Nurse practitioners and physician assistants may have growing opportunities in rural emergency rooms. That’s because many rural hospitals are adding advanced practice providers to their physician-led ER teams to help improve their emergency departments. Further, there are new federal, state, and local funding resources that may help rural health facilities and critical access hospitals hire more clinicians. If you’re an APP who is considering practicing in a rural area, here’s an update on current challenges in rural ERs and how your specialized skills can help.
Unique Challenges for Rural Emergency Departments
Emergency departments in rural areas across the nation grapple with ongoing physician shortages, unpredictable patient volumes and increased COVID vulnerability. These issues can cause bottlenecks in small, rural emergency rooms, leading to less-than-satisfied patients and providers as well as inefficient services.
Continuing physician shortage. Even in the best of times, rural health facilities struggle to attract and retain full-time doctors, including emergency medicine physicians. According to Annals of Emergency Medicine, only 8% of emergency physicians practice in rural areas.
Fluctuating patient loads. Patients have been either avoiding emergency departments due to social distancing or flooding EDs due to surges in COVID cases (CDC MMWR). Unfortunately, patient volumes have once again spiked due to the Delta variant.
Patient vulnerability. Residents of rural areas appear to show increased susceptibility to serious infection or death from COVID-19, likely due to older age, lack of health insurance and underlying health problems (USDA Economic Research Service).
APP Support as a Solution for Rural ER Challenges
To overcome these challenges, some rural facilities are fortifying their physician-led ED teams with specialized APP support.
Nurse practitioners and physician assistants who are trained in emergency medicine can alleviate pressures on ED physicians, help streamline services, and improve patient experience. APPs in the ER can perform rapid medical evaluations (RMEs) alongside triage to reduce the door-to-provider time and promptly initiate the medical workup. They can provide treatment, case management and follow-up care (in accordance with the level of practice autonomy designated by their state).
April Hawthorne, Cross Country Locums Vice President of Recruitment, is seeing a growing trend in rural ERs hiring more APPs. Hawthorne says, “When facilities expand their APP team, patients don’t have to wait as long. APPs can perform an RME on patients, and those patients who don’t need to see the EM physician directly can be safely treated by the APP, decreasing wait times. The PAs and NPs can order lab tests, read results, counsel, diagnose, treat and fully process the patients. If they need help, they can then contact the supervising physician. APPs can address the lower-acuity cases, streamlining services in the ER.”
“As long as there is sound clinical judgment, proper protocols are in place, patient safety is top priority and the provider can consult the supervising physician, the doctor doesn’t have to be there every step of the way.”
For these lower acuity patients, the APPs serve as the first point of contact for the patient after intake, can constantly monitor them during treatment, and can give discharge orders and follow-up care. Having multiple APPs available can help ensure a patient-centered approach, upholding care continuity, decreasing readmission rates, and possibly translating to increased HCAHPS scores.
Varying autonomy of practice. When implementing this approach, rural health leaders and practitioners must follow state laws regarding autonomy of practice and supervision requirements. So depending on location and whether APPs are classified as independent, reduced, or restricted in practice, different arrangements will suit different facilities.
In states where APPs have autonomy of practice, small rural hospitals (those that partner with larger facilities and typically transfer high acuity patients to those facilities) might choose to have APPs onsite to treat low acuity cases with remote access to the emergency medicine physician at the larger hospital. In certain high-acuity environments where onsite supervision may be required, the APP team can consult the onsite physician as needed. Some hospitals may choose to employ telehealth — using virtual health consults with the supervising physician and in-person services with the APP.
Financial resources for building APP teams. Some hospitals have found that federal funding, as part of the COVID stimulus and relief, has helped build their APP teams in the face of increasing pressure from the pandemic. This relief may be an available resource to solve challenges with staffing and retention during this particularly challenging time or to cover other COVID-related costs, freeing other resources for hiring. This is great news for APPs who are seeking positions in rural ERs.