Physician assistants and nurse practitioners are staffing rural ERs full time

The physician shortage is forcing rural ERs to use mid-levels exclusively to staff their emergency departments.

Local doctors are the backup, available by phone and able to go the hospital within minutes for emergencies.

Some hospitals have no choice, since the alternative would be to shut the ER down due to the lack of available physicians.

There is a marked difference in the amount of training an emergency physician receives when compared to a physician assistant or nurse practitioner. Does this training disparity lead to differences in patient outcomes and malpractice suits? That’s difficult to say, but Press Ganey patient satisfaction scores suggest that there is no drop-off.

I wonder if this will be the start of a trend where physicians will staff trauma centers only, leaving the rural ERs to mid-level providers.

Comments

Anonymous
I do QA reviews. Most quality of care problems that I see are due to the obvious standard steps not having been taken–like examining the patient and getting a full history–and are due to factors other than level of training of the examineer (laziness, fatigue, don’t-give-a-shit syndrome).
Having said that, I do see quality of care problems that result from NP’s being put into situations where the highest level of training is called for–at the critical decision making point for newly presenting patients. They do great work with defined ongoing problems with a defined course of management and a few options. But where the field of diagnostic and management options is wide open I see some major consequential boo-boo’s. This has all been in new inpatients, new consults to a specialty service that tries to farm that out to NP’s, and urgent care outpatients ostensibly presenting with a run-of-the-mill problem that is not run of the mill at all.
I have never seen anyone staff an ER with NP’s or PA’s only. I confidently predict that there will be avoidable deaths.
The mind and eye only find what is expected. If you don’t have enough experience to have seen the outliers, the unusual, then you will not expect or look for it and usually not see it even when right in front of you.
Just this week two cases with life-long consequences for two patients due to the obvious, but unusual, being missed because it was missed by the initial evaluator–NP’s in each case. While one can’t be certain, I expect that in each of these cases had the attending physician did the initial work-up himself/herself, they would have picked up the important elements and provided the timely intervention needed to avoid permanent consequences.
Increased malpractice? I doubt it. Very few of the actual cases like this result in a lawsuit.
Anonymous
why on earth would press-ganey’s be used here to evaluate this experiment?
The Happy Hospitalist
With comment number one, I agree completely. The value of physician level care is most apparent in the differential diagnosis. It’s difficult to know what you don’t know.
In critical care cases with unstable multiorgan failure, the value of physician level care will shine through.
The question for rural America being staffed by PAs or NPs indepedenlty for complicated unstable patients:
Can they find a hospitalist physician to accept them before the patient dies.
As is often the case, I accept unstable critically ill patients,receiving report from extenders in the ED.
Just a couple months ago I accepted a patient with a “swollen face” and “acute heart failure”. After benadryl and epinephrine were given in the rural ED by the extender, I was asked to accept the patient for management of heart failure and allergic reaction.
I can assure you in my close to 10 years as a physician and student in training, I have never seen a swollen face as a result of heart failure. Nor have I seen an acute allergic rxn(?drug since the patient was taking no medication) and heart failure present simultaneously.
It became painfully obvious to me, within five minutes of his presentation that the patient had neither heart failure and unlikely to have had an allergic reaction.
The rural EDs own lab indicated his albumin level of 0.8 in an uncontrolled diabetic. This patient had nephrotic syndrome.
How we go from allergic reaction and acute heart failure to nehprotic syndrome is a matter of education and diagnostic skills, mastered at the physician level.
These are emergency rooms. Where emergencies show up. Staffing them with less than physician level training will have consequences.
I think the determining factor will be how quickly you can get an ambulance there to transfer the patient.
Perhaps they should be staffed by a triage nurse. Nurse K perhaps? To determine whether the patient stays at rural hospital or goes to big city USA.
Anonymous
First of all, NPs and PAs are not interchangeable. PAs get more medically oriented clinical and didactic training in diagnosis. PA clinical rotations average 2000 hours, NPs 800 hours. With the new trend toward “entry level masters NPS” (accepting someone with a non-nursing bachelor’s degree for RN and NP training combined at the master’s level and only two years long), NPs are being graduated with less experience and less clinical training than PAs, regardless of their antecedent careers. These programs are very popular and popping up all over.
Secondly, no one will know if this is problematic until you study the problem…..i.e., take these hospitals, a comparable rural hospital staffed with non BC/BP docs, and then a comparable hospital staffed with BC/BP docs, with even patient mix. There are hospitals in Michigan which fit each criterion and would make an excellent study. The proof will be in the pudding and not the opinion.
Trey
I am one of those NPs caring for patients in the ED. I regularly diagnose ARF, CKD, CHF exac, AMI, PE, COPD exacerbation, PNU, RSV, acute abd -perforations, illeus, SBO, anaphylaxis… I can readily determine toxic from non-toxic. I intubate, place chest tubes perform pericardiocentesis, needle decompression of pneumothorax, lumbar puncture…
I have seen surgeons, internists and family docs misdiagnose and miss stuff -plenty. I am not a midlevel I am not a nonphysician or extender. I spent as many years in school and training as a family practice doc. I am a board certified family practice NP and provide superior complex healthcare to those I serve.
Troy
Anonymous
“am not a midlevel I am not a nonphysician or extender. I spent as many years in school and training as a family practice doc”
So by saying that you are “not a nonphysician” therefore you are saying you ARE a physician.
An FP spent 4 years in undergrad, 4years in med school, and 3 years in residency. You spent 4 years in undergrad (assuming you are a BSN) and two years in NP school. Out of curiousity how does 6=11?
Anonymous
two questions-
1. trey or troy?
2. do you have your patients call you “doctor?”
Anonymous
Trey-
As a board-certified Internist, i have NEVER seen a pericardiocentesis performed, except on the hit tv show ER! Do they teach that in NP school?
Anonymous
i have seen many excellent midlevel providers. this troy guy has the one thing that stands out to me in a bad midlevel- not knowing one’s limits.
god help the zebra that walks into this guy’s ED.
Anonymous
I am sooo special that 6 + me = 11
Anonymous
Anon 8:13 you totally missed the point. Tre(o)y stated “I spent as many years in school and training as a family practice doc”. Which is patently false. By the way, I am not an FP. Frankly given the constant abuse of this specialty it amazes me that anyone still goes into FP. The problem here is someone who thinks he is equal to an FP yet never went to med school or did a residency. I personally have no problems with PA/NP’s when they act within their scope of practice. But I also don’t think 6=11.
Throckmorton
We have seen a significant increase in our transfer numbers from the outside ERs that are only staffed by PAs and NPS. My groups own experience is that the description of the patient more times than not is not accurate of what is really going on. This was shared at our last medical staff meeting. Because of EMTALA, our staff pretty much has to accept the patients but they are afraid to accept them because they really have no idea of what is going on with them, much less if they are stable.
These are some of the cases that were presented at our last staff meeting.
Patient diagnosed with severe renal colic witg stones and obstruction. Actually had a disecting aorta. (Was sent to urology)
Several severe pneumonias with shortness of breath. (They needed intubation and actually had cardogenic shock. Pneumonia was pulmonary edema)
Numerous cases of patients who needed to be intubated and stabilized prior to transfer who were not.
What really scares me is that at least these patients made it to the medical center. What about the patients that are sent home from the ER?
Anonymous
This is sort of an amalgam of some earlier comments, but …
At our (urban) ED 80-90% of what comes in the door (excluding the stuff in the trauma bays) is BS related to either a lack of (access to) primary care or an entitlement attitude that you can get free and immediate care by calling 911 and getting a ride to our ED (because everyone knows we won’t try to collect on a bill). Any NP/PA (or heck, good 4th year med student) can deal with these people.
That leaves the 10-20% which truly require intervention and admission. As someone pointed out, one issue is correctly identifying these people (I’m pretty sure that once they do, they could keep most folks alive for 30 minutes so an MD could see them).
The other issue is the MD staffing one. Sure you’d probably get better outcomes if you had an BC/BE ED MD on site 24/7, but if the choices are between closing an ED in a rural area or staffing with extenders and causing some excess of deaths compared to an MD staffed ED, I’m pretty sure the open ED actually saves lives vs the extra travel time (ie if you close the ED, the nearest ED isn’t 30 minutes away, it is an hour).

Physician assistants and nurse practitioners are staffing rural ERs full time

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