MDs in house or at home

[OutsideRN]

Question regarding physician presence...

I have been a PICU RN for 10+ years, beginning at a large teaching hospital and then as a PICU traveler, again to all larger teaching hospitals, all where there are generally always multiple PICU attendings and NPs in house and available at all times, rarely working more than 12 or 16 hour shifts at a time, maybe one 24 hour shift at a time. Life has since taken me to smaller cities and to work in smaller PICUs (and no longer a traveler), and I am having a difficult time adjusting to the lack of provider presence at the hospital I am currently at, and also felt this way at a previous smaller facility I worked at.

For example, it is common for our PICU attendings to work 7 days in a row, 24 hours per day. One PICU attending, no NP help or anything. We are a smaller PICU, but still do have critical patients- level 2 trauma, intubated, EVDs, vasoactive drips, lots of complex medical and chronic patients. Not constantly.... sometimes we are dead slow with barely a few stepdown type patients, you never know. No cardiac, CRRT or ECMO. Our physicians generally do a great job with the workload they have, but are often exhausted, cranky, not in the mood to teach or explain, etc., and I cannot say I blame them. Night shift- we often have intubated patients and are titrating sedation and/or epi, levo, dopamine, vaso, and no MD in house- they are asleep at home, 15+ minutes away, titration orders in place, of course. This sort of situation makes me nervous, as even the most "stable" ventilated PICU patients can turn quickly the other way. I know my PALS, and generally feel proficient at my ability to troubleshoot emergent/critical situations- but I MUCH prefer having a doc down the hall versus 10 minutes away. We also do not have dedicated PICU RTs on the unit when we have vents.... our RT could be stuck in the NICU or ED for all we know. I have never had a patient code unexpectedly or self extubate, even tho I frequently go through these scenarios and my response in my head. I feel like things that are addressed 24 hours a day in larger PICUs are left for morning, to not disturb the often exhausted intensivist, and at times patient care definetly suffers for it- nothing major, at the moment, but little things add up.

What are your experiences with transitioning from a larger PICU with a strong provider prescense and lots of direction from docs to smaller PICUs with less? Do you feel that a MD should always remain in house with PICU patients? I'm not talking the more stepdown type of patients... I'm talking the intubated, vasoactive drip patients? Has anyone else felt like the care in smaller PICUs is a far cry from the larger ones- often due to the lack of available PICU intensivists in smaller cities and therefore the insane schedules and work weeks, as well as lack of other specialists and support staff? Starting to think that I am not cut out for this type of PICU nursing- I greatly enjoyed the work I did at larger facilities.... now, i mostly feel anxious and nauseous with any sort of critical patient. Am I being a wimp, and do I need to get over it? Or if critical care with a heavier provider prescense is what I prefer (even tho I LOVE living in smaller towns), should I be thinking of either relocating or switching to a different, less critical specialty? Any thoughts or other people with similar experiences?

[PeakRN]

I've known many pediatric and adult ICUs that don't have overnight intensivist coverage, including some very busy centers.

I refuse to work in any critical care setting that does not have 24/7 in house coverage. In my opinion things like having the ED or anesthesia cover overnight for codes/lines/intubations isn't appropriate, it needs to be someone familiar with that patient who has had sign out on them.

I'd also be very hesitant about a physician/physician group who is okay leaving their critical patients in the hospital with no critical care provider coverage. To me this seems like they don't value their patients enough, and don't have the correct priorities.