eICU

[codeb1ue]

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Do any of you have experience working in an eICU? I saw an opening for a position for one in my area but don't know exactly what it entails. How different is it from the standard in-facility shifts? Thanks in advance.


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[G-Man82]

I'm actually in an eICU now. The model we use is one where physicians are present on nights, weekends, and holidays and it's pure shift work, which is nice. But I'm credentialed at all the sites, which can be a pain, and I have access to all the EMRs and can place orders. The camera system is powerful enough that when zoomed in I can read the ingredients off an IVF bag.

The system works well when there are residents or affiliate providers at the bedside so that at least someone can place lines and do quick bedside procedures. I'll tell you this though, it definitely gives you insight into community practice and at times, it's horrifying what people get away with.


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[codeb1ue]

I'm actually in an eICU now. The model we use is one where physicians are present on nights, weekends, and holidays and it's pure shift work, which is nice. But I'm credentialed at all the sites, which can be a pain, and I have access to all the EMRs and can place orders. The camera system is powerful enough that when zoomed in I can read the ingredients off an IVF bag.

The system works well when there are residents or affiliate providers at the bedside so that at least someone can place lines and do quick bedside procedures. I'll tell you this though, it definitely gives you insight into community practice and at times, it's horrifying what people get away with.


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Thanks for the response. If you don't mind, I have a few follow up questions.

What is your day to day shift like? Are you just staring at telemetry monitors? Are you "rounding" by looking at every patient and reviewing all the data and calling consults from afar if needed? Or are you just hanging out browsing the web and answering pages/calls as needed regarding urgent situations. Also what do you do when there isnt an affiliate provider? How do you handle crashing patients and stuff.

 

[G-Man82]

Depends on the model. For us, we can be either very active or just there to put out fires. In general though:

Day to Day. We're 12-hour shifts. Receive sign-outs from the attendings at most of the hospitals and then get to work. We are required to "see" new patients, though that doesn't always mean I write a note. If things go wrong in one unit, they'll hit the button and I'll pop up on screen. If it's a code, I'll help direct it. For new admits, if I need a consult I'll call. My eICU RNs will also help by monitoring. They are the ones who often triage for me and also stare at the telemetry monitors.

Usually, though, I see myself as someone to put out some of the night-time fires that occur and I serve as a resource for some of the residents on duty overnight and for any affiliate providers. In hospitalist-run ICUs, I serve as their CCM consult at night. You'd be shocked at what happens in some of those units that would normally be second nature to us.

There is often down-time for browsing the web. Sometimes there's something happening somewhere and you're kept busy. But at the end of the shift? You sign off and leave. Done.

Some units just have RNs. Those are frustrating but also somewhat rewarding. For things like line placements and intubation, you (or the RN) will call either the ED/Anesthesia etc. Often, you see a different standard of care that is appalling ... just realize that they work at a different level than you're probably used to. At the same time you really change the course of some of those patients.

Hope this helps. A lot of it is MICU based but we cover a bunch of CVICU in the eICU system as well. I'm an Anesthesiologist, but seem to handle the MICU stuff without trouble.


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[lilzelda2]

How does malpractice work in the eICU, especially in regards to procedures. Would you recommend it to people who are interested and what are some the negatives with it as a practitioner?

 

[G-Man82]

I essentially order procedures or the APPs do them on their license and send the note to the Attending on service, not me. So I doubt there's any liability on my end, especially since I'm sometimes 200 miles away. As far as liability otherwise, I'm really not sure. If anyone has a better answer I'd love to know too.

For the most part, I'm a consulting attending because I literally cannot touch the patient. My assumption is liability is limited to what I can and cannot do. If I make a bad call, then sure. But if I'm there putting out fires, then who knows?


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[Laryngophed]

How does malpractice work in the eICU, especially in regards to procedures. Would you recommend it to people who are interested and what are some the negatives with it as a practitioner?

I wondered about this. Four of the places I interviewed were hawking eICU as a strength, but I wondered how that works with a crashing patient who needs procedures. Are you on the hook if the midlevel can't do them? What other liability do you assume in that role?

 

[G-Man82]

You can always have them consult out for the procedures. Or if it's a place where midlevels don't exist, then usually you call surgery, EM, or Anesthesiology depending on the hospital. One of the places I staff via eICU, I call Anesthesiology. They cover L&D at night and so are in-house. If nothing is happening, then they usually come by. Same thing with the hospitalists. At another place, surgery is on the hook for overnight lines. Some places have the ED Attending do them.


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[deleted171991]

I wondered about this. Four of the places I interviewed were hawking eICU as a strength, but I wondered how that works with a crashing patient who needs procedures. Are you on the hook if the midlevel can't do them? What other liability do you assume in that role?

Very curious about liability with eICU myself. It's like supervising anesthesia cases remotely while relying on somebody else's non-handpicked CRNAs.

 

[EMIM2011]

Does anyone know what the typical compensation is?

And how about documentation? Do you write essentially a consult note on every new patient that is admitted during your tele shift?


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[G-Man82]

Not sure what typical compensation is for outside eICUs. Where I am, a voluntary shift actually pays more than an OR shift with, in my opinion, a lot less work and many fewer layers of BS politics.

Documentation really is minimal, at least where I am. A few lines really. We're not writing consult notes. We're an extra layer of care. But then again, what needs to be in a critical care note? 1. The patient is critically ill. 2. CC minutes non-overlapping. 3. Conditions you managed. We don't need to wax on about the way the dude presented or list 14 differentials. Where I am, we are to "see" the new admits and put in a brief note at some point. Also realize that many third party payors don't reimburse eICU, so the money has to come from somewhere.


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[Brahnold Bloodaxe]

Do you guys foresee this "eICU" trend having a deleterious impact on the job market if/as it becomes more prevalent? Presumably there will be ways to leverage IT to increase productivity per CC doc and thus reduce the overall demand. Ie, instead of a CC doc being physically in an ICU of 10 beds with downtime between "actions," that same CC doc could be located remotely and manage the equivalent of ~30 (or whatever) beds through work flow algorithms that assign him a new patient as soon as he is finished with the previous one.

 

[maverickdoc]

Do you guys foresee this "eICU" trend having a deleterious impact on the job market if/as it becomes more prevalent? Presumably there will be ways to leverage IT to increase productivity per CC doc and thus reduce the overall demand. Ie, instead of a CC doc being physically in an ICU of 10 beds with downtime between "actions," that same CC doc could be located remotely and manage the equivalent of ~30 (or whatever) beds through work flow algorithms that assign him a new patient as soon as he is finished with the previous one.

I doubt it , eICU coverage is mostly for night time in small/ midsize hospitals that can't afford a night intensivist and use hospitalists/ nurses to douse fires overnight . It might increase career opportunities imo

 

[G-Man82]

It also exists in academic centers and the VA.


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[CCM-MD]

Do you guys foresee this "eICU" trend having a deleterious impact on the job market if/as it becomes more prevalent? Presumably there will be ways to leverage IT to increase productivity per CC doc and thus reduce the overall demand. Ie, instead of a CC doc being physically in an ICU of 10 beds with downtime between "actions," that same CC doc could be located remotely and manage the equivalent of ~30 (or whatever) beds through work flow algorithms that assign him a new patient as soon as he is finished with the previous one.

The first battle is going to be getting insurance to pay for it. Can't bill critical care time on eICU notes, which is how intensivists generally pay for themselves. I know of one hospital system that does eICU and they are paying for it out of their pocket. If it does become more popular I think it will create more opportunities and improve quality of care. Small hospitals in not so desirable areas that can't get an intensivist will have access to one.

Hard to predict the future but even if it does become more popular, I doubt it will have any impact on the "demand" for the next 10-15 years. To put things in perspective, I remember reading somewhere that around half of all critically ill patients in the country are cared for by intensivists.

 

[tartesos]

The first battle is going to be getting insurance to pay for it. Can't bill critical care time on eICU notes, which is how intensivists generally pay for themselves. I know of one hospital system that does eICU and they are paying for it out of their pocket. If it does become more popular I think it will create more opportunities and improve quality of care. Small hospitals in not so desirable areas that can't get an intensivist will have access to one.

Hard to predict the future but even if it does become more popular, I doubt it will have any impact on the "demand" for the next 10-15 years. To put things in perspective, I remember reading somewhere that around half of all critically ill patients in the country are cared for by intensivists.

It's not only places that can't get one( for enough money one can go anywhere), is the majority that can't have enough to cover at night, vacation etc. eicu is promising and here to stay.


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[G-Man82]

Billing is an issue. Most insurances don't pay for the 0188T and 0189T codes. These are the telemedicine equivalents to 99291 and 99292.

Some hospitals however will pay a set fee for eICU services directly to the system that offers eICU. In academics, this one doc also ends up being the fireman for in-system ICUs that participate and so there isn't a physical attending in-house at night. Pluses and minuses to that.


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[CCM-MD]

Billing is an issue. Most insurances don't pay for the 0188T and 0189T codes. These are the telemedicine equivalents to 99291 and 99292.

I suspect that the billing issues are being worked on behind the scenes. I saw an interesting CMS report about Emory's eICU program a few months ago that showed millions in savings over the span of a year.