Ashley Robertson, BSN, CPEN
Core Charge Nurse
Urgent Care Blue Valley
Children’s Mercy Hospital
Our guest on this edition of the SPUC podcast is Ashley Robertson. She’s a core charge nurse at Children’s Mercy Hospital of Kansas City Urgent Care. One thing I always ask when I talk to people for these podcasts is how you got interested in medicine, in pediatrics, and in urgent care?
Well, I started to work at our pediatric hospital in 2007. It was following a short stint working in early childhood education. And I knew that I wanted to continue to work with kids but my science and math love was really not really used in the early education career that I had started and I was looking to advance that and so I went back to school to be a nurse while I was working as a care assistant at our hospital in what is now one of our ERs. When I started it was actually our first urgent care here at the hospital. It became an ER right about the same time that I became a nurse, which was 2010. And the ER was amazing for my education, for my experience. for me to grow as an RN. However, the stress, the emotional stress that you experience working in an ER was tough for me to bring home to my kids and my family.
So, I decided to actually switch my specialty to vascular access, which is also a very big love of mine within medicine, And I did that for a few years but the schedule wasn’t working and just some other things: the relationship between my work and my family it wasn’t working out great, the balance. So that is when I came back to one of our urgent cares and I found it is such a fantastic mix, for me, of some vascular access, some ER, but the majority, 80% or so, is just taking care of families and the kiddos that come to you in need of help, unsure how to handle their kid’s illness at home, and just needing small procedures, things like that. And so, it has been a great place for me (I’ve been here now since 2016) and now as a part of the leadership team I am able to work with our physicians and work with our nursing leadership to advance our practice — in terms of of the efficiency, so we can see as many kids as possible and not take it too much of the parents’ time while still providing great care. And so that is something I’m involved in and love being a part of, on our QI committee and our leadership committee and hopefully will continue to get to do all this on a national level with SPUC. And being able to provide some of that experience to help other urgent cares in the U.S. that are just getting started, to kind of grow their nursing section.
In the time that you’ve been in nursing and in urgent care , the Urgent Care network at Children’s Mercy has grown. Where does it stand now and do you have things planned?
Yes, it certainly has! Like I said, when I first started I worked at the first — and only — Urgent Care that Children’s Mercy had, and, looking back, it was so different than our Urgent Cares are now. It has grown and become its own department, because previously it was really just a subset of the ER that we already had.
When the first urgent care, which was called Urgent Care South , when it became an ER, there was another small Urgent Care that had opened, which, instead of that Urgent Care becoming an ER as well, they became part of our Urgent Care family that we are now. So, one of the Urgent Cares went on to be an ER and the other Urgent Care is now part of our group of four Urgent Cares that we have in the city (actually one ours is outside of the city now; it just opened in Junction City, Kansas, and it was our first rural Urgent Care, so that has presented different types of challenges because they are partnering with a complete, another entity, another hospital on and so that has been an interesting new development for our Urgent Cares. )
But now our Urgent Cares are so big and we have our own physician leadership and our own nursing leadership and it has really allowed us to be able to say, “We are not an ER and everything for the ER doesn’t fit us; and we are not an ambulatory clinic and everything from there doesn’t fit us. What processes, what policies, what standing orders for nurses fit our specific piece of Urgent Care, as opposed to looking at us as ER-like, or a clinic, because we are a unique entity.
Can you talk a little bit about the differences that you might it have in the requirements for nursing, or what fits your particular niche?
Yes, that is something that has also changed over time. Initially when we were sort of an ER sub-set, we were still being required to have some of the more intense trauma training. PALS was required. I guess TNTC wasn’t required initially, but some people were coming to us with that already. But then, as we have, kind of figured out what the Urgent Care expectations are for our nurses, we have dropped the PALS (pediatric advanced life support) expectation but we have replaced it with PEARS (pediatric emergency assessment, recognition and stabilization) which is just a little bit less training than PALS, but more specific to our setting, where you have access to a higher level care by calling 911 and it is not expected that you can provide that care but it also provides you with education to get the patient from the point that they walk in to the point that 911 can take over. So it is still very important education. We also have started, just in the last few years, doing “mock codes” here at the Urgent Care. We have a simulation group that our hospital employs, I guess it’s a unit in our hospital that does the simulations for all of our nursing. So they come out to all of our locations a couple times a year and people sign up and we do run-throughs of various things that can walk into our unit. And it is required for our nursing and for our Urgent Care care assistants, our “techs,” to go to a certain number of those every year so that we are prepared when an emergency arises.
Do you find that it’s been very useful to be part of the hospital network? Some of the members are actually stand-alone Urgent Cares and have a relationship with a local hospital, but you’re actually part of the hospital network.
Yes, it definitely, in our process, we have our Urgent Cares that are part of the hospital and obviously our new one that is out in Junction City, that is more of a rural setting, I have had the pleasure of helping to get them on to their feet. They are still technically part of our hospital network; it’s more of a hybrid, I guess. It is not completely separate, but they are partnering with another hospital, because their more immediate needs, like radiology and labs, things like that are being run by this outside hospital. So, it’s not completely free-standing, but it is a little bit more dependent on another entity than any of our other Urgent Cares are. So that has been just a little bit more like the freestanding places that you’re talking about. However I am sure that it is a lot more complicated to be free-standing because there are so many resources that we have available to us that other people don’t. We have pediatric radiologists at a phone call; we have pediatric cardiologists, oncologists. . . We can take any of these specialists and get a call back within minutes that will not provide services to our patient here on site, but can help our physicians decide what the right path is for that patient and and that is just such an amazing resource that we have, being part of the hospital system.
Can you talk a little about the staffing and scheduling at your Urgent Cares?
Yes. That is an interesting subject, because up until recently I did not realize the huge differences of the ways that Urgent Cares across the U.S. are staffing. In our main Urgent Cares, we only use RNs as nursing staff and we tend to at least match the number of providers that we have on any given shift. So if our provider side has four providers, then we will either staff with four or five RNs and then usually three or four non-licensed staff that are our ENS techs. I know with this new Urgent Care that just opened we had a very hard time getting RNs, because of the schedule and because it was not opening full time, only on the weekends. So they have made the decision with our new Urgent Care to hire LPNs, which I had not had experience with here at Children’s Mercy because we are a magnet hospital. They do not hire as many LPNs. That has been an interesting thing for me, education-wise, because I do think a good portion of our Urgent Cares nationwide do staff with LPNs or MAs (medical assistants.) And just looking at what the outcomes are for the different choices as far as nursing and their staff, a lot of our nurses also have their Bachelor’s, which is an even higher level of education on the nursing side. I do think that in looking at the staffing and the level of education, I think that our hospital, as far as nursing goes, is very much on the top end of that, as far as the nurses that we have working every day in our Urgent Care.
You talked about the certifications: does every nurse working there have the certifications? Or at least one certification?
No, not everybody and I don’t know the percentage off the top of my head. I do think it is close to 50 percent. Our hospital provides an incentive; you get an extra dollar an hour once you obtain a certification and you keep it. And they will actually pay for you to get up to two certifications, which is an amazing support from our hospital, to further our nursing education and our ability then to pass that on to care for patients.
What kinds of urgent care situations do you see — and is it different at the different centers around the city?
Yes, absolutely. Of the three main Urgent Cares, we are the closest to one of our own ERs. Our Urgent Care, about ten minutes or so difference, just north of us, is a Children’s Mercy ER. So we notice that we see less emergent and critical patients. And I think that that is probably the reason why, because they only have to drive 10 more minutes and they can get to one of our ERs. The other two Urgent Cares that are in the city are more like 20, 25 minutes from our closest ER. And they do tend to see a higher acuity on any given day, because the parents, I think, are just looking for any place that is Children’s Mercy, even though they know it’s an emergency, they know the Children’s Mercy name and they know that is the right place for their child. Even if it is not an ER setting, they know that we’re going to get them the help that they need. We see anything from significant deformities caused by ATV accidents, you know, something as simple as a monkey bar fall. We also see asthmatics that are super-sick and having significant trouble breathing. Anaphylaxis is a really common one that walks in simply because the parents know they need to get somewhere quickly so they tend to go to the closest place as opposed to necessarily the right level of care, again because they know if they walk into a Children’s Mercy they are going to get the care they need even if it isn’t the right level here. Because we can get them to where they need to go.
But we really see the same types of critical situations that the ER does, just on a less frequent basis and not some of the more violent types — you know, significant car accidents we’re not going to see. But we do have car accidents that happen and then that end up coming in a few hours later after being cleared by EMS and there ends up being a problem, you know, a life-threatening issue that did not present initially. So we do see those types of things and knowing what to do when they happen and when we see them is such a huge part of our education. But it is tricky because in the ER, the nurses see it every day and they practice it every day. In our setting, we have to know what to do all the time— but we don’t get to practice it nearly as often, which makes it harder to retain what we need to do when it happens. It’s actually, I think, a little bit more complicated because you have to know how to do everything that an ER nurse would do but you don’t get to practice it as frequently.
One of your interests in SPUC has been the nursing portion of the membership and extending outreach to nurses. Why do you think that’s important and what kinds of thoughts do you have about how to do that?
I am super excited about growing our nursing, the SPUC nationally for nurses and the education that is offered to nurses especially for Urgent Care as we discussed that are free-standing because they don’t have nearly the resources that we do with a hospital backing them to provide CNEs and nursing education and so to help provide that to nurses that don’t have it available is very exciting and also letting Urgent Care nurses feel like there’s a place for them. Because Urgent Care has popped up as its own specialty, Pediatric Urgent Care, specifically, has popped up as own entity so quickly, and it has grown so fast and is continuing to grow every day that we are big enough now to have our own voice and to have our own, just as what has happened with our hospital, where our Urgent Care division has sort of stepped into its own of what processes, what policies, what standing orders and things can we do that are Urgent Care-specific, not copying what the ER is doing, not doing what the clinics are doing but what do we need and what can make us the best we can be. And being able to show what we have been working on and provide options and learning opportunities nationwide is super-exciting to me. And being able to create a group of nurses that all are doing the same thing and where we can share things that we have learned and ideas is really neat. And I’m excited to be a part of it.