only add to the knowledge base of the team, but also actively learn from the many specialists on the team. In the recent pandemic, as acutely and critically ill patients were being hospitalized for care, our hospital's acute care NPs worked with hospital leaders, physician leaders, nursing leaders, and healthcare team members to create a specialized COVID-19 (coronavirus disease 2019) ICU. In this ICU, patients were primarily managed by an experienced acute care NP and an ICU pulmonary critical care physician. Patient care was carefully coordinated among many healthcare team members. The acute care NPs have been specifically trained to perform physical assessments; diagnose, and develop detailed, systems-based plans of care; perform complex ICU procedures; manage multiple life support machines, such as extracorporeal membranous oxygenation; and, most importantly, speak often with family members, who were often unable to visit because of the highly contagious nature of COVID-19.

These are all examples of the nature of an acute care NP's practice, the impetus to lead continuous knowledge acquisition in the ever-evolving evidence in the treatment of acutely and critically ill patients. Acute care NPs are highly collaborative in that their practice demands quality, safety, constant engagement with members of the healthcare team, and close communication with patients and families. Most hospitals have visible dashboards and tools to track outcomes of acutely ill patients, but more and more are developing leading indicators, specific to acute care NP practice, to demonstrate their contribution to care, driving optimal outcomes.7 Nurse executives should advocate for NP practice and lead in the tracking of financial and clinical outcomes to substantiate the business case for advanced practice nursing.

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