When the novel coronavirus disease 2019 (COVID-19) pandemic hit Boston in March 2020, Massachusetts General Hospital responded by redeploying Advanced Practice Providers (APPs), consisting of nurse practitioners (NPs), physician assistants (PAs), certified nurse midwives (CNM), and certified nurse anesthetists (CNAs), into new roles to meet the emerging needs of its patients.
The hospital designed a responsive delivery system that relied heavily on its APP workforce. The delivery system included 7 new APP roles:
- Manning a COVID-19 hotline
- Staffing respiratory illness clinics (RICs)
- Results management team member
- Case management team member
- Supporting mass testing teams
- Manning an isolation hotel
- Performing vascular and enteric access procedures.
APPs demonstrated versatility in these new roles because their clinical skills were transferrable across settings.
COVID-19 Hotline APPs
A COVID-19 telephone hotline was established to connect patients and clinicians to resources and information about respiratory illness symptoms and self-isolation techniques with the goal of appropriately referring patients to the emergency department (ED). An algorithm was created in collaboration with primary care and infectious disease physicians to identify significant symptoms such as difficulty breathing that expedited referral to the ED, moderate symptoms such as fever with malaise to the RIC, mild symptoms such as sore throat and cough to testing sites, and possible exposure to a COVID-positive patient to self-isolation at home. Additionally, patient education information was provided on a broad range of subjects including how to use public transportation and shop for groceries safely.
The hotline operated daily. Overtime, 91 APPs took calls onsite and remotely. The orientation to role expectations evolved as the volume of calls from patients and clinicians increased, patients’ presentations changed, and as the RICs and testing sites expanded.
Respiratory Illness Clinic
Primary care and specialty APPs were redeployed from their usual positions to support the growing number of patients with SARS-CoV-2 infection requiring care in the RICs. The hospital opened 4 RICs throughout its service area to conveniently meet the care needs of patients and mitigate the impact of the pandemic on its ED. Patients were referred by primary care providers or walked into RICs for care. The RICs used 4 APP roles to care for patients:
- Providing direct care
- Conducting screening and testing
- Performing results management functions
- Assessing disease progression through case management strategies.
APPs directly cared for patients suspected of having COVID-19 in the RIC. In addition to COVID-19, they focused on the diagnosis and treatment of respiratory illnesses including pneumonia, asthma, and chronic obstructive pulmonary disease exacerbation. Clinicians relied on symptom presentation, history of present illness, vital signs, auscultation of lung sounds, and chest imaging to care for patients. Physical examination was limited and maneuvers that might have exposed the oropharynx were avoided. As such, presentations of streptococcal pharyngitis, dental abscesses, and tonsillitis were treated empirically and referred for follow up care as needed.
The acuity of many patients required transfer to the ED. These patients generally presented with significant dyspnea, dyspnea on exertion, tachypnea, tachycardia, or hypoxemia. Many patients appeared stable but had asymptomatic hypoxemia discovered on collection of routine vital signs by pulse oximetry. Chest radiograph findings that supported transfer to the emergency room included bilateral lower lobe infiltrates, a finding commonly seen with SARS-CoV-2 that, at the time, was believed to foreshadow the potential for clinical deterioration.
The clinics operated 12 hours a day, 7 days a week. APPs and physicians were used interchangeably. For medical evaluations, each APP was assigned 2 exam rooms. Those from primary care were expected to see 3 patients per hour and APPs from specialty practices were expected to see 2 patients per hour.
Clinicians received training on the care required for patients suspected of having COVID-19, including possible laboratory and radiograph findings along with guidance on available decision support tools and documentation templates within the electronic medical record. To guide decision making and identification of those requiring hospitalization, the medical directors in the RICs developed an algorithm to order a chest radiograph was developed.
Training resources available to all 43 APPs included online videos, training documents, optional question and answer sessions, and a primary care clinician preceptor. Consistent with Centers for Disease Control and Prevention recommendations to minimize and control exposure risk, APPs were educated in the principles of infection control and the correct use of personal protective equipment (PPE). Additionally, at the end of the patient visit, the APP was responsible for sanitizing all surfaces that had been touched during the visit with germicidal wipes.