Surgeons and Anesthesiologists in the ICU

[MoMoGesiologist]

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wtf...30+ acute patients? How?

It's a 30+ beds unit. Usually just try to stay afloat at night time and put out fires, but no way am i optimizing care. Usually it's just post op cardiac patients and if they follow the rules it's not an issue. Throw in some ECMO, post op issues, new admits, and a coding patient and it can get miserable. Usually the attending will come in if someone is coding so that helps.

 

[Psai]

...30+ postop cardiac patients?!

I mean at least they're lined up and maybe still intubated but goddamn

 

[chocomorsel]

...30+ postop cardiac patients?!

I mean at least they're lined up and maybe still intubated but goddamn

Sounds like misery.

 

[Modanq]

Sevo, when your group was approached to take over the units, how did you negotiate with the hospital to determine the stipend (average 99291 x average unit census?)? Regarding your group dynamics, any day that one of your partners is in the unit is a day they're not doing cases. Did your group decide to recruit additional partners due to this expansion, or did everyone just tighten they're belts a little, and each give up a week or two of vacation? I was talking to someone with a different group, and they mentioned that they were approached by their hospital to do something similar, but there was no interest among their group, so they opportunity wasn't pursued.

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I think this is the key point. A lot of ICUs have the need. Many anesthesiologists can provide ICU care and are trained to do so. I am a recent grad - CV and CC - and am starting to get privy to the inner workings of ICU take-over. How can a group generate revenue from the ICU while covering the OR. One option is to break even and hire more physicians but increase goodwill, presence, "iron-fist" over the hospital or second - is there any area for arbitrage in the ICU? Can a group go into a poorly run ICU fiscally and clinically- Then Revamp it and generate revenue from it. That is the key area where anesthesiology groups should start thinking about the ICU. Perhaps it should be a "hyper-acute" model as mentioned and then make the ICU a procedural arena to bill for (Hyperacute ICU 99291 x procedures)

 

[sevoflurane]

I don't think I quite qualify for that designation. I'm a guy that didn't stop doing cardiac after residency, taught myself more echo, then went to CC fellowship. I was supposed to do CC, CT, and general anesthesia at my current job, but that didn't turn out to be true. I'm looking around at what's available within a few hours of family, and one group mentioned that they were approached by their hospital to help run the unit. The group decided not to pursue it, due to lack of interest among the partners. Since the hospital is interested, and the recruiting partner indicated they would not be averse to the idea, I'm wondering if I could show them that it would not be a revenue loss, we could work something out. It's a long shot, but inferring from ICU locums ads, the hospital is really hurting for unit coverage.

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Ahh man. Sorry to hear that so soon out. Hate that kind of BS from our own.
#1 in any group should be transparency.
Sounds like the hospital is seriously in need and you hold the qualifications. Could work things backward and start with a hospital administrative meeting and go from there?
I think for you CC/CT guys it would be a great job to do cases in the CVOR for 2.5 days and then transition to CC for 2.5 days. Would be nice to have that continuity.

 

[sevoflurane]

In fellowship

Gotcha. Sorry if I came off as incenaitive to your fellowship year - didn’t realize you were doing a CC year.

Weren’t you in PP for a while? Now going back to fellowship? Damn...

​

 

[chocomorsel]

Gotcha. Sorry if I came off as incenaitive to your fellowship year - didn’t realize you were doing a CC year.

Weren’t you in PP for a while? Now going back to fellowship? Damn...

​

Thanks. Guess there are some superstars who can do it without a fellowship, but I am not one of them.
Was in PP for a few years. It’s a nice change honestly except for the money. A lot to learn and am really enjoying it, but feeling like I don’t have enough time to learn it all in a year.

 

[vector2]

Thanks. Guess there are some superstars who can do it without a fellowship, but I am not one of them.
Was in PP for a few years. It’s a nice change honestly except for the money. A lot to learn and am really enjoying it, but feeling like I don’t have enough time to learn it all in a year.

No one learns it all in a year. I read as much my first year out as I did as a fellow.

 

[teacher2md]

I read this article about a morbid outcome after hip surgery. I'm curious if any of you have experience with eICU setups. From what the article describes, they sound horrible.

How can an ICU be run where there are no physicians readily available?? This lady was in hemorrhagic shock and apparently there was just a new nurse on site...

 

[Psai]

I read this article about a morbid outcome after hip surgery. I'm curious if any of you have experience with eICU setups. From what the article describes, they sound horrible.

How can an ICU be run where there are no physicians readily available?? This lady was in hemorrhagic shock and apparently there was just a new nurse on site...

The real horrible thing is that no one seemed to talk to the family about the real risks of surgery prior to taking the patient to the OR. A patient on plavix getting a hip is not "routine".

 

[dannyboy1]

The real horrible thing is that no one seemed to talk to the family about the real risks of surgery prior to taking the patient to the OR. A patient on plavix getting a hip is not "routine".

Something is missing from this case. First of all six hour surgery on a broken hip !? Second, if she was bleeding that heavily during surgery why did the surgeon and anesthesiologist draw labs and transfuse? If the surgeon was concerned about ongoing bleeding why did he not order labs and follow up?

 

[deleted547339]

I read this article about a morbid outcome after hip surgery. I'm curious if any of you have experience with eICU setups. From what the article describes, they sound horrible.

How can an ICU be run where there are no physicians readily available?? This lady was in hemorrhagic shock and apparently there was just a new nurse on site...

I’ve worked with them in training and as faculty. They’re not perfect, but they’re a lot better than nothing. They are almost exclusively at relatively low acuity facilities that couldn’t recruit or afford to hire intensivists. They’re not meant to replace boots on the ground in a referral center. The comparison isn’t e-icu vs. in house intensivist, it’s e-icu or e-icu + hospitalist/fp doc vs. no doc/hospitalist/fp doc.

 

[psychbender]

I’ve worked with them in training and as faculty. They’re not perfect, but they’re a lot better than nothing. They are almost exclusively at relatively low acuity facilities that couldn’t recruit or afford to hire intensivists. They’re not meant to replace boots on the ground in a referral center. The comparison isn’t e-icu vs. in house intensivist, it’s e-icu or e-icu + hospitalist/fp doc vs. no doc/hospitalist/fp doc.

Not entirely accurate. Some of the larger corporate critical care groups try to do e-ICU to save money after they acquire a contract. I know of at least one hospital that did have 24hr intensivist coverage before the large corporate group moved in. After a while, they were forced to actually staff the nights with someone local and able to respond to an emergency.

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[deleted547339]

Not entirely accurate. Some of the larger corporate critical care groups try to do e-ICU to save money after they acquire a contract. I know of at least one hospital that did have 24hr intensivist coverage before the large corporate group moved in. After a while, they were forced to actually staff the nights with someone local and able to respond to an emergency.

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Ugh. That makes me want to vomit.

 

[Psai]

Not entirely accurate. Some of the larger corporate critical care groups try to do e-ICU to save money after they acquire a contract. I know of at least one hospital that did have 24hr intensivist coverage before the large corporate group moved in. After a while, they were forced to actually staff the nights with someone local and able to respond to an emergency.

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The sheer greed of the suits will never fail to amaze me

 

[AdmiralChz]

How can an ICU be run where there are no physicians readily available?? This lady was in hemorrhagic shock and apparently there was just a new nurse on site..

Happens VERY frequently. We also have eICU here... it’s awful, there’s typically just a PA or NP on site with no doc. We get a lot of intubation calls at night (ED is spread to thin at night so we take responsibility as we are already there for OB), and subjectively it seems like a lot of these could have been avoided with more appropriate critical care. We have no anesthesiology or surgical critical care here, though, it seems to be all medicine semi-closed units. And we have one of the biggest names in CCM, so strange.

 

[deleted171991]

Happens VERY frequently. We also have eICU here... it’s awful, there’s typically just a PA or NP on site with no doc. We get a lot of intubation calls at night (ED is spread to thin at night so we take responsibility as we are already there for OB), and subjectively it seems like a lot of these could have been avoided with more appropriate critical care. We have no anesthesiology or surgical critical care here, though, it seems to be all medicine semi-closed units. And we have one of the biggest names in CCM, so strange.

My experience exactly, at not one but two community hospitals, except that there was no eICU and there were residents and APRNs at night (but no trace of medical intensivist after hours). It's incredible how little some docs care about their patients. There is a reason that the more a family is involved in the care of an ICU patient, the better the survival; the squeaky wheel gets the grease.

The weeks I am on ICU, I tend to not get much sleep, because my residents know that I'll be really pissed if they muck up my patients overnight, undoing all the good stuff we did during the day, so they tend to call before drowning my patients in fluids etc. But I also have colleagues who sleep like babies, and couldn't care less that the patient takes one step back every night. And since people/hospitals get paid regardless of the real quality of care...

 

[Mman]

And since people/hospitals get paid regardless of the real quality of care...

doesn't the hospital already not get paid if the patient gets a hospital acquired complication like VAP, foley UTI, CLABSI, or decub?

Increasing bundled payments say the hospital is going to eat the cost of every increase in LOS and complication.

 

[chocomorsel]

Happens VERY frequently. We also have eICU here... it’s awful, there’s typically just a PA or NP on site with no doc. We get a lot of intubation calls at night (ED is spread to thin at night so we take responsibility as we are already there for OB), and subjectively it seems like a lot of these could have been avoided with more appropriate critical care. We have no anesthesiology or surgical critical care here, though, it seems to be all medicine semi-closed units. And we have one of the biggest names in CCM, so strange.

Is this one of your off sites? Not the main one you cover?

 

[AdmiralChz]

Is this one of your off sites? Not the main one you cover?

2 of the 3 hospitals we cover have this (including the academic level 1 center) setup. Not sure about the 3rd, where EM responds to all the codes/airways since we aren’t (required) to be in house as there’s no OB.

Worst part - the hospital touts the eICU program as “innovative” “increasing access” and “cost saving” along with crap about supporting advanced practice folks... at an otherwise pretty solid hospital system it makes me sort of sick.

 

[chocomorsel]

2 of the 3 hospitals we cover have this (including the academic level 1 center) setup. Not sure about the 3rd, where EM responds to all the codes/airways since we aren’t (required) to be in house as there’s no OB.

Worst part - the hospital touts the eICU program as “innovative” “increasing access” and “cost saving” along with crap about supporting advanced practice folks... at an otherwise pretty solid hospital system it makes me sort of sick.

Wow, a level 1 trauma center with no real live CCM docs? I guess it has no residency? How does this even fly? The sickest patients in the region are being managed by NPs?

 

[CCM-MD]

Those who haven’t experienced life outside of academia will be shocked but reality is there are many (I would go as far as saying most) hospitals in the US don’t have night time intensivists. The ACCCM (SCCM) doesn’t even recommend 24/7 intensivist staffing outside of level 1 ICUs because studies haven't shown consistent benefit.

We recently transitioned to night time intensivist presence after a bad outcome. Had NP presence with physicians taking home call at night time before. To convince hospital admin types to pay for 24/7 - you need good data to back you up and you need to have intensivists who are willing to work nights. Might have a harder time trying to convince your partners to work nights than the hospital...

Article relating to this for those who are interested:
Is 24/7 In-House Intensivist Staffing Necessary in the Intensive Care Unit?

 

[AdmiralChz]

Wow, a level 1 trauma center with no real live CCM docs? I guess it has no residency? How does this even fly? The sickest patients in the region are being managed by NPs?

At the level 1 the eICU is only at night, there’s a daytime attending until he or she leaves. That individual is medicine trained and typicaAt the community hospital the eICU is night and weekends.

I’m new so I don’t fully understand it, admittedly. And we have a pulm/CCM fellowship!

 

[nimbus]

At the level 1 the eICU is only at night, there’s a daytime attending until he or she leaves. That individual is medicine trained and typicaAt the community hospital the eICU is night and weekends.

I’m new so I don’t fully understand it, admittedly. And we have a pulm/CCM fellowship!

Doesn’t a level 1 trauma center require a trauma surgeon/surgical intensivist in house?

We have 24/7 pulm/cc in-house. But we also have 24/7 in-house trauma and they round on their own patients.

 

[deleted171991]

doesn't the hospital already not get paid if the patient gets a hospital acquired complication like VAP, foley UTI, CLABSI, or decub?

Increasing bundled payments say the hospital is going to eat the cost of every increase in LOS and complication.

That's correct. Still it's very hard to link those to the MD's "quality of care", so the "bad" doc gets paid the same as the "good" doc, plus the former gets to sleep well at night.

I haven't done eICU yet, and I doubt I ever will. Too much liability, too low quality care. My golden rule in medicine is that I don't do stuff to patients I wouldn't do to my mother.

 

[CCM-MD]

At the level 1 the eICU is only at night, there’s a daytime attending until he or she leaves. That individual is medicine trained and typicaAt the community hospital the eICU is night and weekends.

I’m new so I don’t fully understand it, admittedly. And we have a pulm/CCM fellowship!

Are you in PA? If you are... I think I may know which hospital you are at.

: )

 

[AdmiralChz]

Doesn’t a level 1 trauma center require a trauma surgeon/surgical intensivist in house?

We have 24/7 pulm/cc in-house. But we also have 24/7 in-house trauma and they round on their own patients.

Oh, we have an in-house trauma surgeon! And other level 1 people, but our trauma folks don’t seem to do a lot of critical care. 24/7 CCM isn’t explicitly required, to my knowledge, and if so I suppose the eICU counts somehow. I’m not sure, I’ll report back when I have a better understanding.

Note the cardiac portion of the hospital is in a different building with a separate, non-hospital based service.