ICU NP/PA schedules

  1. We currently just have 2 ACNPs for a 24-bed cardiothoracic ICU which is very high acuity and busy. We round, do notes and bill on our 6-12 patients, do procedures, allocate patients to any residents/students we have on service, do signout for the night intensivist. We are having trouble getting out on time as posted are still rolling in right when we try to leave.

    The second NP just started, prior to that I was working Mon-Thurs 6-4, no holidays or weekends. She accepted the job with the director's agreement to move to 3 day weeks. Now I am trying to work out the best schedule. I don't want us to start covering weekends and holidays without the employer reviewing the pay rate because I accepted the job at the current rate for weekday hours.

    What do you do for APPs in your ICUs? Do you do 3x12 and have staff be 0.9 FTE? Or 14/13/13 for 1.0 FTE? What shift times? Do you have a shift differential built into your pay scale? If there are 2 of you there on a shift do you stagger shift hours or both work same time? Did your shifts/schedules change as you added more providers?

    Thanks for any help with this!
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  2. 11 Comments

  3. by   core0
    We use a five person schedule. We have four people on 3 x 13.3 hour shifts (6am to 730p) rotating schedules and one person on weekend option. Our rotating people get $150 per weekend shift and the weekend option person gets $20k above base pay. Our nights will be the same once we get fully staffed. Night pay is $30k above base.

    Prior to that we had four people working rotating weekends. We would have one person on weekend days and nights with the residents picking up more patients on the weekends.

    For comparison we have a 20 bed high acuity surgical ICU. We have 10 FTEs with 24/7 APP coverage. We have between 3 and 7 residents per month. The APPs take 4 each per day (5 if single coverage) and the residents take 12. We have determined optimum patient load is 5-6 during days and 10-11 at night. During the PM the unit is divided among APPs and residents with the APPs covering if they take their designated NAP.

    Basically we bill around 7 hours per day so around 28 RVUs per day. You can plug that into your blended RVUs and figure out what level of support you need.

    We had two for a long time they worked Monday through Friday no weekends. Then we hired two more and had 24/7 coverage. Our night system evolved in a similar manner.

    We use 13.3 hour shifts to avoid the 0.9FTE. We overlap the shifts 1/2 hour on each end for sign out. In reality its more like 630 to 730 but occasionally staying late to finish paperwork.

    Fundamentally there is no good way to do 12s with two people. You can split the week and overlap one day but its really inefficient. Going to 13s will get you out on time since there is built in time for finishing notes and sign out.
  4. by   juan de la cruz
    We all work 3 12-hr shifts so it's basically 0.9 FTE.

    We are members of the university system's nursing union which calls for 5% weekend differential, 10% evening shift differential, 16% night shift differential, time and a half for shifts worked over 40 hrs/week. If we work a holiday shift (based on medical center approved holidays not university holidays) we are paid time and a half. If we work 36 hours on a week when there is a holiday but not work the holiday itself, we get an additional 8 hours of regular pay.

    We've had issues covering night shift when there are sick calls. The solution is to have an NP scheduled on call for nights in case someone is too sick to work. Based on our numbers, we have one on-call shift every two weeks. The NP gets paid 1/2 of what a 12-hour shift would have been for being on-call. If the NP is asked to come to work during their call, they receive time and a half for the hours they had to work. This was a union contract policy.

    We have rotating shifts. New NP's are hired with 75% nights and 25% days commitment. Some NP's prefer straight nights which works great so really, even some newer NP's don't rotate to nights that much. Per the union contract, NP's who reach 10 years of service are not required any night shift commitment.
  5. by   ghillbert
    Thanks guys, you always have answers for me! For now I haven't even given the bosses the option of weekend or night coverage until I have more FTE's. Between the 2 of us, I am planning to cover Mon-Fri 6a to 7-7:30p with one APP each day, and 2 on Mondays which is the busiest OR day.

    Juan, what is your FTE? That is nice that seniority means less nights.

    David - you have 10 FTE but 5 person schedule..? So how many people per shift on weekday days, weekday night, and weekends? Sorry if I am being dense. Do people rotate days/nights by a week at a time, or do both days and nights within the same week? I don't really know what a blended RVU is, but I am going to investigate!

    I have had 1 new NP, 1 NP student, 1 medical student, 2 residents and one PACCM fellow rotating with me this month after having zero people last month, so I don't know what to do with all the help!!

    Thanks again.
  6. by   core0
    Quote from ghillbert
    Thanks guys, you always have answers for me! For now I haven't even given the bosses the option of weekend or night coverage until I have more FTE's. Between the 2 of us, I am planning to cover Mon-Fri 6a to 7-7:30p with one APP each day, and 2 on Mondays which is the busiest OR day.

    Juan, what is your FTE? That is nice that seniority means less nights.

    David - you have 10 FTE but 5 person schedule..? So how many people per shift on weekday days, weekday night, and weekends? Sorry if I am being dense. Do people rotate days/nights by a week at a time, or do both days and nights within the same week? I don't really know what a blended RVU is, but I am going to investigate!

    I have had 1 new NP, 1 NP student, 1 medical student, 2 residents and one PACCM fellow rotating with me this month after having zero people last month, so I don't know what to do with all the help!!

    Thanks again.
    Basically with 5FTEs on Days and 5 on nights we have 2 people 24/7 coverage. This is with one Weekend option on both days and nights.

    In reality we have 9.8FTE. We have 4 full FTEs on days and one .66 FTE WEO. On nights we have 4 full FTEs (including WEO) and one 0.5 FTE. We also have someone who is 0.25 FTE. This person fills in day or nights as needed. The people that have partial FTEs have another job. I do compliance for 1/3 time, another PA works with ID doing Ebola training 50%and the 0.25FTE runs our NP/PA residency.

    We looked at rotating and the evidence is really against it. We hire into either a night or day position. If a day position comes open its by seniority if someone wants to come off nights. Most of our night personnel like the night autonomy and the pay.
  7. by   juan de la cruz
    Quote from ghillbert
    Juan, what is your FTE? That is nice that seniority means less nights.
    All the full time NP's are 0.9 FTE except for our NP supervisor who is 1.0 but he is non-union and has a manager classification (not entitled to OT, shift diff, etc.).

    Our current system makes it harder to recruit new NP's because of the night commitment but once in a while we interview an NP who surprisingly only want to work nights.
  8. by   babyNP.
    I work in a couple of community NICUs now (so, lower acuity although I also cover delivery services) and we do 6x24 hour shifts a month. We are considered 1.0 FTEs and have 2 hours a week of "non-clinical time" which is devoted to various hospital trainings, business meetings, etc etc. Shift time is 7a-7a. We get a 12% salary bonus since we work nights, holidays, and weekends. 16% if you decided to do exclusive night shifts. Because I'm at a community site with lower acuity, I don't have a second NNP with me although the neo is there during business hours.

    My previous institution was a Level IV academic center. There were 10-12 NNPs on day shift and 5-6 on night shift covering 100+ patients. We were also 1.0 FTE employees and did 3x12 hour shifts a week and had 4 hours of what we called "professional time" where we could choose to do whatever we'd like including teaching, research, etc etc. I became a NRP instructor and taught classes. Shift time was 6:30a-6:30p and vice-versa. Night shift got a differential if you were regularly scheduled for it but I don't know what it was since I worked day shift.
  9. by   ghillbert
    Thanks again, guys - this is super helpful! I think I'd die doing 24hr shifts, babyNP - although I have friends that do and they love it. It would be nice to work that few shifts per month and perhaps be able to have a)good QOL or b)ability to work a second job
  10. by   babyNP.
    Quote from ghillbert
    Thanks again, guys - this is super helpful! I think I'd die doing 24hr shifts, babyNP - although I have friends that do and they love it. It would be nice to work that few shifts per month and perhaps be able to have a)good QOL or b)ability to work a second job
    Well I would never work at 24 hour shift at my previous job- acuity was way too high for that and I left many shifts exhausted. With my current job it's less stressful in terms of acuity and I almost always get a few hours of sleep if not a full 8 hours.
  11. by   ghillbert
    One more critical care question re billing:

    - Those of you that have the physicians rather than APP bill for critical care - how do you track APP productivity apart from RVUs and billing?

    I have one ICU where the docs' compensation is not RVU based, and they are happy for APPs to bill critical care time or E/M. In the other ICU, the docs are RVU based, and want to capture 100% of the billing (E/M and critical care) by Attendings. In that case how can the APP not be invisible in terms of productivity?
  12. by   core0
    Quote from ghillbert
    One more critical care question re billing:

    - Those of you that have the physicians rather than APP bill for critical care - how do you track APP productivity apart from RVUs and billing?

    I have one ICU where the docs' compensation is not RVU based, and they are happy for APPs to bill critical care time or E/M. In the other ICU, the docs are RVU based, and want to capture 100% of the billing (E/M and critical care) by Attendings. In that case how can the APP not be invisible in terms of productivity?
    Your question doesn't completely make sense. A physician cannot bill for APP critical care. Critical care cannot be shared billing and can only be billed to the NPI of the provider who does the work. If the physicians are billing for APP critical care then they are committing fraud.

    For non medicare patients, the insurance usually doesn't credential APPs but wants the bill placed under the physician. For those patients our billing software has field for billing provider and rendering provider. All RVUs are credited to the rendering provider. So for critical care I get credit for all the RVUs that I provide whether private payer or Medicare/Caid.

    For E/M some of our ICUs use shared billing. Remember for shared billing the physician must see the patient and personally document one element of the encounter. Seen and agree doesn't cut it. Some ICUs don't bill on APP patients so the billing is under the APP as above (rendering provider gets credit). For shared billing we have another slot for shared provider. The credit for the RVUs depends on the department. Some are 50/50 others are lower. The lowest is 85/15 (app/physician). This represents the extra money that the institution gets from the shared billing. They are trying to discourage this because its really unproductive work (see the patient talk to them and document for 15% of the bill). Its much more effective to see another patient by themselves.

    Our institution does a good job of tracking productivity. In high production sections the expectation is that the APP brings in at least 125% of salary.
  13. by   juan de la cruz
    Quote from ghillbert
    One more critical care question re billing:

    - Those of you that have the physicians rather than APP bill for critical care - how do you track APP productivity apart from RVUs and billing?

    I have one ICU where the docs' compensation is not RVU based, and they are happy for APPs to bill critical care time or E/M. In the other ICU, the docs are RVU based, and want to capture 100% of the billing (E/M and critical care) by Attendings. In that case how can the APP not be invisible in terms of productivity?
    It can be tough to prove our worth without the dollar figures that RVU's reveal but there are other ways that NP's contribute to a specific practice apart from revenue generation. There are many places that put as much emphasis on outcomes as much as profits. It can be convincing to show our worth by measuring the positive impact NP's bring by using quality measures.

    Examples of measurable outcomes would be compliance with vent budles, sepsis activation response times, time to extubation (important in cardiac surgery), etc. I know they can be subjective at times and data can be muddied by the fact that most practices are collaborative in nature so it's hard to pinpoint who deserves the credit. However, some attendings can be poor at EMR usage and important order sets tend to not be written correctly sometimes which doesn't help with compliance. That's where we can come in and EMR data is easy to track.

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