Methods for Utilizing PAs and NPs November 2, 2016

2016 WA-ACEP EM Leadership Summit

Tom Vascik, PA-C

Regional Director, Advance Practice Clinicians, Team Health West Group

Jaime Delcampo, MD, FACEP President, Tacoma Emergency Care Physicians

Who are we?

Tom Vascik, PA-C • Lead APC FHS • Director APC, THW • Practice at

• St. Clare ED • St. Francis ED • St. Joseph ED • St. Anthony ED

• Over 180,000 patients • Utilization varies by site

Jaime Delcampo, MD, FACEP • President, TECP • 35 Physicians, 15 PA/NPs • Practice at

• Tacoma General ED • Allenmore ED • Covington FSED

• Over 100,000 patients • Over 25% of patients are seen by

an APP • APP utilization

• Fast Track • Main ED • Triage

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Expectation

• Assumption: 1/3 of the room does not use APPs 2/3 use APPs in varying capacity

• Interactive discussion • Ask questions at any time • Disclaimer We are not experts but are willing to share our experience

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What is in a name?

Equivalent terms to describe Physician Assistants and Nurse Practitioners: • Allied provider • Midlevel provider(MLP) • Non-physician provider • Physician Extender • Advanced practice clinician (APC) • Advanced practice provider (APP)

Equivalent terms for Nurse Practitioners: • Advance Registered Nurse Practitioners (ARNP) • Advance Practice Registered Nurse (APRN) • Advance Practice Nurse (APN)

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State of Emergency Medicine

Crisis in ED • Increase waiting time • Increase ED crowding • Delayed care and access • Decreased patient

satisfaction

Added complicating factors • ED physician shortage

Rural America o 25% of population o 10% of physicians

practice

• Increasing health care costs

• Decreasing payer reimbursements

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Crisis Management: Increasing use of PAs & NPs

In 2009: • 14.6% of ED patient visits (1 out

of 7) had an APP involved • 2/3 of EDs used APPs • APP use in Urban EDs > non-

urban

In 2016: ?

Source: Wiler et al. Update on Midlevel Provider Utilization in US Emergency Departments, 2006 to 2009. Academic Emergency Medicine 2012 Aug; 19(8):986-9.

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Why have APPs flourished in the ED?

• Yes

ED Medical Director

Quality of Care

Cost Throughput

Patient Satisfaction

Possible Reasons Cost

• 25-50% that of a physician

Throughput • When costs are normalized, in certain settings,

APPs can see more patients per hour

Quality • With specific skill sets (e.g. laceration repair,

wound care), APPs have demonstrated similar performance to physicians

Patient Satisfaction • Majority of patients prefer seeing an APP than

waiting longer for a physician Who in the room is not doing this?

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Who are the APPs in the ED?

• PAs are used more in ED than NPs In 2009, 9.9% (PA) vs 4.7% (NP)

• Comparing 1993-2005 vs 2006-2009 No significant change

o Ambulance arrivals o Acuity of visits o Admission rates

Source: Brown et al. Continued rise in the use of mid-level providers in US emergency departments, 1993-2009. International J of Emergency Medicine 2012, 5:21

PA

NP

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What is the difference between PAs and NPs?

Physician Assistant • Background (varied)

• Paramedics, EMTs • RNs, CNAs, MAs • FMG

• Education

• Bachelor’s or Master’s degree • Completion of accredited PA program

(ARC-PA) • 1000 hrs didactic + 2000 hrs clinical

Nurse Practitioner • Background (uniform)

• RN school

• Education • Master’s or Doctorate degree • Completion from accredited graduate

nursing program (CCNE or ACEN) • 500 hrs didactic + 500-700 hrs clinical • Specialty Track

Family NP (55%) o Family Med & Peds o Lacks acute care & ED

Acute Care (8%) o Good for ED and Hospitalist o Lacks Peds training

Others – Peds, Gerentology, Pysch

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What is the difference between PAs and NPs?

Physician Assistant • Certification

• Pass national exam (PANCE)

• Re-certification/CME • Exam every 10 years • 100 CME hrs every 2 years

Nurse Practitioner • Certification

• Must pass national specialty board exam (ANCC or AANP)

• Multiple specialties: • Family NP • Acute Care • Adult or Pediatric Care

• Re-certification/CME

• Exam every 5 years OR • 1000 clinical hrs and 75-100 CME hrs

in specialty

Reality: The average graduating PA/NP has varied and often limited EM Training

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How do PAs and NPs get EM Training?

Physician Assistant • ED rotations in PA school

• EM Residency/Fellowships

<5% of grads pursue add’l training Usually 18 months ~20 programs nationally

• On the Job Training & CME • EM CAQ (Cert of Added Qualification)

3000 hrs ED experience 150 CME hrs specific to EM ED procedure verification EM Board exam

Nurse Practitioner • Varied ED training depending certification

(Family NP or Acute Care NP)

• EM Fellowships (same as PA but more rare)

• On the Job Training & CME • Emergency NP Certification

2000 hrs ED experience 100 CME hrs specific to EM 30 CME hrs on EM procedures ENP Board exam

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How do PAs and NPs get EM Training?

2009 Survey by Society of Emergency Physician Assistants (SEMPA)

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How do we then transition APPs to an EM practice?

Scope of Practice

Supervision

ED Setting

Supervising physician

ED Medical Director

Hospital Privileges

National Certification

State Licensing

APP Training & knowledge

Sponsoring physician

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Sponsoring Physician & Delegation Agreement

Physician assistants – WA state require that a PA submit a Delegation Agreement defining the working relationship between themselves and their sponsoring physician Nurse Practitioners – In WA state, NPs are independent providers and can function autonomously. No Delegation Agreement is required. Hospital credentialing office may present some limitations to autonomy.

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Does ACEP have guidelines on APP supervision?

ACEP Guidelines (revised and approved 2013) • APPs should not provide unsupervised ED care

• APP Scope of Practice must be clearly delineated

• APPs and ED physicians need to be aware APP scope of practice and physician

supervision responsibilities and requirements

• APPs and ED physicians should have an orientation and onboarding process

• Each supervising physician retains the right to determine his/her involvement in the care of patients managed by APP

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Does ACEP have guidelines on APP supervision?

ACEP Guidelines (revised and approved 2013) - continued

• ED Medical Director (or designee) Has the responsibility of providing the overall director of activities of the APPs Encourage to develop guidelines for APPs outlining the types of conditions APPs

may or may not routinely evaluate and treat Responsible for ongoing professional practice evaluation Responsible to identify the most appropriate staffing model to achieve

operational efficiency while maintaining clinical quality

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How do you define APP supervision?

Direct (ACEP definition): • Supervising physician providing “face to face time” with patient

o CMS requires “face to face time”, otherwise billed at 85% Indirect:

• Verbal supervising physician consultation • Chart review with co-signature • Chart review without co-signature • Some chart review to insure compliance to scope of practice • Required availability of supervising physician (varies by state and by hosp)

o Immediately available in the ED o On site o Accessible by phone or available within timeframe

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How do you define supervision? T

What are the keys to a successful transition to EM?

• Establish and insure compliance to Scope of Practice and supervising expectations

• Foster collaborative and supportive relationships Supervising physicians ED Team Hospital consultants

• Develop an on-going professional evaluation process • Chart reviews with focus on MDM, standard of care, coding • Rounding

• Encourage educational opportunities

• Don’t forget recognition and awards

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Working towards Quality

Scenario: The PA just approached me about a patient that is acutely ill, should I take over the case or what?

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Providing clarity on expectations

Scenario:

Can I Just Refuse to Sign the APC’s Charts?

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How are APPs being utilized?

2009 Report on Emergency Medicine Physician Assistants, SEMPA

68.5%

30.7%

0.7%

Main ED

Fast Track/UC

Triage

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APP in Fast Track

• “Easiest and safest” use of APPs

• Most patients by design are low acuity (e.g. ESI 4 & 5) o Largest percentage that require least amount of physician involvement o Facilitates transition of APPs with little EM experience

• Probably provides best financial yields factoring cost and risk

• Potential pitfalls o “Out of sight, out of mind”, FT is separated from main ED o Mis-triage of sicker patients. Process/procedure to redirect if needed. o Beware of common missed injuries (e.g. tendon injuries)

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APP in Fast Track

• In 2013 Comparison study of MLPs and ED Residents* • APPs treated more patients per hour (2.2 vs 1.5) • APPs generated more RVUs per hour (4.0 vs 3.1) • Residents generated more RVU per pt (2.1 vs 1.8) • No difference in patient satisfaction

*Jeanmonod et al. Comparison of resident and midlevel provider productivity and patient satisfaction in an emergency department fast track. Emergency Medicine Journal 2013; 30.

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APP in Triage

• “Physician in Triage” model • Improve “door to doc” times/patient satisfaction • Reduce risk by quickly identifying sicker patients • Initiate time sensitive treatments (e.g antibiotics) & studies (e.g. CT) • “Treat and street” selected low acuity patients (e.g URI, dental pain)

• Challenges

• Requires significant coordination of Triage team members • High costs – physicians are significantly less productive • Costs can be offset by improvements in patient sats and throughput => few successes

• Alternative: APP in Triage • Mitigates cost • Considerations: Need more experienced APPs to make it work well

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APP in Main ED

• “Most challenging but likely most exciting” – high yield/high risk

• Scope of Practice and Supervision is paramount

• Considerations: • APPs want to be in the main ED – see opportunity for growth

and experience • Increased demand for physician involvement • Varied interests for physicians to co-manage with APPs

• Success will be determined by the relationship between APPs and

Supervising Physicians

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APP in Main ED

• In 2014 comparison study of APPs and ED residents: • APPs saw more patients (1.56 vs 1.23) • APPs coded for less RVUs per patient (2.05 vs 2.73)

o Unclear reason: less thorough documentation vs self selection by APP for lower acuity patients

• Subgroup comparison with PGY3 residents • APPs saw more patients (1.56 vs 1.30) • APPs coded for less RVUs per patient (2.05 vs 2.79)

*Hamden et al. Comparison of resident and midlevel provider productivity in an high acuity emergency department setting. Emergency Medicine Journal 2014; 31:216-219.

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Are there malpractice risk issues with APPs?

2013 NPDB: • 9,447 claims

against MD/DOs • $3.2 Billion of

indemnity paid

APPs account for <1%

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What are APPs getting sued for? J

How to retain APPs?

Communication. Ensure open and honest communication between you and your APCs. Never refuse to discuss a patient or act frustrated when you are approached for help, even when you are very busy. Feedback. Don’t be hesitant to give feedback, but do so in a constructive, collegial manner, just like you would one of your physician partners. Ask for your APC’s opinion about work flow and work processes. Let their voice be heard. Recognition. Acknowledge their value and recognize their good work with open praise and thank-you notes. Education. Teach them whenever time allows, and let them teach you. Remember, they are not physicians and probably won’t have your knowledge or experience, but they are eager to learn and grow.

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• Questions?

• Any experiences to share?