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The Advanced Practice Provider in Observation

By Carla Chipalkatty, MS, PA-C, Assistant Medical Director of Observation

Brigham and Women’s Hospital Emergency Department

November 1, 2018

11/2/2018

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

Disclosure

The Successful APP-Run Unit

Staffing

Beyond Typical ED Management

Customer Service

Quality Assessment

APP Leadership

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Observation at BWH

• Abdominal Pain• Allergic Reaction• Asthma/COPD• Atrial Fibrillation and Flutter• Back Pain• Cellulitis• Chest pain• CHF• DVT• Dehydration/hyperemesis• Febrile Neutropenia• Flank Pain

(Pyelonephritis/Urolithiasis)

• General Complaint• Headache• Metabolic Derangement• Mild Traumatic Brain Injury• Pneumonia• Psychiatric Emergency• PE• Social Interventions• Syncope• Transfusion• TIA/Stroke• GI Bleed• Hyperglycemia/Hypoglycemia

Protocols at BWH

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Protocols at BWH

Generic Protocol26%

Psychiatric Illness12%

Chest Pain11%

Neuro Eval (Stroke/TIA)10%

Abdominal Pain7%

LEFT BLANK5%

Frequency of use (2017)

Protocols at BWH

Generic Protocol26%

Psychiatric Illness12%

Chest Pain11%

Neuro Eval (Stroke/TIA)10%

Abdominal Pain7%

LEFT BLANK5%

Frequency of use (2017)

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Protocols at BWH

Used for:SBOSeizureFeverPICC line issue Non-operative hip fxGoutCrohn’s flareAnd many more

Staffing

My patient in room 2 is looking septic

Better call the backline for a STAT read so I can discharge this one ASAP

Sure, I’d be happy to call your brother, sister and cousin (who is a doctor) to update them too…

Let’s check vitals and start fluids

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Staffing

Emergency medicine

Inpatient medicine

Critical care

Staffing

AAPA: PA Salary ReportUS Department of Labor Capstack, et al. Paradise, et al.

Advanced Practice Providers

Clinical flexibility

Reduce healthcare

costs

High patient satisfaction

rates

Growing profession

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Staffing

• 12 hour APP shifts

• Rotate

– ED

– Urgent care

– Observation

• Experienced provider in OU

Staffing: New Hire Training

Experienced APP

• 4 weeks ED training shifts

• 4 OU training shifts

• Solo OU shift after 6 months

New Graduate APP

• 6 weeks ED training shifts

• 6 OU training shifts

• Solo OU shift after 12 months

• Needs support

All new hire APP’s:• APP peer mentor program• Training checklist • Topic review

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Staffing

How can we prevent this?

Staffing

Dedicated OU staff

• Familiarity

Rotating ED staff

• Perspective

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Staffing: Rounding Models

Downstairs ED OU:

12 hour APP coverage

10 Beds

Located in ED

Shared case manager

LOS 14 hours

13 patients/day

Psych

12th Floor OU:

24 hour APP coverage

10 Beds

Located on 12th floor

Dedicated case manager

LOS 20 hours

8 patients/day

No behavioral health

Staffing : Rounding Models

Downstairs ED OU:

12 hour APP coverage

11AM-11PM APP

-Resident/Attending rounds 6:30AM

ED Resident Coverage Overnight

12th Floor OU:

24 hour APP coverage

6:30AM-6:30PM APP

-APP/Attending rounds 6:30AM

6:30PM-6:30AM APP

Improving communication:✓ Verbal handoff✓ Written

handoff✓ Attending

check in

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Beyond Typical ED Management

Longer LOS = extra time for value added care

Longer LOS = inpatient-like issues arise

Beyond Typical ED Management

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Beyond Typical ED Management

Medication Reconciliation

Diabetes Management

VTE Prophylaxis

Beyond Typical ED Management

Medication Reconciliation

Active medication management • Who does it?• Pharmacies can help• Special considerations

• Metformin and beta blockers in chest pain

• AKI

Lindenauer, et al.

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Beyond Typical ED Management

Diabetes Management

• Order short acting insulin for diabetics

• Check glucose• Beware: steroid induced

hyperglycemia • New onset diabetes and

discharge

Make a reference guide

Common Insulin Conversions

• Levemir (insulin detemir) → Lantus (insulin glargine) 1:1

• NPH → Lantus (insulin glargine) 2:1

• Humalog (Insulin lispro) → Novolog (insulin aspart) 1:1

• Humulin/Novolin (Regular human insulin) → Novolog (insulin aspart) 1:1

• Novolin Mix 70/30 → calculate units as 70% NPH and 30% insulin aspart

Long acting insulin duration

• NPH ~12hrs → typically dosed BID

• Lantus (Insulin glargine) ~24hrs → typically dosed QD

Short acting insulin duration

• Aspart ~3-5 hours (good if patient eating) → typically dosed qAC and qHS

• Regular insulin ~5-8 hours (good if pt NPO) → typically dosed q6hr

Beyond Typical ED Management

Brand Generic

Novolog Insulin Aspart

Humalog Insulin lispro

Humulin/Novolin Regular human insulin (aka Regular insulin)

Lantus Insulin glargine

Levemir Insulin detemir

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Beyond Typical ED Management

Insurance 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 Solostar Pen 100unit/mL)__#__ units SC __freq__Disp: 5 pens Refills: 3

Insulin needles (disposable) 32 x 5/32”Disp: 100 needlesRefills: 3

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

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

GLUCOMETER SELECTION: **Please discuss with case management before ordering

Order Test Strips and Lancets associated with meter (freestyle or one touch) QID testing (120/month supply)

ORDERING LANTUS: Lantus PEN – **Please check with case management, not covered by all insurances

Lantus VIAL – ** Alternative if pens not covered

Give instructions for endocrine follow up: 617-732-5666

Diabetes Discharge

Beyond Typical ED Management

VTE Prophylaxis

Padua Prediction Score for Risk of VTEBaseline 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.

1

Barbar, et al.

Score > 4 is high risk: Anticoagulate

Score < 4 or staying <24 hours: mechanical prophylaxis

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Navigating the intersection of patient expectations with specialty service expectations

Customer Service

Timing of testing and results

Backlines for reading rooms

Weekend and holiday schedule

Consultant availability

Disposition planning

• Case management

• Physical therapy

• Social work

• Patient relations

(complaints department)

Customer Service

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

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• Peer submitted case review

• Review the data

• Steering committee

Quality Assessment

Use caution with diagnosis with no specific, easy to identify endpoint

Quality Assessment

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APP Leader

Job description:Front line Creates relationshipsFacilitates trainingManages complaints

• Director• Chief • PA-I• PA-II

– 5% salary increase– APP education and professional development– Annual renewal

• PA-III– 4% salary increase – Administrative time (typically 4-8hrs/week)– Administrative call – Observation, urgent care, IT, new hire training

• $5000 spot bonus for CAQ • Annual bonus

APP Leadership Structure

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• Recruit experienced APP’s• Ideal staff rotates • Have anchor APP staff • Anticipate inpatient-like issues• Support your current staff with education• Create “cheat sheets” • Manage patient expectations• Case managers and social workers remove barriers to

discharge• Encourage staff feedback • Chose a diagnosis with an endpoint• Create APP leadership opportunity with obs

Summary

Email me: cchipalkatty@bwh.harvard.edu

Questions?

This Photo by Unknown Author is licensed under CC BY-NC

This

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• 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.

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• 2016 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 October 29,2018• United States Department of Labor: Bureau of Labor Statistics: https://www.bls.gov/ooh/healthcare/nurse-

anesthetists-nurse-midwives-and-nurse-practitioners.htm. Accessed October 29, 2018• 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

References