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Can anyone comment on their role in the ICU. Lines, vent mgmt, how much freedom, scope of practice. Thanks
Can anyone comment on their role in the ICU. Lines, vent mgmt, how much freedom, scope of practice. Thanks
Worked with a guy who was full-time in the CT-ICU, dude even did central lines. He was great. Excepting him, though, the vast majority I've worked with function at about the level of a PGY-1.5 which is to say, then can collect data, but not reliable for procedures or anything comprehensive. Even the experienced ones struggle with the nuances of multi-organ dysfunction.
I wouldn't let anyone touch the vent except for MD or RT (and if the MD does it, he/she better be involving the RT) cause I think there's synergy there.
With the on-going push for more autonomy by mid-levels, I'm becoming more resistant to inviting further NP/PA involvement in my unit. I'm tired of my colleagues selling out. I think residency and fellowship means something.
Sorry.
our trauma icu also uses pa's. they admit and follow their own pts and discuss them at morning rounds with the attendings just like our md residents. they do full scope icu procedures( thoracentesis, central lines, chest tubes, etc, etc). also a busy place with high admit rate. level 1 trauma, etc
Really?
There's a word for that: Malpractice
You think they really "admit" their own patients? No - there is a big difference between having admitting privileges and doing the paperwork when the attending makes the decision to admit.
I doubt they do "full-scope" ICU procedures. The guy I know who did central lines still did them under full supervision.
I suspect you're extrapolating from a situation where, really, the mid-level might occasionally do a procedure in a very stable patient, and that the mid-level probably is involved in those trauma patients who are essentially in an observation status for 24 hours.
If your paragraph above actually describes reality, it makes me sick that a so-called Level 1 trauma center would allow that just to save a few bucks. There is NO WAY their ACS certification would survive a review if that was the case.
I'm sorry. Residency and fellowship equips you to manage trauma patients, not PA school.
Sorry if it offends you, bulgethetwine, but emedpa is spot on. The PA's in our critical care units do it all and, perhaps because they have all been at it awhile, do it quite well.
Nope, you aren't making it up. Our critical care PA's do central lines without supervision (the ones who have done enough to be checked off).Thanks for the md confirmation.
( see, I wasn't making it up...)
>As a NP in a large childrens hospital. we are fully staffed by NPs in the PICU. They admit patients, perform ALL procedures which includes lumbar punctures, central lines, art lines, intubations, chest tubes, etc. Most of these procedures were done WITHOUT direct physician supervision. In addition, the NPs and MDs manage vents from simple SIMV to APRV and High Freq Oscillatory Vents, and we DO make changes.
If you thinks its malpractice, talk with all of our intensivists and I think you'll find they feel differently.....
...The NP's main function in the ICU setting is to help carry out the plan of care as created by the attending, not to take over the ICU.
Famous last words. This is how "midlevel creep" starts. Although, by the sounds of it, midlevels have a much more extensive role in at least some ICUs than I expected/consider appropriate.
>
It's been my experience that NP's have a marginal understanding of mechanical ventilation.
Meh, concepts such as flow, total cycle time, inspiratory time, plateau pressures, graphics and so on are rather overrated IMHO. Why not just put em all in SIMV with 10 of PS and call it good? All that other fancy stuff is unimportant.
MD's are not in charge because they do procedures. You can train a tech to put a central line in. What makes the MD the primary decision maker is the plan of action not the procedures they do.
why not?
probably because SIMV is bull****
do you have any other suggestions?
I agree with this sentiment entirely. Unfortunately, as seen in other areas of medicine, this doesn't prevent mid-levels from feeling otherwise and pressing for increased/independent scope of practice. Its a slippery slope.
Famous last words. This is how "midlevel creep" starts. Although, by the sounds of it, midlevels have a much more extensive role in at least some ICUs than I expected/consider appropriate.
I didn't.
My bad.
No worries, I thought poresofkohn would appreciate the humour. With a name like that, he has to be a RCP.
Meh, concepts such as flow, total cycle time, inspiratory time, plateau pressures, graphics and so on are rather overrated IMHO. Why not just put em all in SIMV with 10 of PS and call it good? All that other fancy stuff is unimportant.
As an RN working in a moderate sized Level I PICU, I would be hesitant to work in an ICU with midlevels running the service. I have met a few different RN's who definitely have the experience and knowledge base to manage nearly every type of patient that presents to our PICU. In fact, there are a few nurses that work on our unit who can run circles around a few of our intensivits... those nurses are rare though. Could I manage certain patients? Absolutely.
However, I agree that most critical care units should be managed by physicians who completed a residency and fellowship. I am obviously a proponent for the nursing profession and for mid-level practitioners, but I think there should be a limit. Certain aspects of medical care should be left to trained and qualified physicians.
I do hope your grin means your are just kidding; b/c you can't do that; especially with kids.
I do hope your grin means your are just kidding; b/c you can't do that; especially with kids.
In fact, there are a few nurses that work on our unit who can run circles around a few of our intensivits...
However, I agree that most critical care units should be managed by physicians who completed a residency and fellowship. I am obviously a proponent for the nursing profession and for mid-level practitioners, but I think there should be a limit. Certain aspects of medical care should be left to trained and qualified physicians.
Capital U.
Capital G.
Capital H.
"... most critical care units should be managed by physicians who completed a residency and fellowship"
Er, how about all?
While your post (kind of, in a back-handed sort of way) supports the merits of residency and fellowship your comment that "a few nurses that work on our unit .... can run circles around a few of our intensivists" is laughable.
Haha
But it's not your fault. It's because you've never been to medical school. Or completed residency. Or completed fellowship.
Don't think that is what the person is saying. And your last comment was clearly condescending. It's ridiculous to get into pissing matches. If you think every physician is super sharp and on the ball over ALL nurses and NPS and PAs, who have picked up on imporant things that those physicians have missed, you are NOT living in reality.
We AGREE, as have I over and over and over that medical school and the residency medical system gives much better education and preparation overall. But what you are missing in the individual factor, and that which grows clinically based on experience. That is up to the individual person. DO NOT even try to NEGATE the clinical insights of people that have gained great experience and understanding into particular issues. It's silly. It is weak, and what's more, it equates to nothing more than some juvenille pissing contest. Wsdom and maturity need to be the voice of reason here, especially in light of the fact that NO ONE is trying to take over medicine for the love of God.
Once more, medicine has MUCH bigger concerns that this spagettified fear of "midlevels."
When a person keeps beating a drum on something that is essentially a non-issue, in light of the fact that there are much bigger, "Titanic" issues where the focus must be, one has to wonder what is with the fixation.
No one wants NPs or PAs or DNPS or non-physicians taking over. Stop imagining that the sky is falling over this issue. It is not. It's just NOT realistic, period.
It's not ridiculous when you see what some members of the nursing community (maybe not you) are trying to lobby for, and what some hospital administrators will accept to save a buck.
So I wouldn't characterize it as "no one".
It's disgusting, and the current trend of de-valuing residency and fellowship is dangerous to patients. Don't try and be an apologist for some of your more aggressive colleagues by trying to make it sound like you're attention is focused on the "titanic" issues.
Besides, no one has addressed this yet, but your convenient line of "individual experience" actually doesn't hold up when you consider that your "experience" is 36 hour work weeks taking care of 1-2 patients a shift in the unit, and mostly technical stuff at that.
Puhleeeeeze.
You must know by now, espeically in critical care, one resident, fellow, or doctor cannot look at all aspects of everything at every moment, for he or she has many critical patients and ED admits to evaluate and deal with. Who the hell do you think is there combing over everything in the ICU? I will tell you; it is the intelligent, committed, and hypervigiliant critical care RN.
Now if you want to try to play that down, you go right on ahead. And I agree completely that it doesn't make a physician, and I for one have NEVER, EVER said or ACTED as if it did.
Most of your message talked about an RN doing exactly what they should do when functioning as an RN in the unit.
That was spot on.
It's the idea that somehow being a great RN will translate into the ability to be the sole provider in an ICU in the middle of the night.
That's what some of your colleagues, believe it or not, are trying to argue for. And that's what I'm against -- I'm not against having skilled, experienced nurses (in fact, it's an absolute requirement for me to be able to do my job) doing exactly as you describe in your message.
Residency and fellowship has value. And "mid-level creep" disrespects that. I, for one, am happy to forgo a little sleep and work a little harder in exchange for keeping mid-levels out of my unit, and KEEPING MY PATIENTS SAFER.
Totally agreed.
A few thoughts (in no particular order):
(1) What's this stuff re allowing PAs/AAs but not NPs/CRNAs? By virtue of their training, they have largely similar roles (i.e. are permitted to do similar things) but AFAIK the PAs/AAs aren't pushing for independent practice (as the NPs/CRNAs are). I doubt anyone would mind if NPs/CRNAs were content to work under physician supervision (the fact they are apparently not is why some may take a "tough position" as you say against them; likewise if PAs/AAs sought independent practice we'd see a similar reaction). So I'm not sure where this is coming from.
(2) Re the "holistic" nature of nursing: Obviously, physicians and nurses receive very different training. Having said that, to think that physicians perceive pathophysiologic processes to the exclusion of the rest of the patient is a myth. In fact, both med schools and residency programs are placing increasing emphasis on this aspect of patient care.
(3) Along these lines, let's move on "patient advocacy." This is a role that, for some reason, many nurses want to claim as their exclusive domain. Frankly, I'm not sure why. As a physician, I certainly want what's best for my patient too (ideally obtained in as quick and drama free manner as possible).
(4) Re medical student education being funded by pharmaceutical companies: I assume you're referring to this report (or others like it). Please recognize that there is a big difference between a medical center receiving funding and that money being used to pay for medical education directly. Given that average medical student debt is over $150K for four years, I'm comfortable in assuming that most of us payed for our education directly. Now, its certainly true that medical centers receive a portion of any grant money awarded to faculty members (including grants from drug companies) in the form of indirect costs. Having said that, most medical centers that have med schools also have nursing schools. And before you mention residency funding, realize that its covered by the government.
(5) Re the importance of allowing for individual experience: I'm all for individuals advancing their education and training. However, it doesn't make sense to say that you need to account for individual experience when we're discussing allowing a group of people to have increased scope of practice. Frankly, if an individual nurse is that bright/talented and wants increased responsibility, bite the bullet and go to med school and do residency/fellowship (I know a number of people who have done this).
(6) At the end of the day, we (physicians and nurses) play very distinct but important roles in health care. Although there is inherently some overlap, one cannot replace the other. Ideally, we all recognize this so we can more effectively work together in our defined roles. Frankly, I would like nothing more than to agree on this, shake hands, call it a day, and move on with more productive matters. Unfortunately, this seems unlikely as nurses continue to infringe on the practice of medicine. Yes, you'll likely continue to say that this is much ado about nothing. I submit that we have very different perspectives.
Sorry if it offends you, bulgethetwine, but emedpa is spot on. The PA's in our critical care units do it all and, perhaps because they have all been at it awhile, do it quite well.
Nope, you aren't making it up. Our critical care PA's do central lines without supervision (the ones who have done enough to be checked off).
As a NP in a large childrens hospital. we are fully staffed by NPs in the PICU. They admit patients, perform ALL procedures which includes lumbar punctures, central lines, art lines, intubations, chest tubes, etc. Most of these procedures were done WITHOUT direct physician supervision. In addition, the NPs and MDs manage vents from simple SIMV to APRV and High Freq Oscillatory Vents, and we DO make changes.
If you thinks its malpractice, talk with all of our intensivists and I think you'll find they feel differently.....
Actually I want the name of your hospital so I can talk to the intensivists to figure out why they are getting paid 200k if they arent providing any kind of valuable service worth of such a high income.
You should also notify your hospital CEO -- I'm sure he'd be upset by the fact that he's paying out $200k to a bunch of lazy scrub MDs who are contributing nothing to his ICUs. He could save a ****load of money by firing them -- after all they are getting paid for services not rendered and thats fraud in my book.
Yes. Especially considering it's absolute nonsense.Is anybody else tired of hearing all the bloviation about how us nurses are the jedi masters of holistic care?
Hope you have your fire ******ants on - mostly on here are a bunch of NPs pushing for more responsibility and $$$ without becoming legitimate docs, and a bunch of apologists for their cause.
Good luck though (wink)
That is hardly an expression of pushing for more money or responsibility. In fact no one stated that. When others have posted that having NPs/PAs in the ICU takes some of the load off of the attendings and residents the response (not from you)
You've made your opinion on clear on the appropriateness of midlevels (NPs in particular) managing patients in the ICU. I get it, respect it, and have nooooo desire to argue with it. But don't insult everyone's intelligence by claiming the majority of the respondents to this post are NPs with an agenda.
Hope you have your fire ******ants on - mostly on here are a bunch of NPs pushing for more responsibility and $$$ without becoming legitimate docs, and a bunch of apologists for their cause.
Good luck though (wink)
Spare us this nonsense please. I can cite a dozen articles minimum by all the relevant "advanced practice" nurse organizations that clearly state they desire autonomous, independent practice with no MD involvement whatsoever.
This constant BS of "the MDs are paranoid and are greatly overestimating our goals" has been exposed over and over again as a lie. YOUR OWN FREAKING NURSING ORGANIZATIONS HAVE OPENLY ADMITTED WHAT THEIR "MASTER PLAN" FOR "ADVANCED PRACTICE" NURSES ARE.
So, do you want me to post the links or what?
That won't be necessary as that is NOT what I was referring to. Nice try though.