NAPNAP President-Elect Discusses Upstreaming and COVID-19

Andrea Kline-Tilford, PhD, CPNP-AC/PC, FCCM, president-elect of the National Association of Pediatric Nurse Practitioners (NAPNAP), spoke with Clinical Advisor during the association’s annual meeting. We discussed how nurse practitioners (NPs) are working to upstream health care, nursing innovations during the COVID-19 pandemic, advances in vaccines for children, and whether in-school or virtual school is better for children.

 

Q: I sat in on one of the keynote speakers, Rishi Manchanda, MD, who presented on the upstream movement in health care. Many attendees acknowledged that this was something that they aim to do, but often lack the time and/or resources to focus on social care (food insecurity, housing insecurity, etc). What steps has NAPNAP taken to help “upstream” pediatric nursing care?

Dr. Kline-Tilford: As experts in pediatrics and advocates for children, upstreaming is really at the core of the work that we do at NAPNAP. The organization advocates for policies, regulations, and equitable access to care that promotes improved health and wellness for children. We are always inspired by the stories of the NAPNAP members who are conducting direct outreach in the community, such as working at food banks, shelters, providing health care to homeless populations, and volunteering health services. We have upstreaming as a priority in our organization.

One example of this was in 2019 when NAPNAP joined with other organizations to oppose a tax on the Affordable Care Act (ACA). The tax was part of the plan by the previous administration to dismantle ACA. Any change in the ACA, including changes to the Children’s Health Insurance Program (CHIP) or Medicaid, would affect millions of children and families.

The ACA has made tremendous improvements to children’s health. Young adults can remain on their parents’ insurance plans until they turn age 26, insurance companies can no longer refuse to cover patients with pre-existing conditions or charge them more for coverage, annual limits on lifetime coverage no longer exists, etc. While these protections and improvements are currently in place, NAPNAP is stilled concerned about what the future might hold for children who rely on these provisions.

In early March 2021, NAPNAP joined with the County of Santa Clara, California, California Tribal Families Coalition, American Lung Association, Center for Science and Public Interest, and other organizations to file a legal action against the Department of Health and Human Services over the agency’s “Securing Updated and Necessary Statutory Evaluations Timely” Rule (“SUNSET Rule”). The Trump Administration released notice of the proposed SUNSET Rule the day after the 2020 election and scheduled it to take effect on March 22, 2021.

The SUNSET Rule mandates that the U.S. Department of Health and Human Services (HHS) assess its regulations every 10 years. To prevent the phase-out of these regulations, HHS would have to switch its focus away from the ongoing COVID-19 pandemic and other crucial activities in order to commit unprecedented time and resources to review nearly every agency and subagency regulation. Without this review, nearly 17,000 regulations would automatically be eliminated in 2026. So essentially the SUNSET Rule would eliminate thousands of regulations that govern our health care system including food safety protocols, public health measures, and social services.

We are happy to report that on March 22, 2021, the legal challenge successfully prevented the rule from taking effect. In response to the lawsuit, the HHS issued a 1-year stay. This is just a temporary freeze, so there’ll be more work to do to fully invalidate this rule moving forward. [In the meantime, the Biden Administration has called for a regulatory freeze on any last-minute regulations approved by the Trump Administration.]

Q: NAPNAP has been a leader in exposing child trafficking. During COVID, the number of online enticements of children nearly doubled. What steps can clinicians take to protect families and vulnerable youth against predators?

Dr. Kline-Tilford: Awareness and education for families are most important. I don’t think that most families are aware that this is happening in every community; that children everywhere are at risk. Specifically, there needs to be more education about social media safety, how to put in parental safeguards, as well as recognizing signs of trafficking in the community.  

NAPNAP founded the Partners for Vulnerable Youth. Through Partners for Vulnerable Youth, NAPNAP created the Alliance for Children in Trafficking (ACT). The mission “is to serve as the national leader in coordinating and uniting efforts to end the labor and sex trafficking of youth.” We know we can’t do this alone so we are seeking a broad range of partners. ACT has completed 3 human trafficking continuing education modules for NPs, nurses, physicians, and physician assistants. The latest course is called 3-PAART (Providers Assessing Risk and Responding to Trafficking). These courses are all available online.

Q: The COVID-19 pandemic has affected everyone. At the beginning of the pandemic during lock-down, well-visits and vaccinations were often curtailed. In our reporting of the pandemic, I was impressed by how innovative nurses were at setting up mobile immunization buses that could go to where the children were. What other examples of innovations during the pandemic most impressed you?

Dr. Kline-Tilford: On the ambulatory side of care, telemedicine care exploded at an exponential rate. Clinics began offering in-person care in a different way, including drive-by vaccination clinics. On the inpatient side, there was a lot that was happening to reduce staff risk for exposure to COVID-positive patients. We saw telehealth exploding not only on the ambulatory side, but some inpatient consults became virtual — with the consultants talking to the team and looking at the medical record virtually.

Because clinicians were not gearing up and going into patients’ rooms, they had to amass information in a different way. To reduce staff/patient exposure at the bedside, the bedside nurse was a conduit of information, and instead of daily rounds with 8 people entering the patients’ room, it would be 1 provider on the team who gathered all the information and brought it back to the team to discuss and determine a management plan. Because families could not visit their infected relatives, electronic devices were often used to keep families engaged.

I think COVID-19 pushed our telehealth initiatives across all aspects of care. It will be interesting to see which of those initiatives are going to stay.

Q: Do you have any idea when children will be able to get vaccinated against COVID-19? The initial studies are now ongoing in adolescents, but what about younger school-age children.

Dr. Kline-Tilford: Similar to the adult vaccine trials, we are hoping that these trials will be happening rapidly. We are all very anxious to get children protected, but we don’t have a timeline yet. There are some concerns, however. Pediatric patients are at risk for developing multisystem inflammatory syndrome in children (MIS-C), which is related to COVID-19. We don’t know if the vaccine is safe in children who have had COVID-19 or whether it could trigger MIS-C. The vaccine trials will need time to study that issue.

Although MIS-C can affect children of any age, sex, or ethnicity, studies have found racial disparity among children who have been affected, with a disproportionate number of MIS-C cases occurring among Black and Hispanic children. [According to a recent study, Black children constituted 20% of COVID-19 hospitalizations among patients less than 20 years of age, but 34% of patients with MIS-C; Hispanic children accounted for 30% of MIS-C cases.]

Although we don’t know how long these complications will last, we have seen some cardiac damage related to MIS-C. These children require follow-up by a pediatric cardiologist and/or cardiology team. There is often delayed re-entry into sports until that cardiac recovery can be documented and clinicians feel it is safe for the child to return to sports or vigorous activity. In addition to the heart, complications from COVID-19 have affected the lungs, blood vessels, kidneys, and digestive system of children.

Q: Are you seeing the same kind of long-hauler symptoms in children that have been seen in adults?

Dr. Kline-Tilford: There are some cases of long-hauler symptoms in children [eg, exhaustion, intermittent low-grade fevers, sore throat, coughing, painful limbs, and trouble sleeping]. Cases of long-hauler symptoms in children are more sporadic than in adults, which is probably because it’s really hard to diagnose in younger children, particularly preschool-aged children who are unable to describe their symptoms. But in older children and adolescents, we are seeing the same post-COVID effects that are seen in adults. Fortunately, the numbers are considerably lower overall for children.

Q: Lastly—what is your advice about in-person vs virtual learning?

Dr. Kline-Tilford: This is a tough one. It’s a balancing act. We know the negative effects of keeping our children at home: isolation, psychosocial mental health issues, increased risk for both physical and sexual abuse, and not having access to some of the supportive services for children with disabilities and reduced access to food services.

On March 19, the Centers for Disease Control and Prevention (CDC) released guidelines that revised the physical distancing recommendation from 6 feet to 3 feet between students in classrooms. The agency reemphasized the need to incorporate proper ventilation as a component, in addition to disinfection, to clean and maintain healthy buildings. Studies have continued to report low COVID-19 transmission rates when schools following proper protocols.

As an organization, NAPNAP supports getting children back to school for face to face learning when possible. We have had more time to learn about the virus and although we all hope for herd immunity, it is more likely that COVID-19 will be with us for a while and we need to learn to live with it.

Andrea Kline-Tilford, PhD, CPNP-AC/PC, FCCM, is the nurse practitioner director for C.S. Mott Children’s Hospital in Ann Arbor, Michigan. She has been a nurse practitioner for more than 20 years and has experience in pediatric critical care and pediatric cardiovascular surgery. She is the cofounder of NAPNAP’s Acute Care special interest group (SIG) and is the professional issues department editor for the Journal of Pediatric Health Care. She has presented and published widely on topics of advanced practice nursing and pediatric critical care. 

Visit Clinical Advisor’s meetings section for complete coverage of NAPNAP 2021.