Emergency department uses of physician assistants and nurse practitioners: a national survey

Utilizing Nurse Practitioners and Physician Assistants in Academic Emergency Departments Does Not Reduce Residents' Exposure to More Complex Patients

BACKGROUND

Whether integration of nurse practitioners (NPs) and physician assistants (PAs) into academic emergency departments (EDs) affects emergency medicine (EM) resident clinical learning opportunities is unclear.

OBJECTIVE

We sought to compare EM resident exposure to more-complex patients, as well as patients undergoing Accreditation Council for Graduate Medical Education (ACGME)-required procedures, at nonpediatric academic EDs with lower, moderate, and higher levels of NP/PA utilization.

METHODS

In this cross-sectional study of National Hospital Ambulatory Medical Care Survey (NHAMCS) data for 2016-2020, nonpediatric academic EDs were classified into the following three groups based on the percentage of patients seen by an NP or PA: lower (≤ 10%), moderate (10.1-30%), and higher (> 30%) NP/PA utilization. The proportion of EM resident-seen patients meeting previously established complex patient criteria was then determined for EDs at each level of NP/PA utilization. The proportion of EM resident-seen patients receiving certain ACGME-required procedures was also determined. Survey analytic procedures and weighting as recommended by NHAMCS were used to calculate and compare proportions using 95% CIs.

RESULTS

The weighted 2016-2020 NHAMCS data sets represent 44,130,996 adult resident-seen patients presenting to nonpediatric academic EDs. The proportion of resident-seen patients meeting complex patient criteria did not significantly differ for lower (43.2%; 95% CI 30.6-56.8%), moderate (41.7%; 95% CI 33.0-50.9%), or higher (38.9%; 95% CI 29.3-49.4%) NP/PA utilization EDs. The proportion of patients undergoing an ACGME-required procedure also did not significantly differ across level of NP/PA utilization.

CONCLUSIONS

Higher levels of NP/PA utilization in nonpediatric academic EDs do not appear to reduce EM resident exposure to more-complex patients or ACGME-required procedures.

Physician assistants contribution to emergency department productivity

Introduction

The objective of this report is to determine physician assistant (PA) productivity in an academic emergency department (ED) and to determine whether shift length or department census impact productivity.

Methods

A retrospective chart review was conducted at a tertiary ED during June and July of 2007. Productivity was calculated as the mean number of patients seen each hour. Analysis of variance was used to compare the productivity of different length shifts, and linear regression analysis was used to assess the relationship between productivity and department volume.

Results

One hundred sixty PA shifts were included. Shifts ranged from 4 to 13 hours. Mean productivity was 1.16 patients per hour (95% confidence interval [CI] = 1.12–1.20). Physician assistants generated a mean of 2.35 relative value units (RVU) per hour (95% CI = 1.98–2.72). There was no difference in productivity on different shift lengths (P = 0.73). There was no correlation between departmental census and productivity, with an R² (statistical term for the coefficient of determination) of 0.01.

Conclusion

In the ED, PAs saw 1.16 patients and generated 2.35 RVUs per hour. The length of the shift did not affect productivity. Productivity did not fluctuate significantly with changing departmental volume.

Update on midlevel provider utilization in U.S. emergency departments, 2006 to 2009

OBJECTIVES

Previous studies have noted a sharp increase in utilization of physician assistants (PAs) and nurse practitioners (NPs), up to 13% of all U.S. emergency department (ED) visits in 2005. The authors sought to reevaluate utilization and visit acuity for these midlevel providers (MLPs) in U.S. EDs from 2006 to 2009.

METHODS

This was a secondary analysis of the 2006-2009 National Hospital Ambulatory Medical Care Surveys (NHAMCS), using the "providers seen" fields to categorize visits. Demographic, visit, and hospital characteristics of visits seen by MLPs only were compared to those seen by MLPs with physician involvement and by physicians only.

RESULTS

Of the estimated 496 million U.S. ED visits from 2006 to 2009, 5.8% (95% confidence interval [CI] = 4.7% to 7.1%) were seen by MLPs only and 7.4% (95% CI = 6.3% to 8.5%) by MLPs with physician involvement. The annual proportions of visits seen by MLPs only for 2006 to 2009 ranged from 5.4% to 6.0% without an obvious trend. Acuity of MLP-only visits in 2006-2009 was similar to prior 1993-2005 data for arrival by ambulance (6.5% vs. 6.0%), urgent/emergent triage acuity (33% vs. 37%), and hospital admission (3.3% vs. 3.0%). From 2006 through 2009, 64% of EDs utilized MLPs, with higher utilization in urban (72%, 95% CI = 64% to 78%) compared to nonurban EDs (51%, 95% CI = 39% to 63%). However, among EDs that did utilize MLPs, nonurban EDs had MLPs without physician involvement see a median 27% of all ED visits, compared to 7.5% for urban EDs.

CONCLUSIONS

Despite a rapid expansion of MLP utilization in U.S. EDs, recent growth appears to have plateaued. The scope of practice of MLPs in EDs does not appear to be rapidly expanding. Urban EDs use MLPs more than nonurban EDs, but among EDs that use MLPs, nonurban EDs had MLPs see a larger proportion of overall ED visits.

Continued rise in the use of mid-level providers in US emergency departments, 1993-2009

Background

Emergency department (ED) visits in the US have risen dramatically over the past 2 decades. In order to meet the growing demand, mid-level providers (MLPs) – both physician assistants (PAs) and nurse practitioners (NPs) – were introduced into emergency care. Our objective was to test the hypothesis that MLP usage in US EDs continues to rise.

Findings

We analyzed ED data from the National Hospital Ambulatory Medical Care Survey to identify trends in ED visits seen by MLPs. We also compared MLP-only visits (defined as visits where the patient was seen by a MLP without being seen by a physician) with those seen by physicians only. During 1993 to 2009, 8.4% (95%CI, 7.6–9.2%) of all US ED visits were seen by MLPs. These summary data include marked changes in MLP utilization: PA visits rose from 2.9% to 9.9%, while NP visits rose from 1.1% to 4.7% (both P_trend < 0.001). Together, MLP visits accounted for almost 15% of 2009 ED visits and 40% of these were seen without involvement of a physician. Compared to physician only visits, those seen by MLPs only were less likely to arrive by ambulance (16% vs 6%) and be admitted (14% vs 3%).

Conclusions

Mid-level provider use is rising in US EDs. By 2009, approximately one in seven visits involved MLPs, with PAs managing twice as many visits as NPs. Although patients seen by MLPs only are generally of lower acuity, these nationally representative data confirm that MLP care extends beyond minor presentations.

Emergency department madness: tips to maintain sanity and flow

Physician factors can influence congestion and wait times in emergency departments. This article provides some guidance to improve personal and departmental efficiency.

Physician assistants in emergency medicine: the impact of their role

BACKGROUND

Emergency medicine (EM) in North America has been undergoing significant transformation since the new century. Recent health care reform has put it center stage. Access demand for acute care is increasing at the same time the number of qualified emergency physicians entering service has reached a plateau. Physician assistants (PAs), one alternative, are employed in emergency departments (EDs), but little is known about the impact of their role.

OBJECTIVES

This was a literature review to identify the current role of PAs in patient treatment and the management of emergency services.

METHODS

All publications and designs from 1970 through 2009 were identified using multiple science citation indices. Each author reviewed the literature, and categories were developed based on consensus.

RESULTS

Thirty-five articles and reports were sorted into categories of interest: prevalence of PAs in EDs, efficiency and quality of care, patient satisfaction, rural emergency care, and legal issues. Each category is summarized and discussed. Evidence comparing the clinical effectiveness of PAs to mainstream management of emergency care was only fair in methodologic quality.

CONCLUSIONS

The use of PAs in EDs is increasing, and this expansion is due to necessity in staffing and economy of scale. Unique uses of PAs include wound management, acute care transfer management to the wards, and rural health emergency staffing. While their role seems to be expanding, this assessment identified gaps in deployment research using appropriate outcome measures in the area of clinical effectiveness of PAs.

Vascular neurology nurse practitioner provision of telemedicine consultations

Objective. The objective was to define and evaluate a role for the Vascular Neurology-Nurse Practitioner (VN-NP) in the delivery of telemedicine consultations in partnership with a vascular neurologist. Methods. Prospective stroke alert patients at participating hospitals underwent a two-way audio video telemedicine consultation with a VN-NP at a remotely located stroke center in partnership with a vascular neurologist. Demographic information, National Institutes of Health Stroke Scale (NIHSS) scores, diagnoses, CT contraindications to thrombolysis, thrombolysis eligibility, and time interval data were collected. The inter-rater agreement between VN-NP and vascular neurologist assessments was calculated. Results. Ten patients were evaluated. Four were determined to have ischemic stroke, one had a transient ischemic attack, two had intracerebral hemorrhages, and three were stroke mimics. Overall, three patients received thrombolysis. The inter-rater agreement between VN-NP and vascular neurologist assessments were excellent, ranging from 0.9 to 1.0. The duration of VN-NP consultation was 53.2 +/- 9.0 minutes, which included the vascular neurologist supervisory evaluation time of 12.0 +/- 9.6 minutes. Conclusion. This study illustrated that a stroke center VN-NP, in partnership with a vascular neurologist, could deliver timely telemedicine consultations, accurate diagnoses, and correct treatments in acute stroke patients who presented to remotely located rural emergency departments within a hub and spoke network. VN-NPs may fulfill the role of a telestroke provider.

Nurse practitioner roles in pediatric emergency departments: a national survey

OBJECTIVE

Emergency department (ED) visits continue to climb in the United States despite numerous primary care initiatives. A variety of staffing models including the utilization of nurse practitioners (NPs) and physician assistants (PAs) and the use of fast-track or express care are alternative methods of caring for the ED patients with less acute illness. Our objectives were to determine the prevalence of NPs in pediatric EDs (PEDs) and fast-track areas and to identify common procedures performed by NPs in PEDs.

METHODS

Two telephone surveys were conducted. The first survey was performed with the ED charge nurse at all 205 hospitals in the United States participating in the National Association of Children's Hospitals and Related Institutions. The second survey consisted of an interview with NPs working in those PEDs. Both descriptive data as well as the procedures performed by NPs in the PED were collected.

RESULTS

A total of 198 hospitals completed the first survey (97% response rate), representing 41 states. Fifty-one percent of respondents reported using NPs in the ED, contrasted with only 36% who reported using PAs (P < 0.01). The use of NPs was found to be distributed across all geographical regions, whereas the use of PAs was statistically more likely in the Northeast and Midwest regions (P < 0.01). Freestanding children's hospitals were more likely to use NPs than children's hospital within general hospitals (P < 0.01). Procedures such as fluorescein staining of the cornea were performed by all NPs, whereas only 65% of NPs performed repair of a finger-tip amputation.

CONCLUSIONS

The use of NPs in the PED is common. Nurse practitioners in the PED perform a number of different procedures. Future studies analyzing practice patterns and effectiveness of the NP role in the PED are needed.

Use of midlevel providers in US EDs, 1993 to 2005: implications for the workforce

OBJECTIVE

The aim of the study was to evaluate use of physician assistants (PAs) and nurse practitioners (NPs) in US emergency departments (EDs).

METHODS

We analyzed visits from the 1993 to 2005 National Hospital Ambulatory Medical Care Survey, seen by midlevel provider (MLP), and compared characteristics of MLP visits to those seen by physicians only.

RESULTS

From 1993 to 2005, 5.2% (95% CI, 4.6%-5.8%) of US ED visits were seen by PAs and 1.7% (95% CI, 1.5%-2.0%) by NPs. During the study period, PA visits rose from 2.9% to 9.1%, whereas NP visits rose from 1.1% to 3.8% (both P(trend) < .001). Compared to physician only visits, those seen only by MLPs arrived by ambulance less frequently (6.0% vs 15%), had lower urgent acuity (37% vs 59%), and were admitted less often (3.0% vs 13%).

CONCLUSIONS

Midlevel provider use has increased in US EDs. Their involvement in some urgent visits and those requiring admission suggests that the role of MLPs extends beyond minor presentations.

Trends in midlevel provider utilization in emergency departments from 1997 to 2006

OBJECTIVES

The objective was to quantify the expansion of midlevel provider (MLP) practice in U.S. emergency departments (EDs) over the past decade. Specifically, we sought to quantify the absolute number of patients seen by MLPs, the annual growth rate of patients seen by MLPs, and the expansion in the proportion of EDs using MLPs.

METHODS

Data were analyzed from the ED portion of the 10 most recent years (1997 to 2006) National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative survey of ED visits compiled by the Centers for Disease Control and Prevention (CDC). The main outcomes of interest were the proportion and absolute numbers of ED patients seen by MLPs during the 10-year study period. National estimates derived from sample weights are reported. In addition, a multivariate logistic regression model was created with "seen by midlevel provider" as the dependent variable to determine factors associated with being seen by a MLP.

RESULTS

Between 1997 and 2006, 8.23% (95% confidence interval [CI] = 7.31% to 9.15%) of ED patients were seen by a MLP. The proportion of ED patients seen by MLPs increased from 5.5% (95% CI = 3.8% to 7.1%) in 1997 to 12.7% (95% CI = 10.5% to 14.9%) in 2006 (13% annual growth). This corresponds to an increase in the number of ED patients seen by MLPs from 5.2 million in 1997 to 15.2 million in 2006. The proportion of hospitals using MLPs in the ED increased from 28.3% (95% CI = 22.4% to 34.1%) in 1997 to 77.2% (95% CI = 71.2% to 83.3%) in 2006 (17% annual growth). Slightly over half of MLP cases (54.9%; 95% CI = 49.1% to 60.7%) were also seen by staff physicians. On multivariate regression, younger patient age, non-southern geographic region, and triage acuity were associated with increased MLP use.

CONCLUSIONS

The number of ED patients seen by MLPs has increased sharply, from 5.2 million in 1997 (5.5% of all ED cases) to 15.2 million in 2006 (12.7% of all ED cases). Similarly, the proportion of EDs reporting use of MLPs has increased from 28.3% in 1997 to 77.2% in 2006.

TelEmergency: A Novel System for Delivering Emergency Care to Rural Hospitals

Providing rural emergency medical care is often difficult because of limited resources and a scarcity of medical providers, including physicians trained in emergency medicine. Telemedicine offers promise for improving the quality of care in rural areas, but previous models were not well designed to provide affordable care to unstable or potentially unstable patients. The TelEmergency program was developed to overcome these limitations by providing quality, affordable medical care to patients in rural emergency departments (EDs) using specially trained nurse practitioners linked in real time by telemedicine with their collaborating physicians at the University of Mississippi Medical Center Adult Emergency Department. Since its inception in October 2003, the TelEmergency program has evaluated and treated more than 40,000 patients in 11 rural EDs throughout Mississippi, with a high degree of satisfaction from patients and hospital administrators. This article details the development and implementation of this system and describes the patient population that has been evaluated.

Retrospective comparison of emergency department length of stay for procedural sedation and analgesia by nurse practitioners and physicians

OBJECTIVES

To determine if use of nurse practitioners (NPs) for procedural sedation and analgesia (PSA) compared with physicians (MDs) decreased overall length of stay (LOS) in the pediatric emergency department (PED).

METHODS

Retrospective chart review was conducted on all children (age <21 years) undergoing procedural sedation and analgesia (PSA) for 36 consecutive months at a tertiary academic children's hospital (n = 690). Data included times values for triage, evaluation by practitioner (NP, MD), sedation, discharge, and total LOS in the PED. Data collected also included medications given, patient diagnosis, and severe airway complications.

RESULTS

Results revealed statistically significant time-related advantages to NP-managed sedations. Both PED LOS and time to sedation were significantly lower for NPs versus MDs across diagnoses (P < 0.01). The diagnoses managed by MDs versus NPs were significantly different for 3 diagnoses: fracture, finger, and lacerations. There were no differences between NP and MD for severe airway complication rates.

CONCLUSIONS

Overall LOS and time to sedation were significantly improved when NPs independently managed patients requiring PSA without an increase in documented severe airway complication rates.

Acute care nurse practitioners: the role in neuroscience critical care

In order to meet the needs of the high acuity population in today's critical care environment, the role of the Acute Care Nurse practitioner (ACNP) has been adopted by many intensive care units (ICU's) across the country, including specialized neurocritical care units. In this chapter we will provide a brief historical review of the ACNP as well as their function in various ICU settings. Lastly, we will describe the current role of the ACNP in the Neurosciences Critical Care Unit at the Johns Hopkins Hospital as well as future plans and challenges of the role.

Specialized emergency nurses treating ankle and foot injuries: a randomized controlled trial

OBJECTIVE

To cope with emergency departments (EDs) being progressively overcrowded, the concept of specialized emergency nurses (SENs) was conceived. In this study, the ability of SENs to treat ankle/foot injuries was assessed.

METHODS

Regular emergency nurses were trained in a 2-day session that addressed all aspects of ankle/foot injuries. A randomized controlled trial was set up in which the diagnostic accuracy of SENs was compared with that of house officers (HOs). Secondary outcome parameter was patient satisfaction measured by a standardized questionnaire.

RESULTS

In total, 512 consecutive patients were included. The sensitivity of SENs was 0.94 (95% confidence interval [CI], 0.78-0.99) compared with 0.78 (95% CI, 0.57-0.91) of HOs. Specificity was 0.94 (95% CI, 0.90-0.97) for SENs compared with 0.95 (95% CI, 0.91-0.98) for HOs. The delivered care by SENs was found to be significantly better and the median waiting time at the ED was significantly reduced (21 minutes for SENs vs 32 minutes for HOs).

CONCLUSIONS

Specialized emergency nurses are capable of assessing and treating ankle/foot injuries accurately with excellent patient satisfaction and with a reduction of waiting times. Other injury-specific courses are now developed for this approach.

Diagnostic accuracy of lower extremity X-ray interpretation by 'specialized' emergency nurses

OBJECTIVES

In the quest for a cost-effective and quality-preserving solution to manage crowding in the emergency department, the possibility of deploying regular emergency nurses for the treatment of acute ankle injuries was investigated. The aim of this study is to compare the diagnostic accuracy of emergency nurses with that of senior house officers in interpreting ankle and foot radiographs.

METHODS

A prospective study comparing the assessment of 60 radiographs (30 feet and 30 ankles) by 16 emergency nurses before and after an educational session was performed. Each subset of 30 radiographs contained 12 fractures, hand-picked by a radiologist to represent everyday traumatology in the emergency department. The control group consisted of eight senior house officers representing everyday expertise. The outcome of the diagnostic assessment, represented as the pooled sensitivity and specificity for both groups, was compared using Z-statistics.

RESULTS

Before the training session, the specialized emergency nurse group showed a sensitivity of 0.87 (confidence interval 0.83-0.91) compared with 0.93 (confidence interval 0.88-0.96) for the control group (P = 0.05). The specificity of specialized emergency nurses was 0.87 (confidence interval 0.81-0.92) compared with 0.93 (confidence interval 0.89-0.95) for the senior house officers (P < 0.05). After the training session, specialized emergency nurse diagnostic parameters did not differ significantly from the control group, displaying a sensitivity of 0.89 (confidence interval 0.86-0.92) and specificity of 0.92 (confidence interval 0.87-0.95).

CONCLUSION

Before the training session, the specialized emergency nurse group showed a significantly lower accuracy than the SHO group. After training, however, the diagnostic accuracy did not differ significantly between groups. Therefore, we conclude that emergency nurses are able to accurately interpret foot and ankle radiographs after a short educational session.

Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses

OBJECTIVES

The ED is often confronted with long waiting periods. Because of the progressive shortage in general practitioners, further growth is expected in the number of patients visiting the ED without consulting a general practitioner first. These patients mainly present with minor injuries suitable for a standardized diagnostic protocol. The question was raised whether these injuries can be treated by trained ED nurses (specialized emergency nurses [SENs]). The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules (OAR) and Ottawa Foot Rules (OFR).

METHODS

In a prospective study, all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor (house officer [HO]) randomized for first observer. Before the study, SENs were trained in applying OAR and OFR. In all patients, radiography was performed (gold standard). The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics. Furthermore, from the paired results, reproducibility was calculated using kappa statistics.

RESULTS

In total, 106 injuries were assessed in pairs, of which 14 were ultimately found to concern acute fractures (prevalence, 13%). The sensitivity for the SEN group was 0.93 (95% confidence interval [CI], 0.64-1.00) compared with 0.93 (95% CI, 0.64-1.00) for the HO group (no significance [ns]). The specificity of the nurses was 0.49 (95% CI, 0.38-0.60) compared with 0.39 (95% CI, 0.29-0.50) for the doctors (ns). The positive predictive value for the SEN group was 0.22 (95% CI, 0.13-0.35) compared with 0.19 (95% CI, 0.11-0.31) for the HO group (ns). The negative predictive value for the nurses was 0.98 (95% CI, 0.87-1.00) compared with 0.97 (95% CI, 0.84-1.00) for the doctors (ns). The interobserver agreement for the OAR and OFR subsets was kappa = 0.38 for the lateral malleolus; kappa = 0.30, medial malleolus; kappa = 0.50, navicular; kappa = 0.45, metatarsal V base; and kappa = 0.43, weight-bearing. The overall interobserver agreement for the OAR was kappa = 0.41 and kappa = 0.77 for the OFR.

CONCLUSION

Specialized emergency nurses are able to assess ankle and foot injuries in an accurate manner with regard to the detection of acute fractures after a short, inexpensive course.

Third-Party Reimbursement for Nurse Practitioners??? Services on Trauma Teams: Working through a Maze of Issues

Third-party payers reimburse for physician services performed by nurse practitioners, if the services are within the scope of practice of a nurse practitioner and the payers' rules are followed. However, some hospitals and trauma services have been reluctant to bill the services of nurse practitioners they employ or to hire nurse practitioners, because the rules are complex, vary from payer to payer, can be difficult to find, and because operations are not always set up so that nurse practitioners' services are bundled in ways which conform to the rules. Medicare has developed detailed rules on billing nurse practitioners' services, but neither Medicaid nor commercial payers necessarily follow Medicare's rules. The situation is further complicated by wide variations in state law governing nurse practitioner scope of practice and requirements for physician collaboration. Despite all of these variables, it may be worth the time and effort to sort out the requirements for utilizing nurse practitioners and billing for their services, considering the limitations on residents' hours, the data on quality of nurse practitioners' clinical services and the potential for generating revenue. This article describes the legal and business issues, provides the general rules for billing nurse practitioners' services, and provides a plan for obtaining third-party payment for nurse practitioners' services on trauma teams.

Comparative Review of Use of Physician Assistants in a Level I Trauma Center

In view of the new residency guidelines, which restrict resident work hours, the use of physician assistants (PAs) for patient care continuity during off-hours of residents may become a common practice. The purpose of this study was to assess the quality of patient care during transition from resident- to PA-assisted trauma program (without residents) and comparative simultaneous support. A retrospective analysis of patient care during two 6-month segments was carried out: during resident-assisted program at a level II trauma center in 1998 and a PA-dedicated trauma program in 1999. With reinvolvement of senior surgical residents, a focused analysis for the last quarter of 2002 was done. Regression analysis indicated the only statistically significant outcome was decreased length of stay (LOS) when patients were transferred directly from emergency center (EC) to floor in 1999. The mean LOS was 2.54 ± 4.65 compared to 3.4 ± 5.81, and no statistical difference in other assessments was noted. Focused analysis in 2002 showed 100 per cent participation of PAs during the trauma alert compared to 51 per cent by residents. Substitution of residents with PAs had no impact on patient mortality; however, LOS (from EC to floor), was statistically reduced by 1 day. Trauma programs can benefit with collaboration of residents and PAs in patient care.

Management of Patients in the Intensive Care Unit: Comparison Via Work Sampling Analysis of an Acute Care Nurse Practitioner and Physicians in Training

• Background Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients’ outcomes.

• Objective To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients’ care in a step-down medical intensive care unit.

• Methods Work sampling techniques were used to collect data when the nurse practitioner had 6 months’ or less experience in the role (T1), after the nurse practitioner had 12 months’ experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities.

• Results Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P &lt; .001) and less time in nonunit activities (15% vs 37%; P &lt; .001).

• Conclusion The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients’ families and collaborating with health team members.

Challenges of advanced practice nursing in pediatric acute and critical care: education to practice

The APN role of the future is dependent on our ability to document through research that NPs, CNSs, and the consolidated role of the NP/CNS plays a critical role in the delivery of high quality cost-effective care. Further information is needed regarding how the APN contributes to and enhances the care delivered by the healthcare team. Cost effectiveness and quality outcome studies are needed including those that describe morbidity and mortality rates, patient satisfaction, and cost effectiveness of models of care that includes APNs. Brooten and Naylor suggest the inclusion of sensitive nursing outcomes, including functional status, mental status, stress level, satisfaction with care, caregiver burden, cost of care. Defining and clarifying the APN functions and qualities of scope of practice is imperative. Perhaps there are populations best served by APNs. Contributions such as continuity, consistency of care, attention to issues such as immobility, skin integrity, and health promotion may have a value added effect. Time motion studies and process logs may add to the information about APNs in pediatric acute and critical care. Professional certification validating competence is essential for the practice of APNs caring for sick children and their families. A disparity exists between the primary care examination now available and the practice of NPs in pediatric acute and critical care. A certification examination is needed with content consistent with the practice of pediatric acute care NP. APNs must possess sufficient knowledge and skill to meet the needs of patients and families in the changing healthcare environment. According to Strodtbeck and colleagues, flexibility, ability to be a self directed learner, critical thinking, relationship skills, and leadership skills including interpersonal insight, interpersonal competence, and ability to stimulate group discussion will serve APNs well as they move into the century. Transitioning brings exciting opportunities along with challenges. Using a blend of abilities, the pediatric acute care APN can provide optimal care to sick children and families.

What advanced practice nursing outcomes research is out there?

With a traditional focus on primary care or selected patient populations, advanced practice nurses (APNs) are forging new roles in a variety of practice settings, including acute and critical care. APNs have become important members of the critical care team, yet the impact of their care on acute and critically ill patients has not been well studied. This article presents an overview of the research currently available on outcomes of APN practice for acute and critically ill patients. The findings from these studies are discussed and implications for the future of APN outcomes research are provided.

Acute Care Nurse Practitioners: Creating and Implementing a Model of Care for an Inpatient General Medical Service

Changes in medical education and healthcare reimbursement are recent threats to most academic medical centers’ dual mission of patient care and education. Financial pressures stem from reduced insurance reimbursement, capitation, and changes in public funding for medical residency education. Pressures for innovation result from increasing numbers of patients, higher acuity of patients, an aging population of patients with complex problems, and restrictions on residency workloads. A framework for addressing the need for innovation in the medical service at a large academic medical center is presented. The framework enables acute care nurse practitioners to provide inpatient medical management in collaboration with a hospitalist. The model’s development, acceptance, successes, pitfalls, and evaluation are described. The literature describing the use of nurse practitioners in acute care settings is reviewed.

Doing unto others? Emergency medicine residents' willingness to be treated by moonlighting residents and nonphysician clinicians in the emergency department

OBJECTIVE

Contentious moonlighting policies and the proliferation of nonphysician clinicians (NPCs) in academic emergency departments (EDs) send conflicting messages to emergency medicine (EM) residents regarding appropriate ED staffing patterns. The objective was to assess EM resident (EMR) views on the ED utilization of unsupervised residents and NPCs from their perspectives as both physicians and prospective patients.

METHODS

A survey was mailed to a random sample of senior EMRs (sampling fraction, 68%) from the Emergency Medicine Residents Association membership list. Respondents were instructed to assume the role of patient when presented with hypothetical clinical scenarios of increasing severity; outcomes included provider preferences and the impacts of medical urgency, time delays, costs, and supervision on those preferences. Survey items asked about willingness to see residents, nurse practitioners (CRNPs), and physician assistants (PAs), and perceived impact of NPCs on professional identity.

RESULTS

A total of 251 EMRs responded. Senior EMRs are more willing to have their care handled by residents as opposed to mid-level providers. For a moderate illness or injury scenario, 54% agreed to be seen by a resident alone compared with only 17% and 24% willing to be seen by a CRNP and PA, respectively. Only a small fraction of the residents (22.7%) would allow another resident to treat them for a major injury or illness. Residents are more willing to be seen by mid-level providers if a savings in time can be realized but showed little interest in using NPCs to save money. Approximately one-third (34%) of the residents view mid-level providers as a professional threat, but logistic regression reveals this perception to be 2.25 (1.3, 4.0) times higher in male EMRs and 1.94 (1.1, 3.4) times higher in those with higher household incomes (> or =$75,000).

CONCLUSIONS

When assuming the patient role, senior EMRs have preferences for ED care that are consistent with restrictive EMR moonlighting and NPC staffing policies.

A proposed model for telemedicine to supplement the physician workforce in the USA

Maldistribution of physicians is the norm in much of the USA. This paper explores the effect that the integration of telemedicine into the health system could have on physician workforce requirements in the USA. The analysis is based on preliminary evidence suggesting that telemedicine is an effective and efficient means of delivering a broad spectrum of health services to medically under-served rural and inner-city communities. While the emphasis here is on interactive, video-based telemedicine services, other telemedicine modalities, such as store-and-forward techniques and remote monitoring, are likely to have a parallel effect. As these new technologies become a normal part of health care, they will reshape the medical workforce and exert a profound influence on physician workforce requirements in the USA. This paper presents a potential model for this reshaped workforce that emphasizes an expanded role for mid-level health-care providers.

Measuring advanced practice nursing outcomes

The measurement of outcomes has become an important component of evaluating health care. Although it is clear that measuring outcomes is necessary to establish the effectiveness of advanced practicing nursing, which outcome measures to use and how to conduct an effective outcomes assessment remain unclear. The purpose of this article is to present an overview of advanced practice nursing outcomes research, review outcome measures important to advanced practice nurses (APNs), and discuss sources of outcome measures and instruments that can be used by APNs to establish the effectiveness of the role.

Doctor's assistants--do we need them?

OBJECTIVE

To investigate the potential for the doctor's assistant role within an accident and emergency (A&E) department in relation to consultant workload.

METHODS

A time and motion evaluation of the activities of four A&E consultants before and after a doctor's assistant was established as a team member within our department. A review of the literature was undertaken to allow comparisons with the American model of the physician assistant within the emergency department.

RESULTS

The initial evaluation indicated that over 20% of the consultant's time could have been saved if an assistant were available to perform a variety of non-medical tasks. The restudy performed once the assistant was in post indicated less time was spent by the doctors in "medical" clerical duties (6.7% v 11.5% time), telephone use (5.6% v 7.7%), and venepuncture/cannula insertion (0.4% v 2.1%), and more time was spent on consultation over cases (15.3% v 11.3%) and supervision of other staff (9.3% v 4.1%). These five areas changed significantly (p = 0.005 by paired t test).

CONCLUSIONS

The doctor's assistant may have a role in reprofiling the workload of senior doctors in A&E departments in the UK. They may also have a role in reducing the pressure on junior doctors, though this effect was not evaluated.

Role and productivity of nurse practitioners in one urban emergency department

Data gathered from this one institution, although not necessarily generalizable, proved helpful in retaining the NP role in our emergency department. Other facilities may benefit from a similar analysis of like information.

Use of physician assistants as surgery/trauma house staff at an American College of Surgeons-verified Level II trauma center

BACKGROUND

Historically, surgical physicians staff trauma centers, which provide trauma patients with improved outcomes. Such benefits fuel the expansion of designated trauma centers. Cutbacks in residency programs of surgical specialties, however, necessitate substitutions for traditional trauma providers.

METHODS

A literature and record review was conducted to examine the use of physician assistants in a large community hospital's verified trauma center. Current and historical outcomes were analyzed regarding the trauma surgeon/physician assistant model.

RESULTS

Injury Severity Scores increased 19%, transfer time to the operating room decreased 43%, transfer time to the intensive care unit decreased 51%, and transfer time to the floor decreased 20%. The length of stay for admissions decreased 13%, and the length of stay for neurotrauma intensive care unit patients decreased 33%.

CONCLUSION

The Hurley Medical Center trauma surgeon/physician assistant model is a viable alternative for verified trauma centers unable to maintain a surgical residency program. Consistency and quality of care indicated by shortened length of stay is a hallmark of such a model providing the highest quality of care.