COVID-19 may help all Georgia advanced practice registered nurses (APRNs) in unexpected and circuitous ways. The newest and deadly coronavirus has changed nearly everything — maybe (just maybe) this scourge will be the beginning of rural Georgia’s APRN transformation.

It started when one of the COVID-19 “hot spots” exploded in Albany, Georgia, a small town located in on the Flint River, in Dougherty County in Southwest Georgia.

Dougherty County, GA
Map of Georgia highlighting Dougherty County

Based on its quick transmission and mounting death rate (1,436 cases, 97 deaths by mid-April), the virus has brought more notoriety in two months to Albany (pronounced “all-bennie” in Georgia) than this small city ever wanted or needed.

At the same time, Georgia’s United Advanced Practice Registered Nurses (UAPRN) believe something positive could come from COVID-19’s devastation — especially in places like Southwest Georgia and perhaps the rural south in general.

“About two years ago, the nurses had a bill in the Georgia legislature that would permit full practice authority in Georgia’s counties with smaller populations,” said Dr. Molly BachteI, a legislative liaison for UAPRN.

“But we weren’t able to get it passed,” she added.

Bachtel is highly accomplished. In addition to her doctorate in nursing, she’s a board certified family nurse practitioner, as well as an APRN advocate. She’s referring to one of many “bills” she’s worked on during her 20 years of practice, with the objective of removing critical APRN practice barriers in Georgia.

“We know rural Georgia is where we’re needed the most,” she said.

From that perspective, COVID-19 is currently attacking Georgia’s antiquated laws, along with its rural and metro’s unsuspecting population.

Nursing At A Poultry Production Facility

Trina McMillan, an APRN in North Georgia agrees. The old laws need to go. “The majority of my patients work in a poultry production facility in North Georgia,” she said.

In a recent email to RHQ, McMillan said she is currently screening all respiratory patients by phone. Test results are slow, she admits. It might be as long as seven days to know if her patient can return to work. “I can only assume the state is backlogged,” she said.

As a nurse practitioner for 23 years in Georgia, McMillan is a proponent of legislation that will help all APRNs, especially those in rural communities and on the front lines for COVID-19.

How Did Georgia Fall Behind?

“Georgia has earned the negative distinction as ranging between 45th to 50th in the nation when it comes to easing APRN restrictions,” said Ashley Blackman, UAPRN vice-president.

Today, while rural nurses are battling the reality of COVID-19 in Georgia’s cities and counties, something needs to change. At first, APRNs anticipated the current legislative effort of House Bill 1092 would help. It would improve the ability for APRNs to practice to the full extent of their education and training in some areas:

HB1092 includes:

  • Authorize the delegation by a physician to an advanced practice registered nurse [the authority] to order radiographic imaging tests in non-life-threatening situations;
  • Revise definitions; to increase the number of advanced practice registered nurses with whom a delegating physician can enter into a nurse protocol agreement and supervise at one time; and
  • Provide for related matters; to repeal conflicting laws; and for other purposes.”

It wasn’t until 2006 when Georgia’s APRNs finally received prescriptive authority from their legislature, the last of 50 states to do so.

This year APRNs are fighting for their patients to receive the kind of care they deserve no matter where they live. And they’re fighting back with COVID-19, by seeking “temporary suspension of all practice restrictions” to serve the increased medical needs during this pandemic.

Sadly, Georgia is 45th in COVID-19 testing nationwide. At least 80 of its senior care facilities are already home to residents with positive coronavirus tests, according to a Georgia Recorder report on April 14, 2020.

Many of them are located in rural areas.

To counteract the problem, over 100 Georgia Guardsmen are being sent to long-term care facilities, assisted living facilities and nursing homes with COVID-19 cases. Their role: To implement infection control protocols and enhanced sanitation methods to mitigate COVID-19 exposure among residents.

“If we can keep these populations as healthy as possible, we will be able to conserve precious medical supplies and hospital bed space in the coming days and weeks,” said Gov. Brian Kemp.

“Now, more than ever, we need our APRNs in Georgia,” stated Michelle Nelson, UAPRN president, professor and co-director of Georgia’s Coalition of APRNs. “And we need to be able to easily serve parts of our state that have been the most affected by the coronavirus outbreak.”

Crossover Night

In early February, according to Bachtel, it was the eleventh hour of the 28th day for Georgia’s 2020 legislative session when HB1092 was ready for a vote. APRNs knew if this bill wasn’t passed by the midnight crossover deadline, it would languish until the next legislative session.

To add fuel to the fire, the entire Capitol was on the verge of closure based on a COVID-19 shutdown. Certain Georgia legislators had already tested positive for the coronavirus. APRNs were still focused on helping patients with radiographic imaging (with improved rules), while coronavirus patient numbers surged.

Finally, as the time got closer to midnight, the news was out, and the count was in: Yea = 114; Nay = 38; (with 7 no votes and 21 excused).

“We did it!” shouted those few nurses who stayed until that last vote was counted.

One person who waited with Bachtel was Michelle Nelson.

She was still frustrated. What’s taking the governor so long? For people who come here to do business and then look at our failing health grades, “it gives them pause,” Nelson said. “Who is going to want to relocate their business to Georgia when you see there’s no doctor in some counties, and eight rural hospitals have closed? And even in the throes of a pandemic, our rural population is still struggling with hypertension, diabetes, cancer and other chronic problems.”

“Those patients still need primary care,” she said.

Currently, the Georgia legislature is “on recess,” pending the all-clear to return after the health-based temporary adjournment. That’s when HB1092 will hit the Georgia State Senate for a vote.

However, on March 24, 2020, a letter from the Secretary of Health and Human Services Alex M. Azar, II, went to the nation’s governors. The contents supported many of the things requested in Georgia’s pending bill.

In some ways, it became a stroke of good luck coming from the federal government.

Georgia’s governor was among Azar’s recipients. Specifically, Azar’s letter advocated “allowing physicians to supervise a greater number of other health professionals and to do so using remote or via telephonic means.”

“Our APRNs are ready and willing to serve, but we are restricted,” said Nelson. At this time, Gov. Kemp has not responded to Azar’s request.

 

Green/Full Practice: State practice and licensure laws permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing.
Yellow/Reduced Practice: State practice and licensure laws reduce the ability of NPs to engage in at least one element of NP practice.
Red/Restricted Practice: State practice and licensure laws restrict the ability of NPs to engage in at least one element of NP practice. State law requires career-long supervision, delegation or team management by another health provider in order for the NP to provide patient care.
SOURCE: Map courtesy American Association of Nurse Practitioners, 2020

Shannon’s Story

Shannon Whitten, Nurse Practitioner

Rural APRN nurse Shannon Whitten knows it’s been a long, hard fight. She’s not surprised at the inaction.

“How can you have mandates saying physicians need to be within 25 miles of an APRN’s practice, when nine of Georgia’s 159 counties have no physician?” she said.

Multiple articles confirm there are rural healthcare problems facing Georgia, including being 50th in the nation for maternal mortality. Like other Georgia APRNS, the inability to order non-emergency tests without a physician’s signature creates delays, Whitten stated.

“But more importantly, it has created gaps that can threaten continuity of patient care and safety. My delegating (supervising) MD is not in my office, Whitten said. “Diagnostic reports are often faxed to his place. If he happens to be off, it means calling the imaging facility or his other office in an attempt to track down the report. In most of my cases, the physician would not necessarily have seen or know the patient.”

One example, as Whitten recalls, took place with an order for a non-emergent CT scan. “It was written for a patient with a headache lasting several days — with no other neurological deficits,” she said. Sadly, the radiologist found a cerebral hemorrhage and could not reach Whitten’s delegating physician.

“He kept the patient at the imaging center until he reached me,” she said. “Fortunately, we could send the patient by ambulance from the imaging center to an accepting neurologist at a neighboring hospital.”

“However, this could have been disastrous on so many levels,” she said.

McMillan said she’s had similar problems with radiology exams. She’s found current restrictions for ordering radiology tests for her patients to be frustrating at best and debasing at worst.

“Why should someone who has no connection with my patient be their first contact when learning of his or her diagnostic results?” she said.

“The problem with getting the reports of the diagnostic tests for my patients is real,” Whitten said. As a family nurse practitioner, she currently works at a different location from her supervising physician. Several times, results have gone to the physician’s location, not hers. More than a week might pass before McMillan is notified.

“Since I have the patient relationship as their provider, I should be the one to discuss the results in person, not an MD that’s several hours away,” she said. “In addition, if I’d received the results first, I would be able to answer questions and give reassurance.”

Instead, says McMillan, a complete stranger to the patient gave one of her patients unexpected bad news.

Opposing Forces

The Medical Association of Georgia (MAG) remains opposed to HB1092 because it would “Undermine patient safety by increasing the physician-to-APRN oversight ratio,” according to MAG President, Andrew Reisman, M.D.

In his opposition statement, Reisman said, “Increasing the number of non-physicians [who] can order radiographic imaging — keeping in mind that the differences in education and experience and training between physicians and allied health care professionals are dramatic — the results could be problematic.”

“This bill would also result in higher health care costs by increasing the number of unnecessary tests that are performed,” he said.

But Bachtel and her colleagues are not giving up.

“MAG can say… that our training is different. We do have less hours of training in radiology than a medical doctor,” Bachtel said. “For myself, as a family nurse practitioner, I was trained to take care of the most common health problems in family practice settings. Of course, we know APRNs cannot take care of everything. Like all providers, including our physician colleagues, we are trained to consult and refer to other providers when necessary. And we do.”

“There are already so many exemptions to physician delegates for APRNs,” Bachtel stated. “I work in a college health practice, and guess what? College health is exempted from any ratios whatsoever! One physician can supervise 1,000 APRNs there.”

In fact, a number of practice types are exempted from any ratios, including U.S. military bases, the entire Veterans Administration Health Care System, many birthing centers and others. In addition, there’s a growing body of research which says removing practice restrictions has the potential to reduce costs and improve access to care without compromising the quality of that care.

Nelson and Bachtel know Gov. Kemp has a lot on his plate. For now, they will patiently await the stroke of his pen, which will allow APRNs across the state to offer faster and more efficient care during COVID-19’s darkest days.

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Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.