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11/2/2018
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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: [email protected]
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.
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• 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