ICU procedures

[crieman]

I'm a PA that works in pulmonary/critical care at a large trauma center. Unfortunately there are tons of residents that suck up most of the invasive procedures throughout the day. How do I get around this? What procedures are most of the critical care PA's doing? I've been here six months now and I've done one subclavian and one thoracentesis. I need ideas and arguments to bring to my docs!

[EMEDPA]

work night shift.

[andersenpa]

You may check out SCCM or other related conferences to see if they have workshops. Get a credential/certificate for one of these.

Also get friendly with anesthesia and see if you can spend an off day in the OR putting in lines, intubating, etc.

 

Then you can try to start a procedure or line service. PAs did this at one of my old hospitals. Your best bet is to show that a dedicated team of providers- PAs- perfoming procedures which they are skilled at can result in lower complication rates than with newbie residents.

 

Of course this will be an uphill battle in a teaching program.

[maryfran123]

Still in the planning stages but Eastern Association of Surgical Trauma (EAST) starting with the annual meeting Jan 2011 will have pre-conference forums for Advanced Practitioners. This is one of the many ideas that has come out of the Advanced Practitioner Ad Hoc committee I am on, that the BOD of EAST is fully supporting. One of the seminars will be educational, a second procedure oriented and ideas discussed last night during our conference call included invasive procedures, use of FAST in the ICU, virtual pt scenarios using SIM MAN (eg: difficult airway, acute abd, and exsanguination), and neurocritical care management of ICP/Ventrics, and many other topics. Nothing is definitive but something to look out for.

 

Another option is:

http://www.npinstitute.com/Course.asp?pid=28

 

 

http://www.npinstitute.com/Course.asp?pid=26&UID=

 

If you look under "Hospitalist Procedures" they teach all types of invasive procedures including central lines, Swanz, thoracentesis, Chest tubes, etc. Warning: expensive!! Tuition is $1400!!!

 

Hope this info helps.

[crieman]

Thanks for the replies, appreciate the input. I was able to sneak in an IJ today! I wish we had a night shift actually. Right now we don't do any nights or call which is really nice but I wouldn't mind if it meant procedures.

[ventana]

from and IR persective and talking with other PA's

 

Chest tube, IJ and subclavian (if still doing), paracentesis, thoracentesis, PICC lines

[cobramarty]

Tell your attending that you/he can bill for your procedures and that no attending can bill (legally get paid) for procedures done by students or residents unless they are right there at the bedside, not down the hall, etc. Be business minded, which and how many procedure are you currently 'giving away' to others which you could do in a week. Tell me, your attending, that you could generate $1000/week in proceedure fees, and I am sure he is all ears.

[coloradopa]

Tell your attending that you/he can bill for your procedures and that no attending can bill (legally get paid) for procedures done by students or residents unless they are right there at the bedside, not down the hall, etc. Be business minded, which and how many procedure are you currently 'giving away' to others which you could do in a week. Tell me, your attending, that you could generate $1000/week in proceedure fees, and I am sure he is all ears.

The attending has to be personally present for the critical part of the procedure. Since the attendings are responsible for the residents work they usually come into the room when the procedures are done even when the residents are very proficient. Then they bill for the procedure.

 

To the OP we have two services a PA/NP service and a resident service. The attending rounds with the residents and does teaching during these rounds. There is an NP who rounds with the residents, helps them put orders into the computer and acts as a resource for ICU protocols and policies. If a patient comes in to the resident service during rounds or a patient needs a procedure during rounds he can break away and do the procedure. The NPs and PAs run there patients with input from the attending as necessary. We do a quick walking rounds in the afternoon so they are up to speed on our plans.

 

As for procedures the rule is that if its your patient its your procedure. We really don't fight over procedures. We have a mixed resident staff of PGY 2 and 3s from anesthesia, EM and surgery. The anesthesia residents are very proficient at IJs but like to do subclavians and vice versa. So if I have an IJ and one of the surgery residents wants to do it I'll let them have it. Likewise if they are behind on their patients, I'll help them out by doing art lines and central lines if needed. We have interns scattered throughout the year. Some are interested in critical care and others are not. If they are interested in procedures one of the residents or PA/NPs will walk them through it.

 

In the evening and night the patients are shared globally between the PA/NP and the resident. Usually they switch off and do whatever is needed. There are plenty of procedures to be done.

 

We do central lines (IJ and subclavians), art lines, Vascath, paracentesis, thoracentesis. Occasional chest tubes (credentialed but do less than 5 per year).

 

One issue I see is that around July through October everyone wants procedures. By November everyone has plenty of procedures and they become more of a chore than something fun. We usually try to have PA students in the latter half of the academic year.

 

20 bed surgical ICU with a very high acuity.

[crieman]

ColoradoPA,

It sounds like you guys are really organized and work well together. How long has your service had midlevels? Ours is relatively new. Although we have had one PA on the floor for 4 years, the ICU is new within the last 10 months. I know it's a work in progress. Right now I'm trying to sell the partners on the importance of having a night shift midlevel that can do admits, procedures, cut down on calls to the attendings, etc., while there is no attending in the hospital. Currently there is a gap from 2am to 6am where there is no attending, only a resident. We work in a 40 bed (20 medical 20 surgical) ICU where the intensivists work equally in both. I am only a few lines away from being credentialed, we need 25, and its taken months to get there. Thanks again for the great info.

 

Once again, we need a Critical Care forum

[crieman]

There are currently no standards in our hospital for midlevels to perform thoracentesis. Would anyone be willing to share this info from one of their hospitals? I would likely need a hard copy of the hospital policy to share with my docs. What they're are interested in is how many need to be done supervised before a hospital would consider a PA proficient. I would like to get the same info for obtaining vent privileges. Any help would be greatly appreciated

[coloradopa]

There are currently no standards in our hospital for midlevels to perform thoracentesis. Would anyone be willing to share this info from one of their hospitals? I would likely need a hard copy of the hospital policy to share with my docs. What they're are interested in is how many need to be done supervised before a hospital would consider a PA proficient. I would like to get the same info for obtaining vent privileges. Any help would be greatly appreciated

I can check on the thoracentesis privileges but I think its five under supervision. For vent privileges we do a one hour class with the RTs and then check off on the vent. Thats for actually touching the machine. The vent management is part of the job. Ie no check off.

[coloradopa]

ColoradoPA,

It sounds like you guys are really organized and work well together. How long has your service had midlevels? Ours is relatively new. Although we have had one PA on the floor for 4 years, the ICU is new within the last 10 months. I know it's a work in progress. Right now I'm trying to sell the partners on the importance of having a night shift midlevel that can do admits, procedures, cut down on calls to the attendings, etc., while there is no attending in the hospital. Currently there is a gap from 2am to 6am where there is no attending, only a resident. We work in a 40 bed (20 medical 20 surgical) ICU where the intensivists work equally in both. I am only a few lines away from being credentialed, we need 25, and its taken months to get there. Thanks again for the great info.

 

Once again, we need a Critical Care forum

I don't know what the acuity is there, but you could probably use 1-2 PAs at night. One of the issue you run into is how to pay. Right now the group is losing all the billing on any admits done during the night hours. If you had a PA there you could capture all the admission billing for nights. We get around 15 RVUs per night on a 10 hour shift (less than days but pretty good). One of the measures of how much you need more people is to add PAs until your billing starts to tail off. Basically every person we have added has increased billing without decreasing billing on the others. During the evening and nights the PA/NP and resident switch off doing admits and then the PA does the essential elements of the admit (HPI, PE, assessment and plan) on all the resident patients. We are very careful to explain that we are not supervising or staffing this, its simply a billing matter. Procedures are divided up based on what people want to do. Our night people like doing procedures and the residents like to sleep so it works out pretty well.

 

Right now we just got permission to add a seventh which will be another night person. This will give us two people 4/7 nights and let our night people go to 1/3 weekends from 1/2. It will also give us some slack when someone is on vacation. We will probably add an eight in a month or so and that will be another evening person so that we get weekend coverage. Right now we have a gap on weekends.

 

With the changes in resident work hours there are going to be more opportunities for PAs in the ICU. Come July interns will not do overnight call and we will have suggested "napping" for residents. Lots of opportunities there.

[crieman]

So, the night admissions that are done by the residents can't be billed? What if they staff them over the phone or in person in the morning with the attendings? Currently we have an attending that is on until 2am and a gap from 2-6am where the residents admit. I've been pushing for a night shift so that we can also do all of the floor pulmonary admits too, which currently go to the hospitalists. It's frustrating because I'm trying to increase the group's revenue but it falls on deaf ears. I don't think they like hearing business ideas from a midlevel.

[coloradopa]

So, the night admissions that are done by the residents can't be billed? What if they staff them over the phone or in person in the morning with the attendings? Currently we have an attending that is on until 2am and a gap from 2-6am where the residents admit. I've been pushing for a night shift so that we can also do all of the floor pulmonary admits too, which currently go to the hospitalists. It's frustrating because I'm trying to increase the group's revenue but it falls on deaf ears. I don't think they like hearing business ideas from a midlevel.

Work done by residents can be billed only if the physician is present for the key portion of the encounter (HPI, PE and A/P). This means that they have to be physically present in the unit (not asleep in the call room and definitely not at home on the phone). The rule can be found here:

https://www.cms.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf

 

A very nice AAPA piece and how this deals with PAs can be found here:

http://www.aapa.org/advocacy-and-practice-resources/issue-briefs/505-medicares-final-rule-on-billing-requirements-for-teaching-physicians-the-effect-of-the-rule-on-physician-assistants

 

For us its several hundred thousand dollars per year.

 

Back to Thoracentesis I would look at what the requirements are for the attendings or residents. Model it off that. I highly doubt that they require the residents to do 25 lines to be able to do them independently.

Here are the ABIM requirements:

http://www.abim.org/certification/policies/imss/im.aspx#procedures (no requirements but they recommend 5)

 

The other issue you may be running into is orientation. We have a minimum three month orientation across the different ICUs for experienced PAs and a minimum 7 month orientation for new grads (usually extended). There are plenty of procedures during orientation. Don't think we have anyone short of lines after orientation (we need 10).

[crieman]

not to beat a dead horse, but I'm having trouble believing that what we're currently doing is not correct. Between 2am and 6am, there is no ICU attending. The interns are there to do admissions, lines, etc...

Those patients are either staffed on the phone or in the morning when the attending gets there at 6am. So, can the attending then bill for that H&P that the intern did? because that's what is happening. are there any exceptions to this rule that would make it billable? I need to make this a financial discussion because that is what my group and the hospital care about.

 

Thanks for the great info, very appreciated

[coloradopa]

not to beat a dead horse, but I'm having trouble believing that what we're currently doing is not correct. Between 2am and 6am, there is no ICU attending. The interns are there to do admissions, lines, etc...

Those patients are either staffed on the phone or in the morning when the attending gets there at 6am. So, can the attending then bill for that H&P that the intern did? because that's what is happening. are there any exceptions to this rule that would make it billable? I need to make this a financial discussion because that is what my group and the hospital care about.

 

Thanks for the great info, very appreciated

Two issues. One is it legal for the attending to staff the patient by phone. It will depend on your state law and hospital bylaws but generally this is permitted. Second issue can you bill for this. Absolutely not. From the CMS guidelines posted above:

When teaching physicians bill E/M services, they must

personally document at least the following:

■ That they performed the service or were physically

present during the critical or key portions of the

service furnished by the resident; and

■ His or her participation in the management of

the patient.

On medical review, the combined entries into the medical

record by the teaching physician and resident constitute the

documentation for the service and together must support

the medical necessity of the service. Documentation by the

resident of the presence and participation of the teaching

physician is not sufficient to establish the presence and

participation of the teaching physician.

 

The only exception is for primary care clinics for lower level visits (definitely not the ICU). Academia as a rule has no clue about billing. I saw a similar problem where the NP and PAs were billing for procedures done by the residents when they were in the room. Ie. Essentially supervising. I challenged them to show where the rules allowed a PA or NP to supervise and bill, the response was "Oh that's the way we've always done it". Bottom line if you want to bill for resident work either the physician has to be physically present in the unit (and in the room for procedures) or you have to hire a PA to redo the critical elements. You're still going to lose some procedures but thats the cost of having a residency.