Article In Brief
Advanced practice practitioners are being deployed to care for COVID-19 patients. Read on as they share their experience monitoring patients with chronic neurologic conditions, working with providers outside of their specialty, doing telemedicine visits, and much more amid the COVID-19 pandemic.
Since March, Heather Wopat, AGACNP, ACHPN, a nurse practitioner in neurology at NYU Langone Health, has been redeployed to care for COVID-19 patients. When someone takes a turn for the worse or dies, she has to relay the heartbreaking news by telephone because visitors are seldom allowed.
“Often, families are not able to grasp how sick their loved ones are without seeing them in person,” Wopat said. “Hearing such grief on the other end of the line reminds me how valuable my own relationships are, and it also reinforces my belief that we should gently keep patients and families as realistically informed as possible. While we must be careful not to be overly pessimistic or seem hopeless, we need to make sure that we communicate effectively, using everyday language, to relay the gravity of the patient's condition.”
As New York State, and New York City, in particular, leads the nation in COVID-19 cases and deaths, inpatient nurse practitioner teams in neurology are collaborating with “providers from a plethora of other specialties” to save lives, Wopat said. They share clinical observations, give and receive advice, and offer each other emotional support and snacks.
During these uncharted times, inpatient neurology teams may face new responsibilities with possible reassignment to COVID-19 units. Meanwhile, in outpatient settings, physician assistants and nurse practitioners play pivotal roles in physician-led teams in monitoring people with chronic neurological conditions. Evolving expectations are broadening horizons for these advanced practice providers (APPs), instilling competence and inspiring confidence that will result in more well-rounded clinicians to serve patients as the crisis subsides.
For APPs working in neurocritical care before the pandemic, the virus toll is another stark reminder of life's vulnerabilities. “In general, we have been fortunate, given our overall COVID-19 caseload has been on the lower side up to this point,” said John A. Kenna, MS, ACNP-BC, an acute care nurse practitioner in the division of neurosurgery at the Medical University of South Carolina in Charleston, where he cares for patients in the Level I trauma center.
“That being said, we have a plan in place that, if we have a surge or influx of patients, staff can be redeployed to areas where there is a need—for example, a COVID-19-only ICU or the emergency department to help manage an increase in volume,” Kenna said. “It is very much an all-hands-on-deck mentality at this time.”
The institution has implemented precautionary measures in response to the crisis, such as minimizing the number of providers entering a patient's room, utilizing telemedicine when appropriate, and recognizing who may need COVID-19 testing based on the presentation of a neurological injury, he said.
Meanwhile, a drop in the typical census seems to stem from patients' reluctance to visit hospitals in emergencies, such as transient ischemic attacks or other neurologic illnesses, due to concerns of potential infection with the novel coronavirus. “This is causing an overall reduction in those seeking care,” Kenna said, “and we worry that they will then present with a larger or more severe injury or event that otherwise could have been avoided.”
Considering the highly unpredictable nature of COVID-19, lingering uncertainty compels him to be on the lookout for neurological symptoms, such as acute onset of Guillain-Barré syndrome or acute hemorrhagic necrotizing encephalopathy. As reports from China have noted, patients may present initially with vague neurological complaints—headache, nausea, and vomiting—but then decline rapidly while developing acute respiratory failure.
Most patients and families express anxiety, echoing the angst that health care workers feel day in and day out. They are baffled that some virus-stricken individuals remain completely asymptomatic while others become critically ill and require intubation and ventilation. “There is so much that we don't yet know or understand about this virus and its effects on the nervous system,” said Kenna, who expects to encounter more cases of neurological complications associated with COVID-19.
The learning curve is extending to many neurology providers as the virus upends the familiar framework of both inpatient and outpatient services. “We've all embraced telemedicine, and we're trying to stay very busy,” said Julie A. Gurwell, PhD, PA-C, associate professor and director of advanced practice providers in neurology at the University of Kentucky College of Medicine in Lexington and a member of the editorial advisory board for Neurology Today.
In compliance with the federal government's guidance on elective procedures, the department of neurology decided to cancel appointments for botulinum neurotoxin injections indicated for migraine. “Unfortunately, our patients are getting behind on their botulinum toxin injections,” typically administered at three-month intervals, Dr. Gurwell said.
“Because there's no way to do that within a six-foot distancing, it's really considered more of a risk for potential COVID-19 exposure than a benefit,” she added. “Ultimately, postponing Botox treatment of migraines was enforced to conserve personal protective equipment.”
Dr. Gurwell is now working from home four and a half days per week and spending only a half-day in the clinic. Once a week on Thursday, she directs a one-hour weekly staff meeting via Zoom. “It's a reliable means of bringing together seven advanced practice providers, and one part-time nurse practitioner, who manage patients with neurological conditions,” she said.
“That way,” she said, “I'm in the loop if there are any concerns or issues with the telemedicine, and the meeting helps us stay socially connected. Everyone can see each other on the platform, so it's like the Brady bunch.”
At other times, Dr. Gurwell is available via email, phone and text messaging.
For less tech-savvy patients—and she takes care of primarily those who have Parkinson's disease and are age 70 or older—telephone calls take the place of video-based visits. On a phone call, she can determine if an individual needs an urgent in-person appointment—for instance, to program a deep brain stimulator if a patient incurs falls or is experiencing severe disabling tremor.
Replacement of batteries for deep brain stimulators was postponed during the height of the COVID-19 pandemic, but in Oregon the restrictions have now been lifted. In the interim, APPs followed patients closely through telephone or telemedicine visits in helping them navigate challenges, said Shannon Anderson, MPAS, PA-C, assistant professor of neurology and clinical coordinator of the deep brain stimulation program at Oregon Health & Science University in Portland.
“We have been trying our best to manage with medicines,” she said, while relying on telehealth visits to gauge symptoms and visualize the patient's home environment. Viewing the layout helps determine if an aide, nurse, or physical therapist could make a difference. A careful assessment of the potential benefit balanced with the risk of exposure to infection is crucial in this crisis, Anderson said.
On the video, she can see if someone is struggling with activities of daily living, such as moving in and out of the bathroom or preparing a meal. If the hallways are very narrow, a walker may not be a viable solution, she said.
“Bringing us into the home is new,” Anderson said. “The collection of these data points opens up creative problem-solving possibilities to assist patients with movement disorders and other neurological conditions. We are still learning a lot about that.”
A neurology clinician can glean even more information with the participation of a caregiver at the telehealth visit. For example, the caregiver can perform a modified motor exam by testing individual muscle groups with some coaching from the clinician. How well the patient counteracts this resistance is a reasonable barometer of muscular strength, said John Kramer, PA, a physician assistant in the outpatient neurology clinic at Saint Thomas Medical Partners – Neurology, a part of Ascension Health, in Nashville, TN.
In Tennessee and some other states, governors temporarily suspended physician oversight for APPs while instituting aggressive measures to curb the spread of coronavirus and not overload the health care system with infected patients.
“It's a case-by-case basis, but we're trying to see as few patients as possible in person in the clinic and are now opening up the opportunity for telehealth for all patients,” said Kramer, who has cultivated expertise in multiple sclerosis and other disorders of the nervous system over the course of two decades in outpatient and inpatient neurology practice.
“While there is no substitute for an in-person neurological exam, seeing follow-up MS patients is feasible via telemedicine,” she said.
Many providers are conducting telehealth visits from their homes. Others are still coming into the office mainly for video-based appointments. Among them is Christen F. Kutz, PhD, PA-C, a physician assistant and director of research at Colorado Springs Neurological Associates in Colorado, where the number of COVID-19 cases is lower than in most states.
“Face-to-face visits are reserved for procedures or patients who do not have computers,” Dr. Kutz said. Prior to an in-person visit, a patient is prescreened by phone and upon entry to the clinic. Anyone with a fever or other possible COVID-19 symptoms is rescheduled or converted to a telehealth visit.
At all times, she wears disposable exam gloves and an N95 mask, which another employee sterilizes after every shift by baking it in the oven for 30 minutes, according to decontamination guidelines for reuse. Her attire consists of scrubs, a zip-up athletic jacket, and a white lab coat—all of which go in the washing machine as soon as she returns home. She showers before interacting with her husband and two teenage daughters.
“I do feel safe because I'm taking as many general precautions as I possibly can,” Dr. Kutz said. “And I'm conscientious of what I touch.”
Amid increasing emphasis on infection control, social distancing has brought to the fore the various advantages of telehealth visits. “On a positive note, I believe strongly that telemedicine has facilitated an improvement in access for patients and families, particularly for those with epilepsy who are unable to drive due to their condition,” said Lucretia Long, APRN-CNP, FAES, epilepsy nurse practitioner and clinical assistant professor of neurology at The Ohio State University Wexner Medical Center in Columbus.
Telehealth appointments also ease the travel burden on patients who live far away or rely on others for transportation. “I'm grateful that our department chair has embraced the idea that telemedicine will be an option even after the pandemic,” Long said. “This experience has propelled the use of telemedicine as a viable way to practice medicine in the future.”
At times, however, the transition to telemedicine has been far from seamless. It can be more difficult to monitor some patients due to poor or limited internet connections and lack of access to smartphones, she acknowledged.
Recognizing that “not everyone is an early adopter of this technology,” telephone-based visits are allowing providers to maintain the health of their established patients and adjust medications as needed, said Calli Cook, DNP, APRN, FNP-C, clinical assistant professor at the Emory University Nell Hodgson Woodruff School of Nursing and the Emory Brain Health Center in Atlanta.
For new patients seeking a neurology clinician's opinion, the decision to perform a telemedicine visit hinges on the comfort level of that provider.
“There are some limitations of the telehealth neurological exam, so you would really have to think about the patient situation and the information you will get via a telehealth encounter, and if that will answer your clinical question or not,” said Dr. Cook, who is currently serving her existing patients via telehealth or telephone-based visits.
Wopat, the nurse practitioner at NYU Langone Health, misses the familiarity of neurology practice but welcomes the experience of focusing her attention on patients hospitalized due to COVID-19. While refreshing old skills and developing new ones, she said, “This has been a time of intense learning, and I'll carry this new knowledge with me when I return to neurology.”