NP's in Non-academic Medical Center ICU's

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Hello,

I am currently an ACNP student and work critical care (16 MICU, 16 SICU, 4 CCU) in a rural hospital (360 bed total) in the Southeast. I have been talking with the Critical Care Medical Director (whom I am also precepting with) about the possibility of starting NP coverage for our critical care units. He is very NP friendly and loves to teach. He is just uncertain of how this model can be implemented effective in a non-academic, rural medical center with no residents/fellows. There is also not an MD in the units 24/7, actually, the only MD in the building after 7 pm is the ED MD (I know, right?). He has tasked me with determining whether or not NP coverage is feasible in this type of environment as well as finding if there are other similar facilities that are effectively using NP coverage in their ICUs. How would the billing work in this type of set up? Could an NP peform ICU procedures (intubations, CVL placements and etc) if there is not an attending MD on the unit?

The Critical Care Medical Director is very much for the idea, our biggest problem lies in the fact that the hospital itself essentially owns the intensivist group (they are not private practice), so we have to pitch the idea and get approval from the hospital in order to implement this model.

Any help/experience you can provide with this situation will be greatly appreciated!

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This should be doable. While most of the studies on this have take place at academic medical centers in response to loss of resident work hours, a number of community hospitals use PA and/or NP coverage to get 24/7 coverage. I wouldn't underestimate the issues including night coverage, vacation coverage and insuring continuity. On the other hand the benefits Leapfrog compliance, ICU LOS, more continuity, more time with patients outweigh this.

With the ICU numbers you have it should be pretty easy to justify 4 PAs or NPs during the day and 2 or so at night. On the average each PA or NP should produce around 60% of their time as billable time. Our group did an article on this some time back:

http://www.biomedcentral.com/content/pdf/cc11195.pdf

If you know your payor mix and acuity it should be pretty easy to build a business case. Caveats, it depends on your ICU census, patient acuity, and work flow for how many providers you need.

As far as procedures, our night team routinely puts in CVLs and A lines without a physician present. Depending on the area some perform intubations (we have 24/7 in house anesthesia coverage). We also cover codes on the floor.

Having the physician group hospital owned actually makes things easier in terms of employment and billing. Getting the hospital to hire is actually the problem (although with an optimized PA/NP team it should be revenue neutral).

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

You can perform procedures independent of physician presence depending on the credentialing process and how the actual credentialing document is worded. From a regulatory standpoint, state BON's don't have specific rules about procedures for the most part except for some that require a standardized procedure of some type which does not require physician presence (like California). TJC wants to see that there is a document and a policy in place for credentialing NP's. Our NP's also place all types of CVC's and arterial lines in all sites as well as intubate. We have a policy in place that each procedure must be performed with a training physician for the first few numbers depending on the procedure before the NP is independent (i.e., 10 internal jugular CVC's, 5 radial arterial line, etc.). In your case, the ED physician would serve as a back-up only.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

You could also show this study to pitch the idea:

Central Venous Catheter Placement by Advanced Practice Nurse... : Critical Care Medicine

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Umm not what I would use. First APN is not the same in the US as Australia. Second the paper deals primarily with PICCs and single lumen CVLs which is very different than what is placed here in the US.

The more definitive paper is here:

http://www.mc.vanderbilt.edu/documents/CAPNAH/files/NP%20and%20PAs%20in%20the%20intensive%20care%20unit.pdf

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

I offered that article in terms of using it to justify CVC placements by non-physicians. The technique for CVC placement is the same whether it is single lumen or quad lumen. PICC's are widely used in ICU's. We don't use our PICC team in the ICU, the NP's place them.

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Specializes in Internal medicine/critical care/FP.

sounds like my situation. 300 bed medical center with like 20 or so icu, ccu, cvu beds total. besides the er doc and a family practice resident on call, I'm the only provider in the building at most times of the night. usual i have like 4-8 icu cvu patients. critical care is available by phone call but they rarely will come in to drop a central line. and the ed doc will only do centrals in codes. i am an fnp, cannot intubate since it is not addressed in our contract with the hospital, and i do not do central lines. It is a pretty messy situation, but we handle it. life sucks when we can't get an iv at night.

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sounds like my situation. 300 bed medical center with like 20 or so icu, ccu, cvu beds total. besides the er doc and a family practice resident on call, I'm the only provider in the building at most times of the night. usual i have like 4-8 icu cvu patients. critical care is available by phone call but they rarely will come in to drop a central line. and the ed doc will only do centrals in codes. i am an fnp, cannot intubate since it is not addressed in our contract with the hospital, and i do not do central lines. It is a pretty messy situation, but we handle it. life sucks when we can't get an iv at night.

Take a serious look at IO's. Super easy to do. We are using them in all our code situations. They are good for 24 hours. Put one in at night when you can't get access. You can run just about anything through them.

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Specializes in Internal medicine/critical care/FP.

we use those sometimes, sorry I was thinking of awake patients not on the vent. We've only had to put in two IOs in my 4 months of being here thank gosh. your totally right though, without OIs life would be terrible lol!

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

That's worrisome that patients go without IV's just because no one can place them. Any provider who spends time taking care of ICU patients at night (or any hospitalized patient for that matter) should be taught to place central lines when nurses can't place IV access. It is not a complicated procedure and is a skill easily acquired with the right equipment and practice.

Better yet, any place no matter how rural it is should invest in a reliable ultrasound device with a venous probe (i.e., Sonosite) to help not only with central line placements but also with peripheral IV placements, a skill easily learned by bedside nurses. Most of the studies on nurse placed peripheral IV's using ultrasound-guidance are ED centered but our ICU NP's, Rapid Response Nurses and ICU Charge Nurses are all trained to use them for patients with difficult IV access issues.

Emergency nurses' utilization of ultrasound g... [Acad Emerg Med. 2004] - PubMed - NCBI

Principles of ultrasound-guided venous access

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Specializes in Internal medicine/critical care/FP.

I agree. They should let us but mid levels can't place them where I am at. I haven't yet been trained for it either. Messy situation that administration hasn't addressed. Our Er is the biggest in south eastern ky yet doesn't have bedside ultrasound. We still CT everything that walks through the door because of this. Welcome to rural ky.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

Bedside US does not replace Radiology-performed US and CT. The portable US device is a bedside tool that can help clinicians make important minute by minute decisions by looking at cardiac function, IVC compressibility, FAST exams, and venous and arterial access guidance. You will still need formal input from Radiology (for abd US and CT's) and Cardiology (for echocardiograms) in making the correct diagnosis in presentations that require the appropriate imaging study or you'll have to transfer the patient to a tertiary center that have these services 24/7.

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