Minimally trained NP/PA doing emergency airways. Another dangerous move by healthcare companies to save money...

[coffeebythelake]

Staffing companies (think Envision, Teamhealth, etc) now using NP and PA midlevels to work as hospitalists, functioning essentially independently to respond to emergencies in the hospital. Especially an issue overnight. They are being tasked to perform procedures such as arterial lines, central lines, and even perform emergency intubation on physiologically unstable patients with minimal requirements (e.g., 5 to 10 prior intubation with a glidescope). This includes COVID patients. Appalled.

I am told that there is anesthesiology staff in house 24/7 but the contract deemed these NP/PA to be the initial responders to in-house emergencies. In other words, anesthesia staff (not even a cRNa) do not respond to airway codes unless thr NP/PA specifically request them after presumably bludgeoning the airway. Dangerous and can only end badly for patients. This is the ****ing race to the bottom for standards

Any guesses what hospitals this **** is happening at? And which patient population and ethnicity is disproportionately affected by all this??

(I have first hand knowledge of this. It is not a rumor or hearsay)

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[GassYous]

lol

 

[Groove]

I'm in the SE and we have a pulmonary group in town that routinely staffs their ICU with NPs overnight with no intensivist in house. I was pretty skeptical at first but honestly....the MLPs are rock solid. Somehow we (ED) got roped into an agreement to respond during emergencies if they needed us and over the course of 2-3 years I probably got called up there twice. One was a difficult intubation that required a bougie and another one was another difficult intubation (rotoprone bed nightmare) that ended up in a cric. Occasionally, I'd get called about management questions but not very often. They were extremely skilled and responded to all codes in the hospital. I had 3 GSW teenagers dumped off one night and called one of the NPs down to help out and he tubed one of them and threw in a chest tube in under 5 mins.

Now, I think it was an unwise decision on the part of the ICU docs as they are only shooting themselves in the foot and proving to the hospital that their jobs can be totally performed adequately by cheaper labor. However, I was surprised at the skill level of the MLPs.

At my current hospital, they don't work alone...I don't think. They definitely don't staff the ICU alone but they are allowed to perform the usual routine procedures. We have a few that function as hospitalists but they mainly do the H&Ps and the doc rounds with or behind them. I'm currently at a TeamHealth facility with ED/hospitalist contract.

 

[nimbus]

I'm in the SE and we have a pulmonary group in town that routinely staffs their ICU with NPs overnight with no intensivist in house. I was pretty skeptical at first but honestly....the MLPs are rock solid. Somehow we (ED) got roped into an agreement to respond during emergencies if they needed us and over the course of 2-3 years I probably got called up there twice. One was a difficult intubation that required a bougie and another one was another difficult intubation (rotoprone bed nightmare) that ended up in a cric. Occasionally, I'd get called about management questions but not very often. They were extremely skilled and responded to all codes in the hospital. I had 3 GSW teenagers dumped off one night and called one of the NPs down to help out and he tubed one of them and threw in a chest tube in under 5 mins.

Now, I think it was an unwise decision on the part of the ICU docs as they are only shooting themselves in the foot and proving to the hospital that their jobs can be totally performed adequately by cheaper labor. However, I was surprised at the skill level of the MLPs.

At my current hospital, they don't work alone...I don't think. They definitely don't staff the ICU alone but they are allowed to perform the usual routine procedures. We have a few that function as hospitalists but they mainly do the H&Ps and the doc rounds with or behind them. I'm currently at a TeamHealth facility with ED/hospitalist contract.

I’ve had similar experience in residency with a neonatal NP. She was extremely skilled with neonatal/premie airways, IVs, UAC/UVC. More than anybody else in the unit.

 

[Harpoon1]

If they are competent what is the big deal?

 

[emergentmd]

The reason this crap happens if b/c hospitals and docs get greedy with shared blame.

Typically what happens is Admin gets complaints that Anesthesia is not responding quickly enough to put in Central lines, blood patches, intubations. Admin requests that Anesthesia increase staff to cover these procedures who balks and tells admin that they need a bigger stipend. Admin says, WTF no and the fight begins. Admin eventually gives up and hires NPs/PAs to do these procedures and truthfully sucks initially but eventually gets really good at it.
Then eventually most admins will figure this out and save $$$ buy just using APCs. Happened to ER with NPs back in the day. Admin and ER group fighting over pay then they figure out NPs costs 1/4 the amount.

I don't blame the docs b/c who wants more work for the same pay or less pay hiring an extra hand. Who this screws are future docs when demand drops when NP/PAs are doing intubations and other procedures.

I mean procedures are the easiest thing to learn for 99% of the standard cases. The art of medicine is the hard part.

 

[IlDestriero]

I’m pretty sure we discussed one example a few years ago where the pediatric private group hired a peds NP to cover the deliveries at night because they wanted to be home in their nice warm beds. An after hours CS was called and a CRNA managed the mother but unfortunately the peds NP couldn’t intubate the baby. By the time the Anesthesiologist was called back to the suite to come help and apparently easily intubate the baby, 10-15 minutes had passed and the kid had a severe anoxic brain injury.
It turned out the NP had very little experience ever intubating babies and had not done an intubation in years.
I wouldn’t want money, I’d want blood or criminal charges for that level of malpractice, incompetence, and bad decision making.
Of course not all NPs and PAs are that bad, but you have to insure that they are properly trained and experienced before releasing them alone on a helpless patient. Our NICU NPs are fantastic, and experienced, and backed up.

 

[IlDestriero]

I will add that we have all kinds of people intubating patients at my hospital, NPs, residents fellows, ED, PICU, NICU, transport team NP, etc. they’re well trained/supervised and usually manage airways well. The NICU can manage a micropreemie airway better than anyone. We almost never intubate these kids, until they’re a lost difficult airway at 2am...
However, we have a 3 strikes and you’re out rule. 3 missed attempts by any provider equals an airway emergency by definition. That gets you anesthesia personnel and ENT.
If you’re going to farm out airways, you want a similar rule in place.

 

[coffeebythelake]

If they are competent what is the big deal?

You must have missed the part about having 5 to 10 intubation experience. Hence my emphasis on *minimally trained*..

 

[coffeebythelake]

You guys really think it is in the best interest of patients to have an NP / PA who has barely ever intubated a patient to respond to airway emergencies? Literally the worst possible situation to intubate a patient in either logistically, anatomically or physiologically. Being performed by a midlevel who has been rubber stamped as certified after intubating 5 to 10 times with a glidescope. This is insane.

 

[deleted126335]

You guys really think it is in the best interest of patients to have an NP / PA who has barely ever intubated a patient to respond to airway emergencies? Literally the worst possible situation to intubate a patient in either logistically, anatomically or physiologically. Being performed by a midlevel who has been rubber stamped as certified after intubating 5 to 10 times with a glidescope. This is insane.

Money/resources are tight. A lower level of care is good enough. We just can't call it a lower level of care. BTW, the term "midlevel" is a pejorative, or hadn't you heard? You elitist.

 

[coffeebythelake]

Money/resources are tight. A lower level of care is good enough. We just can't call it a lower level of care. BTW, the term "midlevel" is a pejorative, or hadn't you heard? You elitist.

I'd like to know what the data is on airway complication rates but I'm sure it is closely under wraps. It seems these companies have baked in the cost of extra complications and medicolegal exposure as just part of the business., pt outcomes be damned

Midlevel is a term used by CMS and many other organizations.

 

[sloh]

The reason this crap happens if b/c hospitals and docs get greedy with shared blame.

Typically what happens is Admin gets complaints that Anesthesia is not responding quickly enough to put in Central lines, blood patches, intubations. Admin requests that Anesthesia increase staff to cover these procedures who balks and tells admin that they need a bigger stipend. Admin says, WTF no and the fight begins. Admin eventually gives up and hires NPs/PAs to do these procedures and truthfully sucks initially but eventually gets really good at it.
Then eventually most admins will figure this out and save $$$ buy just using APCs. Happened to ER with NPs back in the day. Admin and ER group fighting over pay then they figure out NPs costs 1/4 the amount.

I don't blame the docs b/c who wants more work for the same pay or less pay hiring an extra hand. Who this screws are future docs when demand drops when NP/PAs are doing intubations and other procedures.

I mean procedures are the easiest thing to learn for 99% of the standard cases. The art of medicine is the hard part.

"It kind of seems like a gentle undersupply would be the best way to go."

What is causing the resurgence of the radiology job market?

At a certain volume of work, even the best radiologist will produce reports approaching a mid level quality not sure if the recent imaging surge is short lived from Covid. But if this is here to stay, we need more radiologists trained I think part of the surge is Covid related-easier/more...

forums.studentdoctor.net

 

[2Fast2Des]

If they are competent what is the big deal?

Um really? You don't want our profession to be managing scenarios where lesser trained folks are doing whatever they want?

 

[GassYous]

You must have missed the part about having 5 to 10 intubation experience. Hence my emphasis on *minimally trained*..

That's like one day for me

 

[Zekchar]

You guys really think it is in the best interest of patients to have an NP / PA who has barely ever intubated a patient to respond to airway emergencies? Literally the worst possible situation to intubate a patient in either logistically, anatomically or physiologically. Being performed by a midlevel who has been rubber stamped as certified after intubating 5 to 10 times with a glidescope. This is insane.

The obvious answer is NO we do not. At the same time we all go to work, come home after work, and have very little say in our day to day situations. We have no leverage. YOU have no leverage either. The only white knights / saviors in the future of medicine is unionization or the malpractice and trial attorneys. Once the bad outcomes stack up and the payments exceed the money spent on utilizing subpar (midlevel) providers, then physicians will be a hot commodity again. Unfortunately there will be lives destroyed along the way. I've accepted this.

Disagree? Offer an alternative.

 

[GassYous]

The obvious answer is NO we do not. At the same time we all go to work, come home after work, and have very little say in our day to day situations. We have no leverage. YOU have no leverage either. The only white knights / saviors in the future of medicine is unionization or the malpractice and trial attorneys. Once the bad outcomes stack up and the payments exceed the money spent on utilizing subpar (midlevel) providers, then physicians will be a hot commodity again. Unfortunately there will be lives destroyed along the way. I've accepted this.

Disagree? Offer an alternative.

We have a lot of leverage. Vote with your feet. Especially in this time when there are plenty of jobs around. They need us for their procedures. You think that anesthesiologists are a commodity? Our hospital knows that they need us to keep the bankroll going and treat us well. The ORs feed everyone who works here.

 

[coffeebythelake]

The obvious answer is NO we do not. At the same time we all go to work, come home after work, and have very little say in our day to day situations. We have no leverage. YOU have no leverage either. The only white knights / saviors in the future of medicine is unionization or the malpractice and trial attorneys. Once the bad outcomes stack up and the payments exceed the money spent on utilizing subpar (midlevel) providers, then physicians will be a hot commodity again. Unfortunately there will be lives destroyed along the way. I've accepted this.

Disagree? Offer an alternative.

Public awareness. This **** only flies because the companies think they can get away with it.

 

[Zekchar]

Public awareness. This **** only flies because the companies think they can get away with it.

I agree that public awareness is lacking. The ASA campaign should be marketing directly to the patient ... "Who is my physician today?"

If you feel this way you should be penning opinion and public awareness pieces (in addition to posting on anesthesia forums). The Washington Post, WSJ, and NY Times are calling your name. In fact, we can make the argument that CRNA only care is racist and discriminatory. Most of the places that will get affected the most by crappy CRNA only care will be remote and rural places, which happen to have more people of color. Why is America ok with denying those patients physician led care that is readily available to white people in large urban metros. Now there is a selling point for physician led care (as it should be).

 

[Endee]

In fact, we can make the argument that CRNA only care is racist and discriminatory. Most of the places that will get affected the most by crappy CRNA only care will be remote and rural places, which happen to have more people of color. Why is America ok with denying those patients physician led care that is readily available to white people in large urban metros. Now there is a selling point for physician led care (as it should be).

Now that's some wokeism that I can get behind!

 

[deleted875186]

This is insane, urgent and emergent airways is the highest risk thing we do. If you would never want to be intubated by these people for a routine elective surgery, why would we let this fly for high risk patients?

by the way, three strikes for an airway? What is that, your assuming this inexperienced operator who can’t intubate will 100% be able to bag. This is nuts. Then again, any complications would probably just be labeled as “hypoxia” or something nonspecific and swept under the rug. This makes me very depressed about our healthcare system.

 

[gasdoc77]

I agree that public awareness is lacking. The ASA campaign should be marketing directly to the patient ... "Who is my physician today?"

If you feel this way you should be penning opinion and public awareness pieces (in addition to posting on anesthesia forums). The Washington Post, WSJ, and NY Times are calling your name. In fact, we can make the argument that CRNA only care is racist and discriminatory. Most of the places that will get affected the most by crappy CRNA only care will be remote and rural places, which happen to have more people of color. Why is America ok with denying those patients physician led care that is readily available to white people in large urban metros. Now there is a selling point for physician led care (as it should be).

Rural pass-through is systemic discrimination.

 

[nimbus]

This is insane, urgent and emergent airways is the highest risk thing we do. If you would never want to be intubated by these people for a routine elective surgery, why would we let this fly for high risk patients?

by the way, three strikes for an airway? What is that, your assuming this inexperienced operator who can’t intubate will 100% be able to bag. This is nuts. Then again, any complications would probably just be labeled as “hypoxia” or something nonspecific and swept under the rug. This makes me very depressed about our healthcare system.

Do you respond to emergency intubations all over the hospital at all hours? We basically never get called for intubations although we have the most experience.

 

[deleted875186]

Do you respond to emergency intubations all over the hospital at all hours? We basically never get called for intubations although we have the most experience.

In residency we did, yes.

 

[nimbus]

In residency we did, yes.

We did in residency too. Who does it where you work now?

 

[deleted875186]

We did in residency too. Who does it where you work now?

I’m doing pain, no idea 🙂

 

[deleted875186]

we have one thread in this forum about a fatal complication from a less invasive procedure, an elective epidural on OB.

than we have a thread about NP/PAs doing emergent airways in sick people, and we have people above saying no problem, they get three attempts at the airway…. Makes total sense.

 

[IlDestriero]

The difference is the non anesthesiologist people intubating patients in my hospital are trained, experienced, and supervised. Why shouldn’t the NICU and PICU team intubate their patients? And the ED? These guys can manage their own airways just fine. Though we get called for all the traumas and they don’t go hero on difficult airways. It’s not like the peds residents and NPs are trying to intubate on the floor when their patient is in respiratory failure.
In general if I’m called, I’m intubating. The traumas are an exception, most of their airways aren’t actually difficult.
The 3 strikes makes people call for help appropriately for an unanticipated difficult airway and keeps people from burning all the bridges before getting help. And most of the difficult airways aren’t that difficult for us anyway.

 

[coffeebythelake]

Do you respond to emergency intubations all over the hospital at all hours? We basically never get called for intubations although we have the most experience.

Yes. And after some airway incidents on the floor even with experienced anesthesiology residents, the on-call anesyhesiogy attendings respond to airways and codes as well

 

[nimbus]

Yes. And after some airway incidents on the floor even with experienced anesthesiology residents, the on-call anesyhesiogy attendings respond to airways and codes as well

Where I work, we almost never get called for intubations. Even though we have 24/7 in house coverage, they are often in a case and not available to respond to airways. So EM responds to floor airways and intensivists in the ICU.

 

[Harpoon1]

You must have missed the part about having 5 to 10 intubation experience. Hence my emphasis on *minimally trained*

you are right, I'd have them do the nighttime epidurals as well to hone their skills.

 

[Gas you down]

What really blows my mind, is thinking that’s it’s okay if a peds mid level who has never intubated a live infant or put in an umbilical line on a live infant, covers OB at night.

 

[chocomorsel]

What really blows my mind, is thinking that’s it’s okay if a peds mid level who has never intubated a live infant or put in an umbilical line on a live infant, covers OB at night.

By themselves? How do you know this? Where is this happening so I can stay away.
Cuz if **** goes south I can intubate, but have never put in an umbilical line either. Forehad, foot and IO kit anyone? Better call your pediatrician though.

 

[Socrates25]

I’m pretty sure we discussed one example a few years ago where the pediatric private group hired a peds NP to cover the deliveries at night because they wanted to be home in their nice warm beds. An after hours CS was called and a CRNA managed the mother but unfortunately the peds NP couldn’t intubate the baby. By the time the Anesthesiologist was called back to the suite to come help and apparently easily intubate the baby, 10-15 minutes had passed and the kid had a severe anoxic brain injury.
It turned out the NP had very little experience ever intubating babies and had not done an intubation in years.
I wouldn’t want money, I’d want blood or criminal charges for that level of malpractice, incompetence, and bad decision making.
Of course not all NPs and PAs are that bad, but you have to insure that they are properly trained and experienced before releasing them alone on a helpless patient. Our NICU NPs are fantastic, and experienced, and backed up.

How much of this was a failure of intubation skills vs a failure of BMV?

I've seen many babies hurt by incessant repeat intubation efforts when the right thing to do is bag the baby until the expert shows up (you guys)

Obviously intubation is critical to survival for some neonates in distress, but in my experience I've found that the number of neonates in which emergent intubation is the sole resuscitation pathway to survival or avoid severe morbidity is lower than many folks think it is.

 

[Socrates25]

By themselves? How do you know this? Where is this happening so I can stay away.
Cuz if **** goes south I can intubate, but have never put in an umbilical line either. Forehad, foot and IO kit anyone? Better call your pediatrician though.

IMO UVCs are substantially easier than the other methods you listed, all of the peds interns in my program were successful on their very first attempt.