Nighttime Intensivist Staffing

[imfrankie]

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another good reason to consider the critical care fellowship, IMHO:

From NEJM Special Article May 21

"The addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing."

http://www.nejm.org/doi/full/10.1056/NEJMsa1201918?query=OF

 

[deleted126335]

another good reason to consider the critical care fellowship, IMHO:

From NEJM Special Article May 21

"The addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing."

http://www.nejm.org/doi/full/10.1056/NEJMsa1201918?query=OF

Just what everybody's dream job looks like: The sickest patients, in the middle of the night, with the least amount of experienced help available in the St. Elsewhere.

If getting the call in the community hospital for the morbidly obese sleep apneic patient who @ 2 am needs intubation, Aline, Central line and dialysis catheter is your thing- go for it. All the while being assisted by a brand new RN or the float RN who usually work peds.

Or more likely you will be "on back up" for the advanced practice nurse ICU practitioner/hospitalist who will make 90% of your income who calls you for this type of case.

 

[BLADEMDA]

Just what everybody's dream job looks like: The sickest patients, in the middle of the night, with the least amount of experienced help available in the St. Elsewhere.

If getting the call in the community hospital for the morbidly obese sleep apneic patient who @ 2 am needs intubation, Aline, Central line and dialysis catheter is your thing- go for it. All the while being assisted by a brand new RN or the float RN who usually work peds.

Or more likely you will be "on back up" for the advanced practice nurse ICU practitioner/hospitalist who will make 90% of your income who calls you for this type of case.

This is the type of sitiuation that the intensivists call me. Most ICU docs can't handle this type of patient alone without a solid Anesthesiologist. By the way, placing a dialysis cathter is nothing more than a very large Central Line. I've done hundreds of them.

 

[sevoflurane]

DC are my favorite lines to put in....🙂

 

[imfrankie]

One thought: while you are in house on call for anesthesia, you are also covering the unit for an additional--and now warranted--stipend

 

[deleted126335]

One thought: while you are in house on call for anesthesia, you are also covering the unit for an additional--and now warranted--stipend

It is easier for the hospital to employ you, and the expand your responsibilities to include ICU.

 

[imfrankie]

It is easier for the hospital to employ you, and the expand your responsibilities to include ICU.

But the study says outcomes are better when an intensivist...

This is exactly the evidence-based stuff the hospitals will be forced to respect.

 

[fakin' the funk]

This is the type of sitiuation that the intensivists call me. Most ICU docs can't handle this type of patient alone without a solid Anesthesiologist. By the way, placing a dialysis cathter is nothing more than a very large Central Line. I've done hundreds of them.

How and what do you bill in this situation?

 

[imfrankie]

How and what do you bill in this situation?

There's a CPT code for putting in a line, intubating emergently, etc. You fill out a billing slip with the CPT code on it, and each procedure is "worth" a flat fee of so-many units.

I defer to others for billing for ICU management. Don't know how to do that myself. I think one can also bill for vent management, but I've not done it, and don't know the process.

 

[BLADEMDA]

How and what do you bill in this situation?

Yes. My billing company charges for each procedure I do. Medicare pays like dirt but private payers pay well.

If I initiate "artifical ventilation" then I charge for that as well. I do not bill for a CC Consult as that requires a detailed note. Billing for artifical ventilation only requires a very brief note and vent settings.

 

[Jay K]

Just what everybody's dream job looks like: The sickest patients, in the middle of the night, with the least amount of experienced help available in the St. Elsewhere.

😀 This made me laugh - thanks.

If I initiate "artifical ventilation" then I charge for that as well. I do not bill for a CC Consult as that requires a detailed note. Billing for artifical ventilation only requires a very brief note and vent settings.

Thanks for this tidbit; We've certainly been losing income despite actually performing services for this one.

 

[deleted126335]

But the study says outcomes are better when an intensivist...

This is exactly the evidence-based stuff the hospitals will be forced to respect.

Hospitals will choose to care about "evidence based studies" that serve their agenda. They will disregard those studies that do not.

 

[nycitygas]

There is a group in Boston where they they have ccm boarded anesthesiologists on call who cover the ICU and OR at the same time. South Shore I believe.

From what I hear they make great money for the location.

 

[seinfeld]

After reading the article I am surprised it was published in the NEJM. Probably only because DAngus was an author. The article has it flaws, mainly it's external validity. Too much emphasis on teaching hospitals with residents. How residents are " counted" etc. I feel it better addressed the question do Icu attendings need to be in house 24/7. I would say that. Not having having an attending available at least by phone at 3am to make decisions such as ECMO, emergent dialysis, and provide back up for central access and intubations is not standard medical practice.

Overall it reaffirmed that intensivists improve mortality. I will always argue that overall mortality is not the best measure of Icu outcomes, but the easiest to study.

 

[seinfeld]

There is a group in Boston where they they have ccm boarded anesthesiologists on call who cover the ICU and OR at the same time. South Shore I believe.

From what I hear they make great money for the location.

You can't bill for both providing anesthesia and critical care at the same time. If you have no OR cases going I can see how it would work out.

 

[imfrankie]

You can't bill for both proving anesthesia and critical care at the same time. If you have no OR cases going I can see how it would work out.

Maybe the hospital stipends (that's a verb) the anesthesia group to be able to say, "we have in-house CCM docs at night"

 

[cchoukal]

Maybe the hospital stipends (that's a verb) the anesthesia group to be able to say, "we have in-house CCM docs at night"

I interviewed with this group a couple years ago, when they were initially thinking they were getting a hospital subsidy to expand to 24/7 in-house intensivist coverage. My plans to move to Boston changed, so I didn't pursue it post-interview, but I was later told by another applicant that the subsidy went away. It's possible things have changed considerably in the intervening 2 years. My sense when interviewing was that the ICU acuity was pretty low (although this may be an unfair comparison to my current academic gig), but that, in general, it was a great group in a great hospital.

 

[nycitygas]

I interviewed with this group a couple years ago, when they were initially thinking they were getting a hospital subsidy to expand to 24/7 in-house intensivist coverage. My plans to move to Boston changed, so I didn't pursue it post-interview, but I was later told by another applicant that the subsidy went away. It's possible things have changed considerably in the intervening 2 years. My sense when interviewing was that the ICU acuity was pretty low (although this may be an unfair comparison to my current academic gig), but that, in general, it was a great group in a great hospital.

Seems like a great group with excellent compensation for a desirable area. I'm curious to know how the financials work as this is an excellent model for more PPs to follow. A group that covers the ICU as well as the OR would be much harder to displace by an AMC