CRITICAL CARE APP FELLOW - DUH - Full Time

Duke University Hospital is consistently rated as one of the best in the United States and is known around the world for its outstanding care and groundbreaking research. Duke University Hospital has 957 inpatient beds and offers comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center; a major surgery suite containing 51 operating rooms; an endo-surgery center; an Ambulatory Surgery Center with nine operating rooms and an extensive diagnostic and interventional radiology area. In fiscal year 2018, Duke University Hospital admitted 42,916 patients and had 1,085,740 outpatient visits in fiscal year 2017.

U.S News & World Report named Duke University Hospital #1 in North Carolina and #1 in the Raleigh-Durham area in 2018-19.

Duke University Hospital is ranked in the top 20 nationally for seven adult specialties, including cardiology and heart surgery, nephrology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology.

In addition to its hospitals, Duke Health has an extensive, geographically dispersed network of outpatient facilities that include primary care offices, urgent care centers, multi-specialty clinics and outpatient surgery centers.

Duke University Hospital

The Duke Hospital Critical Care Fellow Advanced Practice Provider (Nurse Practitioner/Physician Assistant) provides direct patient care services for critically ill complex (multi-organ) and trauma patients in an intensive care setting in collaboration with and under the supervision of the Critical Care Team and Anesthesia Critical Care Team.   The APP Fellow performs physical exams, collects and documents data, conducts diagnostic and therapeutic procedures, orders and schedules laboratory studies and professional consultations, prescribes appropriate interventions and medications, coordinates the care and discharge of patients, and provides direct patient care services under the direct supervision of the critical care team.  The APP Fellow contributes to excellence in patient care, research, teaching, and provides leadership to the organization.

Education:

CCPA:  Completion of an accredited Physician Assistant program. A Bachelor’s degree required; Master’s degree strongly preferred.  

CCNP:  Completion of an Acute Care / Critical Care Nurse Practitioner program.

PA:  Work requires graduation from a Physician Assistant program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) or its predecessor agencies.

NP:  Work requires completion of accredited graduate level Nurse Practitioner program.

Licensure:   NP:  Current licensure as a Registered Nurse in the state of North Carolina and approval to practice as an NP.

PA: Licensure as a Physician Assistant in the state of North Carolina.

Certification: 

CCPA:  National Commission on Certification of PAs (NCCPA) certification is required.

CCNP:  National certification as a NP required prior to employment.   Certification as an Acute Care or Critical Care Nurse Practitioner strongly preferred.

PA:  National Commission on Certification of PAs (NCCPA) certification is required

NP:  National certification as an NP

Experience:

CCPA:  Two years as a Physician Assistant in a critical care setting required

CCNP:  Three years minimum as a registered nurse, with minimum of one year experience as an NP, preferably in an ICU setting.   OR AN EQUIVALENT COMBINATION OF RELEVANT EDUCATION AND/OR EXPERIENCE

Life support:

BLS, ACLS

Physical and mental requirements :

• Able to clearly articulate scope of practice, and practices within those guidelines as a Nurse Practitioner / Physician Assistant in the state of North Carolina and within the Duke University Health System. 
• Able to independently seek out resources and work collaboratively to solve complex problems
• Able to communicate clearly with patients, families, visitors, healthcare team, physicians, administrators, leadership, and others.
• Able to use sensory and cognitive functions to process and prioritize information, perform health assessments, treatment, and follow-up.
• Able to use fine motor skills
• Able to record activities, document assessments & interventions; prepare reports and presentations;
• Able to use computer and learn new software programs
• Able to provide leadership in clinical area of expertise and in meeting organizational goals
• Able to navigate the Hospital and DUHS to provide clinical expertise to specific patient populations
• Able to withstand prolonged standing and walking with the ability to move or lift at least fifty pounds
• Able to remain focused and organized
• Able to work collaboratively with all levels of personnel

Hours

Primary hours will be 12-24 hour day shift covering 7 days per week including holiday, nights and weekends. Schedule may be changed by administrative or clinical leadership to meet department needs.

Responsible to

The Advanced Practice Provider will report directly to the Center for Advanced Practice Team leader and Director.  The APP’s clinical practice is supervised by the Trauma and Surgical Critical Care Supervising Physician or under the supervision of all Trauma and Surgical Critical Care team or Anesthesia Critical Care team attending physicians listed in the Back-up Supervising Physician list.  In addition, s/he will be accountable for clinical outcomes and defined quality indicators as determined by the appropriate inpatient unit / Clinical Service Unit Balanced Score Card and to the standards set forth by the Center for Advanced Practice

Process of Evaluation

Evaluation will be ongoing and will encompass the six general areas of competency as defined by The Joint Commission (patient care, medical/clinical knowledge, practice-based learning & improvement, interpersonal & communication skills, professionalism and systems-based practice).     Annual and midyear evaluations using the CAP PPR process will be conducted by the Dept of Center for Advanced Practice, in coordination with the PA’s primary supervising physician.   Ongoing Review of Care and Quality Improvement meetings with supervising physician will be conducted and documented monthly for the first six months, in accordance with Duke University’s and the designated Board’s standards, then at least once every six months.

Departmental Job Responsibilities and Standards

Standards

• In collaboration with attending team physicians, round daily on patients to assess, diagnose, plan treatment, set priorities and realistic outcomes, and evaluate the effectiveness and cost efficiency of ICU patient care
• Collaborate with the attending physicians, critical care APPs, residents and fellows to formulate treatment plans and monitor patient progress
• May order and/or perform the following procedures:

Please note:  A signed competency sheet will be submitted once training is complete.

• Patient history and perform physical exam
• Laboratory, radiology, and/or diagnostic procedures/tests
• Interpretation of laboratory, basic radiographic and diagnostic tests
• Ordering and administration of blood products
• Intubation / Extubation and airway management
• Flexible bronchoscopy for non-biopsy purposes in patients that already are intubated or has a tracheostomy
• Ventilator management
• Conscious / Moderate Sedation per protocol
• Chest tube insertion / removal
• NGT placement, OGT, NJ (DHT) placement bedside using flouro or cortrak after training
• Foley placement
• Paracentesis
• Thoracentesis
• p.      Evaluation of pleurovacs (chest tube drainage systems)
• q.      First assist supervising or back-up supervising physician in bedside ICU procedures, including bedside tracheostomy and percutaneous gastrostomy tube placement, other bedside surgeries
• r.       Blood sampling via central venous lines (CVLs) including:
• Temporary central catheters
• Tunneled catheters
• Implantable vascular access devices
• s.      Line placement for venous or arterial access:
• percutaneous arterial line placement
• percutaneous central line placement
• peripheral intravenous catheter placement (PIV)
• placement of pulmonary artery (PA) catheter (Swan Ganz)
• Interpretation of PA, CVL, SG, VS interpretation and critical thinking skills
• Central line changes with guide wire assistance
• t.       Suture / Staple placement and removal
• u.      Management of ICP monitoring
• v.      Systemic cooling post arrest
• w.    Internal and external hemorrhage control
• x.      Application of dressings, bandages, wound vacs
• y.      Simple debridement/suturing
• z.      Manage cantor tubes, NG tubes, G tubes, J tubes
• aa.   Manage support devices, including (but not limited to) hemovac, JP drains, arterial lines, wound vac
• bb.   Removal of superficial foreign bodies
• cc.   Administration of infusion therapy, including
• IV Fluids
• Antibiotics
• Anticoagulants
• Antifungals
• Antivirals
• Inotropes
• Electrolytes
• Total Parenteral nutrition, in collaboration with the attending physician
• Enteral nutrition

• Assess patients for change in status and institute appropriate interventions.  Initiates emergency interventions in an effort to stabilize the patient until physician support arrives.
• Preoperative evaluation; including (but not limited to) establishing diagnosis, and baseline status
• Postoperative stabilization and management.
• Develop patient care pathways, protocols and guidelines for the management of specific problems in conjunction with physicians and other members of the health care team.
• Analyze clinical practice patterns so as to provide the best medical care and to increase effectiveness and efficiency.
• Communicate verbally and in writing all pertinent patient information to supervising MD, nursing staff, patient resource manager, home health agency, and other relevant healthcare providers.
• Document in the patients’ chart all relevant data including but not limited to results of diagnostic tests; laboratory results; patients’ condition and response to therapies/interventions; communications with supervising MD.
• Utilize prescriptive privileges only for identified patient population.

• Prescriptive authority for prescribing, ordering, and or administering drugs; including (but not limited to) schedule II, III, IV, and V drugs and necessary medical devices.
• Role models competence in all nurse practitioner / physician assistant advanced skills.

Standards:

• Assess educational needs of the Intensive Care Unit  patient-care staff and provide one-on-one as well as formal in-service education as need.
• Assess educational needs of the Intensive Care Unit  patients / families and provide patient/family education interventions as indicated.  Document all pre and post-op education in pts medical record.
• Implement and evaluate appropriate educational programs for referring MDs, DUHS patient care staff, and other healthcare providers as appropriate.
• Role model and precept healthcare learners through contractual agreements.

3.    Research Utilization and Investigation

Standards:

• Utilize current research and evidence-based decision-making in all clinical practice.
• Incorporate clinical research findings in the development and implementation of standards of care.
• Support IRB approved clinical research/trials though a variety of activities including but not limited to: obtaining consent; ordering diagnostic tests; recording laboratory & diagnostic results; administering therapeutic interventions; and reporting patient outcomes including toxicities or adverse events.
• Participate in interdisciplinary quality improvement and/or research activities.
• Participate in measuring and documenting outcomes.

Standards:

• Provide expertise and resource information to other healthcare providers, patients and families, and the community at large related to critical care procedures, interventions, and conditions.
• Develop, implement and evaluate standards of care/practice guidelines/policies and procedures/care maps/protocols within area of specialization.
• Develop programs and projects in areas of expertise to facilitate the attainment of the goals and objectives of Duke University Hospital and Duke Regional Hospital.

Standards :

• Role model advanced practice professionalism through conduct, communication, dress, leadership, ethical decision-making, critical thinking and problem solving skills.
• Participate in at least one professional organization
• Demonstrate responsibility for professional practice through active participation in the Critical Care Division and Anesthesia Critical Care Division, CAP Department, professional organizations, and obtaining a minimum of 50 continuing medical education hours/year, and in maintaining professional certification.
• Enhance the body of knowledge in area of specialization through written publications, oral presentations, posters, continuing education, etc.
• Maintain all professional requirements for licensure and certification.

      Standards:

• Acts – and makes decisions – in the best interests of patients and their loved ones, and willingly accepts accountability for outcomes.
• Improves performance that enhances patient care and advances individual, team and organizational goals.
• Effectively uses DUHS resources (time, budget and property) to support optional patient care and operational performance while adhering to organizational policies and procedures.
• Seeks opportunities to improve service provided to patients and their loved ones related to clinical care and support.

      Standards:

• Strictly adheres to all established patient, staff and faculty safety procedures.
• Contributes to an environment of safety and security for patients and staff through individual actions.
• Speaks up about all risk of harm; reports patient, staff safety or injury events within twenty-four hours of incident or awareness of incident.
• Actively participates in all mandatory patient and staff safety training.

Integrity – Our decisions, actions, and behaviors are based are based on honesty, trust, fairness, and the highest ethical standards.

      Standards:

• Is truthful and honest with patients, their loved ones, and co-workers, and consistently exhibits actions that reflect our values.
• Is accountable for actions and decisions involving patient care or other operational activities, and strives to learn and improve from experience.
• Follows through on commitments made to patients, visitors, co-workers, and others.
• Conducts work positively while doing so in full compliance with all organizational policies, procedures, expectations and patient-centered values.

Diversity – We embrace differences among people.

      Standards:

• Applies cultural understandings and sensitivities to enhance patient care, and improves interactions with people of diverse backgrounds.
• Treats all individuals – patients, visitors and co-workers – with courtesy, dignity and respect.
• Contributes to a work environment that is welcoming to all – whether patients, visitors, staff or faculty.
• Demonstrates a sensitivity and awareness of the needs of a diverse workforce and patient population.

Teamwork – We have to depend on each other and work well together with mutual respect to achieve common goals.

      Standards:

• Willingly shares expertise and information with others to improve patient care, unit or departmental performance without compromising individual responsibilities.
• Celebrates the accomplishments of others in making a difference in the lives of patients and the success of the organization.
• Takes ownership of decisions made by specific patient care or project teams, and team leaders, and the individual role needed to support them.
• Manages multiple demands while maintaining quality and courtesy; acknowledges and resolves patient or visitor issues.

Work Environment :

The work environment involves risk discomforts that are typical of an acute care setting to include working with patients under isolation and universal precautions. It requires safety precautions, ongoing education and health risk monitoring.  Contact with specimens, chemicals, sharps, radiation, technical equipment and fumes are possible.  Employees are required to wear personal protective attire according to hospital policies and OSHA guidelines.  The work activity and patient acuity levels can create a stressful atmosphere. 

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.