How is your ICU staffed?

[CCM-MD]

We have a total of 42 ICU beds in our community hospital. Acuity is high as we have a large catchment area and we serve as a referral site for surrounding hospitals. Trauma center and comprehensive stroke center. Trying to see how we could make things better.

Currently we have 2 intensivists and 1 NP/PA on days. Open ICU and we see everyone on the vent and on vasoactive agents plus others if we are asked to help. We do multidis rounds on every patient in the unit, regardless of whether we are seeing them or not. Hospitalists, surgeons, cardiologists etc. remain primary and we are a consult service. We are on call every other night from home at night - Hospitalists handle most things but we do have our sleepless nights. We don’t typically go to the ER to see patients waiting for ICU beds but are available for help. I typically don’t see more than 14 encounters but I have had days where it’s 16-17... add procedures on top of that and it can get pretty busy. We also have 4 IM residents in the unit which sucks up time.

How is your ICU set up? How many patient encounters in a day? Are you primary or a consult service? Do you see patients in the ED that are waiting for ICU beds? How many midlevels? Do you have an intensivist in the hospital at night?

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[psychbender]

About the same number of ICU beds, referral center for the region, closed units, but with "co-managing" agreements with neurosurgery and cardiac surgery. Four intensivists and a midlevel on during the day, one intensivist plus midlevel at night. During the day, one intensivist and the midlevel are the ICU triage/admitting team. The other intensivists won't see new consults (except whoever is in the CVICU sees new post-ops themselves). The next day, all new people seen by the admitting team are shunted either to the floor, or one of the three regular ICU services. The three regular intensivists will typically see 8-12 patients per day, but the admitting intensivist can vary wildly.

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[CCM-MD]

About the same number of ICU beds, referral center for the region, closed units, but with "co-managing" agreements with neurosurgery and cardiac surgery. Four intensivists and a midlevel on during the day, one intensivist plus midlevel at night. During the day, one intensivist and the midlevel are the ICU triage/admitting team. The other intensivists won't see new consults (except whoever is in the CVICU sees new post-ops themselves). The next day, all new people seen by the admitting team are shunted either to the floor, or one of the three regular ICU services. The three regular intensivists will typically see 8-12 patients per day, but the admitting intensivist can vary wildly.

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What do you do with patients that are going to be waiting in the ED for ICU beds? Do you assume primary responsibility and start managing them once the ED has ”admitted” them?

 

[chocomorsel]

Why are you seeing and rounding on patients that you aren’t managing? Seems like a waste of time to me.

 

[CCM-MD]

Why are you seeing and rounding on patients that you aren’t managing? Seems like a waste of time to me.

Mostly a waste of time. They last for an hour. I suspect it is an administrative checkbox, potentially for some accreditation body that I am not 100% sure about. Admin gets to say "we have intensivists do daily multidis rounds on all of our ICU patients". The rounds are mostly focused on identifying patients who can potentially leave the ICU early in the morning, identifying foleys and central lines that can be removed, getting PT/OT involved, appropriate prophylaxis etc. We do have the ability to "sign on" to patients... for example someone who got worse overnight, failing NIV etc.

 

[psychbender]

What do you do with patients that are going to be waiting in the ED for ICU beds? Do you assume primary responsibility and start managing them once the ED has ”admitted” them?

They don't generally wait long, and I believe remain under the care of the ED until they physically arrive in the unit. I haven't shown any time in that role yet, so there are some aspects that are still a black box to me

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[CCM-MD]

They don't generally wait long, and I believe remain under the care of the ED until they physically arrive in the unit. I haven't shown any time in that role yet, so there are some aspects that are still a black box to me

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Though usually not a problem... We sometimes have people waiting in the ED for a long time.

 

[leviathan]

And I thought my community hospital was big. We have 14 physical beds, in flu season we don't cap and will often be up to 18-20. Two daytime intensivists, one person covering overnight. The daytime staff take turns being on for consults each day.

 

[CCM-MD]

And I thought my community hospital was big. We have 14 physical beds, in flu season we don't cap and will often be up to 18-20. Two daytime intensivists, one person covering overnight. The daytime staff take turns being on for consults each day.

I did a few rotations at a community hospital in fellowship that was even larger... close to 900 total beds with ~80 ICU beds.

 

[MedicineZ0Z]

We have a total of 42 ICU beds in our community hospital. Acuity is high as we have a large catchment area and we serve as a referral site for surrounding hospitals. Trauma center and comprehensive stroke center. Trying to see how we could make things better.

Currently we have 2 intensivists and 1 NP/PA on days. Open ICU and we see everyone on the vent and on vasoactive agents plus others if we are asked to help. We do multidis rounds on every patient in the unit, regardless of whether we are seeing them or not. Hospitalists, surgeons, cardiologists etc. remain primary and we are a consult service. We are on call every other night from home at night - Hospitalists handle most things but we do have our sleepless nights. We don’t typically go to the ER to see patients waiting for ICU beds but are available for help. I typically don’t see more than 14 encounters but I have had days where it’s 16-17... add procedures on top of that and it can get pretty busy. We also have 4 IM residents in the unit which sucks up time.

How is your ICU set up? How many patient encounters in a day? Are you primary or a consult service? Do you see patients in the ED that are waiting for ICU beds? How many midlevels? Do you have an intensivist in the hospital at night?

What are the IM residents managing and why isn't it helping you?

 

[CCM-MD]

What are the IM residents managing and why isn't it helping you?

Residents are rarely helpful and typically slow things down.

 

[MedicineZ0Z]

Residents are rarely helpful and typically slow things down.

They do solo overnight call in teaching hospitals. Your ICU doesn't implement that into its staffing model?

 

[CCM-MD]

They do solo overnight call in teaching hospitals. Your ICU doesn't implement that into its staffing model?

No resident is operating truly “solo”, they are always supervised in some way. Some attending physician is always responsible for their actions to a degree. There are all kinds of set ups out there. But no critical care physician I have personally worked with would be excited about being responsible and liable for the actions of a resident in the management of the types of patients we are being asked to help care for. Especially at night time when we are not there. I can’t imagine how much sleep we would be losing if we just had a resident in house... when we have hospitalists calling us for help at night.

 

[SurfingDoctor]

They do solo overnight call in teaching hospitals. Your ICU doesn't implement that into its staffing model?

No

 

[Dr.CCM]

No resident is operating truly “solo”, they are always supervised in some way. Some attending physician is always responsible for their actions to a degree. There are all kinds of set ups out there. But no critical care physician I have personally worked with would be excited about being responsible and liable for the actions of a resident in the management of the types of patients we are being asked to help care for. Especially at night time when we are not there. I can’t imagine how much sleep we would be losing if we just had a resident in house... when we have hospitalists calling us for help at night.

You must have never been a fellow that covered the VA hospital

 

[MedicineZ0Z]

You must have never been a fellow that covered the VA hospital

I guess I'm also confused at what he's saying. R2s very routinely are in the ICU overnight with a fellow who's asleep and other places put R3s or R2 and R1 on without a fellow (no fellowship program) with attending at home available by phone. Yes this is all supervision but it's not direct supervision of any sort.

 

[CCM-MD]

I guess I'm also confused at what he's saying. R2s very routinely are in the ICU overnight with a fellow who's asleep and other places put R3s or R2 and R1 on without a fellow (no fellowship program) with attending at home available by phone. Yes this is all supervision but it's not direct supervision of any sort.

What’s confusing?

 

[redpanda]

You must have never been a fellow that covered the VA hospital

My being this fellow at home with R3/R2s of variable ability at the VA with sick patients is why I lose a lot of sleep at night.

 

[jdh71]

Bah! You can’t kill a VA patient as long as he’s getting his dialysis.

We all know that!