Executive Interview: Serving on the Front Lines

Emergency physicians were tired, but determined, amid rising hospitalization rates and COVID cases.

Dr. Ryan Stanton, an emergency physician practicing in Kentucky, didn’t have to think long about what words he would use to sum up how he feels after months of providing emergency care amid the COVID-19 pandemic.

“Fatigued and tired,” he said. “Everybody’s worn out.”

Indeed, the nation’s frontline caregivers have paid a physical, mental, and emotional toll in fighting the pandemic. Record-breaking hospitalization rates have taxed emergency physicians and emergency department staff in unprecedented ways. Dr. Stanton, a board member of the American College of Emergency Physicians (ACEP), talked to The Journal of Healthcare Contracting about the challenges, and the repercussions for emergency departments and healthcare as a whole moving forward.

The Journal of Healthcare Contracting: Can you describe the toll that the pandemic has taken on emergency physicians and their departments? How has it affected their mental and physical health?

Dr. Ryan Stanton: I think everybody in medicine, but especially emergency medicine, is just tired now. Everybody is worn out. We can’t see each other’s faces, and everything’s very isolated. We can’t get together, we can’t do the things that we used to do for team building.

Then you’re especially nervous because a lot of folks outside the hospital feel like you’re always contagious. So we have friends that haven’t been willing to talk to us since the onset because we’re in healthcare and they feel like we’re a Typhoid Mary, just waiting to spread COVID to everybody.

Then there were the initial frustrations with lack of PPE, or adequate PPE, when you’d start opening up masks and all the instructions are in Chinese.

And even now with the vaccine. Most that have access to it are overjoyed. But we’re hearing from places where it may not be getting to physicians in emergency conditions, emergency staff, front line folks. The logistics are tough, and trying to fight all the false narratives and conspiracies and everything that is out there is frustrating as well.

JHC: What has COVID’s effect been on staffing shortages?

Dr. Stanton: The shortages are twofold.

In my situation, I started getting symptoms Thanksgiving week, so it was hard to get a test to confirm it. I had shifts coming up, so I was worried about getting those shifts covered. Thankfully for me it went very smoothly.

But for the nursing situation, you have exposures, people are out and of course the changing amount of time that it’s going to be – whether it’s 10 days, 14 days, etc., A lot of hospitals and facilities have models where even with exposure you still work unless you develop symptoms, because some people were taking advantage of it.

When we had our numbers drop in March, a lot of hospitals cut their staff. So in March and April, the workforce numbers were down, and they’re still down in some places. They cut their staffs, but like everything does, volumes came back. We’re about 90% to 95% of our volume, but we still haven’t been able to hire back or find the folks to fully staff the ER and hospital again. Then you have those that transitioned to traveling nursing gigs and things like that.

So it’s been a real challenge not only with the virus itself, but with the workforce numbers that came during this unexpected drop in volume, and then the rebound.

JHC: How are hospitals and health systems trying to help in these areas from an organizational standpoint?

Dr. Stanton: There are very lucrative opportunities in hard hit areas that promote transition to travel nursing opportunities. This poses a challenge for staffing in community and rural settings.

Hospitals are trying to hire, but you can’t just flip a switch on staff and hire somebody and have them in. You have to onboard. Almost all nurses in the emergency department, whenever they’re hired, they’re precepted for at least a couple of weeks, if not longer (especially if they’re a new nurse) to get used to the system, to get used to our emergency department. So it takes quite a while to get the numbers back up. And during that time, you may lose a few more. Hospitals are trying their best, it’s just that there’s a limited commodity, and everybody’s looking right now.

JHC: What’s the communication between the emergency departments and supply chain been like as far as trying to get the necessary PPE, medical supplies and adjusting to the new demand?

Dr. Stanton: The biggest thing with that is whether your C suite – the part of the hospital that has carpeted offices – is connected to emergency medicine. Is there physician leadership that understands emergency medicine, or is it a disconnected?

A lot of places see the entire healthcare setting as one entity, and don’t understand the unique environment of the emergency department. Thus understanding the flow, speed, turnover, acuity and everything else involved with it. The closer that the administration was with emergency medicine and frontline health, the better the process was.

For instance, knowing that we can’t say we’re not going to wear N95s until we have high suspicion that somebody has COVID. We learned that our first COVID patient didn’t come in with COVID symptoms, the patient came in with a stroke. So everybody was in the CT scanner room with no PPE on. That was before we understood the nature of COVID. We learned we have to wear PPE for COVID in every single room.

So getting those understandings, and understanding when the volumes are going to come, and when they’re not going to come. Now in the winter with the amount of COVID cases, bed space is an issue. I have a friend that posted last week that he has a 20-bed emergency department and they had 34 boarders in the emergency department, so they had more people admitted to the hospital in the ER than there were beds. One of those boarders had been there 15 days.

Communication has to be evolving. What you established in March is not going to work now. Currently one of the biggest things with the communication is on the vaccine. Who gets it, and understanding who are the highest risk exposures. At first, our system didn’t put our treatment center on the first round of vaccines. But that’s our second line where we’re sending our COVID patients, they’re the primary care offices in a community, and so they have very high risk of exposure. Understanding your whole landscape is very important. And I think different places have done better, some have done worse, and everything in between.

JHC: What are some long-term implications of the pandemic for emergency departments?

Dr. Stanton: I think it’s going to change the face and practice of medicine overall, because I think we’ve figured out some things that we’ve been doing wrong, but we’ve never been in a situation where we get the risk associated with it.

With supply chain, we’ve been very satisfied with just-in-time delivery and lean processes for the last 20 years. But that doesn’t work when you have a pandemic. You can’t have just-in-time delivery, because nobody can deliver. I think we’ve learned a lot of stuff about when we are prosperous, we may be putting ourselves in a position of risk. Over the last 20 years, we’ve been very prosperous in terms of having stuff at our fingertips, being able to order something and have it in house later that day, whatever it may be. And that works until there’s a pandemic or a big disaster. That puts a lot of people, including our healthcare folks, at risk.

From a workforce standpoint, I think we’re going to see significant attrition after the pandemic, with physicians, nurses, and techs wanting to get out of health care. The message they’re hearing is, “Thank you for serving on the front lines of the pandemic, now we’re going to cut your pay and benefits.” With that going on and then what’s happening with Medicare and insurance, I think you’re going to see a fair amount of attrition and turnover, which could make access to care even more difficult moving forward.

JHC: Are organizations anticipating the attrition and trying to work toward preventing it?

Dr. Stanton: I think some are. While I think you’ll be able to make up with bodies, the question is quality.

There is a big difference between having a board certified emergency physician versus a nurse practitioner that just finished their online degree. Though they are both providers, the quality is going to be very different, the experience is very different. There are mechanisms by which to replace, but the question is, what is the experience and knowledge and what’s being lost from a patient exposure standpoint?

The average emergency physician sees about 20,000 patients before they’re considered sufficiently competent in emergency medicine. We typically have 20,000 hours of training before we can be board certified. When we replace, when we backfill, what’s the loss because of that? I think a lot of facilities are trying to put plans of succession and future growth and pipelines to staffing models. But again, there’s a shifting landscape of where are your people? What are their degrees and qualifications? And what’s the demand out there?

The challenge now is that we have a whole country that’s going to be dealing with supply and demand, as opposed to just regional stuff, which is just easy to fix with people moving from site to site to get a better job, better facilities, better support. But now it’s the whole country.

JHC: What do the next few months look like for emergency physicians?

Dr. Stanton: The biggest thing that has uplifted medicine, especially emergency physicians and emergency staff, has been the vaccine. The vaccine was the first time in nine months that we’ve seen frontline health care workers with a positive outlook on the pandemic and that there’s going to be an end. Before it seemed like the goalposts were moving farther and farther away. Everybody is finally upbeat with seeing the potential light at the end of the tunnel.

Also, there have been some side benefits. I’ve not seen a single flu case so far this year. We aren’t seeing RSV, we’re not seeing norovirus, we’re not seeing the usual things this time of year. So there’s been a benefit from those standpoints. Those tend to be high risk for our young children, so our children are probably safer this winter than they’ve ever been.

We’re looking forward to 2021 being an exit strategy to the pandemic. We’re starting to see a change in the mood towards more positive now than what we would have seen a month ago. And I think that’s going to continue as we see the numbers start to drop off in mid-January, which is expected after the holidays. They’ll shoot up a little bit and then start to tail off, and hopefully with the vaccine distribution, we’ll see it go away for good. 

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