January–March 2009 Journal of Trauma Nursing • Volume 16, Number 1 33 Midlevel Practitioner Role Evolution in an American College of Surgeons–Verified Trauma Surgery Service: The 23-Year Experience at Hurley Medical Center Judy Mikhail, MSN, MBA, RN William Miller, MS, PA-C James Wagner, MD ■ ABSTRACT The purpose of this study was to evaluate our 23-year experience with midlevel practitioners in an American College of Surgeons–verified trauma surgery service in the absence of a surgical residency. A retrospective review of the utilization of trauma surgery midlevel practitioners was performed at a community hospital American College of Surgeons–verified trauma center from 1985 to 2007. The trauma surgery service has expanded in volume, acuity, and services offered over the 23-year period. This model has allowed us to estab- lish effective and efficient surgical coverage while growing the trauma program, as well as general sur- gery and bariatric services. Judy Mikhail, MSN, MBA, RN, is Administrator, Trauma and Neuro Services, Hurley Medical Center, Flint, Michigan, William Miller, MS, PA-C, is Chief Clinical Practitioner, Hurley Medical Center, Flint, Michigan, and James Wagner, MD, is Trauma Director, Hurley Medical Center, Flint, Michigan. The authors thank Renee Link, RHIT, CSTR, CAISS, Trauma Registrar Hurley Medical Center, for her support to this study. Corresponding Author: Judy Mikhail, MSN, MBA, RN, Administrator, Trauma and Neuro Services, Hurley Medical Center, One Hurley Plaza, Flint, MI 48503 (jmikhai1@ hurleymc.com). ■ KEY WORDS Advanced practice nurses, Midlevel practitioners, Midlevel providers, Nurse practitioners, Physician assis- tants, Physician extenders O ver the past 3 decades, the scope of midlevel providers (MLPs), defined as physician assistants (PAs) and advanced nurse practitioners, has rapidly expanded to include all aspects of the care of hospitalized patients. Many hospitals began hiring MLPs originally to extend the reach of the physician but now more impor- tantly to ensure continuity of care, safety, throughput, and lower length of stays in the face of an ever-increasing patient acuity and volume. Further impetus for MLP expansion in healthcare occurred after the restriction of resident house staff duty hours in 2003. To our knowl- edge, Hurley Medical Center was the first American College of Surgeons (ACS)–verified level II and then level I trauma center using MLPs in lieu of a surgical residency in the country. Our experience now covers over 20 years with a total of 22 MLPs employed. This article will review the use of an MLP model for a trauma surgery service. ■ METHODS Hurley Medical Center is a 450-bed tertiary care public safety net hospital serving up to 38 counties in northeast- ern mid-Michigan of the Lower Peninsula. The level I trauma center’s emergency department sees over 76,000 visits and admits over 1,600 trauma patients annually with a 70% blunt, 20% penetrating, and 10% burn dis- tribution. Hurley Medical Center began using MLPs when its long-standing surgical residency closed in 1984. During this time period, Flint was regularly ranked within the top 10 most violent cities in North America, ADVANCED PRACTICE