ICU Nurse Practitioners in teaching hospitals

Advanced Practice Columnist / Guide · Apr 13, 2018

I work at an academic medical center as an ICU NP on the West Coast. By academic, I am referring to a university hospital with affiliated medical, nursing, pharmacy, rehabilitation sciences, and dental schools. One thing about academic medical centers is that you will always have a hierarchical structure in everything and that applies to MD-NP collaboration models. The attending physician (who is also a faculty member) will be the ultimate person responsible for a specific patient. As academic medical centers go, there's always a physician faculty expert for every condition that the hospital treats and in many cases multiple teams of providers care for a single patient.

I happen to work at an institution that welcomes interdisciplinary collaboration especially between nursing and medicine. The institution is NP-friendly and the affiliated nursing school has a number of highly ranked NP programs (per US News for what that is worth). We have enough autonomy to do procedures (lines, intubations) but the overall care of each patient is dealt with in a team approach model. That's not to say that an NP is unable to manage an admission in the middle of the night because for sure, that is what happens when the entire "team" is no longer present at the bedside.

The other aspect of this environment is the requirement that the NP should be able to work with fellows and residents as well as NP students and medical students. The NP's have their own patients of course and does the procedures, notes, and orders on their own patients. But we must be able to also work alongside providers and providers-in-training in a teaching environment.

I won't discuss pay and location here but you are welcome to PM me.

allennp · Apr 27, 2018

Well said.

SopranoKris, MSN, RN, NP · Apr 27, 2018

I work at a teaching hospital in the ICU and we have NPs, particularly in CV surgery and pulmonary. During the day, the NPs I've seen mostly assist in surgery and round on surgical ICU patients. At night, the NPs actually do quite a bit more. As we all know, in a teaching hospital, the residents are the ones running the show at night (with the attending on-call). The NPs usually have more experience than the residents and end up doing difficult intubations, central line insertions, etc., if the residents failed the first attempt. It's a fairly collaborative environment. During the day, they do multi-disciplinary rounds each day with the attending, fellow, residents, med students, NP/PAs, dietician, PharmD, respiratory & PT/OT.

As far as pay, there is a pay scale based on years of experience. Most of the entry-level NPs in ICU were ICU RNs prior. There are some NPs who are hospitalists in the step-down & med-surg floors, but I've mostly seen them at night. The ED & trauma units have NPs 24/7, but it's definitely a good mix of NPs & PAs.

Jules A, MSN · Apr 27, 2018

The NP's have their own patients of course and does the procedures, notes, and orders on their own patients. But we must be able to also work alongside providers and providers-in-training in a teaching environment.

How do they handle the requirement of a physician co-signer for your medicare patients?

Advanced Practice Columnist / Guide · Apr 29, 2018

How do they handle the requirement of a physician co-signer for your medicare patients?

It's built in to Epic our EMR. When a patient is admitted, the initial order that says "Admit to in-patient under Critical Care with Diagnosis X" is routed to the attending who co-signs it.

allnurses Guide · May 17, 2018

I work in a SICU which is primarily cardiothoracic. I am an ACNP. "Autonomy" is in the eye of the beholder, and is a limited thing when cardiac surgeons are involved; its an open ICU.

I have my own patient load (I see half the patients and the residents see the other half), then round with the ICU attending then multidisciplinary team and present my patients, my assessment and my plan. Attending may have input or agree with my plan. I do procedures independently such as limited bronchoscopy, intubation, central lines, arterial lines, pigtails. Attending is present on the unit for intubations. I bill for my own procedures and for my critical care time under my NPI.

PollyJ · Jun 8, 2018

Does your attending have to see all of your patients or do they just cosign your notes?

Advanced Practice Columnist / Guide · Jun 9, 2018

Does your attending have to see all of your patients or do they just cosign your notes?

In our case, we both see the patients during the day. The attending is ultimately responsible for the patient's management and any outcomes so it makes sense that they are involved in all the patients. During the hours that the attending is no longer in house, the NP's do make decisions on their own based on our scope and training with back up from an ICU fellow. The attending is called for issues and may need to come in if the situation calls for it.