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ghillbert MSN, NP

CTICU

Content by ghillbert

  1. ghillbert

    Sepsis, causes,vitamin c?????

    Follow up - Vanderbilt and Johns Hopkins are about to start a multi center RCT into VitC/Thiamine/Steroids for septic shock.
  2. ghillbert

    DNP vs MD

    LOL I missed these last few posts until now for some reason. I made no threatening statements and find that statement pretty laughable. I think I was very clear that I feel you cannot possibly compare medical school to NP school. I have great respect for my physician colleagues. My comment was very clearly directed to the medical students and/or inexperienced residents on SDN who feel the need to make every mention of an NP into some kind of adversarial mission. "They will learn" refers to the fact that generally physicians gain more, rather than less, respect for their APP colleagues over time and with experience. ie. literally, they will learn better. Sorry you felt so offended for your SDN pals.
  3. ghillbert

    Walden PhD

    Their admission requirements are $$$, transcripts and "work history". No recommendations required, no true admission criteria. I would be wary of such a program, depending on what you want to get out of it. The most important thing I think for a PhD is to find a place with faculty whose research interests match yours.
  4. ghillbert

    Chatham vs NOVA DNP program

    I applied for spring start also :)
  5. ghillbert

    Anyone do Transitional Heart Failure??

    Congrats - sounds great! I work on the other end with CTICU heart failure patients when they get LVADs etc. They certainly have a high burden of care in the community and so many meds to keep up on etc - sounds like an awesome program you will be starting.
  6. I don't know if that was meant as a dig, but you won't get a very good reception by describing our practice and profession as "mid level practice of medicine". It's a pretty simple concept - nurse practitioner is an ADVANCED PRACTICE NURSE. You can't be advanced with out being basic. The point is that the medical knowledge gained in NP school builds on to the RN education and experience. How much it affects NP outcomes, you can decide for yourself, but obviously it's clear where that comes from. If you want to be a PA, go do PA. I probably would if I had to choose again, just for the ease of moving around different specialties (get a new job, get on the job training) versus having to go back to school for everything as an NP.
  7. ghillbert

    Critical Care interview

    Things I'd want to know - are you an admitting or consult service? - will you (NP) be doing notes and billing for critical care? for E/M services? both? - who will be your preceptor and how do they teach - how independent do they see you being? - what do they consider valuable in your role? - what kind of outcomes or quality data do they collect? how do they use it? - will you have an opportunity to participate in research or QI? - any teaching responsibilities?
  8. ghillbert

    Initial Prescription Limits

    Go to the source of the regulations, as the pharmacist should do: https://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf The rules prior limited Pennsylvania CRNPs to 72hr dose of Schedule II and 30d of Schedule III or IV. The bulletin regarding the 2009 changes: PA Bulletin, Doc. No. 09-2276 Additionally, your prescriptive authority agreement on file with the state specifically spells out what day supply you are authorized to prescribe, as should your hospital collaborative agreement.
  9. ghillbert

    For-Profit NP admissions... I thought they were joking!

    What are you not understanding? I think people were fairly clear in their criticisms of the program. I am not sure what your point is. As has been stated multiple times, not all students at Walden or other for-profit schools are terrible. Many are just fine and smart and will do well. However the school is NOT doing anything to safeguard patients by implementing even minimum admission standards (beyond an ability to pay the bills). If you are a patient advocate and you don't see anything wrong with that, I am not sure how to explain it. I know after a google search which one I would call for an appointment first... Several things - Walden isn't the only program criticized. It's just one of the more aggressively recruiting ones, so people have heard of it. Any program with NO admission standards beyond financial ability, is doing a serious disservice to patients, students and the NP profession as a whole. If school reputation isn't important, why did you tell us that your former instructor went to Pitt and Syracuse? Exactly - those names impart an understanding of what caliber of degree she obtained. This is precisely what places like Walden jeopardize. You have chosen your path, and that's fine, and hopefully you will be very successful. Nobody is doubting that. The point is that many of your classmates who will also graduate will NOT be of an acceptable clinical standard, but they'll also be given a diploma. If you are a serious student who works hard, that should annoy YOU more than anyone else.
  10. ghillbert

    Tips for New Critical Care NP

    Agree with most of the above. - Read, read, read. - Listen to everyone (nurses, RT, specialists, ccm), but don't act on every suggestion, or that's all you will do all day. You have to sort and filter the input you get, and with time you get better at triaging whose advice to listen to and act on immediately. It takes a long time to develop your own instincts. - Err on the side of caution, always, particularly with invasive procedures. If you can check something twice, ensure that they are acting safely, do it. If you ever get a bad, sinking, gut feeling - ask your CCM for help. There's often a valid reason you are worried. - The seasoned ICU nurses need you stat? Go. They have probably already tried several interventions, before they ever even thought of calling you. This is good and bad. But be warned that if they need you, they generally REALLY need you. - There is a high turnover of ICU RNs because it is very demanding and not for everyone. Be supportive of the RNs, teach where you can, but don't get sucked into a beginner RN's paranoia. Listen to their concerns, explain what they should be watching for, and leave it. - Treat the patient, not the numbers or data. It's easy in ICU to collect infinite labs and numbers and values- these are irrelevant if the patient looks perfect with a paO2 of 54, or crap with a paO2 of 100. - Don't forget to ASK THE PATIENT or their family stuff you don't know. ie. what year they had such-and-such done, why they are on this med, how long this has been happening. So often people now rely on the EMR, which is only as good as whatever the past people entered. - Use the available resources. SCCM membership is a must, use their website and get involved where you can. - All your collaborating intensivists may tell you a different way of doing something. Don't get too attached to a particular way, or say "but so and so said xxx". Just listen, ask why they do it that way, try it their way - and when you are more experienced, you can take pieces of each advice and come up with how you prefer doing things. Just collect information and skills as a newbie. - Don't try to be an ICU nurse. The transition at times can be tough, and sometimes to engender collegiality, you have to jump in and reposition a patient, or help with some "nurse duties" - continue to do so, but don't forget to delegate non-APP tasks too. There's not much you can totally learn before starting - its a constant learning process to work in critical care!
  11. ghillbert

    ICU NP/PA schedules

    We currently just have 2 ACNPs for a 24-bed cardiothoracic ICU which is very high acuity and busy. We round, do notes and bill on our 6-12 patients, do procedures, allocate patients to any residents/students we have on service, do signout for the night intensivist. We are having trouble getting out on time as posted are still rolling in right when we try to leave. The second NP just started, prior to that I was working Mon-Thurs 6-4, no holidays or weekends. She accepted the job with the director's agreement to move to 3 day weeks. Now I am trying to work out the best schedule. I don't want us to start covering weekends and holidays without the employer reviewing the pay rate because I accepted the job at the current rate for weekday hours. What do you do for APPs in your ICUs? Do you do 3x12 and have staff be 0.9 FTE? Or 14/13/13 for 1.0 FTE? What shift times? Do you have a shift differential built into your pay scale? If there are 2 of you there on a shift do you stagger shift hours or both work same time? Did your shifts/schedules change as you added more providers? Thanks for any help with this!
  12. ghillbert

    ICU NP/PA schedules

    Thanks! I am really trying to pinpoint who is the keeper of the data... it's hard bc the ICU is mixed cardiac surgery, vascular, thoracic, transplant... and all the primary services seem to keep and track their data differently. I don't see a central ICU method of tracking the data or monitoring quality outcomes so I would like to implement such.
  13. ghillbert

    ICU NP/PA schedules

    Sorry for confusion. By this I mean the APP is working in critical care, seeing patients and managing issues during the day. The physicians round, see patients in person and complete exam, discuss as multidisciplinary group, and then physician bills cc. It was very difficult for me to explain why APP care was different than resident/fellow in that they could not attest/addend the cc note by an APP and bill for it. I understand that in billing land, you can't share cc, but in practice the APP doesn't see patients entirely independently in that unit. Since attendings round, examine patient and participate in plan, they feel they should be able to bill. I told them then they have to have APP write a 99233 and bill that and have it attested and billed at 100% by physician, but they can't do it with CC codes. That's nice, I don't think our software has that ability. My billing is just through Epic but admittedly no-one at my hospital has any idea about APP cc billing so it's hard to get answers about anything lol. Makes sense. Interesting. I know my RVUs are high bc I see about 12 patients per day. It sounds amazing at some of these bigger systems with more established APP programs and infrastructure. We are interviewing for an APP Director so hopefully my institution gets on board with investigating some of this stuff. Thanks for your valuable input as always, David. I appreciate your time.
  14. ghillbert

    Any Hospitalist APRNS?

    Is the collaborating physician actually seeing all the patients as well as you seeing them? Or just signing notes and billing?
  15. ghillbert

    ICU NP/PA schedules

    One more critical care question re billing: - Those of you that have the physicians rather than APP bill for critical care - how do you track APP productivity apart from RVUs and billing? I have one ICU where the docs' compensation is not RVU based, and they are happy for APPs to bill critical care time or E/M. In the other ICU, the docs are RVU based, and want to capture 100% of the billing (E/M and critical care) by Attendings. In that case how can the APP not be invisible in terms of productivity?
  16. ghillbert

    New NP Job Not What I Thought...

    Good luck. And remember next job - get all these pre-employment promises in writing!
  17. ghillbert

    Brick and Mortar AGACNP Programs

    I did brick and mortar and found a lot of it redundant - lectures particularly that were available by PPT prior to class - I didn't see the need to go to a class to have a teacher read out slides I could read in the quiet of my own house. I did find the small group classes, assessment labs, simulations etc very helpful in person. I went to Pitt.
  18. ghillbert

    How much debt would you go into for NP school?

    My MSN was around $35k. I did not go into any debt as I saved and worked full-time to pay for it. I had tuition assistance from my employer and a few small scholarships but essentially paid from savings. I would not go into any more debt than that. I found the cost worth it as the difference in pay rate meant that I the degree would pay for itself with a few years. There are doctorate programs I would KILL to do, but I just can't justify spending $60-80k on something that won't increase my income.
  19. ghillbert

    What is a challenging specialty

    I am a similar nature and went right into critical care as a new grad and have loved it and found it endlessly challenging for 20 yrs. I am now an ACNP in critical care and I still learn things I don't know every. single. day.
  20. ghillbert

    CCTN Transplant Nurse Certification Study Advice

    I did CCTC. It was the hardest certification I have done, including CCRN, subspecialty CC certs AND my NP cert lol. Mostly because it covers every organ transplant including pediatrics so it was a lot of "not my specialty" that I had to learn. And to be honest, I did not study a LOT. I read the core curriculum a lot and went over bullet point stuff. -I recall a lot of what would you tell the patients if they called and told you XXX which was meant to assess your understand of the disease process and the transplant management and meds. -Know the meds back and forth, classes, common side effects and what the patients will notice especially -Know signs and symptoms of rejection for all organs very well, esp the organs you don't work with -I remember for kidney and pancreas there was a lot about checking urine versus serum labs and how you tell if the organ is failing -Resist the temptation to study what you know; focus on all the organs you are unfamiliar with. Good luck - it really was very educational to study for, and I learned a ton. I agree re the specialty board!
  21. ghillbert

    Sepsis, causes,vitamin c?????

    We use Vit c/Thiamine/Steroids for patients in septic shock with hypotension refractory to multiple vasopressor agents. Unclear if it helps - not enough evidence and the patients are at death's door when it's added. It's more of a "shouldn't hurt them and may help so let's do it"
  22. ghillbert

    ICU NP/PA schedules

    Thanks again, guys - this is super helpful! I think I'd die doing 24hr shifts, babyNP - although I have friends that do and they love it. It would be nice to work that few shifts per month and perhaps be able to have a)good QOL or b)ability to work a second job
  23. ghillbert

    New NP Job Not What I Thought...

    You're a psych nurse, now having to do dressings in home health? What is your NP certification? I agree I would clarify the role responsibilities in your job description. I certainly would not be acting outside my education and certification/legal scope. I am also in a new position and the first NP in this type of role. Some confusion and having to feel your way around is normal, but switching your clinical responsibilities, doing the work of a home health RN is not normal. Better to have the wrong job for a month than for a year. If it's not changing, I'd start looking elsewhere.
  24. ghillbert

    Australian Nurse wants to work in USA

    -I had a job in PA which at that time required CGFNS exam, so I applied for initial licensure in Vermont and then endorsed my license to PA. - I fully expected to be deficient in OB and/or pediatrics, so I completed modules at Deakin Uni in preparation but my transcripts were evaluated by CGFNS CES evaluation as consistent with US nursing degree (I went to Deakin in Melbourne in the mid 90s) - I arrived as an NP with a partially completed MNP from Australia. I then applied and completed MSN in Acute Care Nurse Practitioner while I was working here, and for the past 5 years have worked as ACNP.
  25. ghillbert

    Strange question

    It's pretty clear if asked if you currently have HTN - no. If asked if you have a past history of HTN or have ever been diagnosed with HTN - yes. If asked if you have ever had a suicide or self-harm attempt - yes.
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