Emergency Planning and APP Leadership
Author Jason Fisher-Beck, MHS-PAS, PA-C
Editor Elizabeth Moran, MSN, RN, CPNP-PC
When it comes to healthcare, the needs and decisions of frontline providers and those making executive decisions don’t always align. Within healthcare institutions, one of the many lessons arising from COVID-19 has been how—particularly in crisis or pandemic situations—care decisions made by providers often contrast those of executive leadership. Organizations seeking ways to recover from the impact of COVID-19, and to create systems and processes to address future pandemics, can aggregate wisdom from their healthcare leaders in nursing, medicine, and advanced practice. Advanced Practice Providers (APPs) in leadership roles are important voices needed at the executive level. APPs can help administrators understand clinical challenges and provide important insight to help create plans for patient care during pandemics and bring organizations back online once the threat has lessened.
What are some lessons to learn from COVID-19?
At the onset of COVID-19, frontline providers were forced to make real time decisions regarding patient care, facility utilization, and resource allocation—decisions that may be otherwise made by executive leadership. Preparedness was key to success, and many institutions learned tough lessons from a lack thereof. Moving forward, organizations have the opportunity to develop an emergency plan to be better prepared to make decisions during times of crisis. For example, as demand grew for intensivist staffing, one resource hospitals identified of particular value are APPs. This included Nurse Practitioners (NPs), Physician Assistants (PAs), and Certified Registered Nurse Anesthetists (CRNAs). As organizations review strategies to manage the next crisis and reopen their services, particular focus should be paid to establishing APP leadership to work collaboratively with nursing and physician leadership.
A retrospective look back at how health systems have prepared for patient surges reveals a variety of approaches.
The most prepared hospitals disseminated information about surge protocol before COVID-19 was even a threat. They established clearly defined roles for providers, nurses and ancillary staff. Communication was clear and pertinent. During low census times, leadership would often run through mock scenarios to ensure staff readiness. This higher level of planning makes all the difference when disaster strikes.
Alternatively, other institutions only discussed a general outline of plans and procedures. Specifics regarding roles, involvement, planning, and reporting structure were lacking and needed further clarification. Updates on the surge process or helpful details on resource allocation were buried in a daily barrage of lengthy emails describing hand washing, mask use, screening checkpoints. When the surge came, many institutions found that information regarding the plan was unclear.Unfortunately, staff was then left to make decisions on their own.
Many organizations fell somewhere in the middle of the two situations described above. Yet, it was difficult for any facility who had a surge beyond capacity to have a plan that managed all the challenges. Though there will always be the need for frontline staff to make real time decisions, during a pandemic the needs are ever changing. Frontline providers and their managers must make changes to protocols, procedures, resources, and facility use on a daily basis. However, aside from at the several hotspots around the country, most hospitals were not fully stressed.Now that the surge has turned more into a rolling wave, hospitals must reflect and perform gap analyses to learn where weaknesses still lie as they work to bring all facilities back online, safely.
How APP Leaders Addressed the Demands for Intensive Care Providers
A PA leader who is the Assistant Director of Advanced Practice Providers from the northeast, developed an emergency plan in response to COVID-19 which serves as a great example of APP leadership. The cross-coverage emergency plan was successfully implemented in Wisconsin and then adapted to provide adjunct support to the existing emergency plan already in place at a facility in Marysville, California. It is a great example of team-based, collaborative care using APPs to the top of their licenses.
The crux of the plan was to partner non-ICU APPs with current ICU providers in a ratio dependent on availability. In preparation for surge cross-coverage, non-ICU providers completed a baseline critical care curriculum using resources such as UpToDate and the Society of Critical Care Medicine’s online training titled Critical Care for the Non-ICU Clinician. Pre-surge training also took place to familiarize non-ICU providers with equipment such as ventilators, as well as proper PPE donning and doffing. Additionally, CRNAs and Certified Anesthesia Assistants (CAAs) are non-ICU APPs prepared to provide adjunct care in the critical care setting. With their prior intensive care experience and comfort managing critical patients on ventilators, these APPs were crucial members of the healthcare team. Pre-COVID, in most states, the CRNA and CAA licenses are limited in scope to perioperative patient care. Although the ability to utilize CRNA and CCA providers in the ICU depends on the state’s licensing requirements, most states changed regulations to allow CRNAs and CAAs to function in this role during COVID-19 if coupled with a MD, PA, or NP acting as the provider of record.
Where Are We Now?
Though healthcare workers are fatigued, we are also proud to serve our communities in a time of need. On the other side, hospitals and clinics are ironically taking a financial haircut. Some systems are worse off than others, but all have taken particular notice of their balance sheet. Layoffs, furloughs, rate adjustments, and forced paid time off are unfortunately all too familiar terms circulating in the healthcare field. In the slow transition to open revenue generating services back up, organizations have the opportunity to assess their deficiencies, opportunities for improvement, and leadership capabilities.
One example of the benefit of APP leadership is the knowledge of what it takes to hire, orient, and retain APPs. Organizations that laid off or furloughed employees will need to re-hire when they open up. APP leaders are important to healthcare systems to educate administrators on how the cost of losing an APP is two times the total cost of employing them. Unless the organization will be going out of business, it is more economical to cut hours or furlough APPs then it is to lay them off.
In this process, APP leaders can provide important insights, processes, and guidance on day-to-day operations. One of the benefits of APP leadership is a clear understanding of the APP workforce including cost, top of license utilization, and team optimization. APP leaders can work with nursing and physician leaders at the executive level to provide alignment between the goals of the organization and the needs of the APPs. As the demand for APPs increases, organizations should consider adding or growing this important asset as they work to open up services and create a lean and efficient system.
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In order to serve the needs of APPs and healthcare organizations, APPs need to continue to advocate for leadership responsibility. APPs are passionate about providing excellent patient care. Now is as good a time as ever to be equally passionate about advancing the APP role in the administrative structure of healthcare organizations. Organizations should invest in leadership development, communicate the value of APPs on the frontlines, and show how APPs play a significant role in achieving organizational goals. More than ever, APPs need a seat at the table. Healthcare organizations need collaborative leadership, an emergency plan, and adaptability to create a better solution during the next crisis. APPs are here to help!
If you have questions regarding building or growing an APP structure, please contact Jill Gilliland, President, Melnic firstname.lastname@example.org