Rightly so, advanced practice clinicians like PAs and NPs are becoming more and more essential to ED operations. But who is addressing the difficult questions surrounding APC supervision and training?
It doesn’t take a rocket scientist to acknowledge that many patients treated in the ED don’t require the background and training associated with being seen by a board-certified emergency physician. As a result, most emergency departments in the United States are now incorporating “advanced practice clinicians [APCs]” (otherwise known as PAs and NPs) into their ED staffing.
In most EDs about 80% of the patients go home. A subset of these patients are truly straightforward – routine lacerations not involving joints or tendons or areas requiring special care, ankle sprains, musculoskeletal back pain, toothaches, sunburn, UTIs in women. This represents a huge number of cases.
So why would it be expected that these “easy” cases be seen by an emergency physician with 4 years of medical school and four years or more of an emergency medicine residency? In answer to this question, EDs in the United States have become addicted to the use of APCs. And, with at least one seasoned EP in the department, there is always someone to supervise and become involved in the atypical cases (I know of one ED that has three APCs and one physician).
What’s not to like? Patients are generally very satisfied with the care provided by APCs and, in fact, they often receive better patient satisfaction scores than EPs. Now EPs can see the more difficult cases and the right cases are being seen by the right providers. (I know, nobody likes the word “providers”, but there aren’t any socially acceptable synonyms.)
In some EDs all patients can be seen by APCs – this was the case in our ED. The patients with abdominal pain and shortness of breath and a bad headache could all be seen by an APC if the physician was otherwise tied up. They would start the evaluation and treatment knowing that a physician would be involved with all of these patients at some point.
I’m aware of very large multicontract ED staffing groups where 30+ percent of all of their ED patients are treated by APCs. Given the relative shortage of emergency physicians (just look at the huge number of ads looking for EPs in all of the trade publications), “right” staffing with APCs is just a logical choice.
So, I’m a big time believer. But things are never as simple as we would like. There are some real problems that aren’t being substantively addressed. About 30 years ago it was asserted that physicians working in an ED, where feasible, should have special training and certification to practice emergency medicine. The American Board of Emergency Medicine was created to certify that physicians met certain minimum standards to practice emergency medicine. Initially the Board grandfathered in physicians who had substantial experience in emergency medicine but who had not gone through a formal EM residency. After a relatively short period of time, only physicians who completed an emergency medicine residency could sit for the ABEM exam and that has been the case for about the last 25 years.
Clearly, not all emergency departments can be staffed by an ABEM or AOBEM-certified physician. In most major metropolitan areas, EDs are essentially all staffed by board-certified EPs (be they allopathic or osteopathic). You would be hard pressed to find a job in the greater Los Angeles area without being board-certified in EM. But in some more remote EDs this is just not feasible. In fact, in some situations there are no physicians staffing the ED and it is done by APCs exclusively.
Which brings up an interesting point. What certification in EM do the vast majority of APCs have to work in EDs? The answer currently is none. So there seems to be a paradox – EPs need board certification and APCs, who are seeing more and more ED patients, need no certification. Oh sure, they may have ACLS and ATLS and the other merit badges, but this is nothing equivalent to the certification process for physicians. So it is largely on-the-job training – exactly the type of training that is no longer acceptable for physicians.
So there are some issues. Most training of APCs focuses on primary care. And that is fine. But is it enough to work in an ED? Particularly when in some EDs APCs are seeing a substantial minority of all the ED patients – often alone in an ED “fast track.” This is where the supposedly “minor” cases are triaged. But we all know that some of those minor cases are anything but – the necrotizing fasciitis case, the epidural abscess case, the “carpal tunnel syndrome” case (the patient went home and had their CVA – a real suit resulted).
And what is this thing where the doctor signs a bunch of charts at the end of the shift of the patients exclusively seen, treated and released by an APC? Just what does that signature mean? Does it mean the APCs have been supervised? Hardly.
There are some solutions. I know of a major group where every patient is seen at least during part of their ED stay by an EP. That was our practice. Our APCs could see anybody in the ED since ultimately one of us would also see the patient. Clearly this was not the most efficient use of our APCs and doctors – but I can tell you the doctors felt a lot better having seen each patient, no matter how briefly. Most groups don’t do this. They basically learn to trust the judgment of their APCs to seek them out for atypical cases. Sometimes this works and sometimes it definitely does not. And what about the physicians who give the APCs a hard time about seeing their patients – this has been reported by lots of APCs.
The problem is straightforward – APCs don’t know what they don’t know and their physician supervisors also don’t know what their APC colleagues don’t know. This is an intrinsically risky proposition in the very dangerous environment of the contemporary ED.
There is a much-awaited move afoot to certify both PAs and NPs in emergency medicine. In fact, the PA process is currently underway. The only problem – you can’t take the test until you’ve worked in an ED for three years! What happens during the first three years, the years when a PA will have the least amount of ED experience? Seems ED directors would want PAs to start working already having a certificate of special competence – not having to wait three years.
And what about the NPs? There is a program in final development in collaboration with the Emergency Nurses Association to certify NPs in EM. The ENA website notes seven university programs providing specialty instruction in EM for NPs. The certification process involves the concept of gathering a portfolio of credentials in order to become certified which includes 2,000 hours of ED experience, a certain amount of CME but no exam is required among the other components.
So it seems the real issues are training (which is being addressed but is not really there yet) and supervision. Although NPs in many states can practice independently, the hospital can establish, or the ED group for which the NP is working, the level of supervision that it expects in the ED. Supervision is clearly a challenge as reflected in a growing number of lawsuits involving APCs. In some of these cases the APC claims he/she spoke with the physician, while the physician denies any direct knowledge of the case. It’s one of the reasons that APCs should expect supervising physicians to write a note in the chart when they have seen a patient with an APC.
Collaborating with APCs in the ED is clearly a great idea whose time has come. But ED directors need to be especially careful about providing access to as much EM-specific training early on as feasible (given that both PA and NP certification will only come after a considerable amount of ED exposure) and assuring careful supervision.
Before providing some abstracts focusing on the quality of care and patient acceptance of APCs, here’s a few stats regarding the anticipated explosion in the number of these providers.
Regarding PAs, there were 74,476 in the active work force in 2010 with a mean age of 42, with 65% being female. There were 154 accredited programs producing an average of 44 graduates annually. It is anticipated that the number of active PAs will grow to 93,009 in 2015 and 111,004 in 2020. These statistics do not consider adequately the fact that an additional 80 PA programs are slated to be credentialed by 2016. The bottom line – the number of PAs will continue to increase dramatically over the next years.
According to the Agency for Healthcare Research and Quality, as of 2010 there were 106,073 NPs, however others estimate the current number at roughly 155,000. According to the American Association of Nurse Practitioners there are approximately 850 NP specialty tracks available at over 350 institutions in the U.S. Approximately 10,000 NPs graduate per year.
Here is a recent abstract from Canada (where APCs are only starting to practice in EDs) indicating that parents with minor trauma themselves or in their children would readily elect to see a PA if it would result in faster care than that able to be provided by a physician.
CANADIANS’ WILLINGNESS TO RECEIVE CARE FROM PHYSICIAN ASSISTANTS
Doan, Q., et al, Can Fam Phys 58(8):e459, August 2012
BACKGROUND: Physician assistants (PAs) have been utilized for the provision of healthcare in the United States since the 1960s, but their incorporation into the Canadian healthcare system has only recently been considered. Primary care capacity shortages in Canada have resulted in decreased resources and longer wait times to be seen by a physician. The use of PAs could improve patient flow and decrease the costs of care.
METHODS: In this study, mothers accompanying children to be seen at the British Columbia Children’s Hospital were surveyed about their willingness to be treated by a PA for minor injuries. The scenarios that were presented included a sprained ankle and a forearm laceration in the respondent, and a forehead laceration in a child. Wait times that were presented were four hours to be treated by a physician vs. 30 minutes, one hour or two hours to be treated by a PA.
RESULTS: Responses were received from 229 of 270 potential participants (mothers who were familiar with PA services were excluded from participation). Nearly all of the respondents (99%) opted for treatment by a PA for at least one of the time trade-off scenarios for an ankle sprain or forearm laceration in themselves. Choice of a PA over a physician increased from about 85% if the wait to see the PA was two hours to 99% if the wait to see the PA was 30 minutes. For a forehead laceration in a child, 96% of the respondents opted for treatment by a PA for at least one of the time trade-off scenarios, increasing from 67% if the wait for a PA was two hours to 96% if the wait was 30 minutes.
– no reprints) (PMID: 22893348)
Copyright 2013 by Emergency Medical Abstracts – All Rights Reserved 9/13 - #13
The following paper also noted substantial satisfaction with NP care by patients. Ten percent preferred being seen by an NP rather than a physician, 10% preferred a physician, and 80% expressed no preference.
PATIENT SATISFACTION WITH A NURSE PRACTITIONER IN A UNIVERSITY EMERGENCY SERVICE
Rhee, K.J., et al, Ann Emerg Med 26(2):130, August 1995
BACKGROUND: Changes in the health care environment may require alteration in traditional patterns of care. Several studies conducted in varying practice environments have reported that the quality of care provided by nurse practitioners (NPs) and physician assistants is comparable to that of care provided by physicians. However, patient satisfaction with care provided by these practitioners has not been extensively evaluated.
METHODS: This study, from the University of Nebraska Medical Center in Omaha, compared satisfaction with care in ED patients managed by an attending physician or an NP. During the period of study, a single NP was employed in the ED and patients seen by the NP were also evaluated by a physician. Patients not managed by the NP were first seen by a medical student or house officer before being seen by an attending physician. A total of 30 patients seen by the NP and 30 matched control patients not seen by the NP were contacted by telephone and questioned concerning satisfaction with care.
RESULTS: Overall satisfaction rates, on a scale ranging between one (poor) and five (excellent), were 3.9 for the group seen by the NP and 4.0 for controls. Ten percent of the patients seen by the NP indicated that they would have preferred to be seen by a physician and 10% preferred being seen by the NP. The remaining 80% had a neutral position.
CONCLUSIONS: These findings suggest that NPs may be well accepted by ED patients, and that an evaluation of the role of midlevel practitioners in providing emergency care should focus on efficiency and quality of care and should not be limited by a fear regarding patient acceptance of these providers. 8 references
Copyright 1995 by Emergency Medical Abstracts - All Rights Reserved 11/95 - #18
Finally two very, very old papers that are both positive regarding care provided by PAs and NPs.
QUALITY OF PATIENT CARE BY NURSE PRACTITIONERS AND PHYSICIAN’S ASSISTANTS: A TEN YEAR PROSPECTIVE
Sox, H.C., Ann Int Med 91(3):459, September 1979
The authors, from Stanford University, performed a literature review of English language studies reported between 1967-1978 that compared primary care given by nurse practitioners/physician’s assistants (PAs) to care given concurrently by physicians. Of the 45 studies concerning nurse practitioner’s/PAs reported during this period, 21 met the authors review criteria. Each study was analyzed to determine if its conclusion was justified and if the conclusion could be extended to all practitioners and all activities in a primary care practice. Eight studies had a design in which patients were allocated randomly to see either a nurse practitioner/ PA or a physician. In four of these studies patients treated by the nurse practitioners/ PAs were more satisfied with their care and in one of these, the patients had a better outcome. Concerning the other seven studies, it was noted that no measurable differences could be ascertained between the quality of care given by either group. In four studies in which the same patient was assessed and treated by both nurse practitioners/ PAs and physicians, essentially the same diagnoses and triage decisions were made. In nine studies where patients were nonrandomly assigned to see either a nurse practitioner/ PA or physician there were no significant differences seen in the quality of patient care. It is noted that of the 21 studies reviewed, design deficiencies limited the usefulness of many. Despite these limitations, there is enough data to conclude that a nurse practitioner or PA should be expected to be well accepted by patients and provide the average primary care office patient with care that compares well with physician care. Because of the limited scope of these studies there is no experimental basis for extending this conclusion to adults seen in an emergency department. 56 references. 2/80-#15
PHYSICIAN AND PATIENT ACCEPTANCE OF EMERGENCY NURSE PRACTITIONERS
Alongi, 5., et al, JACEP 8(9):357, September 1979
The emergency nurse practitioner is a category of registered nurses that, because of special postgraduate training, is able to function in an expanded role in the emergency department under the supervision of a physician. To date, three programs have been established to train emergency nurse practitioners. This study, from the University of Virginia Medical Center, was designed to determine the acceptability of the emergency nurse practitioner from both the patients’ and the supervising physicians’ point of view. Patients and physicians completed the questionnaires that served as the basis of this study. Response rate for patients was 40% (50 patients) and 90% for physicians (22). The patients were informed that they were being cared for by emergency nurse practitioners under a physician’s supervision and they felt their care was prompt (78%), courteous (92%), good or satisfactory (90%) and thorough (92%). When asked, 94% of the respondents stated that they would be examined again by a nurse practitioner. These results are quite similar to prior studies of patient feelings about physician assistants. Of the responding physicians, 90% rated the physical examinations performed by the nurses as good or satisfactory. When asked to rate clinical judgement of the nurses, 70% of the physicians felt it was good or satisfactory. When broken down by patient type, clinical performance of the nurses when treating “emergent” cases was felt to be good/satisfactory by about 59% of the physicians. This percentage increased to 80% in “urgent” cases and 93% in “non-urgent” cases. It is concluded that patient and physician acceptance are not serious obstacles for emergency nurse practitioners to overcome. 1/80-#11
So, the bottom line appears to be that patients can, in general, be expected to be very satisfied when care is provided by an APC. Whether satisfaction with care may be further increased when care is provided by both a physician and APC has not been determined nor has it been determined whether the severity of the patient’s problem effects satisfaction with APC care. In addition, there remains the substantial challenge of providing assurance that the APCs are well trained to practice in the ED environment prior to seeking certification. Finally, there is the clear necessity to provide adequate supervision to assure consistent quality patient care.
The effective collaboration of PAs and NPs with physicians to provide efficient, timely, evidence-based, quality care in the ED is the goal of every ED medical director. All the involved parties want to meet these challenges. To achieve these goals, ongoing education focused on the care of ED patients coupled with careful supervision will remain paramount.
Richard Bukata, MD
Editor of Emergency Medical Abstracts (www.ccme.org)