SGEM#308: Taking Care of Patients Everyday with Physician Assistants and Nurse Practitioners

Date: November 19th, 2020 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Reference: Pines et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. AEM November 2020. Case: You are the medical director of a medium sized urban emergency department (ED). Volumes have increased over the past few years and you’re considering adding an extra shift or two. Your hospital has asked you to consider adding some advanced practice providers (APPs) instead of physician hours. Background: Advanced practice providers (APPs) such as nurse practitioners (NPs) and Physician Assistants (PAs) are increasingly used to cover staffing needs in US emergency departments. This is in part driven by economics, as APPs are paid less per hour than physicians. The calculation works if APP productivities are similar enough to physicians to offset differentials in billing rates. However, little data exists comparing productivity, safety, flow, or patient experiences in emergency medicine. The American Academy of Emergency Medicine (AAEM) has a position statement on what they refer to as non-physician practitioners that was recently updated. The American College of Emergency Physicians (ACEP) has a number of documents discussing APPs in the ED. There has been a concern about post-graduate training of NPs and PAs in the ED. A joint statement on the issue was published in September this year by AAEM/RSA, ACEP, ACOEP/RSO, CORD, EMRA, and SAEM/RAMS.  Clinical Question: How does the productivity of advanced practice providers compare to emergency physicians and what is its impact on emergency department operations? Reference: Pines et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. AEM November 2020. Population: National emergency medicine group in the USA that included 94 EDs in 19 states Exposure: Proportion of total clinician hours staffed by APPs in a 24-hour period at a given ED Comparison: Emergency physician staffing Outcome: Primary Outcome: Productivity measures (patients per hour, RVUs/hour, RVUs/visit, RVUs per relative salary for an hour) Safety Outcomes: Proportion of 72-hour returns and proportion of 72-hour returns resulting in admission Other Outcomes: ED flow by length of stay (LOS), left without completion of treatment (LWOT) Dr. Jesse Pines This is an SGEMHOP episode which means we have the lead author on the show. Dr. Jesse Pines is the National Director for Clinical Innovation at US Acute Care Solutions and a Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and also leads the USACS opioid programs.  Authors’ Conclusions: “In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery. Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Unsure Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes