Abstract
JADPRO Live Virtual kicked off with the opening panel on advanced practitioner leadership during the COVID-19 pandemic. The group discussed their institutional emergency protocols, how they leveraged advanced practitioners (APs) to provide care during the crisis peak, and how they responded to the personal issues and anxieties of their AP colleagues.
As health-care systems face challenges never before encountered in the era of modern medicine, advanced practitioners (APs) are playing critical roles in developing protocols, managing health-care teams, and delivering patient care. JADPRO Live 2020 kicked off its virtual meeting with a discussion about this experience.
The panelists, all of whom hold leadership positions, described their institutional emergency protocols toward the emerging COVID-19 pandemic: how they leveraged staff to optimize patient care during the crisis and how they responded to the personal issues and anxieties expressed by their colleagues. Gabrielle Zecha, PA-C, MHA, Director, Advanced Practice Providers, Seattle Cancer Care Alliance/University of Washington Medicine, moderated the discussion with panelists Andrew S. Guinigundo, MSN, RN, CNP, ANP-BC, Lead APP/Genetics Lead, OHC, David Johnson, PA-C, Director of APP Services, Moffitt Cancer Center, and Sara Toth, RN, APRN, FNP-C, AOCNP®, AGN-BC, Director, APP Services, Texas Oncology.
PATIENT PRIORITIZATION, VIRTUAL PLATFORMS
From the first days of the pandemic, a top priority was mitigating exposure to patients and care team members. The way this was done at Moffitt Cancer Center was to institute a task force and patient prioritization system. As described by Mr. Johnson, three categories of patients were assigned: Category A patients had daily care continued as usual, as they were undergoing active treatment or experiencing oncologic emergencies; Category B patients could have their care deferred for up to 3 months; and Category C patients had care deferred for 3 months or so, as these patients tended to be in survivorship or surveillance, or undergoing screening or genetic assessment. Telehealth became a useful platform for continuing to deliver patient care to Category B and C patients, Mr. Johnson noted.
“Delaying care for up to 3 months seemed rational early on. Obviously, COVID-19 is still impacting us and we don’t know the endpoint,” Mr. Johnson added.
Community sites dealt with the early stages of the pandemic similarly, according to Ms. Toth. “We had a massive telemedicine initiative in the community oncology setting and within weeks, we got more than 600 providers and support staff onto a virtual platform…We had great collaboration between physicians, advanced practitioners, business operations, support staff, and IT [information technology],” she said.
Mr. Johnson added that the urgency of the situation triggered an amazingly fast response. “Things that once took weeks or months, we essentially accomplished overnight…Good things came out of this: we are still using telehealth. As an organization, we felt, ‘Look what we can accomplish when we set our minds to it.’ “
SHIFTING ROLES FOR APs
It was often necessary to “redeploy” APs or otherwise leverage how COVID-19 patients were cared for. At Moffitt, many APs were put on the front lines. “We had an overwhelming response from APs volunteering to care for patients positive for, or suspected of having, COVID. If their new responsibilities fell outside of their skill set, we trained them. The human spirit has been remarkable in this crisis,” Mr. Johnson said.
Mr. Guinigundo pointed out in the panel that in the community setting, things were different. “We interact with a variety of health systems, and it’s not so easy to just jump into working on the internal medicine or emergency medicine service ‘tomorrow.’ But we did deploy in different ways,” he said.
Interestingly, the day-to-day volume of community oncology practices became lighter, and this offered time for staff to examine policies and procedures, he added. “We tackled tasks that had been set aside for months or years.”
Similarly, Texas Oncology also took advantage of extra time to develop an initiative for training APs in advance care planning. This seemed particularly timely, considering that the cancer population is at higher risk for COVID-related side effects and deaths. “We focused on having those difficult conversations about patients’ values and goals, and their fears and anxieties—not just about having cancer but having cancer during a pandemic. These efforts were met with open arms by clinicians, patients, family members, and caregivers. We built this into our AP training,” Ms. Toth said.
PPE IN SHORT SUPPLY
As was much publicized, personal protective equipment (PPE) supplies were limited, and this presented challenges for leadership. Efforts were made to be innovative about the use of PPEs and to triage distribution and reduce use where possible. Staff who could work from home did so. Some institutions worked with local distilleries to make hand sanitizer. All the panelists said communication with staff became more important than ever.
“It was challenging—securing PPE and abating anxiety about exposure,” Mr. Johnson said. “Our leadership engaged at a level of communication we’ve never seen before—we called it ‘hyper-communication.’ We were transparent about our limited supply of PPEs, how we were working to secure PPEs, and how we were going to prioritize PPEs. Through a combination of listening and hyper-communicating to team members, we did the best we could to mitigate anxiety.”
Mr. Guinigundo called his administrators “super stars” for how they optimized communication, not only about the PPE shortage but also about dealing with COVID-19, which was still a fairly unknown foe. “My colleagues and I in the trenches, caring for patients, received daily emails as things unfolded, telling us, for example, ‘Here’s what we know now… Use this kind of PPE in this setting.’…With COVID-19, every day is a new and ever-changing dataset we are analyzing and trying to fit with what we are doing.”
ANXIETY ALL AROUND
Session moderator Ms. Zecha commented that COVID-19 has caused a lot of anxiety among providers as well as patients. “Patients have been scared to come in and some providers have been reticent as well. How did you manage this? And with no normalcy in sight, what will be the difficulties going forward?” she asked the panelists.
Mr. Guinigundo offered that anxiety, stress, and burnout will continue to be big problems, especially with fewer outlets, such as vacations (or conference attendance). Being able to attend JADPRO Live, for example, gave people opportunities to relax, learn, and commune with colleagues, “to bounce things off of them,” he said.
“Our practice president enacted a health initiative for staff. Instead of packing on the ‘COVID- 19 pounds,’ we participated in a program where we competed, for example, in miles walked in the past week. The office with the most miles had lunch delivered,” he said. Other online resources included free yoga, links to meditation websites, and other forms of information for combatting stress and depression. “These things may have been distractions, but they helped.”
He added that while travel may not be possible, APs still need to find some downtime, which can help reduce anxiety and stress.
Mr. Johnson agreed: “People miss the human connections we used to have.” While virtual platforms that allow staff to “see each other” have helped, he added, “It is not the same as personal get-togethers” and speaks to the need to “be more creative, to mitigate this.”
WITH “2020” HINDSIGHT
In conclusion, Ms. Zecha posed this question: What has been your biggest lesson, or what would you do differently now, knowing what you know 9 months into the pandemic?
“I wish I’d taken the time to ask what this situation looks like long-term—what I should put in place now to make things successful moving forward,” Ms. Toth commented. “In the very beginning, it was a shocking and challenging time, with emotional ups and downs. From the administrative side of things, I was going week to week—or even day to day or hour to hour. With ‘2020’ hindsight, I wish I’d taken time to sit down and examine my role, and the role of APs, long-term.”
Mr. Johnson said he would have liked to have “more personal visibility upon myself and the leadership team.” Early on, as a dire situation was quickly unfolding, administrators were “busy being innovative, trading policies and procedures, distributing emails,” he said. “I wish that during that time I had gotten out there with the teams more, because good leaders need to show calmness; they are anchored to the mission…I wish I could have cloned myself to have more one-on-one and face time with the team.”
Mr. Guinigundo said he would emphasize to his AP team that providers are role models. “Everyone’s eyes are on us. They trust our opinions. If we model the best attitudes, best behaviors, and the newest policy, the office builds on this. If we are lagging behind or fending for ourselves, that’s not good. We need more of the team approach that we talk about but don’t always participate in,” he said.