What do NPs/PAs do in the ICU?

[sozme]

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I was reading the new edition of Principles of Critical Care and in chapter 3 it discusses ICU staffing issues. There is a section on "NONPHYSICIAN EXTENDERS."

In said section, it states that NP staffing in the ICU has been highly beneficial, and cites a few studies showing that there is no difference
in mortality when patients are cared for by NPs vs. CCM fellows (in a step-down MICU). And PAs vs. house staff in the MICU showed no difference
in 28-day mortality, etc. whatever... my question is what do these individuals actually do in the ICU?

I notice none of these studies compare NP to fellows in MICU or SICU, the most it seems is just in "step-down MICU."

I don't see how this book can actually suggest said providers are simply "EXTENDERS" when they over-emphasize equivalence of care? Surely
they aren't deluded into thinking they will remain in that role for the long-term what with all these "equivalence" studies.

So I am just curious what type of cases an NP is able to manage on their own and what sort of procedures they are allowed to do on their own.

 

[jdh71]

My NPs and PA don't manage anything on their "own". They don't even want to. They just help me get stuff done. Occasionally they will help write some follow up notes if I super busy. They will do supervised central lines. Though they've probably done enough now that they don't need to be supervised directly but I want to bill for them. They also run my chest tube lytics which is actually a pretty huge time saver for me. I like them.

 

[deleted547339]

We have NPs that have their own service in my program. The NPs essentially function as perpetual interns/residents. They round, write notes, write orders, do some procedures.

All admissions get seen by the fellow. Attending does walking rounds once daily and sitting rounds in the afternoon.

It helps decompress the resident service.

 

[quickfeet]

My NPs and PA don't manage anything on their "own". They don't even want to. They just help me get stuff done. Occasionally they will help write some follow up notes if I super busy. They will do supervised central lines. Though they've probably done enough now that they don't need to be supervised directly but I want to bill for them. They also run my chest tube lytics which is actually a pretty huge time saver for me. I like them.

Do you feel like they could manage complex cases on their own?

I'm kind of curious what the most complex thing a very experienced PA or NP could be trusted to handle in the ICU. I've been told by my school that after a certain time, they can pretty much do and manage anything a fellowship trained intensivist can. Not really sure I believe that.

 

[jdh71]

Do you feel like they could manage complex cases on their own?

I'm kind of curious what the most complex thing a very experienced PA or NP could be trusted to handle in the ICU. I've been told by my school that after a certain time, they can pretty much do and manage anything a fellowship trained intensivist can. Not really sure I believe that.

Manage completely on their own? No. But then our practice isn't set up like that. They could easily get a work up started but where to go there would be a nonstarter for them I think. Nuance of vents is lost on them for instance. They don't bronch. Don't put in arterial lines.

 

[deleted547339]

Manage completely on their own? No. But then our practice isn't set up like that. They could easily get a work up started but where to go there would be a nonstarter for them I think. Nuance of vents is lost on them for instance. They don't bronch. Don't put in arterial lines.

Ours do A-lines.

 

[G-Man82]

One of the APNs in the trauma ICU where I'm at does all forms of standard ICU lines and also perc trachs and will also do bronchs if the trauma fellows are busy. I don't think the trauma surgeons particularly care because they'd rather operate or manage the trauma bay.

At a place I interviewed, a private practice ICU/Anesthesia job that covers micu, sicu, transplant ICU, and Neuro ICU at a level 1 trauma center, the APNs and PAs do similar things: notes, lines, minor procedures, etc. largely because the attendings are spread too thin. I don't want to go there though bc of other issues.

It's not ideal, but in busy places without enough physician staff, it's a reality unfortunately.

 

[jdh71]

Ours do A-lines.

Right. Ours don't.

 

[jdh71]

Any monkey can BAL. And I wouldn't really even care if my mid levels learned how to do ICU bronchs. Or A lines. I do that stuff because I want to bill for it and I'm faster.

The problem is "doing things" to patients IS NOT "critical care". The folks I work with are great people. Smart. But still unable to manage everything that would need managing. Maybe throw them in the deep end of the pool and let them splash around maybe they pick it more than they don't?? It's probably conceivable that midlevs could do a lot of management. But very complex medical ICU patients?? Probably not to my level.

 

[G-Man82]

Agreed. The problem that I see with most mid-level providers, and now that I'm moonlighting as an Attending in my free time, and especially our CRNAs, is that they don't really know when to call us if something is happening. Or, sometimes they act on their own, and are completely wrong. I ran into an issue earlier today in the OR for a patient going to SICU. My CRNA gave lasix without asking me, just because the patient's urine output was low. Looking at the monitors, there was definitely respiro-phasic pulse pressure variation. Not an example of something catastrophic, but still; no real thought, but potentially bad implications in the post-operative period. At least they didn't start renal dose dopamine; I would have lost it.

As for that place at which I interviewed, the very sick patients were seen and actively managed by the MDs; the bread and butter cases were mostly managed by the PA/APN, with MD supervision of bigger procedures (bronchs, intubation), and an MD daily note.

 

[quickfeet]

My CRNA gave lasix without asking me, just because the patient's urine output was low. Looking at the monitors, there was definitely respiro-phasic pulse pressure variation. Not an example of something catastrophic, but still; no real thought, but potentially bad implications in the post-operative period. At least they didn't start renal dose dopamine; I would have lost it.

As for that place at which I interviewed, the very sick patients were seen and actively managed by the MDs; the bread and butter cases were mostly managed by the PA/APN, with MD supervision of bigger procedures (bronchs, intubation), and an MD daily note.

Why would she do this? Isn't this the criticism.. that they don't really understand what they don't know because of their very limited education and training?

 

[jdh71]

Why would she do this? Isn't this the criticism.. that they don't really understand what they don't know because of their very limited education and training?

To be fair. I feel like the ones I work with have a good sense of what they don't know. And it's a tough right rope to walk because you really don't want them bothering you with everything either.

 

[G-Man82]

Why would she do this? Isn't this the criticism.. that they don't really understand what they don't know because of their very limited education and training?

Yes. And it drove me nuts. But at this place that's the culture unfortunately and it's tough to change. With this particular group of APNs though, they think they know a lot, but in reality it's shocking what they don't. As the newbie, I've already dismissed one from one of my rooms for doing what I consider harm. It's the talk of the town unfortunately. Good thing I'm just a moonlighter.

 

[quickfeet]

Yes. And it drove me nuts. But at this place that's the culture unfortunately and it's tough to change. With this particular group of APNs though, they think they know a lot, but in reality it's shocking what they don't. As the newbie, I've already dismissed one from one of my rooms for doing what I consider harm. It's the talk of the town unfortunately. Good thing I'm just a moonlighter.

Lol I bet you are well loved

 

[Hernandez]

Lol I bet you are well loved

At the end of the day, you're there to take care of patients not coddle people with fragile egos, ICU midlevels come in 2 main flavors, those that think they're docs and are better than everyone else, and well.....those that arent like the first type.