Using State Licensure Data to Assess North Carolina’s Health Workforce COVID-19 Response Capacity

Health Care Workers Combating COVID-19 in North Carolina: Are There Enough and Are They in the Right Places?

To address concerns about health workforce supply in March and April 2020, researchers at the Cecil G. Sheps Center (Sheps Center) at the University of North Carolina at Chapel Hill conducted workforce analyses and released the results to the public in a series of blog posts (internal data). The goal was to provide data on the supply of these professions to state decision-makers who needed to determine how to allocate resources, redesign workflows, modify regulatory requirements, and signal managers in delivery systems where there may be a need to ramp up recruitment or shift responsibilities. The Sheps Center was able to respond quickly due to the existence of the state’s Health Professions Data System (HPDS), which tracks annual data on 21 different health professional workforces in North Carolina. The HPDS is a collaboration between the Sheps Center, the health professions licensing boards, and the North Carolina Area Health Education Centers (NC AHEC) Program.

Given the lessons learned from Seattle and New York at the outset of the pandemic, policymakers in North Carolina were initially focused on “surging,” or increasing workforce capacity in acute care settings focusing on pulmonary care. For this reason, Sheps Center researchers focused on describing the availability and distribution of three health professions central to treating hospitalized COVID-19 patients in critical condition: respiratory therapists (RTs), critical care physicians (CCPs), and registered nurses (RNs).

Limitations

The HPDS is built on annually updated licensure data that provide a picture of the health professional workforce at a specific point in time. The data system is not built to reflect rapid changes in health workforce supply that occur during events such as a pandemic. As a result, licensure data may not indicate sudden attrition due to health professionals retiring or leaving their jobs due to the COVID-19 outbreak. Conversely, inactive licensees may have reactivated their licenses to help serve patients during the pandemic. For example, in May, DHHS put out a call for volunteers, recruiting nurses, clinicians, and non-clinical support workers to bolster the health care workforce [1]. While we did not track how HPDS data were used and by whom, we did provide DHHS with data on numbers of inactive licensees by location who might be deployed as volunteers during a surge. We also acted as a liaison between DHHS and health professional regulatory bodies regarding questions about regulatory changes that would promote workforce flexibility.

A more acute limitation of the HPDS: as noted in the methods, critical care nurses were not a distinct category in our database, and the use of a proxy (hospital-based nurses with a specialty of acute care, emergency, or critical care) is an imperfect estimate. That said, the potential ICU RN workforce can be broadened in a surge by cross-training existing staff, such as emergency and acute care RNs, perioperative RNs (e.g., post-anesthesia care unit and operating room RNs), nurse anesthetists, and acute care nurse practitioners, to care for ICU-level patients. The Society of Critical Care Medicine (SCCM) [23], American Association of Critical Care Nurses (AACN) [24], and NC AHEC provide several resources to support cross-training non-ICU clinicians to care for patients with COVID-19.

In general, the scope of practice (SOP) of many health professionals is more flexible than license data descriptions would suggest [25]. Individual health professionals’ SOP can vary based on geography, health care system, and individual preference. SOP is especially subject to flux during pandemic response [26]. In late March, the SCCM recommended hospitals adopt a tiered staffing model in which one experienced critical care physician supervises four ICU teams, better utilizing providers with less ICU training [24]. In hospitals with an “open unit,”— a model of ICU in which an intensivist consults but specialty teams have full admitting rights—hospitalists often already help cover ICU and step-down patients. Similarly, family medicine and internal medicine physicians, especially those who were recently residents, can flex as needed to work in emergency departments and inpatient and ambulatory settings. Hospitals and health facilities that canceled elective procedures and primary care visits redeployed staff to conduct COVID-19 screening and address primary care and behavioral health needs of non-COVID-19 patients. Other clinicians shifted their practices from providing in-person care to telehealth visits. Licensure data alone do not sufficiently capture the potential workforce and how health professionals address patient demands in a health care landscape rapidly adjusting to a novel coronavirus. Neither can licensure data capture the entirety of the frontline health workforce deemed “essential workers” in addressing COVID-19, including many public health professionals [27].

Any catastrophic event requires the ability to quickly assess the adequacy of the health workforce and retrain, redeploy, and reconfigure workers as needed to meet surges in demand. This was the key lesson learned from North Carolina’s pandemic response. Having a longstanding data infrastructure as well as established and trusted relationships with policymakers and state agencies, health professionals, and regulatory bodies that allow for the use of the data in decision-making is a critical asset in any response. Further expansion and resourcing of databases like the HPDS will allow researchers to anticipate and better respond to future crises.