Healthcare and Medical News for Atlanta Physicians

Meeting Patients’ Needs

By Dr. Shamie Das, Alexis Lynch, Meredith Stauch and Jocelyn Montgomery

emergency medicineCreating the emergency department workforce of the future.

Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs), have been members of healthcare teams across various specialties for decades. Since the program’s beginnings in the 1960s, the role of APPs in clinical practice have continued to evolve, serving the needs of patients and organizations by providing access to care and lowering economic demands on the healthcare system.[1] According to the Bureau of Labor Statistics, more than 300,000 NPs and 130,000 PAs are practicing in the United States, with rates of growth expected to outpace most professions.[2],[3]

APPs are a necessary part of the team-based solution to ensure access to care as the aging population accelerates the demand for healthcare.[4] From 2012 to 2018, APP staffing in emergency departments (EDs) has collectively increased by 66% (NP growth of 99% vs. PA growth of 53%).[5] Recent data indicate APPs see over 20% of patients presenting to the ED for acute unscheduled care. APPs practicing emergency medicine are projected to reach nearly 40,000 by 2030.4

Workforce Challenges

Like many specialties in the United States, emergency medicine (EM) faces workforce challenges. Workforce estimates over the past decade have predicted shortages in emergency physician supply, creating opportunities for care models incorporating APPs.[6] The calculus has changed post-pandemic due to the explosion of EM residency training programs, a growing proportion of patients seen by APPs coupled with growth in APP training programs, and above-expected physician attrition accelerated by the COVID-19 pandemic.[7]

This past year’s Match saw a significant decline in medical students entering EM residency training with only 81.7% spots filling initially.[8] It remains to be determined if this is a trend or an outlier event, as the pipeline for EM physicians lags by a minimum of 7 years (duration of medical school and residency training).

Studies have demonstrated mixed results in terms of APP productivity, but general consensus is that clinical productivity is approximately half of their physician counterparts. Cost also varies proportionally, as APPs’ hourly rates are a fraction of physicians’. Nonetheless, organizations such as Grady Memorial Hospital have effectively utilized APPs in a structured academic setting to expand access to the community and deliver safe, quality care with similar patient outcomes.[1]

APP Education and Training

Significant differences exist between physicians, PAs, NPs and advanced practice registered nurses (APRNs) in postgraduate education and training. Administrators, supervising physicians, policymakers and the community must understand these differences in order to successfully create staffing models that support appropriate on-the-job training, collaboration and oversight for APPs.

Advanced practice providers are typically trained in general medicine, and while they function similarly in the emergency department, they have different training routes.[2] The minimum education level for an NP is a master’s degree. All Emergency Nurse Practitioners (ENPs) must first become Family Nurse Practitioners (FNPs), given they provide care for patients of all ages.9

PA programs are primarily master’s degree programs. PAs must take the Physician Assistant National Certifying Examination (PANCE) to receive a state license. PAs can obtain an additional Certificate of Added Qualifications (CAQ) in emergency medicine.9

The American College of Emergency Physicians has recommended that APPs have specific experience or specialty training in emergency medicine.[3] The American Academy of Emergency Nurse Practitioners (AAENP) and the Society of Emergency Medicine Physician Assistants (SEMPA) identify the need for formalized training for APPs practicing in EDs.[4],[5] However, no standardized approach has been applied to address the lack of training, and variations in educational curricula and experiences make it difficult for leadership teams to assess competency.

A Model for the Future

The EM APP team at Grady is the organization’s largest and fastest-growing group of APPs. There are currently 54 APPs (21 PAs and 33 NPs), including a leadership team of one Chief APP and four Leads to help oversee hiring/onboarding, clinical operations, continuing education and performance management.

Of the 29 nurse practitioners eligible, 14 are certified as Emergency Nurse Practitioners (ENP-C). The APPs staff a wide variety of clinical areas: triage; low-, moderate- and high-acuity medical zones; a Level I trauma center; 23-hour stay ED observation unit; a dedicated acute care center for patients with sickle cell disease; as well as a stand-alone urgent care clinic adjacent to the ED.

The APPs take an interdisciplinary approach to patient care in collaboration with attendings, residents, nurses and other team members.  All APPs must maintain BLS/ACLS and ATLS certifications, and NPs are strongly encouraged to obtain an ENP certification.

The onboarding program for EM APPs at Grady is an excellent model of graduated responsibility and supervised practice. Grady’s APP leadership team created a formal onboarding and orientation process to ensure APPs are equipped with the skills necessary to care for ED patients. Over 20 new APPs have been successfully onboarded in the last two years alone.

Once credentialing by the medical staffing office is complete, new hires begin classroom orientation facilitated by a Lead APP. The classroom orientation includes information about scope of practice, departmental policies and procedures, EMR training, workflows for each clinical area, documentation, billing/coding and interdisciplinary communication. New graduate APPs are also encouraged to purchase “The Original Emergency Medicine Bootcamp,” a course designed by nationally recognized emergency medicine faculty with the information needed to practice emergency medicine.

After the first week of classroom orientation, the APP is paired with an experienced peer who provides on-the-job training in a low-acuity medical zone. All patients seen by the new hire are staffed with an attending physician. The APP also meets weekly with APP leadership to discuss their progression through the orientation process and review feedback. After completing two months of orientation, the APP continues working in low-acuity areas for the first year and staffs all patients with an attending.

After one year of practice, the APP begins the second phase of orientation to the moderate acuity zones, typically working 4-5 shifts per zone following the same outline as the first year.

After 2-3 years of experience in the low- and moderate-acuity zones, APPs may have the opportunity to onboard in the high-acuity medical zone and/or Level I trauma center. This advancement is based on clinical readiness as determined by APP leadership.

Completing the “Foundations of Emergency Medicine” (FoEM) course is a prerequisite to high-acuity onboarding. FoEM is a free, open-access emergency medicine curriculum developed by one of Emory’s attending physicians, Dr. Kristen Moore. Onboarding to high-acuity zones also includes any area-specific procedural skills. Extended Focused Assessment with Sonography in Trauma (eFAST), for example, is taught by APP superusers who were trained by EM Ultrasound Faculty.  APPs are also encouraged to attend weekly residency lectures as supplemental education.

High-acuity medical and trauma patients seen by APPs are always staffed with an attending, in keeping with team-based care. Consultation is encouraged for complex patient presentations.

Team-Based Care

The concept of team-based care is at the core of emergency medicine as a specialty. We work alongside nurses, paramedicine providers, techs and other allied health professions, including APPs, to best meet the needs of our patients, continually striving to match scarce resources with what feels like insatiable patient demand. This remains truer than ever in the post-COVID-19 era.

The American College of Emergency Physicians (ACEP) recently published guidelines around the scope of practice of APPs in the ED, highlighting the importance of physician-led, team-based care and the development of thoughtful, evidence-based structured training to ensure optimal practice.[1] More high-quality studies are necessary to help advance those policies that further these goals.

Emergency medicine stands ready to meet patients’ growing need for acute, unscheduled care visits. Team-based care is being used in other capacities, such as telemedicine, and can potentially improve delivery in urgent care, retail and satellite clinics. The future of emergency medicine and healthcare should strongly emphasize educating and building the advanced practice provider workforce to meet the changing healthcare demands.4

Leaders should support structured training programs that are inclusive of all members of the interdisciplinary team, focusing on interprofessional relationships, physician/APP/nursing engagement and staffing models. Supporting these concepts builds employee retention and job satisfaction, ultimately improving patient satisfaction and access to high-quality care.4

References

  1. Advanced practice providers – a historical review. Neurocritical Care Society. https://currents.neurocriticalcare.org/blogs/currents-editor/2021/07/28/advanced-practice-providers-a-historical-review. Accessed April 1, 2023.
  2. Nurse anesthetists, nurse midwives, and Nurse Practitioners: Occupational Outlook Handbook. U.S. Bureau of Labor Statistics. https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm. Published September 8, 2022. Accessed April 8, 2023.
  3. Physician assistants: Occupational Outlook Handbook. U.S. Bureau of Labor Statistics. https://www.bls.gov/ooh/healthcare/physician-assistants.htm#tab-1. Published September 15, 2022. Accessed April 8, 2023.
  4. Marco C, Richwine C, Vafaie N, et al. The emergency medicine physician workforce: projections for 2030. Annals of Emergency Medicine https://www.annemergmed.com/article/S0196-0644(21)00439-X/fulltext. Published September 2, 2021. Accessed March 31, 2023.
  5. Marco C, Richwine C, Vafaie N, et al. The emergency medicine physician workforce: projections for 2030. Annals of Emergency Medicine https://www.annemergmed.com/article/S0196-0644(21)00439-X/fulltext. Published September 2, 2021. Accessed March 31, 2023.
  6. Bennett CL, Sullivan AF, Ginde AA, et al. National Study of the Emergency Physician Workforce, 2020. Ann Emerg Med. 2020;76(6):695-708. doi:10.1016/j.annemergmed.2020.06.039
  7. Gettel CJ, Courtney DM, Janke AT, et al. The 2013 to 2019 Emergency Medicine Workforce: Clinician Entry and Attrition Across the US Geography. Ann Emerg Med. 2022;80(3):260-271. doi:10.1016/j.annemergmed.2022.04.031
  8. Advance Data Tables 2023 Main Residency Match. NRMP. 2023. Accessed March 22, 2023.
  9. Pines JM, Zocchi MS, Ritsema TS, Bedolla J, Venkat A; US Acute Care Solutions Research Group. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. Acad Emerg Med. 2021;28(1):36-45. doi:10.1111/acem.14161
  10. Advanced practice providers (physician assistant and nurse practitioner) medical-legal issues.https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/medical-legal/mlc_adv-prac-prov-ip_final_nov-2016.pdf. Accessed March 31, 2023.
  11. Harrington J. Competency measurement approach for advanced practice providers in emergency medicine – page 4 of 4. ACEP Now. https://www.acepnow.com/article/competency-measurement-approach-advanced-practice-providers-emergency-medicine/4/. Published November 5, 2015. Accessed April 1, 2023.
  12. Chekijian, S.A., et al., Integration of advanced practice providers in academic emergency departments: best practices and considerations. AEM Educ Train. 2018. 2(Suppl Suppl 1): p. S48-s55.1.
  13. Kraus, C.K., T.E. Carlisle, and D.M. Carney. Emergency medicine physician assistant (EMPA) postgraduate training programs: program characteristics and training Curricula. West J Emerg Med. 2018. 19(5): p. 803-807.
  14. “Guidelines on the Role of Physician Assistants and Advanced Practice Registered Nurses in the Emergency Department.” ACEP Clinical Policy Statement. March 2022. https://www.acep.org/globalassets/new-pdfs/policy-statements/guidelines-reg-the-role-of-physician-assistants-and-nurse-practitioners-in-the-ed.pdf

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