APPs in Operative Cardiovascular Surgery

APPs have long played a role in the intraoperative phase of major surgery. Most open heart cases in the U.S. have a Physician Assistant (“PA”) or Advance Practice Registered Nurse with a First Assistant certification (“APRN / DNP RNFA”) scrubbed in the case. The range in the level of autonomy afforded APPs during the intraoperative period is largely based on the APP’s technical skill set, the type of institution where the surgery is being performed (academic v. non-academic) and most importantly, the level of comfort that the lead attending surgeon has with the APP. In some instances, the APP will function at a level equivalent to a “co-surgeon” whereas others may be limited to more support functions (prepping / draping, retracting, etc.).

Operative efficacy & continuity: What has long been missing is understanding the value that APPs bring to operative efficacy. APPs, unlike residents and fellows, do not rotate nor have a set timeline. This enables a significant return on investment for those that find surgeons willing to spend the extra time to train and reinforce the mentality that “excellence is the expectation and not the aspiration”.

Continuum-of-care: The idea of a provider with involvement in the whole process has many benefits. For patients, most find it incredibly comforting to have someone scrubbed-in on their cases who are part of the entire surgical process - from intake to consultation to planning to surgery and eventually to discharge. For instance, if closing an aorta post AVR and the aortic tissue is particularly fragile, the APP will know that post-op blood pressure management will be even more critical to monitor. If a different practitioner had been operating, that concern may not be communicated adequately even in a robust ‘hand-off’ protocol. The surgeon who practices with an APP First Assistant can feel at ease knowing that both his or her needs and the patients’ needs will be met.  The APP who is familiar with the patient will know just what the surgeon will want in the operating room, will have appropriate equipment, supplies, support staff etc available, therefore making the patients’ surgical experience smooth and uneventful. A first assistant that does not have that relationship with the surgeon or patient cannot offer those intangible benefits. Ideally, the best ‘surgical assistants*’ would be patient care roles that encompassed the entire patient surgical experience from pre-operative evaluation to patient discharge, which is the spectrum of both APRN RNFAs and PAs.