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

[earthsalt]

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!

[chillnurse, BSN, RN, NP]

Nobody said anything about replacing it. It was an example to describe the lack of technology and assistance with iv access. And it can save some people from getting CTs. Just not an overwhelming majority

[Corey Narry, MSN, RN, NP]

Nobody said anything about replacing it. It was an example to describe the lack of technology and assistance with iv access. And it can save some people from getting CTs. Just not an overwhelming majority

like which patients?

[Corey Narry, MSN, RN, NP]

Well, I have an example...patient brought in as a code from the floor with syncope, was profoundly hypoxemic, had to be intubated, hemodynamically unstable on multiple pressors. We grab our bedside US and found severe RV dilatation/strain and we have a strong suspicion for a PE. Nurse and provider hesitant to travel for CT Scan to confirm diagnosis due to fear that patient will code en route. Called IR who agreed that this is likely PE based on clinical presentation and history. We all agreed to take the patient directly to IR suite with provider, nurse, RT accompanying for CTA and catheter-guided tPA embolectomy for a saddle PE. Patient did well afterwards. We saved the trip for a CT PE protocol but the patient still needed a higher level diagnostic procedure and intervention. The bedside US did help make the diagnosis.

[chillnurse, BSN, RN, NP]

Emergent rule ins that need or

[Corey Narry, MSN, RN, NP]

We may not be thinking of the same thing. When I say bedside ultrasound, that means use of a portable ultrasound device by a critical care provider. The device can be part of the equipments necessary to run an ICU or an ED similar to how you could make sure there is a Glidescope for difficult intubations. All our 5 adult ICU's have a dedicated device or two in each of the units.

If a formal ultrasound is needed to make a diagnosis, you still have to order it as a procedure performed by a Registered Sonographer and read by a Diagnostic Radiologist for many reasons, legal repercussions of scope of practice being one. That's what I mean when I say that bedside ultrasound as a clinician-performed tool does not replace actually having to order an ultrasound study or CT scan in scenarios that call for their use.

[chillnurse, BSN, RN, NP]

I think I just meant for very emergent situations which if a bedside US performed by the er physician or np or pa or whatnot found something extreme in an unstable patient (insta surgery call in type situations) I haven't seen it in real life yet though, since we don't have it. Past that I don't know much about bedside US, at least until they start using it. We don't even have diagnostic ultrasound at night, unless called in. bleh