Good afternoon, everyone. My name is Adam Holman. I'm one of the doctoral faculty at North Dakota State University School of Nursing. I currently teach in the Family Nurse Practitioner program there, as well as provide emergency department coverage at critical access hospitals. I'm excited to talk today about emergency preparedness for rural providers. I have no financial obligations nor disclosures. Of note, though, there are some images within the presentation that are not an endorsement of the products per se, but they're there for discussion purposes. I wanted to give this talk today on two fronts. First, you know, I have a much better appreciation now in my career. As I currently work in critical access facilities, you know, I spent most of my NP and nursing career actually in a tertiary center. And so having seen the side of critical access hospitals, it certainly has given me a better appreciation for what they do and how critical care looks in that setting. I also, as I reflect back on COVID over the past few years, as I imagine many of you have, when we look at the type of critical care that we've had to do and how our critical access hospitals have certainly kept a lot more acutely ill and injured patients in their facilities due to issues such as bed or staffing or other logistical concerns. So this talk today is hopefully to accomplish a couple of objectives. Certainly first is to talk about how provider experience and resource limitations need to be mitigated in rural America in regards to critical care. And hopefully spend quite a bit of time talking about gaps and opportunities for rural provider emergency skill preparedness. And so to start off with, I really want to share this quote. I think this kind of sets the table for our conversation today. You know, this was said by Dr. Safar in 1974, that critical care is a continuum, which begins with pre-hospital care, continues with the emergency department intervention and culminates with ICU admission and management. I think nothing is more true when we think about critical care as a continuum, which I believe truly starts in critical access hospitals. These rural providers are oftentimes the first receivers of acutely injured or ill patients. And they really are the backbone as we think about critical access. They are a critical cog in the critical care continuum, if you will. You know, many of these providers are family medicine, docs, PAs, NPs, who happen to have ER and hospital responsibilities as part of their coverage there. When you think about the ruralness of America, about 97% of our landmass is considered rural, which means about 20% of our population receives care either in a rural clinic or a critical access hospital. And so they really are the backbone and safety net for these people in rural areas who are oftentimes underserved. What I oftentimes get asked, having been in a tertiary care center, now in critical access rural settings, you know, what's it like? How different is critical care there? Certainly there are some obvious things on the surface, like there, you know, not ECMO, there's not a lot of intensive care unit beds. But I think the best way to explain this is think about in critical access hospitals as the rural American battlefield. And the best analogy I can give you is what the military oftentimes refers to as rules of care. Rule one is oftentimes that point of care injury, that quick stabilization and casualty transport to a higher level of care. And I think that's where a lot of our critical access hospitals to use that analogy kind of exists. They have capabilities to provide stabilization and then transfer to a higher level of care. Rule two in the military often seen as the army forward surgical team that's essentially is damage control surgery and essentially a tent. Certainly a lot of our level threes have damage control capabilities. And we think about the civilian side of the trauma system. The role three in the military roles is kind of a theater hospital. So that too may oftentimes be our level three trauma centers, in my opinion. Level four and role five, they tend to be, again, more of those tertiary centers. And this is where I see if you use this analogy, this is where our level two and one trauma centers exist. So again, critical access hospitals really tend to be out at the tip of the spear, if you will, kind of in austere resource constraint environments. And I think it's important to note here, this is often where that golden hour gets used to treat acutely injured or ill patients. And that I think is an important piece of this talk that we'll hopefully get into a little bit later. As you move through roles of care, certainly there are more resources and more capabilities. When you look at critical access hospitals from a staffing perspective, oftentimes many of these facilities have one provider on call. It's a PA and NP, maybe a family med doc. They may have two to three nurses, depending on the size of the facility, who the nursing staff are responsible for not only nursing care, but they cover the emergency department, the inpatient hospital beds. On the night shift in particular, where I work anyway, the nursing staff cover the role of an RT, they're the pharmacist, they're the registration desk, they're the unit clerk. And of course they do their nursing functions as well. And that's a level four facility where I'm at right now doing some coverage. One of the things I think is also really important to illustrate as we talk about roles of care and capabilities in rural medicine is many of these facilities, particularly once you get below the level three facilities, they don't have respiratory therapy, they don't have CRNAs, they don't have anesthesia. Some of the communities I've covered for, they don't even have a physician who lives in the community, let alone one available on call at the time that an acutely injured or ill patient may show up in the emergency department. And so I think to better augment our conversation today, let's talk a little bit about the tyrants of rural critical care. If we define tyranny, it's a rigorous condition imposed by some outside agency or forced by dictionary definition. And I would say the tyranny here, of course, is a tyranny of rural America. And there are many aspects of that that I think they're important to acknowledge as we embark upon this conversation about what critical care looks like in the continuum out in rural settings. Certainly, the tyranny of distance, which we're all familiar with, you know, long transport times for patients, be it ground or air, so I'm not going to spend much time talking about that. But I do want to hit on a few other highlights when we talk about tyrannies of rural care. Certainly volume can be an issue and volume can be kind of a double edged sword. It can be, you know, low output emergency departments where they don't have a lot of visits. So when a critically injured patient does show up or critically ill patient shows up on their doorstep, it's a high acuity, low opportunity occurrence. So high stress for the patient, high stress for the provider. These low volume emergency departments also, on the essence of low occurrence, produce an environment where there's infrequency of maintaining skill, preparedness, such as intubation. The flip side of this coin also can be in rural emergency departments is that oftentimes providers who are on call for weekend call, for example, where I work, you start call at 5pm on a Friday and you're on call all the way through 8am on Monday, and you may or may not sleep during that 48 hour period. So certainly sleep deprivation and mental tiredness is a huge issue as well. When we look at another tyranny of experience, as I referenced previously, many providers oftentimes come from a family medicine background in rural America, their family med docs, PAs, NPs, many of them do not have trauma or critical care board certifications. Many of them have little to no experience sometimes in emergency care or critical care. You know, it's very uncommon, at least in North Dakota, to find an emergency nurse practitioner or an acute care nurse practitioner in a rural facility. I always tell my colleagues that I work with in rural medicine that I'm very grateful for the experience I had at the Mayo Clinic with my critical care experience there that they probably couldn't pay me enough to come work in a critical access hospital about my prior experience just because of the resource constraint environment and that unknowing of what's coming through your door with little support to help take care of it. That brings me to minimal staffing and resources. You know, many of these facilities work with resource constraint environments. Like I mentioned earlier, staffing at any given time in my facility where I provide coverage right now, there's maybe three to four of us and myself and the rest are nursing staff to run a trauma code. So certainly there's some concerns there. And then the last thing is not really a critical access hospital direct tyrant, but more of an indirect. You know, as I mentioned, many of these providers who go to rural practice oftentimes are family medicine prepared. And so at least from the family nurse practitioner standpoint, I can speak to the curriculum demand is there's just not a lot of room in today's modern curriculum to add more credits for acute care or critical care capabilities. Part of that certainly is because we're a family practice program, but what oftentimes inherently comes with primary care placement in rural settings is not only clinical responsibilities in an outpatient basis, but they oftentimes have an emergency department and a hospital cover. And that's where my passion lies now is to how do I help rural providers feel a higher level of preparedness for performing skills and feeling more at ease in that resource constraint environment where they don't always have support. And that's actually backed up in the literature. There's a study done by Owens and all in 2019, where she looked at role transition and role identity as a nurse practitioner transitions into their role, particularly in the emergency department. There were some very common themes that came out of her study. Certainly there were themes of feelings of frustration, isolation, as these providers felt like there was not support and they were kind of on their own out in the rural setting, but yet expected to take care of critically ill patients or acutely injured or ill patients. One thing that really stuck out to me in that study also was the lack of confidence that they expressed due to the infrequency of skills and due to the lack of a kind of structured training program prior to entering that environment as far as validation goes. And so it's with that, that I've really had an interest in, you know, how do we sharpen that tip of the spear? How do we make the rural environment more comfortable for our rural colleagues? Because they are oftentimes the first receivers of our patients at our tertiary centers. And so I'm going to spend the last part of this conversation talking about the way forward. And I do want to pose a couple of disclaimers, I guess, if you will, here, what we're about to talk about certainly is not a one size fits all approach. There are many world providers and facilities who are very comfortable with their skillset, very comfortable with the resources they have. And this is not a one size fits all conversation. I also want to acknowledge that we are not suggesting anything here that's going to delay the transport of patients and delay the care of patients to a higher, more definitive care. Because that's oftentimes a conversation piece that comes up when I have these conversations in academic circles or in clinical circles is, you know, why, why worry about this? You know, they have telemedicine in rural America, they have the responsibility only of rapid transfer after stabilization. And most certainly those two things remain cornerstones of rural care. Because the debate becomes when we talk about skill sustainment or levels of preparedness, since many of these can be high acuity, low occurrence events, whether you want to consider those intubations, chest tube insertions, or whatever other emergency skill, many say, what's the return on investment when you give that much time, money and resources to a provider who maybe covers the emergency department three, four, six times a year, or has a low volume department where the likelihood of them encountering the urgently ill individual is pretty low. And I would say, certainly, yes, that's a valid argument. But I would say for no other reason, it's for the future of the rural workforce, for the well being of our rural providers. We all know how much burnout there's been during COVID. But rural providers were having a lot of that even prior to COVID. If you look at studies, going back to the Owens et al. study from 2019, one of the themes there too, was the role of job dissatisfaction due to those feelings of isolation. And one of the main reasons people left rural practice was due to the demands and the anxieties and the stress of covering an emergency department in isolation without feelings of preparedness or support. And so what I want us to look at as we go forward in this conversation, because this is going to require a lot of buy in from leadership, from staff, not only the critical access hospitals, but also our tertiary centers that many of us who are part of SCCM work in. How do we make our way forward with our critical care starting in rural America? One of the things I would advocate is that facilities start looking at ways for funding for training modalities, such as airway mannequins, vascular access mannequins, things that providers can have readily available as a self-study module or a low fidelity simulator of some sort, or a homemade simulator, because there's a lot of good simulators you can produce for low cost budget. Having those available, so when they're on shift for their own call, they can come in and practice. When I was part of the flight team, we used to have quarterly requirements where you had to intubate, put in a chest tube, do some other various procedures, but those weren't always real patients that you did those skills on, depending on your workload. It might be documenting that skill on a mannequin or whatever the case may be, so that we can help mitigate some of the skill degradation that happens. We know that as people get trained, after roughly two months of not using a skill, their skill set degrades quite substantially. When you think about low volume emergency departments, that's a pretty big problem for them. The other thing to recognize as we have this conversation is there are certainly shortfalls of capabilities in rural America. Not every facility has a ventilator. Not every facility had BiPAP, quite honestly, prior to COVID. The facility I worked at right now, their most aggressive non-invasive ventilation was a CPAP. I'm going to let Dr. Hawkins address sedations and lack of drugs in a resource-constrained environment during his talk, but I think going forward, the thing we need to focus on is doing the little things well. How can we set up an environment and a culture for rural providers to feel that they're at a level of preparedness to deal with what may come through the door? Again, many may say, well, it's a return on investment, and is it really worth it with these being lower currency events? I would, again, go back to it's about the future of the workforce, maintaining and sustaining people who want to work in rural environments. Doing the little things well, I think, comes down to providing them some sort of education. We're going to talk about some opportunities and strategies here because I think there are many. I certainly think there's some other areas here of concern that I have when we think about critical care in rural environments is the perception of what it means to be in rural. These are perhaps anecdotal biases of my own having worked in these environments, but a number of things have stuck out to me over the last five years looking at the role of rural providers in critical care. I've sat through a number of conversations where administrators were having a discussion about the types of trauma, doing a trauma evaluation of trauma charts, and it was said, well, they're providers. What's the issue here with not being able to intubate? It kind of clicked that there was this perception that all providers are created equal, that because you're board certified in whatever your family medicine, for example, that you know how to intubate, you know how to take care of trauma, and we know that that's not necessarily the case because we all come from different backgrounds and have different training environments. I think it's important as we think about orientation, in particular, when providers who come into a rural emergency department or hospital, that they're not all created equal in that their orientation is a valuable part because oftentimes this is very abbreviated for a lot of rural providers because of the workforce shortage, but taking the time to invest the time and money in them so they have an individualized orientation, not just putting them through your work four months in the emergency department where you give any ATLS, where you give any ACLS, so you're good to go because that's kind of the current approach. You give them those kind of core courses required by JACO, and magically, they're this robust emergency provider overnight, and having worked in those environments, I can tell you it's very unnerving at times to not have the resources that you're accustomed to to take care of these acutely injured and ill patients. I think we also need to look at the role of what is the platforms we can produce to help sharpen the tip of the spear, if you will, for rural critical care, and look at collaborating with local universities, collaborating with our tertiary care centers. One thing we've had a lot of success with on the Air Force side since we have similar problems with Guard and Reserve sustainment of skills for critical care transport teams is developing a platform of sustainment for skills in between. So, for example, our transport teams will take a basic course, they'll take an advanced course, but oftentimes in between that may be a two to four hour window, and how do you maintain skills when you don't have staff to train with, you don't have equipment to train with? We've been able to come up with a sustaining platform where teams will come in to our unit and train with us because we have all the components of training available, aircraft, air crews, medical equipment increments, and then subject matter experts to provide the training. I think a similar format can be used to help our desire, if you will, to bolster rural critical care, which we've seen that need during COVID. We kept a lot of acuity in critical access hospitals and having been there, I feel like we owe that to our rural providers to support them. You know, I think there's some other ways outside the box that kind of go along that standpoint, but it works in collaboration with tertiary care centers. Is there a way to develop things such as bringing tertiary providers to those critical access hospitals so that those providers can get away for training? Because oftentimes a big issue for them is they don't have enough providers, so it might be only one or two in the community. So, to get away for training is hard. I know it's a big ask when we talk about time and budget constraints of tertiary centers as well, but something to think about to take that one step further. Is there an opportunity here where we can develop shadow experiences or an exchange program where rural providers can come into a tertiary center and shadow and observe, much like we would have a student do with clinicals, but where they can participate in skills and just see the day-to-day operations of a busy emergency department to help with skill sustainment? Again, a lot of these topics that we talk about certainly require buy-in from the staff that would be involved with this also. And then lastly, is there a way to flip the classroom, as we like to talk about, you know, rather than tertiary, or excuse me, rather than critical access hospital providers coming to the tertiary center for training, is there a way we can bring courses like FCCS to their facility, rather than them having to travel such long distances? Or other modalities, such as virtual training or seminar platforms, which we've had success with our university in developing kind of quarterly seminars where graduate students drive a lot of that, but they develop educational platforms based upon needs assessments of their preceptors in regards to emergency care skills. That's been very helpful. Well, you know, things I think we have an opportunity to do is finally come to an agreement as a health care system as to what is the actual ER competencies we expect our providers to have. And I think, honestly, that varies whether you're urban or rural. There are many competencies put up by the Emergency Nurses Association. I think there's 60 of them, quite honestly. Some of those are probably not pertinent to a rural emergency department like a lumbar puncture. You're probably not going to do that in rural America because you can't run the lab, number one. But coming to an agreement of what that competency is, because the reality is for rural providers, it's going to be a rarity that you're going to find an emergency nurse practitioner, a acute care nurse practitioner, or perhaps a family med doc with extensive trauma critical care training. We have, you know, we kind of have to bolster what we have available, because that's the reality in rural America is most of our people are family meds, as myself. And so I think we need to think outside the box, because having been on both sides of the fence, tertiary care and critical access hospitals, they do an amazing job at the critical access hospitals. But I think we have an opportunity to also help support them. If we look at the literature regards to burnout, feelings of isolation, and feeling like there's a lack of preparedness to perform skills, whether it's infrequency or, you know, not validation in their training. There's a lot of opportunity here to think about. And so with that, I'm kind of at the end of my time. And so I look forward to questions you may have at the end of the session, brainstorming ideas, maybe things that you're already doing. And again, I certainly know that not everybody will agree with this approach, and that's okay. But I look forward to having healthy dialogue about this. And with that, I'm going to turn it over to the next speaker. Thanks a lot.

emergency preparedness

rural healthcare providers

critical access hospitals

limited resources and staffing

training modalities and simulation resources

collaboration within healthcare community