Pictured Left to Right: Casey Massimini, MSN, RN-CV; Deborah Hetrick, MSN, RN, CNM; and Kelsey Barlow, LPN.
As patient volume at Chester County Hospital dramatically increases, a new program is reintroducing the licensed practical nurse (LPN) to acute care institutions throughout the country are struggling to hire enough nurses and ancillary services personnel such as phlebotomists, respiratory therapists, and physical therapists. The issue has been compounded at Chester County Hospital, which has seen a surge in its patient volume – particularly those with behavioral health needs – over the last two years with the closure of Jennersville and Brandywine Hospitals.
Emergency Department visits at Chester County Hospital are also up nearly 40 percent, with a further increase expected. And it's taking 45 to 60 percent longer for Emergency Department patients to be transferred to inpatient beds.
Because the complexity of the cases has increased along with the number of cases, discharges may also be delayed, says Casey Massimini, MSN, RN-CV, a charge nurse on 4 Lasko at the hospital.
"That further delays getting people into beds and receiving the care they need," she says. "Some days, it's just hard for our nurses to catch up."
To aid in that endeavor, the Department of Nursing launched a program last year in which six licensed practical nurses were incorporated into the hospital's nursing care model. The Chester County Economic Development Council awarded the hospital $175,000 to help fund the initiative.
Licensed practical nurses work under the supervision of doctors and registered nurses, providing more basic nursing care. They're also often responsible for the comfort of the patient. They do not administer medication, treatments, or provide educational advice to patients.
Deborah Hetrick, MSN, RN, CNML, Clinical Operation Manager for Chester County Hospital's adult inpatient units, says that when she started at the hospital 30 years ago, LPNs worked under registered nurses (RNs). The increasing complexity of care coupled with the focus, in recent years, on Magnet designation signifying a higher nursing education and certification likely contributed to LPNs shifting into long-term care and outpatient settings.
Licensed practical nurses were reintroduced at Chester County Hospital early in the pandemic to assist with Covid testing and vaccinations. This program is more ambitious in scope and scale' Each of the six newly hired LPNs works three 12-hour shifts per week. They're paired up on a shift and charged with completing at least 32 admissions between them, according to Hetrick, who hired the LPNs.
Admitting a patient from the Emergency Department to an inpatient bed in the hospital is a process that can take anywhere from 15 minutes to more than 45 minutes, depending on the state of the patient. Before the LPNs were brought in to handle admissions, RNs on the floors where the patients were admitted were responsible for the task. It was a potentially time-consuming undertaking for someone already tending to several patients.
"You could have a nurse who's discharging three to four patients, and those beds will most likely already be spoken for because the Emergency Department's packed," Massimini says. "So, then, this nurse is expected to quickly admit the patients in waiting and fill those beds, but they're just one person. In the middle of all this, another patient under their care may suddenly take a turn."
The expectation with the LPN program is to better support the hospital's RNs while simultaneously alleviating the bottleneck in the Emergency Department.
"The new LPNs are not replacing the RNs or anyone else in the unit," Hetrick says. "We're maintaining the same nurse-to-patient ratio. The LPNs are here to complement our existing staff and help the admission process be more efficient than what it has been, which we hope will enhance the experience of both our patients and the staff caring for them."
A Day In The Life of An LPN
Casey Massimini, MSN, RN-CV and Kelsey Barlow, LPN prepare to hand off patient.
Kelsey Barlow, LPN, starts a typical shift by reviewing a board that displays the patients currently being cared for in the Emergency Department, noting which ones are ready to be moved to an inpatient bed. She then messages a floor nurse to let them know that she and her fellow LPN for the shift are available to start the admission once the patient has arrived. The Emergency Department charge nurse is responsible for arranging a patient's transportation to their inpatient bed.
At the patient's bedside, "we introduce ourselves, tell them we're the admissions nurse, that it's a new thing," Barlow says.
After guiding the patient through a series of required documents, Barlow takes the patient's vital signs, does a skin check, asks the patient if they're in pain, and determines their level of alertness. She then reports her observations to the RN who will ultimately assume the care of the patient. Once the admission is done, the RN conducts a more in-depth assessment of the patient.
A week earlier, Barlow arrived to admit an elderly patient with severe dementia. It was immediately clear she wasn't capable of answering any of Barlow's questions, so the LPN called a family member. More pressing, however, was the patient's agitated state. It would be more than an hour before the patient was comfortable and her admission was complete.
"Not all admissions are the same," Massimini says. "So, it's been a very welcome change for our nurses to be able to share some of that responsibility. Now they can take the time to get themselves in a better place before they enter the room, catch the patient up on their medications, and do their assessment."
Barlow was a nursing assistant at Jennersville Hospital before it closed. She enrolled in a Bachelor of Science in Nursing (BSN) program after high school, but then Covid hit. Barlow, who describes herself as a "very, very hands-on learner", says she struggled with the clinical aspects of the curriculum when they were shifted online. Eventually, she withdrew from the university.
In 2022, she jumped at the chance to enroll, through a series of scholarships, in a 15-month program to become an LPN at the nonprofit Chester County Intermediate Unit. She graduated last June, passed her licensure examination in July, and started working at Chester County Hospital as an LPN in August.
She's now studying to become an RN – in between shifts at the hospital – at Saint Joseph's University in Lancaster, PA.
Potentially Scratching The Surface
Kelsey Barlow, LPN checks a patient.
Massimini says she believes her nurses have felt more supported doing their jobs since the institution of the LPNs. As a result, they're able to better manage their time, she says. They also feel less isolated by their work.
"So far, this program has revived this sense of being a part of a team here," she says. "We're working together and taking care of more people."
Hetrick says she and others who are involved in deploying the program are beginning to determine the metrics that will gauge the program's impact. With so many personnel affected by the addition of the LPNs, it took a few different attempts to establish an efficient workflow. Confident that they now have one, Hetrick says they're sifting through columns of data that include how quickly patients in the Emergency Department were assigned a bed, how long it took them to make it to the room once it was available, and how quickly the RN called the Emergency Department to receive a report on the patient. She says they're also considering surveying the relevant staff to determine their level of satisfaction with the operation.
Their findings will help inform the future of not only the new program but, likely, the entire nursing care model at the hospital. Hetrick says that only a fraction of the LPNs' skill set is being used in their current job description.
"So, there's the possibility that we could add to their responsibilities, as long as it helps improve patient care," she says. "And that will probably open up a larger discussion about how we can incorporate LPNs in other roles."
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