US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis

Adherence to "Choosing Wisely" Recommendations in Pediatric Emergency Medicine

STUDY OBJECTIVE

In 2022, Choosing Wisely released recommendations to decrease the frequency of low-value testing in pediatric emergency medicine. The extent to which low-value testing occurs in US emergency departments (EDs) may vary by ED experience. We compared the frequency of low-value testing with ED volume.

METHODS

We conducted a cross-sectional study using data from the Healthcare Cost and Utilization Project in all EDs in 8 states from January 1, 2014 to December 31, 2020. We included children aged below 18 years with one of the addressed diagnoses: respiratory tract illness, mental or behavioral health condition, seizure, constipation, or respiratory viral illness. ED volume was defined using National Pediatric Readiness Program categories of pediatric visits per year: less than 1,800 (low); 1,800 to 4,999 (low-medium); 5,000 to 9,999 (medium); or ≥10,000 (high) with an outcome of low-value testing, determined using procedure codes. We evaluated the adjusted association of volume with low-value testing using logistic regression with clustering by site.

RESULTS

We analyzed 5.6 million visits. Low-value tests were obtained in 19.3% of encounters. Low-value tests were obtained in 12.2% of visits to low-volume EDs, 20.5% for low-medium-volume EDs, 23.1% for medium-volume EDs, and 18.7% for high-volume EDs. Low-volume sites had the lowest rates of testing for mental or behavioral health conditions, constipation, and respiratory viral illness. High-volume sites had the lowest rates of testing for respiratory tract illness and seizure.

CONCLUSIONS

Low-value testing occurred in one fifth of ED visits for children with a study condition. The relationship of ED volume to low-value testing was inconsistent across conditions.

Breaking Barriers and Navigating the Future of Emergency Care: The Role of the Emergency Nurse Practitioner

Over the past two decades, the emergency nurse practitioner (ENP) role has significantly enhanced emergency care in the United States. With the increasing complexity of emergency care, ENPs have expanded into nontraditional settings, necessitating regulatory updates to maintain patient safety. The Consensus Model for Advanced Practice Registered Nurse Regulation has influenced ENP practice, yet consistent regulatory recognition is still needed due to the marked evolution in ENP practice. Despite collaborative efforts to prepare the ENP workforce and ensure competency through standardized education, certification, and licensure, recent unethical publications and skewed statistics have threatened the specialty's progress. Addressing these challenges is crucial for advancing the ENP role and ensuring high-quality emergency care delivery.

Racial difference in receiving computed tomography for head injury patients in emergency departments

STUDY OBJECTIVE

Prior studies have suggested potential racial differences in receiving imaging tests in emergency departments (EDs), but the results remain inconclusive. In addition, most prior studies may only have limited racial groups for minority patients. This study aimed to investigate racial differences in head computed tomography (CT) administration rates in EDs among patients with head injuries.

METHODS

Patients with head injuries who visited EDs were examined. The primary outcome was patients receiving head CT during ED visits, and the primary exposure was patient race/ethnicity, including Asian, Hispanic, Non-Hispanic Black (Black), and Non-Hispanic White (White). Multivariable logistic regression analyses were performed using the National Hospital Ambulatory Medical Care Survey database, adjusting for patients and hospital characteristics.

RESULTS

Among 6130 patients, 51.9% received a head CT scan. Asian head injury patients were more likely to receive head CT than White patients (59.1% versus 54.0%, difference 5.1%, p < 0.001). This difference persisted in adjusted results (odds ratio, 1.52; 95% CI, 1.06-2.16, p = 0.022). In contrast, Black and Hispanic patients have no significant difference in receiving head CT than White patients after the adjustment.

CONCLUSIONS

Asian head injury patients were more likely to receive head CT than White patients. This difference may be attributed to the limited English proficiency among Asian individuals and the fact that there is a wide variety of different languages spoken by Asian patients. Future studies should examine rates of receiving other diagnostic imaging modalities among different racial groups and possible interventions to address this difference.

Practice as you Teach: Comparing Ordering Practices Between Shared and Physician-Only Visits in Academically Affiliated Community Emergency Departments

BACKGROUND

Considerable variability exists in emergency physicians' (EPs) rates of resource utilization, which may cluster in distinct patterns. However, previous studies have focused on academic and tertiary care centers, and it is unclear whether similar patterns exist in community practice.

OBJECTIVE

Our aim was to examine whether EPs practicing in community emergency departments (EDs) have practice patterns similar to those of academic EDs. Secondarily, we sought to investigate the effects of shared visits with advanced practice professionals and residents.

METHODS

This was a retrospective study of two community EDs affiliated with an academic network. There were 62,860 visits among 50 EPs analyzed from October 1, 2018 through January 31, 2020 for rates of advanced imaging, admission, and shared visits. To classify practice patterns, we used a Gaussian Mixture Model (GMM), with groups and covariance determined by Bayesian Information Criteria.

RESULTS

Our GMM revealed three groups. The largest had homogeneous patterns of resource use (n = 28; 50% were female; years of experience: 7; interquartile range [IQR] 2-11; advanced imaging: 28%; admission: 19%; shared: 34%), a small group with lower resource use (n = 4; 0% were female; years of experience: 6; IQR 4-10; advanced imaging: 28%; admission: 16%; shared: 8%), and a modest high-resource group (n = 18; 28% female; years of experience: 5; IQR 2-16; advanced imaging: 34%; admission: 23%; shared: 43%). Rates of shared visits had little direct correlation with imaging (r2 = 0.045) or admission (r2 = 0.093), and rates of imaging and admission were weakly correlated (r2 = 0.242).

CONCLUSIONS

Our data suggest that community EPs may have multiple patterns of resource use, similar to those in academic EDs.

A comparison of the practice patterns of emergency department teams that include physicians, nurse practitioners, or physician assistants

BACKGROUND

Physicians see most emergency department (ED) patients, but, recently, nurse practitioners (NPs) and physician assistants (PAs) have provided an increasing amount of ED care.

PURPOSE

Compare NP and PA teams' practice patterns to physician teams in EDs.

METHODS

Using 12 years of data from the National Hospital Ambulatory Medical Care Survey (2009-2020), we used multivariate regression analysis to separately examine the associations between the ED practice patterns (i.e., number of diagnostic services, number of procedures, waiting time, boarding time, length of visit, and hospital admission) of patients seen by NP or PA teams compared with physician teams.

DISCUSSION

Patient visits to NP and PA teams received fewer diagnostic services and procedures, had shorter visits, and were less likely to be hospitalized.

CONCLUSION

If the additional diagnostic services, procedures, and hospital admission provided by physician teams were unnecessary for the patients studied, NP and PA team care could be more efficient.

Supporting Emergency Care Delivery Through Updated Emergency Nurse Practitioner Competencies

As multidisciplinary emergency care becomes increasingly complex, all team members must be aware of their respective roles and responsibilities. In the emergency department, nurse practitioners are integral members of the team. They possess a wide range of clinical and leadership competencies that allow them to perform specific and differentiated tasks within the emergency department. A well-defined competency not only contributes to the promotion of a positive work culture but also clarifies performance expectations, identifies skill gaps, and supports team development. Furthermore, it allows the nurse practitioner to adapt to changing conditions while maintaining patient safety. The competencies of emergency nurse practitioners have evolved over the past 2 decades. The authors discuss the importance of establishing clear expectations for emergency nurse practitioner practice in this article and the alignment of competencies with organizational culture and objectives.

Analysis of nurse practitioner practice in US emergency departments: Evidence supporting educational preparation, credentialing, scope of practice, and outcomes

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.