How CMOs Can Overcome Lack of 24/7 Physician Coverage of Emergency Rooms

A recent study found 7.4% of emergency departments lack 24/7 coverage by attending physicians.

Hundreds of emergency departments do not provide 24/7 coverage by attending physicians, particularly at rural hospitals, according to a recent study.

The study, which was published by the Journal of the American College of Emergency Physicians Open, examined 2022 data from 4,621 emergency departments. The researchers found that 344 (7.4%) of the EDs did not have 24/7 attending physician coverage. The states with the highest percentages of hospitals where there was not 24/7 attending physician coverage of emergency departments were North Dakota, South Dakota, and Montana.

Sioux Falls, South Dakota-based Sanford Health struggles to have 24/7 attending physician coverage at its emergency departments in rural communities.

"We cover about 55 medical centers throughout the Upper Midwest. Some of those facilities are Level 1 trauma centers and are well-equipped to handle most emergencies," says Jeremy Cauwels, MD, CMO of Sanford Health. "Some of those facilities are in towns of about 800 people, and they have either a low volume of patients or low condition acuity to support a physician in their emergency departments on a regular basis."

The CMO of Sioux Falls, South Dakota-based Avera Health says it is difficult to find emergency medicine physicians to work at rural hospitals.

"It is challenging for us to have full-time physician coverage at our emergency departments, especially at our rural communities and settings, where recruitment for physicians is difficult," says Kevin Post, DO, CMO of Avera Health. "When you think about recruiting physicians for a small, rural community, when the physicians are not from that area it can be difficult."

Recruitment of emergency medicine physicians to work at rural hospitals is also a predicament for Sanford Health.

"The biggest challenge is finding a physician who wants to live in a town of 800 people," Cauwels says.

The absence of attending physician coverage at many emergency departments is a trend that will continue in the future, according to Post.

"We are facing an increasing physician shortage that will not lift for at least the next five to 10 years," Post says. "We need to acknowledge the physician shortage is the reality, then be proactive about what we can do about the shortage."

Jeremy Cauwels, MD, is CMO of Sanford Health. Photo courtesy of Sanford Health.

Rising to the staffing challenge

To provide adequate full-time clinician coverage of emergency rooms in the absence of an attending physician, Sanford Health and Avera Health rely on advanced practice providers (APPs).

"If we have a scenario where a physician is unable to cover an emergency department, we will have the staff at a rural hospital covered by an advanced practice provider such as a certified nurse practitioner or physician assistant," Post says. "It is important for these APPs to have the adequate training to serve in this role and adequate staff to support them."

With the right experience and training, an APP is equipped to provide care for 90% of the patients who seek care at an emergency room, according to Cauwels.

"Many of the patients who come into emergency departments are already managed in small towns and big cities by APPs," Cauwels says. "If you walk into a large hospital emergency department in Minneapolis, you will be seen by an APP in many situations, particularly for triage."

Avera Health and Sanford Health provide training for APPs who are overseeing emergency rooms.

"At Avera, we are exploring additional emergency medicine certification for our rural nurse practitioners and physician assistants, so they can have additional training specifically for rural emergency medicine," Post says. "This will help address the challenges of having limited resources at a rural facility."

Sanford Health provides simulation training for APPs who are leading emergency rooms.

"We have a motor home full of manikins that goes to hospitals throughout our footprint to train APPs on care such as how to deliver a baby precipitously, how to insert a chest tube, and how to manage an emergent airway," Cauwels says. "We actively engage with our teams to make sure they have those skills."

Kevin Post, DO, is CMO of Avera Health. Photo courtesy of Avera Health.

Leveraging telehealth

Avera Health and Sanford Health provide APPs who are overseeing EDs with access to emergency medicine physicians and specialists through telehealth. At Avera Health, Post explains that the health system has embedded telehealth technology into its rural emergency departments.

"With the push of a button, an emergency medicine physician and nurse can be available in an exam room," Post says. "These professionals can interact with the APP and the entire care team. It can be as simple as assisting with documentation or as complicated as helping with care guidelines."

Sanford Health supports APPs with telehealth at 31 of the health system's rural hospitals.

"APPs can get a virtual consult in real-time while they are treating a patient," Cauwels says. "These virtual consults include neurology, psychiatry, and board-certified emergency medicine physicians."

Using telehealth to support an APP at an emergency department ensures that patients receive quality care despite the absence of an attending physician on-site, Cauwels says.

"A physician does not have to live in a rural town to digitally appear in an exam room at a hospital and do the right thing for the patient," Cauwels says. "With digital technology, we can have physicians work with patients in real-time in small town emergency rooms."