Don’t think I could cope with a Omicron outbreak

[Nephro critical care]

I single cover a small 16 bed closed ICU. I don’t know how I got through last week. It was Thanksgiving and no PICC team or IR available for most of the week. I was responsible for all procedures.
It was bad. Non stop stream of Covid’s. Everyone by the end was proned and paralyzed. No one looking remotely like they could get extubated. I wanted to transfer a couple but was spending hours on the phone with 3-4 hospitals none of which had beds.
Left home every day at 7:00 AM and was reaching home after midnight. Still families were complaining I wasn’t calling them everyday. We were talking about expanding ICU into the PCU.
I don’t think I could cope with an Omicron outbreak.

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[robellis]

How much you getting paid for this?

 

[Nephro critical care]

How much you getting paid for this?

About $177 per hour.

 

[Katheudontas parateroumen]

I single cover a small 16 bed closed ICU. I don’t know how I got through last week. It was Thanksgiving and no PICC team or IR available for most of the week. I was responsible for all procedures.
It was bad. Non stop stream of Covid’s. Everyone by the end was proned and paralyzed. No one looking remotely like they could get extubated. I wanted to transfer a couple but was spending hours on the phone with 3-4 hospitals none of which had beds.
Left home every day at 7:00 AM and was reaching home after midnight. Still families were complaining I wasn’t calling them everyday. We were talking about expanding ICU into the PCU.
I don’t think I could cope with an Omicron outbreak.

Oh my gosh so sorry. That is rough. What part of the country are you? You are definitely fighting the good fight and doing everything you can. I’m hearing omicron is some how less virulent but we really won’t know for another month or so. It’s also scary hearing all the talk about our vaccines waning and possibly not effective to omicron. I’m in Houston and although our number of hospitalizations have dipped 80% or so from the peak, I still get 2-3 covid icu admissions a day at least. The strain is still there. Definitely never going away. God help us all.

 

[lymphocyte]

I single cover a small 16 bed closed ICU. I don’t know how I got through last week. It was Thanksgiving and no PICC team or IR available for most of the week. I was responsible for all procedures.
It was bad. Non stop stream of Covid’s. Everyone by the end was proned and paralyzed. No one looking remotely like they could get extubated. I wanted to transfer a couple but was spending hours on the phone with 3-4 hospitals none of which had beds.
Left home every day at 7:00 AM and was reaching home after midnight. Still families were complaining I wasn’t calling them everyday. We were talking about expanding ICU into the PCU.
I don’t think I could cope with an Omicron outbreak.

I just want to say I'm sorry for what you're going through, which sounds awful. Especially when families are calling to complain and yet you're fighting to save their loved ones. (It's even worse when they're unvaccinated!).

Anecdotally, it seems like Omicron is indeed less virulent but more infectious, which maybe a boon if it beats out Delta. It's going to be a long wait until we have actual data.

 

[SurfingDoctor]

Even outside of COVID, it seems in general, families overtime are getting less grateful. I mean, I really don't care if they are thankful or not, that's not why I do this, but do they really need to complain so much? That is entirely unhelpful.

 

[CCM-MD]

About $177 per hour.

That is sad.

 

[Nephro critical care]

There is one thing about the pandemic that I cannot understand. Why is it that the whole world has been on its bended knees for the last 22 months and there is one nation which is impervious to COVID. And its the one country where COVID started.
Why despite having rather ineffective vaccines they are invulnerable to COVID ? Why have they kept their country shut to the rest of the world for two years ? What is it that they know about COVID that they haven’t shared with the rest of the world ?

 

[Matthew9Thirtyfive]

There is one thing about the pandemic that I cannot understand. Why is it that the whole world has been on its bended knees for the last 22 months and there is one nation which is impervious to COVID. And its the one country where COVID started.
Why despite having rather ineffective vaccines they are invulnerable to COVID ? Why have they kept their country shut to the rest of the world for two years ? What is it that they know about COVID that they haven’t shared with the rest of the world ?

If you believe what China reports about its covid numbers, I have a beach in Florida to sell you.

 

[deleted941485]

I’m sorry your in this situation. You’ve done more than most and honestly if you can get something less demanding that would probably be best. No one will think any less of you but then again **** others opinions.

CC is a beast all it’s own. Time to take a hard look at your life because burn out and psychological implosion are a B.

 

[Spikebd]

I’m one of the most anti-covid hysteria people on this board, but I’m sorry you’re going through this. I respect all of you for helping sick and critically ill patients. Take care of yourselves. Medicine isn’t everything, though I know it can feel that way when you’re surrounded by many of our colleagues.

 

[Nephro critical care]

Working at a smaller shop what I fear most is getting overwhelmed with patients and then making an medical error. Society / medical boards don’t take into account that I may be taking care of far more patients then I can safely take and then overlook something. If it was an ICU nurse who made an error because she had too many patients she will definitely make everyone know that she was swamped and everyone will listen too. However for some reason physicians are held to a different standard and the expectation is that they will be able to provide perfect care even if they are seeing an unsafe number of patients / no speciality support / inability to transfer because tertiary care hospitals are full.

 

[grt398]

Sorry things have been so bad at your shop. I think your latter point about providing perfect care regardless of the number of patients and that putting you at risk of a bad outcome is something to consider. I've talked to people who got stuck as the solo attending (with 1 midlevel) covering 30+ patients regularly during the last surge (with no ability to transfer, like you're mentioning) and it's pretty clear you cannot provide standard of care under that model. Depending on your geographic flexibility there are a lot of options out there right now...

 

[aafisahar]

About $177 per hour.

why? i wouldn't take a hospitalist job for this, nevermind critical care

 

[Siggy]

Working at a smaller shop what I fear most is getting overwhelmed with patients and then making an medical error. Society / medical boards don’t take into account that I may be taking care of far more patients then I can safely take and then overlook something. If it was an ICU nurse who made an error because she had too many patients she will definitely make everyone know that she was swamped and everyone will listen too. However for some reason physicians are held to a different standard and the expectation is that they will be able to provide perfect care even if they are seeing an unsafe number of patients / no speciality support / inability to transfer because tertiary care hospitals are full.

I'm not sure if it did any good, but one thing I started documenting during our big surge during July/August 2020 was our capacity precentage. I was routinely having 40-50 patient encounters a day for a 22 bed ICU. There is a surge capacity consensus statement put out by Chest and SCCM (among others) that clearly states that standard of care is decreased at over double capacity. It also explicitly uses pandemics as an example of a wide spread, slow moving MCI. "Conventional" (up to 20% over capacity), "contingency" (up to 100% over capacity) and "crisis" (up to 200% capacity) has specific meanings and is where I drew the phrase "crisis surge capacity."

My disclaimer was "Care provided today was done under the auspices of crisis surge capacity as our ICU is currently at over 200% capacity (Hicks Et. Al. Surge Capacity Principles, Chest, 2014)."

DEFINE_ME

 

[chocomorsel]

I single cover a small 16 bed closed ICU. I don’t know how I got through last week. It was Thanksgiving and no PICC team or IR available for most of the week. I was responsible for all procedures.
It was bad. Non stop stream of Covid’s. Everyone by the end was proned and paralyzed. No one looking remotely like they could get extubated. I wanted to transfer a couple but was spending hours on the phone with 3-4 hospitals none of which had beds.
Left home every day at 7:00 AM and was reaching home after midnight. Still families were complaining I wasn’t calling them everyday. We were talking about expanding ICU into the PCU.
I don’t think I could cope with an Omicron outbreak.

Let them complain. Ain't nobody got time for that mess. You want me to spend time on the phone or with your loved one?
Covid is not bad where I am thank God, but it tends to hit us last.

 

[chocomorsel]

About $177 per hour.

Why oh why are you doing this to yourself for ICU RN wages?

 

[Nephro critical care]

Why oh why are you doing this to yourself for ICU RN wages?

I am location bound because of family reasons and the mothership requires me to spend some time every month at a smaller site.

 

[Nephro critical care]

I'm not sure if it did any good, but one thing I started documenting during our big surge during July/August 2020 was our capacity precentage. I was routinely having 40-50 patient encounters a day for a 22 bed ICU. There is a surge capacity consensus statement put out by Chest and SCCM (among others) that clearly states that standard of care is decreased at over double capacity. It also explicitly uses pandemics as an example of a wide spread, slow moving MCI. "Conventional" (up to 20% over capacity), "contingency" (up to 100% over capacity) and "crisis" (up to 200% capacity) has specific meanings and is where I drew the phrase "crisis surge capacity."

My disclaimer was "Care provided today was done under the auspices of crisis surge capacity as our ICU is currently at over 200% capacity (Hicks Et. Al. Surge Capacity Principles, Chest, 2014)."

DEFINE_ME

40-50 encounters ! That’s nuts. I would need to round from 3 am to midnight to see that number.

 

[Siggy]

40-50 encounters ! That’s nuts. I would need to round from 3 am to midnight to see that number.

I had 3-4 NPs to “help” and was often at the hospital from 7am to 9 or 10 pm. It was painful to say the least. We did what we could, but… pandemic.

 

[BicepsTriceps]

I had 3-4 NPs to “help” and was often at the hospital from 7am to 9 or 10 pm. It was painful to say the least. We did what we could, but… pandemic.

Does your hospital provide extra protection for you in this case?

If I had to cover 20+ patients I would resign on the spot.

Nothing worth a lawsuit in the future unless I'm explicitly protected under crisis standards of care or something similar.

Working with NPs is similar to playing minesweeper. Goes well for the most part until you click "co-sign" on that landmine.

 

[Nephro critical care]

When I am seeing that many patients I find that all parts of the system start to fail. The nurses miss stuff, RT misses stuff , pharmacy misses stuff. To compensate for stuff that I may miss , i start putting everyone on Vanco/Meropenem and ordering pan CT on everyones. Everyone is kept intubated ; no one gets extubated, no one transferred out.

 

[CCM-MD]

Does your hospital provide extra protection for you in this case?

If I had to cover 20+ patients I would resign on the spot.

Nothing worth a lawsuit in the future unless I'm explicitly protected under crisis standards of care or something similar.

Working with NPs is similar to playing minesweeper. Goes well for the most part until you click "co-sign" on that landmine.

I was seeing close to 30 a day during our last surge. We have a weak organization who decided not to get locums and worked us way too hard. Nice thing is we have a productivity component, so we were compensated handsomely. Unfortunately, as a result of this though, half of our group is leaving.

 

[BicepsTriceps]

I was seeing close to 30 a day during our last surge. We have a weak organization who decided not to get locums and worked us way too hard. Nice thing is we have a productivity component, so we were compensated handsomely. Unfortunately, as a result of this though, half of our group is leaving.

As they should.

Physicians should never tolerate any kind of work abuse. Zero.

You have a family? Find a new job, sell your house, buy a new one and move to a better job.

Kids in school? You move first then take them when school year is over.

Relatives/ parents in town? Are they working? If not move them with you. If yes then they're functional enough they don't need you to be close 24/7.

Physicians should start doing this across the country until things improve.

I believe there has never been a better time for a physician union than now.

Current working climate is utterly ridiculous.

 

[Nephro critical care]

30 critical care encounters = 30 * $233 encounter. That's $7000/day in billing. And that even if you don't count procedures or extra CC time. That's about $600 per hour for a 12 hour shift.

 

[CCM-MD]

30 critical care encounters = 30 * $233 encounter. That's $7000/day in billing. And that even if you don't count procedures or extra CC time. That's about $600 per hour for a 12 hour shift.

Billing 30 x 99291 in a day is almost equivalent to sending CMS an email asking to be audited. We did not do that.

We also rarely spent 30 minutes with a patient and thus billed mostly 3s. It involved seeing the patient from the window, making sure they were on lung protective ventilation, on dex, abx if needed, as dry as their kidneys would allow, and proning if PF <150. The Optiflow patients took less than 5 min to evaluate. We actually still got out on time some days.

 

[Siggy]

Billing 30 x 99291 in a day is almost equivalent to sending CMS an email asking to be audited. We did not do that.

We also rarely spent 30 minutes with a patient and thus billed mostly 3s. It involved seeing the patient from the window, making sure they were on lung protective ventilation, on dex, abx if needed, as dry as their kidneys would allow, and proning if PF <150. The Optiflow patients took less than 5 min to evaluate. We actually still got out on time some days.

I billed a mix of 91s and 33s. There were some days were I just refused to bill half the patients, the company could bill under the NPs if they liked. It depended on how many I saw and how much I did. There were certainly days I billed more than 24 91s, but I also rarely got out at 12 hours anyways, and some of them became 15 hour shifts including attempts to contact proxies for those amazing COVID hospice discharges.

Our group's management at that site was a mess to the point where I started to refuse to do days (we didn't have 24 hr physician coverage yet) and ended up switching to one of our other, much better run, hospitals instead.

Unfortunately it was literally my first job out of fellowship, and if I had more experience I likely would have handled things differently both with billing more 33s and complaining more about getting additional coverage.

 

[aafisahar]

30 critical care encounters = 30 * $233 encounter. That's $7000/day in billing. And that even if you don't count procedures or extra CC time. That's about $600 per hour for a 12 hour shift.

Billing 30 x 99291 in a day is almost equivalent to sending CMS an email asking to be audited. We did not do that.

We also rarely spent 30 minutes with a patient and thus billed mostly 3s. It involved seeing the patient from the window, making sure they were on lung protective ventilation, on dex, abx if needed, as dry as their kidneys would allow, and proning if PF <150. The Optiflow patients took less than 5 min to evaluate. We actually still got out on time some days.

Your second paragraph is basically critical care and you probably did spend 30 minutes total but billing 30 of these is going to get audited as you said,especially if there's evidence of you leaving before 15 hours of work. The better part of Valor is dropping some RVUs for your licenses sake.

 

[Nephro critical care]

I had a recent billing class in which the billers were saying that in 2021 Medicare rules have changed so a physician can bill for an NP note for critical care as long as the two together have spent greater than 30 minutes and the physician spent more time than the NP.
So if NP spent 14 minutes and the MD spent 16 minutes the MD could bill a 99291. Maybe with this rule change an MD would be less susceptible to an audit ? There is a lot of billing jargon that can be used to show that physician time was spent on critical care management i.e pressor / vent adjustment etc.

 

[CCM-MD]

I had a recent billing class in which the billers were saying that in 2021 Medicare rules have changed so a physician can bill for an NP note for critical care as long as the two together have spent greater than 30 minutes and the physician spent more time than the NP.
So if NP spent 14 minutes and the MD spent 16 minutes the MD could bill a 99291. Maybe with this rule change an MD would be less susceptible to an audit ? There is a lot of billing jargon that can be used to show that physician time was spent on critical care management i.e pressor / vent adjustment etc.

Don’t know about this. Perhaps you mean these changes take effect in 2022. Even then, I haven’t heard this. Please share a reference if you have one.

I actually read the opposite - if you “co-sign” inpatient midlevel notes with an attestation, you can no longer bill at the physician rate if the midlevel spent more time with the patient. They will now be reimbursed at the fractional midlevel rate. Can’t confirm this as it comes from a questionable source.

Edit:
Found something along the lines of what you are saying: What's New in the Proposed Physician Fee Schedule Rule

 

[Nephro critical care]

Don’t know about this. Perhaps you mean these changes take effect in 2022. Even then, I haven’t heard this. Please share a reference if you have one.

I actually read the opposite - if you “co-sign” inpatient midlevel notes with an attestation, you can no longer bill at the physician rate if the midlevel spent more time with the patient. They will now be reimbursed at the fractional midlevel rate. Can’t confirm this as it comes from a questionable source.

Edit:
Found something along the lines of what you are saying: What's New in the Proposed Physician Fee Schedule Rule

That is indeed correct. Under this rule I would not be able to bill on an NP pt unless I had spent more than 50% time.

Some physicians will try to game the system with this rule. They will make the NP document that she spent less than 50% time and document that they spent > 50% of the time.

Personally I never co-signed or billed the NP pts. I would try to see and bill the critical care pts by myself alone and ask the NP to bill the moveouts which she billed as a level 3.

 

[Nephro critical care]

I think in general we as physicians in general tend to underbill. With a little extra effort on documentation I could bill more CC / level 3s. I certainly spent the time with these pts. But I underestimate the time and then end up both underdocumenting and underbill.

I know physicians who document a lot and bill critical care time and when I come on the next week the notes are fabulous but absolutely nothing was really done with the pt whole week.

 

[Siggy]

If it's an AM transfer out or one of our chronic patients, I tend to bill a -32 (I've seen the criteria for a -33 and I don't get how most people get to it on a continuing note unless new stuffs happening... in which case I'd likely bill a 91).

If I do stuff throughout the day to stabilize to the point of transfer (cardene patients weaned in the afternoon with new PO meds, DKAs who close their gap in the afternoon, etc) or the patient is continuing to need critical care, I normally just bill 35 minutes and a 91.

Right now they want the NPs documenting their CC time as well. I normally ignore what ever they put and just add my own critical care addendum at the bottom. One thing I keep trying to tell the NPs, and I'm not sure how much they listen, is that they are responsible for what they put in regards to billing and what is billed under their name.

 

[bingbongbink]

Working at a smaller shop what I fear most is getting overwhelmed with patients and then making an medical error. Society / medical boards don’t take into account that I may be taking care of far more patients then I can safely take and then overlook something. If it was an ICU nurse who made an error because she had too many patients she will definitely make everyone know that she was swamped and everyone will listen too. However for some reason physicians are held to a different standard and the expectation is that they will be able to provide perfect care even if they are seeing an unsafe number of patients / no speciality support / inability to transfer because tertiary care hospitals are full.

Honestly, you’re hospital should’ve hired Locums to help you out. Sorry you went through this, hope you are doing alright now.

 

[chocomorsel]

About $177 per hour.

Just an FYI, ICU RNs in California are getting $200 an hour. My COO cousin is paying them this. In TX it’s like $120 or so. And think about their overtime.
Think about this as you bust your ass for less than RN pay.

 

[Nephro critical care]

i am doing better. Started an SSRI and regular counseling. Last week when I went to work all the ICU nurses were dealing with 3-5 vent pts while they usually have 2. Obviously nothing was getting done. And this was self inflicted the hospital let go of its antivaxxer staff and now they cant staff the beds they have. They are now calling some of these antivaxxers back but some of them have found other jobs.
Normally when pt care is substandard I feel really bad. But now I am more accepting and realize that in the end I did all I could.

 

[Nephro critical care]

Just an FYI, ICU RNs in California are getting $200 an hour. My COO cousin is paying them this. In TX it’s like $120 or so. And think about their overtime.
Think about this as you bust your ass for less than RN pay.

Yes I am now looking for another place that is better staffed.

 

[chocomorsel]

Yes I am now looking for another place that is better staffed.

Hopefully also pays you better. Much better than $177 an hour. Right now you gotta think a little like a mercenary even though you can’t leave town.

 

[chocomorsel]

i am doing better. Started an SSRI and regular counseling. Last week when I went to work all the ICU nurses were dealing with 3-5 vent pts while they usually have 2. Obviously nothing was getting done. And this was self inflicted the hospital let go of its antivaxxer staff and now they cant staff the beds they have. They are now calling some of these antivaxxers back but some of them have found other jobs.
Normally when pt care is substandard I feel really bad. But now I am more accepting and realize that in the end I did all I could.

Glad you are doing better. You are one person and you cannot fix everything and everyone. You can only do your best and sounds like this is what you are doing.