Help w/ overnight ICU coverage

[MaxAttack, BSN, RN]

I work in a 15 bed ICU in a community hospital. We have no intensivists - all patients have an admitting doctor with consults as needed. It works most of the time, but the problem we're having is when we have patient's deteriorating and we don't have time to wait at 3 in the morning for a physician to wake up and call us back. The only time we can rely on the ER docs is in the event of cardiopulmonary arrest.

I've seen solutions here like eICU's, but I can guarantee you management won't even consider something at that cost. The obvious solution would be to have ER docs step in sooner, but they complain about their own ER patient load and not wanting to give orders on patients they don't know as it is.

How do other hospitals handle this?

[Corey Narry, MSN, RN, NP]

Acute Care NP's or ACNP's.

I work full time as an ACNP at an academic medical center with all levels of physicians in various adult ICU's. Clearly, no issue with night coverage in this setting but I also moonlight as a per diem ACNP at a smaller community hospital with a mixed 14-bed Med-Surg-Neuro ICU. The intensivist are only present during daytime hours. Nights are covered by ACNP's who admit and manage patients during the night. They intubate, place lines, order meds, etc.

[MaxAttack, BSN, RN]

Thanks for the quick reply. Having a constant overnight presence would be the best possible outcome, but there's a couple sticking points. First, we have several physicians that admit to our unit and from there several physicians within each specialty. Each would have to be ok with someone in-house making decisions on their patients. Getting approval from every group sounds like quite the steep challenge. Second, and probably the biggest problem, is the massive cost increase of having an overnight mid-level presence. We're a community hospital with a limited budget. It sounds like the hospital you per-diem at likely had this set up before you arrived, but any idea how they justified the additional cost expenditure?

Thanks for your time. I'm going to be bringing some solutions to administration and I'm trying to at least start working out issues that are going to be brought up.

[Corey Narry, MSN, RN, NP]

It looks like it is going to be challenge since you do not have the intensivist nor a hospitalist model to begin with. Who is the ICU director then? Is he/she a Pulmonologist? I think the first step would be to speak to that ICU Director because if anything that would be the person to start such a program.

NP's are credentialed providers in a hospital setting. They must be approved to act as providers (admit, order stuff, perform procedures) by the hospital's medical affairs board. That is why an MD (ICU Director) must be supportive of such a model in order to advocate for their presence and rally his troops (the other physicians who admit to the ICU) to support the idea.

NP's do not act independently in many states. In an ICU, many big decision made by NP's at night can be discussed with an attending physician (i.e., intubation, line placement, starting a pressor). However, orders such as labs, EKG's, meds for pain or nausea and such, would be easily entered by an NP without having to consult with a physician first.

In the community hospital I work at, the NP's are actually hospital employed. Some hospitals prefer this because though the NP's are an additional cost, their presence makes the unit safe when patient events are addressed before they become serious and more costly. There are other ways NP's can be employed including being part of the medical group (i.e, working under the ICU Director). NP's can bill for their services like MD's do if they are part of the medical group, hence, can be a revenue opportunity rather than a cost to the system.

SCCM has existing literature on NP's and PA's in ICU: SCCM | Workforce

[MaxAttack, BSN, RN]

Our ICU director is a MSN-prepared administrator and yes, everything will have to go through her. She would love an intensivist as much as any of us, but the cost will always be an issue.

The mid-level approach is a great idea and is already being utilized in the ER and by some of the specialists. I'll look into the link you provided and do some additional research to present.

The only other idea I could come up with is eICU technology, but on a as-needed instead basis instead of the typical whole-unit implementation. This would reduce the up-front cost while still allowing us access to a physician in emergent situations.

[Wile E Coyote, ASN, RN]

Our ICU director is a MSN-prepared administrator and yes, everything will have to go through her.

Juan is referring to the MEDICAL director of said unit. There is physician oversight for surgery, ED, medicine, etc. in some configuration in your hospital. This person's opinion on the matter will make or break your plan.

To be honest, it's quite likely the nursing director you referred to will have little to no sway in the matter (in the opinion of the medical leadership)