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In Depth: ACEP Rural Emergency Care Task Force 2020, Part 2

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 second of two planned on the topic, focused on the last two 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.

4. Objective: Provide several models of successful rural care practices.

Methods: Review of several models of rural ED practice by expert panel. Discussions with rural ACEP members.

Assessment: Mayo and TeamHealth onboarding practices reviewed and summarized. Alternative programs for non-EM board certified physicians and PAs/NPs requiring additional EM knowledge and procedural skills training leading to other credentials and Certificates of Added Qualification (CAQs) reviewed. Review of low volume EDs to better understand challenges of staffing these sites.

Comment: The Mayo and TeamHealth models are addressed in the combined (Objectives 4 and 5) recommendations and I’ve commented on that information below. Of note is that Mayo model is a structured mechanism for preparing, placing and supporting APP’s. It appears that the TeamHealth model, while in transition, seems to focus on preparing physicians for placement. I was not aware of the EM Fellowship (primary care to Boarded EM) pathway, and the information provided in the report is a bit sparse. The matter of added qualification sts the stage for a conflict between the practices’ requirements for use of APP;s; be they under internal control (see; Mayo, Mississippi) or system credentialing requirements (no example given).. The initiative does address the criticism and concern that a new APP graduate lacks the experience and skill set to work in the ED, and a practicing APP lacks the opportunity to systematically acquire these attributes. 

Goal: Highlight institutions that have quality rural care practices such as the Mayo model
Suggested ACEP action:
Conduct a study of low volume frontier ED practices to understand and address unique challenges of these sites (staffing, inpatient care).

Comment: The inpatient care mention stands out, in that the report addresses the ED and doesn’t directly refer to or investigate the increasingly common hybrid ED / inpatient models.

Create ACEP Now articles and other communication devices to promote best practices

5. Objective: Make recommendations on opportunities to improve rural emergency care including accreditation programs, incentives, and policies.

Methods: Review and opinion of expert panel. Discussions with rural members.

Assessment: Many rural EDs staffed by non-EM board-certified physicians, PAs, and NPs lack oversight/supervision by EM board certified physicians.

Goal: Develop a model onboarding curriculum for PAs and NPs practicing without EM board certified EP presence in rural EDs, to include EM specific didactic knowledge and procedural skills training. Encourage rural EDs to utilize telemedicine supervision by EM board-certified EPs for initial onboarding and supervision of PAs and NPs, as well as ongoing availability of telemedicine supervision and support.

Comment: While two educational models are mentioned, the report notes that TeamHealth is ending use of one in favor of starting the other (which Mayo already uses). Telemedicine support is mentioned, but details as to how and when the system is used are not provided. the fact that the study authors did not investigate and report on the mature, high functioning system in Mississippi is a puzzlement. 

Suggested ACEP action:
As above, create a document with ACEP recommendations for onboarding and ongoing telemedicine supervision and support.

Excerpt from the body of the report:

The gold standard for the care of ED patients is provision of care by EM residency trained and EM board-certified emergency physicians, with board certification from (ABEM/AOBEM). Based on a recent workforce study,1 however, it was found that only 8% of all emergency physicians (not necessarily ABEM/AOBEM certified) work in rural EDs, and only about 2% work in very low volume ED’s. Primary care physicians typically fill this void, but increasingly we see it filled by PAs and NPs – at times working with, or under the supervision of, a physician and at times working as solo practitioners. This workgroup was asked to identify several best practices, where emergency groups, hospitals, or health systems had developed an educational program or mandatory education for physicians and PAs/NPs in an effort to better prepare them to adequately manage the population of emergency patients that present to these rural facilities. Patient safety is paramount, and when an EM residency trained, EM board certified physician cannot be present, we must advocate for improved education of our emergency care colleagues. Because the very low volume rural EDs have, arguably, the most at-risk patients, we focused our efforts on training for physicians, PAs, and NPs at these facilities

Comment: The report details its findings on the EM Fellowship and Certificate of Added Qualification for APP’s” and, while interesting (summary: post-graduate, pre-placement programs based on classroom and supervised ED experience), I’ve chosen to compare and contrast the recommendations for bridge education modeled after the Mayo program.

Excerpt from the body of the report:

The Mayo system in MN was found to have the most robust onboarding and monitoring process for PAs and NPs to work solo in Frontier Rural EDs, which often are part of the federal Critical Access Hospital (CAH) program. The process is as follows:

a.   PA/NP Fellowship track to work at Frontier CAH

1.      18-month program

2.      Variety of clinical rotations including EM

3.      EMCT (Emergency Medicine Core Training) Program

4.      RSI (Rapid Sequence Intubation) course

5.      Endotracheal intubations in OR

6.      Ultrasound course

7.      ACLS

8.      CALS

9.      Bridge to solo practice (supervised solo shifts)

10.  Procedure/skills review with supervisor and medical director

11.  Telemedicine oversight as needed at solo site

b.  Non-PA/NP Fellowship track at Mayo to work at Frontier CAH

1.      Need years of experience in large volume ED – supervised

2.      EMCT (Emergency Medicine Core Training) Program

3.      RSI (Rapid Sequence Intubation) course

4.      Endotracheal intubations in OR

5.      US course

6.      ACLS

7.      CALS completion 

8.      Bridge to solo practice (supervised solo shifts)

9.      Procedure/skills review with supervisor and medical director 

10.  Telemedicine oversight as needed at solo site

Comments: The APP curriculum appears to be a fellowship model, with an agenda focused on skill (as opposed to knowledge) acquisition, though the core, video-based, training ( EMCT (Emergency Medicine Core Training) Program) may have that attribute. 18 months is a substantial investment for both the APP and the system. Telemedicine’s role (decision support and permission by BCEM physicians at a Mayo hub) is presumably present, but not explained in detail. The use of supervised shifts as a bridge to “solo” shift  is notable and clearly a best practice adopted from residencies. 

The modification of the program for physicians interested in transitioning into EM is interesting, in the way that it has been modified to address a willing physician recruit who lacks the experience and training to function effectively in the ED (though this phrase is confounding in that context: Need years of experience in large volume ED – supervised. The question as to whether these doctors were being groomed for the “frontier” ED’s as APP equivalents (it’s intimated that the Mayo frontier hospitals have moved to APP’s with telemedicine support) in that market segment or whether they’d be accepted practitioners in busier hospitals typically staffed by BCEM physicians.

The report and recommendations are worthy of your attention in its entirety, my hoe is that these excerpts and comments help explain its pertinence through the lens of a practice executive focused on the rural niche.

Paul Hudson, FACHE
Chief Operating Officer