Critical Care NP/PAs

  1. I am the first APP hired into critical care in my hospital. Now that they see the benefits, the docs are all about hiring more. I currently work 4x10s, weekdays, no weekends or nights. Obviously as we get more people, the intensivist attendings would like to change that so that we have 24/7 coverage and less nights/weekends for them.

    How many APPs does your unit have?
    What is their schedule?
    How do you organize your coverage?
    How many patients do you see and chart/bill for?
    Who do they report to?
    How did you integrate new hires, if you started with a few and grew your APP presence?
    Does your intensivist APP group cover hospital codes?
    Does your MD intensivist work inhouse overnight/weekends or on call?

    Thanks for any assistance! Trying to have some involvement as we start this growth as obviously it will affect my schedule and my compensation. I also love having an intensivist in house with me at all times now for learning purposes so I want to ensure we have adequate clinical support by MDs if we transition to APP coverage out of hours.
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  2. 11 Comments

  3. by   babyNP.
    I assume that you're in an adult ICU based on your specialization- I work in NICU which is very different patient population but I'll share what we do if that's helpful. NNPs were the first in-patient intensivist NPs practicing. I first worked at an academic center (children's hospital) where we did anything and everything up to ECMO, immediate post-ops, cooling, dialysis, oscillators, etc etc and now work at a community Level III where we have vents, oscillators, and occasionally some vasoactive drips, and then obviously covering the delivery room where we run codes on occasion. I'll number them below (#1 for the academic center, #2 for the community site)

    How many APPs does your unit have?

    1. The group was ~50 or so NNPs with 10 on (11 ideally with one as a float) each day, 5-6 on each night
    2. The group has ~30 or so NNPs covering multiple community sites and one academic center; my community site has 1 NNP on each day/night along with a neo that is on during the day.

    What is their schedule?

    1. Three 12 hour shifts (days or nights) per week, 4 hours paid professional time
    2. Three 12 hour shifts (days/nights) per week or three 24 hr shifts in a 2 week period, 2 hours call time, 2 hours professional time. Folks can do either or a mixture of both

    How do you organize your coverage?

    1. Self-scheduling. Used to have someone on call for each shift for a sick call, but we got rid of it as we weren't being paid for it. Now if someone is sick or there is a hole in the schedule, you can work and get paid a premium, set at $72/hr
    2. Similar, although the premium for an extra shift is $100/hr

    How many patients do you see and chart/bill for?
    1. My caseload was 6-8 patients- but they were generally all very complex with multiple co-morbidities. They would often have 15+ diagnoses. Did not bill as our attendings did that, although their note was at least partially based off our note for the day.
    2. Generally 12-20, but the bulk of them are "feeder growers," not a true ICU patient. In this job, I bill for any deliveries that I attend and admits that come in after the neo goes home in the afternoon.

    Who do they report to?

    1. Attending neonatologist
    2. Attending neonatologist

    How did you integrate new hires?

    - NNPs have been around for a few decades (I believe since the 80's if not earlier)

    1. Orientation as a new grad for me was 4 months
    2. Not sure about this job, as I came in with experience and didn't need an extensive orientation

    Does your intesivist APP group cover hospital codes?

    1. Only in the NICU
    2. NICU, delivery room, and occasionally the ED will call us if they have a baby down there

    Does your MD intensivist work in-house overnight/weekends or on call?

    1. Full set of neos during week days, one on each night, and about half as much on weekend days.
    2. Neo will stay overnight if the unit is crazy but is otherwise on-call for any problems and/or if the NNP needs additional help. Weekends are treated the same as weekdays, but the neo goes home a bit earlier usually if there aren't many anticipated changes.

    Hope this helps!
  4. by   core0
    Quote from ghillbert
    I am the first APP hired into critical care in my hospital. Now that they see the benefits, the docs are all about hiring more. I currently work 4x10s, weekdays, no weekends or nights. Obviously as we get more people, the intensivist attendings would like to change that so that we have 24/7 coverage and less nights/weekends for them.

    How many APPs does your unit have?
    What is their schedule?
    How do you organize your coverage?
    How many patients do you see and chart/bill for?
    Who do they report to?
    How did you integrate new hires, if you started with a few and grew your APP presence?
    Does your intensivist APP group cover hospital codes?
    Does your MD intensivist work inhouse overnight/weekends or on call?

    Thanks for any assistance! Trying to have some involvement as we start this growth as obviously it will affect my schedule and my compensation. I also love having an intensivist in house with me at all times now for learning purposes so I want to ensure we have adequate clinical support by MDs if we transition to APP coverage out of hours.
    1. Our Unit has 9.5 FTEs. There are two of us that are less than full time. We have more than 100 APPs across our center. Our unit also has 4-8 residents per month who take night call if not interns. Less than 1/2 of our ICUs have residents.
    2. We work either days or nights 13.3 hour shifts. 4.6 on days and 4 on nights with 4 days per month vacation coverage. We have 2 people each day Monday-Sunday and 2 on nights Monday through Thursday with one on nights Saturday and Sunday.
    3. We use Qgenda as an organization. One APP does day schedules and one does night schedules. Basically you submit your days off a month ahead of time and then they move the schedule around to cover. We occasionally have one person on days or midweek on nights if more than one are on vacation. The expectation is that there is at least one person on each day and night. We shift the patient load with the residents when we are short.
    4. On days we generally cover 4-5 patients. We have looked at this extensively and feel around 6 is the sweet spot. Over six and patient care and billing suffers. Under 5 and its hard to get your billing. The expectation is that we spend 75% of our time in patient care (billed and non billed). On average we hit around 55% of our time as billed time. At night we see between 10 and 20 but only bill if there is an admission or critical care time. We chart and bill on all our own patients. In some of our ICUs the attending does shared billing on E/M patients and bills some time on the APP critical care patients. We use IM bills and each provider (APP or physician) submits their own bills. Medicare/caid is billed under our NPI. Other insurance is billed under the physician NPI but credited back to us when paid.
    5. We have a lead APP for each ICU. They report to the medical director for unit problems and to the lead APP for the center for APP problems.
    6. Originally we had two APPs working M-F. We added two more and covered weekends 2 on M-F 1 on Sat-Sun. We added two for nights then added two more a year later. We have a graduated orientation that seems to work well. Generally we have to write a business plan to add positions and justify either with billing or patient safety.
    7. All ICU APPs cover code blue on designated floors. We don't cover code mets.
    8. We don't have any intensivists in house at night. Some of our ICUs have intensivist on home call +/- fellows as buffers. Some have EICU to handle night time issues. The fellows and intensivists come in when something big happens but its been over a year since we had to call the intensivist in (fellows come in maybe 1 x month). Basically our model is APP 24/7 with daytime intensivist coverage.

    If you have SCCM membership we did a talk at the last SCCM about building an APP program that included residency, retention and paying for the program.
  5. by   juan de la cruz
    How many APP's does you unit have?
    - currently, we have a total of 17 full time ACNP's and 5 Per Diems. We cover mostly mixed provider model ICU's including a 16-bed Med-Surg ICU (PGY2 and 3 residents and NP's), a 16-bed Cardiac and Vascular ICU (PGY4 resident and NP), a 30-bed Neuroscience ICU (PGY1, 2, and 4 residents and NP), and a 14-bed community-based private practice model ICU with a large surgical and OB population staffed with an NP and an attending. There are ICU fellows in each of the ICU except for the 14-bed ICU in the community setting.

    What is their schedule?
    - 12-hour days and nights rotation with night commitment tapering in number as seniority grows, those with over 10 years of service have no night commitment.

    How do you organize your coverage?
    - with a lot of "jigsaw puzzle work" and coordinating with the GME scheduler for the residents. NP's self-schedule using a scheduling software used by the Department of Nursing.

    How many patients do you see?
    - typically 4-6, in ICU's where the service provides more of a consultant role, the number can be up to 8.

    Who do they report to?
    - there is an ICU NP supervisor (lead NP if you will) but ultimately, both the CNO and the Chief of the Division of Adult Critical Care Medicine.

    How did you integrate new hires?
    - at least 4 months of orientation for new grads, some experienced NP's have required much less than that. We have a probationary period (typically before union membership kicks in) and have let go of a few hires in the past.

    Does you ICU group cover hospital codes?
    - yes

    Does the MD intensivist work in-house on nights and weekends?
    - no intensivist in-house on nights but there is an ICU fellow in-house 24/7 and an on-call intensivist for nights. The primary intensivist for each of the ICU's like to be called directly from home for certain issues typically.
  6. by   ghillbert
    Thank you so much for the detailed responses, I appreciate your time! These numbers amaze me, given that we have a total of 1 APP lol.

    Our unit is 24 bed SICU, mostly cardiac surgery, vascular, transplant (heart, liver, kidney, pancreas). There is only one MD intensivist on 24/7, 12hr shifts rotating days/nights. They are actively recruiting but having trouble finding someone with that schedule. So far since I started, myself and the attending are splitting the unit but I really am feeling overwhelmed with 12-15 (counting transfers and new postop admissions during the day) patients to round on, examine, write notes on and bill on. I wasn't sure if it was reasonable to put my foot down about the ratio given that whoever I don't see, the attending has to, but everything I have read says APP:Pt ratio of ~6 is reasonable.

    They are very happy with the help and quickly saw the merit of hiring more APPs, so we just have to get budget approval, but may be able to transition the advertised MD job into a few APPs... just have to find appropriate staff to hire now.

    Again thanks, it's fascinating how the ICU APP role has evolved in different centers across the country - I guess we are where you guys were 10-15yrs ago lol. I do have SCCM so I will look for that talk, David. I saw a conference listed for you a couple years ago about the staffing etc for ICU... if only I wasn't 2 years too late for it!
  7. by   lilstudentnurse19
    Hello! I'm sorry I can't answer your question but I have seen you answered alot of questions on Australian RN transferring to the states and I was really looking for advice on it as I'm moving there soon. If you could spare any time at all to message me and answer a few questions or give advice, I'd be really grateful. Private messaging is disabled for me as I haven't made any posts yet but let me know if I can email or you can email me if you don't want to share any info
  8. by   romantic
    Hello Juan,

    How long have you been an NP? You said there are 17 and 5 NPs; how many females NP are among them?

    Thank you.
  9. by   juan de la cruz
    Quote from romantic
    Hello Juan,

    How long have you been an NP? You said there are 17 and 5 NPs; how many females NP are among them?

    Thank you.
    I graduated from ACNP December 2003 but didn't start as an ICU NP until around August 2005. Our group has hired a few since my last post, currently our group has 9 males and 14 females. Ages range from late 20's to late 40's.
  10. by   ghillbert
    Just an update - I've been in my role 6 months now and just hired a new ACNP to start as soon as paperwork is done. My unit is the CTICU. The CCU also just got approval and hired 2 ACNPs for their unit, which is currently staffed by residents/fellows with rounding cardiologists. I am excited that my organization has quickly seen the benefit of NPs in critical care. I have billed far more than any of the intensivists every month since I started work - initially the admin were concerned that getting 85% of physician billing would reduce the income, but they realized I complete far more notes than the intensivists were able to when they were singlehandedly taking care of 24 patients in our unit... and 85% of a lot is better than 100% of nothing.
    After six months in the role, I am still amazed by those of you with no MDs on at night etc - we have such a high acuity with people crashing onto ECMO and having chests opened, difficult airways for intubation etc that I cannot imagine a time I wouldn't need the MD around! I hope I am able to become as autonomous as some of you with more time.

    Next challenge will be creating an on-boarding process for our new hires. I have found some literature with helpful orientation tips and checklists but welcome any other tools you have or know of to help with APP orientation to ICUs.
    Last edit by ghillbert on May 14
  11. by   WKShadowRN
    I too am interested in formalizing an onboarding process. I'm getting adequate support but I would like a process in place which has milestones or stated expectations and competencies.
  12. by   juan de la cruz
    Quote from ghillbert
    After six months in the role, I am still amazed by those of you with no MDs on at night etc - we have such a high acuity with people crashing onto ECMO and having chests opened, difficult airways for intubation etc that I cannot imagine a time I wouldn't need the MD around! I hope I am able to become as autonomous as some of you with more time.
    There has been discussions about having an attending intensivist at night but the decision was still to make the role on-call rather than on-site since there is a Critical Care Medicine fellow on-site at night. Each of the ICU's are covered by a single provider (NP or resident) at night with the fellow in charge of the entire service. Fellows typically leave the NP's alone to do their thing and watch the residents who need more hand-holding. Our fellows come from a variety of backgrounds - Anesthesiology, Pulmonary, Neurology, and Surgery.

    There is an overnight attending anesthesiologist that can supervise intubations although the fellows with anesthesia background have attending privileges in terms of intubations. We have a difficult airway cart and all ICU providers are familiarized on it's use during orientation. Some of our patients are also high risk for hemodynamic compromise on induction - for that, we have an on-site Cardiac Anesthesiologist who can assist if needed.

    Bedside ECMO cannulations are performed by Cardiothoracic Surgery not the Critical Care Medicine service and their fellows initiate the process while their attending is on his/her way to the bedside. A Cardiac anesthesiologist is present to provide anesthesia at the bedside in these cases as the ICU providers can not be stuck in that room unable to answer to other emergencies in the unit.
  13. by   ghillbert
    Makes a lot of sense, thanks for the info!!

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