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In Depth: ACEP Rural Emergency Care Task Force 2020, Part 1

The 2020 Rural Emergency Care Task Force, convened by the American College of Emergency Physicians (ACEP) Board of Directors, began work in June 2020 and published a report in October.

The 24 page summary can be accessed here. The goal of this series of two articles will be to further distill and explain the findings from the perspective of a practice – ACUTE CARE, INC. – specializing in and experienced with Rural Emergency Medicine. The report includes input from two ACEP Sections – Workforce Development and Rural – to which ACUTE CARE, INC. belongs.

The Task Force addressed assigned objectives using published methods and provided key recommendations.

In this article, the first of two planned on the topic, focused on the first three of five objectives, we draw directly from the report as a means to summarize and discuss the recommendations and how they affect the practice of Emergency Medicine in rural America.

1. Objective: Review the data from the ongoing workforce study. Review the data regarding recent closure of rural hospitals. Provide an assessment and recommendations on the current and projected workforce. 

  • Methods: Review of current workforce study; original data analyses.
  • Assessment: Current understaffing of rural emergency departments (ED) is likely to worsen and restricting this assessment to emergency medicine (EM) residency trained, EM board certified emergency physicians (EPs) provides a far worse situation and forecast. More rural EDs are closing than opening.

Comment: I had seen some of the preliminary data that became the report Dr. Camargo contributed to this section of the report. The measure of “EP density” is used, and it’s noted that Board Certified Emergency Physicians continue to be underrepresented in rural areas. The data regarding rural hospital closures is well known and oft-reported.

  • Goals: Support physicians, physician assistants (PA), and nurse practitioners (NP) currently staffing rural EDs, acknowledging prior training is often limited in formal EM, through EM-focused professional development activities. Develop strategies to avoid further rural ED closures.
  • Suggested ACEP actions:
a. Develop a recommended knowledge and experience base for non-EM board certified physicians who are working in rural areas. This should not be confused as a substitute for board certification. Require a period of mentorship with an EM board certified physician via telemedicine.
b. Develop a recommended knowledge and experience base for PAs and NPs who are working in rural areas. Require a period of mentorship with an EM board certified physician via telemedicine.
c. Work with the American Hospital Association and other specialty organizations to provide support for rural hospitals and practitioners.
Comment: ACUTE CARE, INC. supports this excerpt from the more detailed portion of the report.

Assessment and Recommendations for Rural Workforce

Based on the best available evidence, current understaffing of rural EDs by EPs is likely to worsen in the years ahead. Restricting analyses to only those EPs with EM training or EM board certification provides an even worse situation – and forecast.

Evidence also indicates that more rural EDs are closing than opening. While the numbers are small – relative to the total of 1,899 rural EDs open in 2018 – the trends are concerning.

Taken together, we encourage ACEP to better support the EPs now working in rural EDs – regardless of their EM training or EM board-certification status – and to work with rural hospitals to develop strategies to avoid further ED closures. Ongoing support of the Critical Access Hospital Program should be an important part of any ACEP strategy to maintain and potentially improve access to rural emergency care

2. Objective: Review the outcomes of residency training programs with specific rural emphasis and make recommendations on ways to increase the number of board-certified EPs practicing in rural areas.

  • Methods: Program director (PD) survey, structured interviews.
  • Assessment: Majority of PDs reported educational benefit of rural rotations. Rural rotations provide a bridge between academic training and community practice. Barriers to offering rural rotations during residency training include financing, housing, and supervision.

Comment: We have participated in discussions regarding rural rotations for EM residents, and understand the value assigned to this experience. Whether the exposure to the rural environment as part of clinical learning influences a resident physician to choose placement in such a setting is not addressed.

  • Goals: Reduce barriers involving the credentials of a ‘supervising physician’ with the Accreditation Council for Graduate Medical Education (ACGME) Review Committee-Emergency Medicine (RC-EM). Enhance knowledge of rural training through collaboration with national groups. Establish loan repayment for EM residency graduates practicing in rural areas. Promote rural EM residency tracks.
  • Suggested ACEP actions:
a. Meet with RC-EM to discuss rural ED rotations and current barriers to these experiences.
b. Collaborate with CORD and EMRA to increase the options for rural ED rotations.
c. Highlight rural EM through ACEP Now articles.

Comment: The report does not address a current and pressing concern that EP supply was already exceeding demand before the pandemic, and has been exacerbated by the pandemic. If we have too many residencies and too many graduating residents for the job market these physicians in training anticipated, they may need to adjust their expectations for where they will practice, and reconsider rural areas.

3. Objective: Perform a needs assessment of our rural members, including equipment (eg, video laryngoscopes, ultrasound, etc.), consultation, education (physician, nursing, etc.), and policies.
  • Methods: Survey of ACEP Rural Emergency Medicine Section, American Academy of Emergency Nurse Practitioners (AAENP), and Society of Emergency Medicine Physician Assistants (SEMPA).
  • Assessment: Most rural sites report adequate equipment to provide care, and most required ACLS, ATLS, and PALS. Few rural sites required additional education or onboarding activities to address EM knowledge or procedural skills training.

Comment. This is in keeping with my observation as well, though ACUTE CARE, INC. is continually evaluating and trailing education activities that address the need for critical skills maintenance. The fact that simulation and skills lab training was not addressed is a puzzlement, as these modalities are increasingly available in regional centers and accessible to rural practitioners.

  • Goals: Develop a model onboarding for PAs and NPs practicing without EM board certified EP presence in rural EDs, to include EM specific knowledge and procedural skills training. Facilitate the utilization of telemedicine in rural sites to enable supervision by EM board certified physicians for initial onboarding supervision of PAs and NPs, as well as ongoing telemedicine availability.
  • Suggested ACEP actions:
a. The Board of Directors should discuss the role of ACEP in driving improved quality of care in rural hospitals.
 b. Create a document that outlines the recommended on-boarding for PAs and NPs in settings without EM board certified EPs, which would include specific knowledge and skills competency, as well as recommendations for supervision by EM board certified EPs.
c. Create a policy that advocates that hospitals without EM board certified physician coverage should have telemedicine availability for consultation.
Comment. The role of the Advanced Practice Provider in the ED, deployed as the sole practitioner, with or without telemedicine support, is an enormously controversial subject in EM. ACUTE CARE, INC. has been following the implementation of systems using PA’s and NP’s, and continues to evaluate whether such a model would match our requirements and that of our partner hospitals. The report’s mention of bridge/boot camp education that identifies and provides the skills and knowledge required to address the previous experience of the APP’s and the requirements for practice in the ED is of particular interest and will be addressed in Part of 2 of this report.

Paul Hudson, FACHE
Chief Operating Officer