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Wilbeck J, Davis WD, Tyler D, Schumann L, Kapu A. Analysis of nurse practitioner practice in US emergency departments: Evidence supporting educational preparation, credentialing, scope of practice, and outcomes. J Am Assoc Nurse Pract 2023; 35:373-379. [PMID: 37159426 DOI: 10.1097/jxx.0000000000000874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/29/2023] [Indexed: 05/11/2023]
Abstract
ABSTRACT The nurse practitioner (NP) role within emergency care has grown in recent years and now there are an estimated 25,000 NPs employed in diverse emergency care settings. Despite this significant growth and expansion of the NP within emergency care areas, challenges exist. In addition to the pervasive confusion regarding the NP role in emergency care, data and statistics detailing characteristics and outcomes of NP practice in emergency care are either lacking or misrepresented. This article explores barriers and provides current and accurate information describing the current educational preparation, credentialing, scope of practice, and outcomes among NPs in US emergency departments. The totality of available evidence reviewed supports safe, timely, efficient, and patient-centered care provided by NPs in emergency care.
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Affiliation(s)
- Jennifer Wilbeck
- Vanderbilt University School of Nursing, Nashville, Tennessee
- American Academy of Emergency Nurse Practitioners, Leander, Texas
| | - Wesley D Davis
- American Academy of Emergency Nurse Practitioners, Leander, Texas
- College of Nursing, University of South Alabama, Mobile, Alabama
| | - Diane Tyler
- American Academy of Nurse Practitioners Certification Board, Austin, Texas
| | - Lorna Schumann
- American Academy of Nurse Practitioners Certification Board, Austin, Texas
| | - April Kapu
- Vanderbilt University School of Nursing, Nashville, Tennessee
- American Association of Nurse Practitioners, Austin, Texas
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Gettel CJ, Schuur JD, Mullen JB, Venkatesh AK. Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019. Acad Emerg Med 2023; 30:89-98. [PMID: 36334276 DOI: 10.1111/acem.14625] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Advanced practice providers (APPs) comprise an increasing proportion of the emergency medicine (EM) workforce, particularly in rural geographies. With little known regarding potential expanding practice patterns, we sought to evaluate trends in independent emergency care services billed by APPs from 2013 to 2019. METHODS We performed a repeated cross-sectional analysis of emergency clinicians independently reimbursed for at least 50 evaluation and management (E/M) services (99281-99285, 99291) from Medicare Part B, with high-acuity services including Codes 99285 and 99291. We describe the outcome proportion of E/M services by acuity level and report at (1) the encounter level and (2) at the clinician level. We stratified analyses by clinician type and geography. RESULTS A total of 47,323 EM physicians, 10,555 non-EM physicians, and 26,599 APPs were included in analyses. APPs billed emergency care services independently for 5.1% (rural 7.3%, urban 4.8%) of all high-acuity encounters in 2013, increasing to 9.7% (rural 16.4%, urban 8.8%) by 2019. At the clinician level, in 2013, the average rural-practicing APP independently billed 22.8% of services as high acuity, 72.6% as moderate acuity, and 4.5% as low acuity. By 2019, the average rural-practicing APP independently billed 36.2% of services as high acuity, representing a +58.8% relative increase from 2013. Relative increases in high-acuity visits independently billed by APPs were substantially greater when compared to EM physicians across both rural and urban geographies. CONCLUSIONS In 2019, APPs billed independent services for approximately one in six high-acuity ED encounters in rural geographies and one in 11 high-acuity ED encounters in urban geographies, and well over one-third of the average APPs' encounters were for high-acuity E/M services. Given differences in training and reimbursement between clinician types, these estimates suggest further work is needed evaluating emergency care staffing decision making.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeremiah D Schuur
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jay B Mullen
- BlueWater Emergency Partners, LLC, Brunswick, Maine, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
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Pines JM, Courtney DM. How to effectively integrate advanced practice providers into the ED workforce. Acad Emerg Med 2023; 30:154-156. [PMID: 36445097 DOI: 10.1111/acem.14633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 11/25/2022] [Accepted: 11/25/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jesse M Pines
- US Acute Care Solutions, Canton, Ohio, USA.,Department of Emergency Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - D Mark Courtney
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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Bouchibti S, Maul T, Rivera-Sepulveda A. Comparison Between Physicians' and Nurse Practitioners' Resource Utilization in the Diagnosis and Management of Bronchiolitis in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1564-e1568. [PMID: 36040473 PMCID: PMC11061880 DOI: 10.1097/pec.0000000000002608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to describe the resource utilization of nurse practitioners (NPs) in the pediatric emergency department (ED) and compare among physicians. METHODS A retrospective cross-sectional study of secondary data analysis in a level 1 academic pediatric trauma center was conducted. Patients were aged 1 to 24 months, evaluated in the ED between January 1, 2014, and November 30, 2018, with a diagnosis of bronchiolitis or wheezing. Data included age group, length of stay, disposition, diagnostic tests (chest radiography [CXR], viral testing, respiratory syncytial virus test), treatment (bronchodilator, corticosteroid, antibiotic), and medical provider (physician, NP, combination of both). Resources were evaluated before (early era) and after (late era) the implementation of an institutional clinical practice guideline.Comparisons between groups were done through χ2, Fisher exact, or Kruskal-Wallis test, as appropriate. RESULTS A total of 5311 cases were treated by a physician (65.3%), an NP (30.3%), or a combination of both (4.3%). The was a difference in the use of CXR, respiratory syncytial virus testing, bronchodilators, and corticosteroids among providers (P = 0.001). In the late era, NPs were less likely to order a bronchodilator (odds ratio [OR], 0.390 [95% confidence interval, 0.318-0.478; P < 0.001]), whereas physicians were less likely to order a CXR (OR, 0.772 [0.667-0.894, P = 0.001]), bronchodilator (OR, 0.518 [0.449-0.596, P < 0.001]), or a corticosteroid (OR, 0.630 [0.531-0.749, P < 0.001]). CONCLUSIONS Nurse practitioners made fewer diagnostic and therapeutic orders. A clinical practice guideline on the diagnosis and management of children with bronchiolitis successfully decreased the use of nonrecommended tests and therapies among NP and physicians.
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Fant A. A tale of two professions, but should it be? Acad Emerg Med 2022; 29:257-259. [PMID: 35064996 DOI: 10.1111/acem.14449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Abra Fant
- Department of Emergency Medicine Feinberg School of Medicine Northwestern University Chicago Illinois USA
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Carpenter CR, Abrams S, Courtney DM, Dorner SC, Dyne P, Elia T, Jourdan DN, Kaji AH, Martin IBK, Mills AM, Nagasawa K, Pillow M, Reznek M, Starnes A, Temin E, Wolfe R, Chekijian S. Advanced practice providers in academic emergency medicine: A national survey of chairs and program directors. Acad Emerg Med 2022; 29:184-192. [PMID: 34860436 DOI: 10.1111/acem.14424] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Society for Academic Emergency Medicine Board of Directors convened a task force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The task force surveyed academic emergency department (ED) chairs and residency program directors (PDs). METHODS The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member chairs and their respective residency PDs in 2021. We surveyed 125 chairs with their self-identified PDs. The survey sampled hiring, state-independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. RESULTS Of the AACEM-member chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast-track settings, 80% work in the main ED, and 54% work in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents reported that APPs manage high-acuity patients without attending involvement. Two-thirds of chairs believe that APPs contribute positively to the quality of patient care, while 44% believe that APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe that residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. CONCLUSIONS APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic ED within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.
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Affiliation(s)
- Christopher R. Carpenter
- Department of Emergency Medicine Washington University in St. Louis School of Medicine Emergency Care Research Core St. Louis Missouri USA
| | - Stacy Abrams
- Department of Emergency Medicine Columbia University College of Physicians and Surgeons New York New York USA
| | - D. Mark Courtney
- Department of Emergency Medicine UT Southwestern Medical Center Dallas Dallas Texas USA
| | - Stephen C. Dorner
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
| | - Pamela Dyne
- Department of Emergency Medicine UCLA David Geffen School of Medicine Olive View‐UCLA Medical Center Sylmar California USA
| | - Tala Elia
- Department of Emergency Medicine University of Massachusetts Medical School‐Baystate Springfield Massachusetts USA
| | - Daniel N. Jourdan
- Department of Emergency Medicine Henry Ford Hospital–Detroit Detroit Michigan USA
| | - Amy H. Kaji
- Department of Emergency Medicine Harbor‐UCLA Medical Center David Geffen School of Medicine at UCLA Torrance California USA
| | - Ian B. K. Martin
- Department of Emergency Medicine Department of Medicine Medical College of Wisconsin Medical School Milwaukee Wisconsin USA
| | - Angela M. Mills
- Department of Emergency Medicine Columbia University College of Physicians and Surgeons New York New York USA
| | - Kat Nagasawa
- Society for Academic Emergency Medicine Des Plaines Illinois USA
| | - Malford Pillow
- Department of Emergency Medicine Faculty, Department of Education, Innovation & Technology Baylor College of Medicine Houston Texas USA
| | - Martin Reznek
- Department of Emergency Medicine University of Massachusetts Medical School Worcester Massachusetts USA
| | - Andrew Starnes
- Wake Forest University School of Medicine Winston‐Salem North Carolina USA
| | - Elizabeth Temin
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
| | - Richard Wolfe
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston Massachusetts USA
| | - Sharon Chekijian
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
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Mori K, Tsukamoto Y, Makino S, Takabayashi T, Kurosawa M, Ohashi W, Okumura M, Fujita Y, Fujiwara Y. Effect of intensive care provided by nurse practitioners for postoperative patients: A retrospective observational before-and-after study. PLoS One 2022; 17:e0262605. [PMID: 35061830 PMCID: PMC8782326 DOI: 10.1371/journal.pone.0262605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/29/2021] [Indexed: 11/20/2022] Open
Abstract
Nurse practitioners are increasingly now members of intensive care teams in Japan, but no data exist about their effect on the outcomes for critically ill patients. This study aimed to compare the outcomes of postoperative patients on mechanical ventilators before and after the participation of nurse practitioners in intensive care teams. We retrospectively identified 387 patients who underwent postoperative mechanical ventilation at a University Hospital in Japan, using data from medical records from 1 April 2015 to 31 March 2017. We extracted data and compared patients' length of stay in the intensive care unit and the hospital, mechanical ventilation days, postoperative rehabilitation start date, rehabilitation prescription, intensive care unit and hospital mortality, and intensive care unit readmission. Multiple regression analysis was used to analyze the factors affecting length of stay in the intensive care unit. Patients who received care from nurse practitioners and physicians had significantly shorter stays in intensive care (4.8 ± 4.8 days versus 6.7 ± 10.3 days, p < 0.021). Mechanical ventilation days, total length of hospital stay, rehabilitation prescription, mortality in intensive care and hospital, and readmission to intensive care were all similar to those who received care only from physicians. The multiple regression analysis suggests that participation of nurse practitioners in intensive care reduced the length of stay in the unit by 2.6 days (p = 0.003). These findings could help to increase use of non-physician healthcare providers in intensive care. Our results demonstrated that it is both effective and safe for nurse practitioners to participate in intensive care teams that provide care for postoperative patients receiving mechanical ventilation.
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Affiliation(s)
- Kazunao Mori
- Division of Nursing, Aichi Medical University Hospital, Aichi, Japan
| | - Yoko Tsukamoto
- Department of Nursing and Social Sciences, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Satoshi Makino
- Division of Nursing, Aichi Medical University Hospital, Aichi, Japan
| | | | | | - Wataru Ohashi
- Division of Biostatistics, Clinical Research Center, Aichi Medical University Hospital, Aichi, Japan
| | - Masatoshi Okumura
- Department of Anesthesiology, Aichi Medical University, Aichi, Japan
| | - Yoshihito Fujita
- Department of Anesthesiology, Aichi Medical University, Aichi, Japan
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Westafer LM, Bond C, Milne W. Hot off the press: Diagnostic testing differences between advanced practice providers and physicians. Acad Emerg Med 2021; 28:922-924. [PMID: 33721344 DOI: 10.1111/acem.14247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Lauren M. Westafer
- Institute for Healthcare Delivery and Population ScienceUniversity of Massachusetts Medical School–Baystate Springfield Massachusetts USA
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield Massachusetts USA
| | | | - William Milne
- University of Western Ontario Goderich Ontario Canada
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