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The Advanced Practice Provider in Observation By:

Carla Chipalkatty, MS, PA-C, Brigham and Women’s Hospital

The Advanced Practice Provider in Observation

By Carla Chipalkatty, MS, PA-C,

Assistant Director of Observation, PA-III

Brigham and Women’s Hospital

Brigham and Women’s Faulkner Hospital

Emergency Department

September 12, 2019

Disclosure

I have no actual or potential conflict of interest in relation to this presentation.

The APP Run Observation Unit

Staffing

Training

Hiring

Beyond typical ED management

Customer service

Quality and safety

APP leadership

Three Observation Units

APP Staffing

• 48 APP staff total

• 12 hr shifts

• Staff covers 3 sites

• Main campus ED

• Satellite campus ED

• Urgent Care

• Individuals Rotate to 2 sites

• BWH ED (main campus)

• ~5-7 shifts/day

• BWFH ED (satellite campus)

• 3 shifts/day

• Urgent Care

• 1 shift/day

• Observation

• 5 shifts/day

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APP Staffing

Daytime Overnight

~36 Rotating ED APP staff (24-40 hr/wk)

6 Observation APP staff (40 hr/wk)

~6-8 per diem staff (2 observation/all trained)

=60% Obs shifts &90% Obsovernight shifts

APP Staffing

How do you staff your observation

unit?

APP Staffing

• Attending rounds 1-2hrs

• Patient-to-APP ratio 8-12:1

• Consider additional coverage during morning and evening hours

• Other tasks during mid-day• Microbiology results follow

up

• Critical results from discharged patients

• Patient calls

Protocols

Abdominal Pain Allergic Reaction Asthma/COPDAtrial

Fibrillation/Flutter

Back Pain Cellulitis Chest pain CHF

DysglycemiaDehydration/

Hyperemesis

Febrile Neutropenia

Flank Pain (Pyelo/ Stones)

Generic/

General ComplaintGI Bleed Headache

Mild Traumatic Brain Injury

Neurologic Complaint

PneumoniaPsychiatric Emergency

Social Interventions

Syncope Transfusion TIA/Stroke VTE: DVT and PE

What is our most frequently used protocol?

Generic Protocol23%

Chest Pain13%

Psychiatric Illness11.5%Neuro Eval (Stroke/TIA)

10.5%

Abdominal Pain7%

LEFT BLANK

4.5%

Frequency of use (2015-2019)

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What is our most frequently used protocol?

Generic Protocol23%

Chest Pain13%

Psychiatric Illness11.5%Neuro Eval (Stroke/TIA)

10.5%

Abdominal Pain7%

LEFT BLANK4.5%

Frequency of use (2015-2019)

• Fever

• PICC line issue

• Nephrostomy tube issues

• Non-operative hip fx

• Pancreatitis

• Falls

• Weakness

• Failure to thrive

• Hypertension

• Hyponatremia

• Hand infection

• Gout flare

• And many, many more…

Staffing My patient in room 2 has chest pain after walking to the bathroom

I better call the back line to get a STAT read and get this one discharged ASAP

I’d love to hear more about your dog’s surgery, but first let’s review your home medications

Let’s check an EKG, give nitro and send a troponin STAT

Hire for Observation

• Prefer experience

• Perks• Autonomy

• Expedited care

• Reduced documentation burden

• Work/life balance

• Welcomed change for seasoned EM or IM APP

Emergency medicine

Inpatient medicine

Critical care

Training APP Staff

• 4 weeks of observation training shifts

• 2-4 ED training shifts

Experienced APP (Obs)

• 4 weeks ED training shifts

• 4 observation training shifts

• Solo observation shift after 6 months

Experienced APP (ED rotating)

• 6 weeks ED training shifts

• 6 observation training shifts

• Solo observation shift after 12 months

• Need support

New Graduate APP (ED rotating)

Training

• Peer mentor program

• Teaching topic list

• Training checklist

• Training manual

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Support Your Existing Staff

Observation updates at

monthly staff meetings

Provide CME opportunities

Specialist guest lectures at staff

meetings

Beyond typical ED management

Beyond Typical ED Management

MEDICATION RECONCILIATION

DIABETES MANAGEMENT

VTE PROPHYLAXIS

Beyond Typical ED Management

MEDICATION RECONCILIATION

Active medication management

• Clarify responsible team

• Pharmacy may help

• Special considerations

• Chest pain

• AKI

• Bowel regimen

Beyond Typical ED Management

• Order insulin sliding scale and home basal insulin for diabetics

• Check glucose TID with meals & hs

• Beware: steroid induced hyperglycemia

• Diabetic discharge support

DIABETES MANAGEMENT

Diabetes Management in ObsCommon Insulin ConversionsLevemir (insulin detemir) → Lantus (insulin glargine) 1:1NPH → Lantus (insulin glargine) 2:1Humalog (Insulin lispro) → Novolog (insulin aspart) 1:1Humulin/Novolin (Regular human insulin) → Novolog (insulin aspart) 1:1Novolin Mix 70/30 → calculate units as 70% NPH and 30% insulin aspartLong acting insulin durationNPH ~12hrs → typically dosed BIDLantus (Insulin glargine) ~24hrs → typically dosed QDShort acting insulin durationAspart ~3-5 hours (good if patient eating) → typically dosed qAC and qHSRegular insulin ~5-8 hours (good if pt NPO) → typically dosed q6hr

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Diabetes DischargeInsurance Preferred Meter

BCBS of MA One Touch

Caremark (CVS) One Touch

Commonwealth of MA (Unicare Sate

Indemnity Plans)

One Touch

Express Scripts National Preferred

Formulary

One Touch

Fallon Community Health Plan One Touch

Harvard Pilgrim Health Plan FreeStyle

MA Medicaid (MassHealth) FreeStyle

Medicare (Part B) FreeStyle

Tufts Health Plan One Touch

Insulin glargine (Lantus 100unit/mL)__#__ units SC __freq__Disp: 3 vialsRefills: 3

Insulin syringe-needle U-100 1mL 31x15/64”Disp: 100 syringesRefills: 3

Beyond Typical ED Management

VTE PROPHYLAXIS

• PADUA prediction score

• Automatic notification at 24hr mark in EMR

• VTE order set with medication choices

Baseline features Score

Active cancer* 3

Previous VTE (with the exclusion of superficial vein thrombosis) 3

Reduced mobility†

3

Already known thrombophilic condition‡

3

Recent (≤1 month) trauma and/or surgery 2

Elderly age (≥70 years) 1

Heart and/or respiratory failure 1

Acute myocardial infarction or ischemic stroke 1

Acute infection and/or rheumatologic disorder 1

Obesity (BMI ≥30) 1

Ongoing hormonal treatment*Patients with local or distant metastases and/or in whom chemotherapy or radiotherapy had been performed in the previous 6 months.

†Bedrest with

bathroom privileges (either due to patient’s limitations or on physicians order) for at least 3 days.

‡Carriage of defects of antithrombin, protein C or S, factor V

Leiden, G20210A prothrombin mutation, antiphospholipid syndrome.

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Score > 4 is high risk: pharmacologic prophylaxis is indicated

Customer Service

Timing of testing and results

Backlines for reading rooms

Weekend and holiday schedule

Consultant availability

Can you come back tomorrow? Maybe then I’ll be ready to go home…

Disposition support from:• Case management• Physical therapy• Social work• Patient relations

Quality and Safety

• Safety huddle policy

• Peer submitted case review

• Review the data

• Steering committee

APP Leadership Structure

PA-I

Initial hire

PA-II

Salary increase

Extracurricular project

Annual renewal

PA-III

Salary increase

Discretionary admin time

Takes APP admin call

Observation, urgent care, IT, new hire training

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Observation APP Leadership

APP training/mentoring

APP staff updates/communication

Works with department leadership for

• Protocol review/development

• Policy review/development

• Quality assessment process

• Data review/steering committee

Residency updates/orientation

New attending orientation

Summary• Recruit experienced APP’s

• Hire dedicated APP observation staff

• Ideal staff rotates

• New graduates need more training/support

• Support your current staff

• Anticipate inpatient-like issues

• Organize testing schedule and back line #’s

• Encourage staff feedback

• Create APP leadership opportunity with observation

References• Ross MA, Hockenberry JM, Mutter R, Barrett M, Wheatley M, Pitts SR. Protocol-driven emergency department observation units

offer savings, shorter stays, and reduced admissions. Health affairs. 2013 Dec 1;32(12):2149-56.

• Conley J, Bohan JS, Baugh CW. The Establishment and Management of an Observation Unit. Emergency Medicine Clinics of North America. 2017 Aug 31;35(3):519-33.

• 2019 AAPA Salary Report. American Academy of Physician Assistants.

• United States Department of Labor: Bureau of Labor Statistics: https://www.bls.gov/ooh/healthcare/physician-assistants.htm#tab-6. Accessed August 28,2019

• United States Department of Labor: Bureau of Labor Statistics: https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm. Accessed August 28,2019

• Capstack TM, Segujja C, Vollono LM, Moser JD, Meisenberg BR, Michtalik HJ. A comparison of conventional and expanded physician assistant hospitalist staffing models at a community hospital. Journal of Clinical Outcomes Management. 2016 Oct 1;23(10):455-61.

• Paradise J, Dark C, Bitler N. Improving access to adult primary care in Medicaid: Exploring the potential role of nurse practitioners and physician assistants. Henry J. Kaiser Family Foundation; 2011.

• Nurse Journal: http://nursejournal.org/nurse-practitioner/nurse-practitioner-salary-statistics/. Accessed Sept 1, 2017

• Blue Cross Blue Shield of Massachusetts: https://provider.bluecrossma.com/ProviderHome/wcm/connect/67462dc4-5fab-4988-a66e-348020c69353/PA_PA-PCP_Billing_Guidelines.pdf?MOD=AJPERES. Accessed Sept 1, 2017.

• Lindenauer PK, Shieh MS, Pekow PS, Stefan MS. Use and outcomes associated with long-acting bronchodilators among patients hospitalized for chronic obstructive pulmonary disease. Annals of the American Thoracic Society. 2014 Oct;11(8):1186-94

• Barbar S, Noventa F, Rossetto V, Ferrari A, Brandolin B, Perlati M, De Bon E, Tormene D, Pagnan A, Prandoni P. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score.Journal of Thrombosis and Haemostasis. 2010 Nov 1;8(11):2450-7.

• Department of Health and Human Services: Office of Inspector General: https://oig.hhs.gov/oei/reports/oei-02-15-00020.pdf. Accessed August 10, 2017

Contact me!

Carla Chipalkatty, MS, PA-C

cchipalkatty@bwh.harvard.edu

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