The hospital extended its reach into the community by providing testing to at-risk populations. Partnerships with the City of Boston and surrounding communities, such as Chelsea, which became a hotspot city, were formed. Ambulance services would perform testing on individuals housed in densely populated apartment complexes, group homes, correctional facilities, and other sites where contact tracing had identified clusters of infected individuals. The results management APPs were tasked with providing results to these at-risk populations, which required the development of new processes and workflow to communicate to populations with limited telephone access and who were not signed up for or did not utilized the hospital’s electronic medical record portal.
Often exceeding 200 tests per day, APPs worked for up to 8 hours a day, 7 days a week. Education materials in both English and other languages were provided to guide those with both positive and negative results. The APPs were fundamentally prepared for this type of counseling and results management. Often, patients needed an interpreter to help convey the clinical information if the APP was not certified bilingual staff. Many patients needed clinical documentation in the form of a letter for leave from or return to work, or for upcoming travel plans.
Many patients in the most at-risk and hardest hit communities could not self-isolate due to limited living space with multiple family members. In collaboration with several area hotels, the hospital created isolation rooms for patients who were COVID-19 positive but did not require acute clinical care. Selection criteria for inclusion and processes for arrival and discharge were developed. Individuals needed to be able to perform activities of daily living and medication administration independently.
APPs who worked in the isolation hotels participated in reviewing patient care needs, providing onsite clinical assessments, coordinating transfers to higher levels of care as symptoms progressed, providing patient education, and facilitating the flow of information to families of the housed individual while supporting the emotional health of those with limited contact to their social system.
The hotel was staffed 24 hours per day, 7 days a week with APPs from the hospital’s global disaster response team and APP faculty from its affiliate graduate school, the Massachusetts General Hospital Institute of Health Professions. There were 18 NPs and 3 PAs who had prior experience caring for families and adults. The hotel lobby housed a temporary urgent care clinic from where APPs conducted admission interviews as well as managed episodic care needs and provided health education.
Bundled Response for Access (COBRA)
The hospital introduced a new APP role to perform vascular and enteric access procedures throughout the intensive care units (ICUs) during the pandemic. The COBRA APP team was designed to minimize infectious exposure and preserve personal protective equipment. These APPs had demonstrated experience in securing venous access, central line placements, and catheter insertions for dialysis, paracentesis, and thoracentesis.
The COBRA team was staffed 24 hours a day, 7 days per week and reached by hospital pager or a request for consult in the electronic medical record. An interventional radiology NP who was proficient in central line and PICC placements was part of the team. As such, the APP did not require any specific training. The maximum number of procedures performed was 25 on 20 patients in a 24 hour period. The team participated in formal orientation and daily huddles.
Opportunities and Challenges
The creation of new APP roles was the result of the changing needs of our patients during the pandemic as well as the need to support parts of our delivery system that were expected to be overused, like the ED and ICU and those that would no longer have access to patients due to state-mandated shelter in place restrictions, like ambulatory care. Managing the availability of clinicians and anticipated system overload associated with patient surges presented opportunities and challenges for each of the new roles.
Providing access to community resources for food and housing issues required case management APPs to share information verbally, send links through social media, and connect with patients on the hospital’s electronic portal. All groups utilized telephone and video connections, which necessitated quickly gaining proficiency in a variety of software meant to ensure patient privacy and confidentiality. Through it all, APPs had to be vigilant about accurately assessing patient symptoms and providing the appropriate amount and type of education so as not to overwhelm and make patients more fearful. During this time, immigrant populations were particularly reserved about providing information related to living situations and household members which required APPs be sensitive to and aware of other influences on patients’ health status.
Except for the RIC and screening and testing APP roles, there was an opportunity for APPs to work remotely. Patients for which telehealth methods were available appreciated APPs reaching out to them. The APPs became adept at telephone visits, video conferencing, and written communications through the electronic portal.
Technical issues arose for all APPs who assumed roles outside their usual departments related to access to patient level data due to electronic medical security access within our hospital. Some processes newly designed within the system did not work as expected because there was limited time for robust testing prior to implementation. Errors in patient level data resulting from other role groups being redeployed to support other operations, like entering test results from external laboratories, impacted workflow.