Advice from acute/critical care NP's

Advanced Practice Columnist / Guide · Dec 7, 2006

Well I'm not exactly looking for advice as much as looking to hear about your job. I am still up in the air as far as whether I'd like to become a CRNA or critical care NP. I have looked into both professions quite extensively as well as the training involved. I have also shadowed a CRNA at my hospital. I know that CRNA salary is generally higher than that of an NP but I would really hate for salary to be the deciding factor in which profession I choose since money doesn't mean squat if your miserable at work. What I'm looking for is any acute/critical care NP's who are willing to share info about your job such as what responsibilities you have, what hours you work, where you work, what you would change if you could, and if your willing to share info about pay. Maybe hearing from some more people who do the job for a living will help me out in making my decision. I am also putting a similar posting in the CRNA area. Thank you.

I had the same dillema deciding which graduate school program to choose. CRNA was really tempting because of the wage difference (especially in Michigan where I'm practicing) but I wasn't sure I was going to like what they do. Although I was also getting swayed by a lot of fellow RN's who are pursuing the CRNA route, I thought I would enjoy patient management and teaching more so I ended up deciding to pursue the ACNP instead.

I am now an ACNP (since 2004) and am currently working in cardio-thoracic surgery. I am part of a team of NP's that manage patients (along with an intensivist and a team of CT surgeons) in the Cardiothoracic Surgical ICU at our hospital. We provide 24-hour coverage of the unit. We manage fresh open hearts and lung surgery patients. Our hospital is also a heart and lung transplant center. We also do VAD's in this facility. As NP's, we are credentialed to insert triple lumens, float Swan-Ganz, place A-lines, and insert thoracostomy tubes for hydro/pneumothoraces. We have also been doing bronchoscopy for sputum sampling but I have yet to develop the skill to use the scope (my peers are a lot better than me on it). We don't assist in the OR - the PA-C's do that.

I enjoy what I do and have no regrets about my decision to pursue ACNP. However, I have to admit that the pay doesn't seem to commensurate the amount of work we do. It's also tough that we have to rotate to night shift from time to time.

CAPRN77 · Dec 7, 2006

I had the same dillema deciding which graduate school program to choose. CRNA was really tempting because of the wage difference (especially in Michigan where I'm practicing) but I wasn't sure I was going to like what they do. Although I was also getting swayed by a lot of fellow RN's who are pursuing the CRNA route, I thought I would enjoy patient management and teaching more so I ended up deciding to pursue the ACNP instead.
I am now an ACNP (since 2004) and am currently working in cardio-thoracic surgery. I am part of a team of NP's that manage patients (along with an intensivist and a team of CT surgeons) in the Cardiothoracic Surgical ICU at our hospital. We provide 24-hour coverage of the unit. We manage fresh open hearts and lung surgery patients. Our hospital is also a heart and lung transplant center. We also do VAD's in this facility. As NP's, we are credentialed to insert triple lumens, float Swan-Ganz, place A-lines, and insert thoracostomy tubes for hydro/pneumothoraces. We have also been doing bronchoscopy for sputum sampling but I have yet to develop the skill to use the scope (my peers are a lot better than me on it). We don't assist in the OR - the PA-C's do that.
I enjoy what I do and have no regrets about my decision to pursue ACNP. However, I have to admit that the pay doesn't seem to commensurate the amount of work we do. It's also tough that we have to rotate to night shift from time to time.

See, that sounds like an awesome job! Thanks for the Reply.

CAPRN77 · Dec 7, 2006

I had the same dillema deciding which graduate school program to choose. CRNA was really tempting because of the wage difference (especially in Michigan where I'm practicing) but I wasn't sure I was going to like what they do. Although I was also getting swayed by a lot of fellow RN's who are pursuing the CRNA route, I thought I would enjoy patient management and teaching more so I ended up deciding to pursue the ACNP instead.
I am now an ACNP (since 2004) and am currently working in cardio-thoracic surgery. I am part of a team of NP's that manage patients (along with an intensivist and a team of CT surgeons) in the Cardiothoracic Surgical ICU at our hospital. We provide 24-hour coverage of the unit. We manage fresh open hearts and lung surgery patients. Our hospital is also a heart and lung transplant center. We also do VAD's in this facility. As NP's, we are credentialed to insert triple lumens, float Swan-Ganz, place A-lines, and insert thoracostomy tubes for hydro/pneumothoraces. We have also been doing bronchoscopy for sputum sampling but I have yet to develop the skill to use the scope (my peers are a lot better than me on it). We don't assist in the OR - the PA-C's do that.
I enjoy what I do and have no regrets about my decision to pursue ACNP. However, I have to admit that the pay doesn't seem to commensurate the amount of work we do. It's also tough that we have to rotate to night shift from time to time.

pinoyNP, I do have another question. Did you learn the "technical" skills such as triple lumen and Swan placement in school or did you learn them on the job?

Advanced Practice Columnist / Guide · Dec 7, 2006

Aside from having placed one A-line and a failed femoral triple lumen attempt during clinicals in NP school, I was trained to perform those skills on the job. We are fortunate to have had 6 months of precepted orientation for this job. I was the third NP to join the team so by then, the 2 others were already proficient in those skills. I also forgot to mention that we have second year general surgery residents on our team. They are not the greatest resource as far as cardiothoracic surgery management but they are great when you need some help with central lines. On some months, we have a critical care fellow on our service so they are great as far as teaching us skills. And by the way, we do 12-hour shifts, 3 days a week. A lot of us pick up an extra shift for extra income. We get paid overtime for that.

CaseAlum · Jan 29, 2007

Thanks Pinoy for the response . I was/am also in teh same boat regarding ACNP vs CRNA. I ultimately chose ACNP because I didnt think I'd be happy in the CRNA role. I initially applied to CRNA school, was wait-listed, then accepted - I turned down the offer and now i'm in the ACNP program. Though the money is good for CRNA, the malpracitce is also very high. Here in Ohio they pay $9,000 / year for malpracitce!!! SPeaking of malpractice, while I want more autonomy / responsibility, I am afraid of being lumped in with physicians and malpracitce suits. I guess you have to realize that anyone in any profession can be named in a lawsuit. Can anyone comment on the rates of NP malpractice suits? While I feel I am a competent RN, being sued is one of my worst fears.

core0 · Jan 30, 2007

Thanks Pinoy for the response . I was/am also in teh same boat regarding ACNP vs CRNA. I ultimately chose ACNP because I didnt think I'd be happy in the CRNA role. I initially applied to CRNA school, was wait-listed, then accepted - I turned down the offer and now i'm in the ACNP program. Though the money is good for CRNA, the malpracitce is also very high. Here in Ohio they pay $9,000 / year for malpracitce!!! SPeaking of malpractice, while I want more autonomy / responsibility, I am afraid of being lumped in with physicians and malpracitce suits. I guess you have to realize that anyone in any profession can be named in a lawsuit. Can anyone comment on the rates of NP malpractice suits? While I feel I am a competent RN, being sued is one of my worst fears.

This is part of the landscape these days. If you have an overwhelming fear of being sued, then any ANP profession is probably going to be a problem. The $9,000 for a CRNA is very low. Other states it runs much more and for the MD's it will be much more. I'm in GI and my malpractice runs $4000. I've never been sued. Our MD's have malpractice rates that run $20-30,000 depending how long that they have been in practice. The reason that anesthesiology and CRNA's have high rates is that any problem tends to be catastrophic.

One of the unintended consequences of the cap on pain and suffering is the inclusion of NPP's in any lawsuit. This allows them to collect multiples of pain and suffering. The best you can do is take good care of the patient and document well. Even then you will probably eventually be sued.

From the NPP standpoing make sure that you:

1. Have your own policy with sufficent coverage ($1mi/$3mil is suggested).

2. make sure your policy has provision for a tail.

3. Document document document

David Carpenter, PA-C

Advanced Practice Columnist / Guide · Jan 31, 2007

The National Practitioner Data Bank was created to collect information on all payments by professional Liability Insurance companies on behalf of their healthcare provider clients to injured parties for successful malpractice claims. It also receives data from licensing boards, hospitals, and professional quality assurance committees regarding disciplinary actions given out to health care providers.

I have attached an excerpt from the National Practitioner Data Bank's 2004 Annual Report below. It is the latest one available on-line. I think this information can be valuable to us mid-level providers and those who are training to become a mid-level provider as far as tracking trends and hopefuly guiding our malpractice prevention strategies.

For the full version link to: http://www.npdb-hipdb.hrsa.gov/pubs/stats/2004_NPDB_Annual_Report.pdf

Malpractice Payments: Nurses and Physician Assistants

Although physicians and dentists have the most Medical Malpractice Payment Reports in the NPDB, there are also many of these reports for nurses and physician assistants. There has been particular interest in both of these professions' reports, as shown in requests for information made to the PDBB, and the following describes the information the NPDB contains on them. The NPDB classifies registered nurses into five licensure categories: Nurse Anesthetist, Nurse Midwife, Nurse Practitioner, Clinical Nurse Specialist/Advanced Practice Nurse, and nonspecialized Registered Nurse not otherwise classified, referred to as Registered Nurse.

Only about 1 out of 100 Malpractice Payment Reports were for nurses, most for other-classified RNs: All types of Registered Nurses have been responsible for 3,139 malpractice payments (1.2 percent of all payments) over the history of the NPDB. Nonspecialized Registered Nurses were responsible for 62.7 percent of the payments made for nurses. Nurse Anesthetists were responsible for 20.7 percent of nurse payments. Nurse

Midwives were responsible for 9.2 percent, Nurse Practitioners were responsible for 7.3 percent, and Advanced Nurse Practitioners were responsible for 0.2 percent of all nurse payments.

Reasons for nurse Malpractice Payment Reports varied depending on type of nurse: Monitoring, treatment, and medication problems were responsible for the majority of payments for non-specialized nurses, but obstetrics and surgery-related problems were also responsible for significant numbers of payments for these nurses. As would be expected, anesthesia-related

problems were responsible for 83.4 percent of the 1,035 payments for Nurse Anesthetists. Similarly, obstetrics-related problems were responsible for 79.7 percent of the 459 Nurse Midwife payments. Diagnosis-related problems were responsible for 44.8 percent of the 368 payments for Nurse Practitioners. Treatment-related problems were responsible for another 23.9 percent of payments for these nurses. Of the eight reports for Clinical Nurse Specialists/Advanced Nurse Practitioners, five were for treatment-related problems, one was for an anesthesia-related problem, one was for a medication-related problem, and one was for a surgery-related problem.

Median nurse payment amounts were smaller than physicians', but mean nurse payment amounts were larger: The median and mean payment for all types of nurses in 2004 was $100,000 and $302,738 respectively. The median nurse payment was $70,000 less than the median physician payment ($170,000) but the mean nurse payment was $4,278 larger than the mean physician payment in 2004 ($298,460). Similarly, the inflation-adjusted cumulative median nurse payment of $101,392 was $22,886 less than the $124,278 inflation-adjusted cumulative median payment for physicians. The inflation-adjusted cumulative mean nurse

payment of $316,949 was $56,203 larger than the inflation-adjusted cumulative mean physician payment of $260,746. The mean payment amount for nurses was likely larger because there were relatively fewer nurse payments, which means one significantly large payment can impact

the mean more than if there were more nurse payments. The median payment amount was more representative of typical payments.

There was a wide variation in States' nurse Malpractice Payment Reports

compared to physicians' reports: Vermont had only 6 nurse Malpractice Payment Reports in the NPDB while New Jersey had the most (615). The ratio of nurse payment reports to physician payment reports (using adjusted figures13) for Vermont (with only 6 nurse payments) was one of

the lowest in the nation at 0.01, but 8 States had only one nurse payment report for 100 or more physician payment reports. In contrast, the ratio for Alabama, which was the highest in the Nation, was 9 nurse payment reports for every 100 physician payment reports. Four other States

also had ratios of 7 nurse payment reports for every 100 physician payment reports. There may be several explanations for differences in the ratio of payment reports for nurses and physicians, including possible differences in the ratio of nurses to physicians in practice in the State.

Physician Assistants had less than one percent of all Medical Malpractice Payment Reports, most of them for diagnosis-related problems: Physician Assistants have been responsible for only 912 malpractice payments since the opening of the NPDB (0.34 percent of all payments). Both cumulatively and during 2004, diagnosis-related problems were involved in about half of all Physician Assistant malpractice payments (55.8 percent cumulatively and 46.7 percent in 2004). Treatment-related payments were the second largest category both cumulatively and in 2004 (24.7 percent and 29.6 percent, respectively).

Payments in the diagnosis-related category for Physician Assistants were larger than treatment-related payments: Payments in the diagnosis category had a median payment amount of $100,000 in 2004 and a cumulative inflation-adjusted median payment amount of $103,215, while treatment-related payments had a median payment of $67,500 for 2004 and a cumulative inflation-adjusted median payment of about $35,052.

gizmo12 · Jan 31, 2007

"I enjoy what I do and have no regrets about my decision to pursue ACNP. However, I have to admit that the pay doesn't seem to commensurate the amount of work we do."

Do you think it is because they trained you that you are getting paid less that the amount of work you are doing would seem to warant? Do the PA-Cs get paid more?

Advanced Practice Columnist / Guide · Jan 31, 2007

Not necessarily, I think. It's an academic hospital located in an inner city setting with a considerable load of underinsured population. In other words, the hospital isn't really making a lot of profit. Compared to the market in the area, our hospital pays on the lower end since the other hospitals are located in affluent suburbs and have an insured patient base as well as private physicians on staff. I love where I am because of the learning opportunities I get and the high level of expertise available.

Not counting hospital benefits (medical, dental, 403B, pension plan), my W2 indicated that I am about a few hundreds short of having made six figures last year and I think I could have worked more OT last year. I think that's not bad considering I only have 2 1/2 years of NP experience and that the hospital paid for conferences, recertifications, professional association memberships as well.

All mid-levels get paid at about the same rate where I work. The difference is that PA-C's have different levels - there is the medicine PA, and then the surgical PA. The surgical PA's make more than the medicine PA's. With us NP's there used to be just one category with the pay scale similar to the medicine PA's. We insisted on making us a separate category - ICU NP. That has been accomplished and an ICU NP is started at a higher pay scale than regular NP's in the hospital.

Beaumont · Feb 2, 2007

the role

[color=#009999]the master of science in nursing (msn) acute care nurse practitioner program prepares graduates to function as advanced practice nurses in adult critical/acute care. the emphasis of the program is on clinical practice with acutely or critically ill adults that prepares practitioners to function autonomously across the spectrum of health care in a variety of settings. [color=#009999]

i'm sure this is a great program, but it would be nice if they used the term "autonomously or collaboratively". most acutely or critically ill patients are under the care of an attending physician.

np_wannabe · Feb 2, 2007

Not necessarily, I think. It's an academic hospital located in an inner city setting with a considerable load of underinsured population. In other words, the hospital isn't really making a lot of profit. Compared to the market in the area, our hospital pays on the lower end since the other hospitals are located in affluent suburbs and have an insured patient base as well as private physicians on staff. I love where I am because of the learning opportunities I get and the high level of expertise available.
Not counting hospital benefits (medical, dental, 403B, pension plan), my W2 indicated that I am about a few hundreds short of having made six figures last year and I think I could have worked more OT last year. I think that's not bad considering I only have 2 1/2 years of NP experience and that the hospital paid for conferences, recertifications, professional association memberships as well.
All mid-levels get paid at about the same rate where I work. The difference is that PA-C's have different levels - there is the medicine PA, and then the surgical PA. The surgical PA's make more than the medicine PA's. With us NP's there used to be just one category with the pay scale similar to the medicine PA's. We insisted on making us a separate category - ICU NP. That has been accomplished and an ICU NP is started at a higher pay scale than regular NP's in the hospital.

Hi PinoyNP.

I was wondering...how many hours per week do you work? and, since you are in a hospital, i assume you work in shifts? May I ask what a typical week's schedule looks like for you? I assume, though, that the downside to this is that you are still required to work weekends and holidays....:trout:

Thanks!!