APP (NP/PA) staffing trends in ICU

[chocomorsel]

Attending.
Never seen my department chair being pushed to hire someone by admin without asking & approving.
Sure for anesthesia. ED and CCM are not dependent on surgeons money.

Good for you. But I mean we don’t bring money to hospitals via sending in patients.
I am a locums so don’t see the inner workings. Often times I think the docs are on board. The ones who aren’t tend to get outvoted.

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[chessknt]

Im curious how many nights a month the guy who wants 24 hour in house doc coverage actually works? Are you answering primary pages on these shifts?

Also: How do you reconcile the garbage billing with the huge cost to actually get someone to work at nights? Just the hospital has to find it and pay it because its the right thing to do?

 

[Katheudontas parateroumen]

This whole mid level stuff has been a doom from the beginning by allowing independent thought from people without full medical training ie medical school and then residency/fellowship. We allow them to play doctor without the credentials. I believe mid levels should not be anymore than scribes. You can collect info and regurgitate it to me and then I tell you the plan and you put in the orders and I tell you what I want in the note. Sure it makes it harder work for us, but thereby we provide better care and they are truly just playing the role of an assistant which is still valuable. But at this point, there doesn’t seem to be any way going back. I think as physicians we have to continue to play but also up our role where we can. As in, I’ll do that intubation, line if I can instead of pawning it away to an eager mid level. We need to be more present and assert our respect, check up on patients often instead of the once daily rounds that’s pervasive in medicine. At the end of the day, I still hear patients say they want to speak with the physician. So patients want doctor care still!

 

[deleted126335]

Alright. I give you that.
But what do you mean “doing the math?”

deciding whether or not to hire more CRNAs or work the docs ever harder. Deciding whether or not to train CRNAs in labor epidurals or cover all the OB with MD only, etc.

 

[chocomorsel]

deciding whether or not to hire more CRNAs or work the docs ever harder. Deciding whether or not to train CRNAs in labor epidurals or cover all the OB with MD only, etc.

Well if you can’t bring on more MDs, then sure. I will give you that.
But there are are plenty of practices who would rather bring on less MD and more CRNAs in order to keep a larger piece of the pie. That makes me question their intent long term.

 

[FunnyDocMan1234]

I don't really see the problem (maybe in SICU when an attending surgeon is still involved in the patient's care but definitely not in MICU). No family will ever be ok with asking to speak to the ICU doctor when their loved one is in septic shock on a vent and being told "there is no physician, the MICU-trained NP is in charge." So it's impossible for MICU attending jobs to get replaced, and we get the huge benefit of having APPs to be frontline providers (there aren't enough residents to work everywhere) so our jobs don't include being getting paged incessantly by nurses to change orders. Finally, home call with someone to do the grunt work is way better than in-house call.

 

[thorwayCC]

I don't really see the problem (maybe in SICU when an attending surgeon is still involved in the patient's care but definitely not in MICU). No family will ever be ok with asking to speak to the ICU doctor when their loved one is in septic shock on a vent and being told "there is no physician, the MICU-trained NP is in charge." So it's impossible for MICU attending jobs to get replaced, and we get the huge benefit of having APPs to be frontline providers (there aren't enough residents to work everywhere) so our jobs don't include being getting paged incessantly by nurses to change orders. Finally, home call with someone to do the grunt work is way better than in-house call.

so your only reasoning is that family wont be ok with it? .. What if they suddenly ok with it, no need for intensivist?

 

[bronx43]

I don't really see the problem (maybe in SICU when an attending surgeon is still involved in the patient's care but definitely not in MICU). No family will ever be ok with asking to speak to the ICU doctor when their loved one is in septic shock on a vent and being told "there is no physician, the MICU-trained NP is in charge." So it's impossible for MICU attending jobs to get replaced, and we get the huge benefit of having APPs to be frontline providers (there aren't enough residents to work everywhere) so our jobs don't include being getting paged incessantly by nurses to change orders. Finally, home call with someone to do the grunt work is way better than in-house call.

I’m at a large tertiary care academic center. Most units are run by midlevels and the attending drops by once a day for 2 hours to “round.” Families have no problem speaking to the midlevels...

 

[CCM-MD]

I’m at a large tertiary care academic center. Most units are run by midlevels and the attending drops by once a day for 2 hours to “round.” Families have no problem speaking to the midlevels...

Awesome. We don’t need intensivists!

 

[SpacemanSpifff]

I’m at a large tertiary care academic center. Most units are run by midlevels and the attending drops by once a day for 2 hours to “round.” Families have no problem speaking to the midlevels...

Vandy?

 

[bronx43]

Vandy?

No, but this is present at most large academic institutions.

 

[chocomorsel]

No, but this is present at most large academic institutions.

I trained at a 1000 bed hospital in a large academic center in the South. Our attendings were there for a good half day if not longer. But our attendings were anesthesiologists, not pulmonologists who seem to always have a disappearing act wherever you go. Even on their non outpatient weeks when they are supposed to be in the Unit. Where the hell do they go? And if they hate being in the unit so much, why do they even train in CCM instead of just pulmonary?
But yeah, quite a few mid levels.

 

[CCM-MD]

I trained at a 1000 bed hospital in a large academic center in the South. Our attendings were there for a good half day if not longer. But our attendings were anesthesiologists, not pulmonologist who seem to always have a disappearing act wherever you go. Even on their non outpatient weeks when they are supposed to be in the Unit.
But yeah, quite a few mid levels.

That disappearing act can be quite beneficial for residents and fellows. For me personally, supervision without the constant physical presence of an attending shaped me tremendously. This is not a pulmonologist vs. anesthesiologist thing. I trained in a program where I had both as faculty.

 

[chocomorsel]

That disappearing act can be quite beneficial for residents and fellows. For me personally, supervision without the constant physical presence of an attending shaped me tremendously. This is not a pulmonologist vs. anesthesiologist thing. I trained in a program where I had both as faculty.

Ok. Sure. Let them figure it out trial by fire. When you are supposed to be there to assist. These are people’s lives we are talking about. Let’s not experiment and kill people if we don’t have to. Attendings are supposed to be readily available. Not necessarily looking over your shoulder but easily accessible in case residents need help and patients are crashing.
This is not an anesthesiologist versus pulmonary thing. I travel full time and I hear that from multiple ICU nurses and midlevels at how the pulmonary docs are always disappearing and managing everything via phone. I hear it from the place I currently am at. From my current boss even who’s an IM doc at how the pulm docs leave early. Many nurses want us taking care of their patients because we are readily available and they see us rounding repeatedly.

 

[CCM-MD]

Ok. Sure. Let them figure it out trial by fire. When you are supposed to be there to assist. These are people’s lives we are talking about. Let’s not experiment and kill people if we don’t have to. Attendings are supposed to be readily available. Not necessarily looking over your shoulder but easily accessible in case residents need help and patients are crashing.
This is not an anesthesiologist versus pulmonary thing. I travel full time and I hear that from multiple ICU nurses and midlevels at how the pulmonary docs are always disappearing and managing everything via phone. I hear it from the place I currently am at. Many nurses want us taking care of their patients because we are readily available and they see us rounding repeatedly

I wouldn’t call it an “experiment” or “killing people” to give an senior trainee some autonomy. The attending can be easily accessible without constantly physically being there.

 

[chocomorsel]

I wouldn’t call it an “experiment” or “killing people” to give an senior trainee some autonomy. The attending can be easily accessible without constantly physically being there.

I am talking about disappearing and being easily accessible not just by phone. Like you need them and they are there within a few minutes. Being there in an office or at a computer station in/near the unit is great. Attendings are supposed to supervise. Not disappear.

 

[SpacemanSpifff]

No, but this is present at most large academic institutions.

In my limited experience (N=3), the large academic institutions I've worked at don't operate that way. Residents/fellows ran the unit when attendings disappear, APP's do the notes and scut. I guess I've just been lucky as a learner.

 

[bronx43]

In my limited experience (N=3), the large academic institutions I've worked at don't operate that way. Residents/fellows ran the unit when attendings disappear, APP's do the notes and scut. I guess I've just been lucky as a learner.

APPs don’t work with residents and fellows where I have been. I’m not sure why they would do the notes and scut for residents though..

what I have seen: APPs have separate services and operate like trainees. They do the scut and notes for the attendings who typically disappear after rounds

 

[SpacemanSpifff]

APPs don’t work with residents and fellows where I have been. I’m not sure why they would do the notes and scut for residents though..

what I have seen: APPs have separate services and operate like trainees. They do the scut and notes for the attendings who typically disappear after rounds

I guess the institutions I have worked at understand that residents should be prioritized over APP's🤷‍♂️

 

[bronx43]

I guess the institutions I have worked at understand that residents should be prioritized over APP's🤷‍♂️

So they would put APPs with the residents?? Not sure how they can work out the finances for that.

 

[FunnyDocMan1234]

I’m at a large tertiary care academic center. Most units are run by midlevels and the attending drops by once a day for 2 hours to “round.” Families have no problem speaking to the midlevels...

Families are ok getting updates and asking questions to midlevels, while knowing an MD is ultimately in charge of the patient. Families will never be ok with their critically loved one not having a physician overseeing their care.

While many people are fine with midlevels being in charge for things like primary care appointments or getting stitches at urgent care, trust me in that they will never be ok with it when life or death is involved like major surgery or a loved being on on a ventilator. There's much lower hanging fruit out there for midlevels to take over (which they already are for better or worse)

 

[chocomorsel]

Families are ok getting updates and asking questions to midlevels, while knowing an MD is ultimately in charge of the patient. Families will never be ok with their critically loved one not having a physician overseeing their care.

While many people are fine with midlevels being in charge for things like primary care appointments or getting stitches at urgent care, trust me in that they will never be ok with it when life or death is involved like major surgery or a loved being on on a ventilator. There's much lower hanging fruit out there for midlevels to take over (which they already are for better or worse)

Yeah, I don't buy this argument as much as I would like to. I really would like to believe this, but Americans want cheap fast care and don't seem to care who it's from. How many times do you hear people say they prefer to see an NP because they "listen?"

 

[spacegun]

All things equal, if given a clear and informed choice, I think most patients would pick a doctor over an NP or PA.

But all things aren't equal, and some militant midlevels try to blur the lines between doctor and noctor.

So the question really comes down to how many patients will just reluctantly or grudgingly accept an NP or PA if they are told that's what they're going to get? How many patients are willing to speak up that they want a doctor, not a midlevel?

A hospital or healthcare system (especially rural ones) could easily employ solely or mainly NP's or PA's and only one or two doctors to oversee lots of NP's and PA's. How many patients would protest this? Sadly I think many people are more like sheep and just accept things as they are.

Maybe the only hope is if it becomes so bad that it's not just a few random patients in random places around the nation speaking up over the loss of their loved one. But enough patients speak up that it becomes a big enough movement to actually change things. Otherwise I doubt much will be done. It's almost always easier to go with inertia (hospitals and healthcare systems buying out doctors, midlevels expanding, midlevels passing themselves off like they're doctors, etc.) than to oppose it.

 

[bronx43]

Families are ok getting updates and asking questions to midlevels, while knowing an MD is ultimately in charge of the patient. Families will never be ok with their critically loved one not having a physician overseeing their care.

While many people are fine with midlevels being in charge for things like primary care appointments or getting stitches at urgent care, trust me in that they will never be ok with it when life or death is involved like major surgery or a loved being on on a ventilator. There's much lower hanging fruit out there for midlevels to take over (which they already are for better or worse)

If this is what you tell yourself in order to sleep at night, then have at it. And to be honest, if the battle is simply that families BELIEVE a physician is ultimately calling the shots, then we've already lost the war. Because what's the difference between 20 NPs practicing independently and 20 NPs practicing mostly independently with one doc "supervising?"

 

[blue.jay]

Outpatient setting is where patients have some option of choosing who they want to see. Like others mentioned patients have no choice who their ER, hospitalist or intensivist will be. Patients or their families can't just walk out of the unit because a midlevel is managing under teleICU supervision. In a life or death situation they have no choice other than to be okay with whatever care they get I guess.
Admins of the future might make midlevels run the ICU by pan consulting specialists for a fraction of intensivist pay who knows.

 

[CCM-MD]

The future of all medicine is pretty bleak when it comes to midlevels unless something big happens. There will be an army of mid levels with a few “supervising” physicians (if any), in everything. ICU is no exception. It’s already happening. Inpatient consult service lines are all front line mid levels already, and getting worse. I get a mid level for every consult I call. Tons of outpatient practices being bought out by private equity and being loaded up with mid levels and fewer docs. Independently practicing mid levels on the outpatient side is becoming more and more common nowadays. Anesthesia, EM, ICU, hospital medicine, being loaded with mid levels by large health systems like HCA or parasitic staffing companies.

 

[CCM-MD]

Outpatient setting is where patients have some option of choosing who they want to see. Like others mentioned patients have no choice who their ER, hospitalist or intensivist will be. Patients or their families can't just walk out of the unit because a midlevel is managing under teleICU supervision. In a life or death situation they have no choice other than to be okay with whatever care they get I guess.
Admins of the future might make midlevels run the ICU by pan consulting specialists for a fraction of intensivist pay who knows.

The “consult specialists” you are talking about are already essentially mid levels. There are ****ty attendings that co-sign without having any idea what’s going on.

Sure the families can’t walk out of the unit but they will gladly talk to thirsty attorneys. It’s already a highly emotional and high liability environment, I’m sure that’s gonna get better with no physician!

 

[chessknt]

The future of all medicine is pretty bleak when it comes to midlevels unless something big happens. There will be an army of mid levels with a few “supervising” physicians (if any), in everything. ICU is no exception. It’s already happening. Inpatient consult service lines are all front line mid levels already, and getting worse. I get a mid level for every consult I call. Tons of outpatient practices being bought out by private equity and being loaded up with mid levels and fewer docs. Independently practicing mid levels on the outpatient side is becoming more and more common nowadays. Anesthesia, EM, ICU, hospital medicine, being loaded with mid levels by large health systems like HCA or parasitic staffing companies.

Eh I am not buying it. The cash rich specialties with a big inpatient presence (cards, IR, CT surgery) are loading up on midlevels who, in my experience, are completely useless. I actively intervene to undo and contradict what the cardiologist recommends in patients from time to time because it is like an outpatient-centric formula with a singular purpose of generating as many procedures as possible while ignoring the actual condition a patient is in. The bedside nurses know who provides better care and they have a lot more political power than many give them credit for.

 

[CCM-MD]

Eh I am not buying it. The cash rich specialties with a big inpatient presence (cards, IR, CT surgery) are loading up on midlevels who, in my experience, are completely useless. I actively intervene to undo and contradict what the cardiologist recommends in patients from time to time because it is like an outpatient-centric formula with a singular purpose of generating as many procedures as possible while ignoring the actual condition a patient is in. The bedside nurses know who provides better care and they have a lot more political power than many give them credit for.

What exactly are you disagreeing with? Because I don’t think I really disagree with anything you have said.

 

[chessknt]

What exactly are you disagreeing with? Because I don’t think I really disagree with anything you have said.

I just can't see a scenario where icu rns would accept a mid-level directing them with nonexistent md supervision.

 

[bronx43]

I just can't see a scenario where icu rns would accept a mid-level directing them with nonexistent md supervision.

And they would do what exactly? Run to the admin, who needs the proceduralists in their suites/ORs pumping out procedures so the hospital can collect that juicy facility fee?

 

[CCM-MD]

I just can't see a scenario where icu rns would accept a mid-level directing them with nonexistent md supervision.

Really? The same ICU RNs that are all in school to become NPs?

 

[chessknt]

Really? The same ICU RNs that are all in school to become NPs?

The ones I work with on a regular basis very rarely have aspirations to do that. And those that do want to become crnas not icu nps.

 

[chessknt]

And they would do what exactly? Run to the admin, who needs the proceduralists in their suites/ORs pumping out procedures so the hospital can collect that juicy facility fee?

Find a different job with better working environment? Who do you think runs the hospital if it isn't nurses? Do you think they are going to ignore safety concerns/reports or high turnover forever?

 

[CCM-MD]

The ones I work with on a regular basis very rarely have aspirations to do that. And those that do want to become crnas not icu nps.

Ok regardless of what type of “advanced nurse” they want to be, you really think that type is going to have an issue working with an unsupervised midlevel? These types feed off each other. And >50% of the ICU nurses I work with currently and the ones I worked with in training are in NP school. Also usually a couple that are NPs already, can’t find a job, and continue to work in the unit.

 

[bronx43]

Find a different job with better working environment? Who do you think runs the hospital if it isn't nurses? Do you think they are going to ignore safety concerns/reports or high turnover forever?

Lol what? Those are some funny claims. Show me evidence that midlevels on consults lead to higher turnover rate for floor or ICU nurses.

Also, where are they going to go? Another hospital (aka every hospital in large metro) with midlevels on consults?

 

[bronx43]

Ok regardless of what type of “advanced nurse” they want to be, you really think that type is going to have an issue working with an unsupervised midlevel? These types feed off each other. And >50% of the ICU nurses I work with currently and the ones I worked with in training are in NP school. Also usually a couple that are NPs already, can’t find a job, and continue to work in the unit.

I second this. It’s easily >75% if not higher where I am.

 

[CCM-MD]

Find a different job with better working environment? Who do you think runs the hospital if it isn't nurses? Do you think they are going to ignore safety concerns/reports or high turnover forever?

The ICU nurses will love them. Midlevels will sedate the F out everyone. The midlevels will have excellent “nurse satisfaction scores”. Patients might die but who cares.

 

[chocomorsel]

The ones I work with on a regular basis very rarely have aspirations to do that. And those that do want to become crnas not icu nps.

They want to be independent! CRNAs especially and NPs alike.
Come on. Plenty of RNs cheer them on and would love for them to lead the team instead of an RN.

 

[Matthew9Thirtyfive]

Find a different job with better working environment? Who do you think runs the hospital if it isn't nurses? Do you think they are going to ignore safety concerns/reports or high turnover forever?

Sorry to jump in here as a med student, but my wife is a nurse. They absolutely will ignore safety concerns forever if they can. That’s part of why she doesn’t do clinical nursing anymore.

 

[chessknt]

Sorry to jump in here as a med student, but my wife is a nurse. They absolutely will ignore safety concerns forever if they can. That’s part of why she doesn’t do clinical nursing anymore.

Once you do some QI type work you'll find that the vast majority of safety reports being generated are by nurses. I think it is unfair at a minimum to say they ignore safety.

 

[blue.jay]

When your national society recommends **** like this, you know these midlevel hyenas will only take it a notch further.
I predict soon nationally they will make MDs sit in front of monitors in an eICU and let midlevels roam free in the non-academic ICUs without resident/fellow slaves. It will still be physician led for liability purposes.

 

[Katheudontas parateroumen]

View attachment 326373

When your national society recommends **** like this, you know these midlevel hyenas will only take it a notch further.
I predict soon nationally they will make MDs sit in front of monitors in an eICU and let midlevels roam free in the non-academic ICUs without resident/fellow slaves. It will still be physician led for liability purposes.

Yeah like seriously this is the dumbest thing I ever seen! Our own medicine colleagues putting mid levels above full fledged physicians. IM, EM, anesthesia, surgeons docs take care of ICU pts regularly! And to put ICU APP above them is just ludicrous. How did these people get put on such a pedestal is just beyond me. And I’m not one against midlevels either. I get along with my Srna/crna, NP, PA very well. But I’d never have them just doing whatever they want without physician leadership. That’s what they were created to do in the first place.

 

[Matthew9Thirtyfive]

Once you do some QI type work you'll find that the vast majority of safety reports being generated are by nurses. I think it is unfair at a minimum to say they ignore safety.

It doesn’t matter how many safety reports they file if the nursing managers and charge nurses ignore them.

 

[chocomorsel]

Once you do some QI type work you'll find that the vast majority of safety reports being generated are by nurses. I think it is unfair at a minimum to say they ignore safety.

Maybe you are a little biased here? Just maybe?
Obviously not all of them are in support of NPs over MD/DO, but come on. Plenty of them are. Plenty of them aspire to be NPs and therefore leaders. And plenty of these NPs act very snooty and above bedside nurses like they forgot where they came from.

 

[chocomorsel]

View attachment 326373

When your national society recommends **** like this, you know these midlevel hyenas will only take it a notch further.
I predict soon nationally they will make MDs sit in front of monitors in an eICU and let midlevels roam free in the non-academic ICUs without resident/fellow slaves. It will still be physician led for liability purposes.

I don’t understand the difference between the “non ICU physician” versus the MD/DO?
I thought they fixed this.

 

[CCM-MD]

I don’t understand the difference between the “non ICU physician” versus the MD/DO?
I thought they fixed this.

There is an updated one. This one pissed off a bunch of people off.

 

[blue.jay]

There is an updated one. This one pissed off a bunch of people off.

This is the old version which pissed off anesthesiologists. There is a reddit sub in r/anesthesia discussing how non-ICU MD like psych/ortho can be in a higher tier than MD anesthesia.

 

[blue.jay]

I don’t understand the difference between the “non ICU physician” versus the MD/DO?
I thought they fixed this.

This is the only picture which is still available online. I think this is the updated one compared to previous one.

SCCM | United States Resource Availability for COVID-19

With the onset of COVID-19, and the strong possibility of large percentages of the U.S. population being admitted to the hospital and intensive care unit (ICU), the Society of Critical Care Medicine (SCCM) has updated its statistics on critical care resources available in the United States.

www.sccm.org

 

[blue.jay]

Next decade is going to be these midlevels managing sick dying patients in the ICU.

So many training programs have started so they can saturate the job market. Looks like EM kind of situation is next for crit

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Advanced Practice Provider Critical Care Fellowship Program | RWJUH

Learn about the Advanced Practice Provider Critical Care Fellowship Program offered by Robert Wood Johnson University Hospital (RWJUH) in New Brunswick, New Jersey, a twelve-month paid post-graduate APP program accredited with distinction by the ANCC.

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APP Fellowship Program

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Mayo Clinic School of Health Sciences in Minnesota offers the one-year Nurse Practitioner or Physician Assistant Critical Care Fellowship.

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