The Role of Advanced Practice Providers in Pediatric Emergency Care Across Nine Emergency Departments

OBJECTIVES

Advance practice providers (APPs) have been increasingly incorporated into emergency department (ED) staffing. The objective of this study was to describe patient factors that predict when pediatric patient care is provided by APPs and/or physicians. We hypothesized that APPs care for a significant proportion of pediatric patients and are more likely to care for lower acuity patients.

METHODS

We performed a retrospective chart review of encounters in patients aged younger than 18 years across 9 EDs from January 2018 to December 2019. Data on age, acuity level, International Classification of Diseases, Tenth Revision code, procedures performed, disposition, provider type, and length of stay were extracted from the electronic health record.

RESULTS

Of 159,035 patient encounters, 37% were cared for by an APP (30% APP independently, 7% physician + APP) and 63% by physicians independently. Advance practice providers were more likely to care for lower acuity patients (60.8% vs 4.4%, P < 0.05) and those in EDs with less pediatric emergency medicine (PEM) coverage (33.4% vs 6.8%, P < 0.05). In an adjusted multinomic regression model, APPs were less likely than physicians to care for high-acuity patients (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.01-0.09), admitted patients (OR, 0.31; CI, 0.28-0.35) and patients in EDs with more PEM coverage (OR, 0.09; CI, 0.09-0.09).

CONCLUSIONS

Advance practice providers cared for more than one third of pediatric patients and tended to care for lower acuity patients and for patients in EDs with less PEM coverage. These data highlight the importance of integrating APPs into initiatives aiming to improve pediatric emergency care.

The contribution of physician associates or assistants to the emergency department: A systematic scoping review

Background

New health care professionals, such as the physician associate or assistant (PA), have expanded the ability of health systems to meet the needs of the population in both primary and secondary health care settings. Although PAs are widely deployed in the emergency department (ED), their role in the ED has not previously been formally described. This systematic scoping review synthesizes and critically analyzes existing literature on the impact and perception of the role of PAs working in the ED.

Methods

We performed a systematic scoping review. We searched Medline, PubMed, Scopus, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE) and EMCare for English language peer-reviewed studies describing PA roles in the ED. Both qualitative and quantitative studies were included. We assessed the quality of the articles using QualSyst and the mixed methods appraisal tool. Themes regarding PA roles in the ED were identified.

Results

We included a total of 31 studies. Themes identified in the review included perceptions of the PA, wait times, acuity of patients seen, length of stay, those leaving without being seen (LWBS), clinical outcomes, pre-admission rates, well-being and scope of practice. Both the doctors' and patients' perception of PAs in the ED were generally high. The hindrance of them not being able to prescribe was evident. Studies showed a reduction in waiting times, length of stay, readmission rates, and those leaving without being seen when PAs work in the ED seeing moderate- to low-acuity patients. Evidence shows that PAs have a positive impact and the perceptions of the PAs are high in international EDs. There is significant evidence of PAs being key members of the health care team. Their work is particularly helpful for low- to moderate-acuity patients. With the increase in health care demand and a suffering UK National Health Service (NHS), the evidence synthesized in this review supports the potential positive impact PAs can have on the NHS and more specifically, the improvements of ED throughput metrics.

Conclusions

This review identified the roles and positive influence of PAs in the ED. These findings highlight current and future challenges for PAs in the ED.

A curriculum to improve knowledge and skills of nurse practitioners and physician assistants in the pediatric emergency department

ABSTRACT

Nurse practitioners (NPs) and physician assistants (PAs) have an important role in delivery of care in a tertiary children's hospital emergency department (ED). Most NPs and PAs have not had any formal training to work in a pediatric ED; although our NPs and PAs had no formal ED training, some were acute care certified. We describe a curriculum designed to improve knowledge and skills of NPs and PAs in the pediatric ED. The curriculum consists of three modules, namely, online lecture series, procedural workshops, and case scenarios in a simulated setting. Module 1 consisted of online lecture on 10 common ED diagnoses. The second module consisted of procedural workshops on lumbar puncture, incision and drainage of abscesses, gastrostomy insertion, and laceration repair. The third module included simulation scenarios on ED-specific cases of seizure in an infant, bronchiolitis and ruptured appendicitis with shock. Each module was evaluated by a survey. Participants rated each item on the survey using a Likert scale response (1 = disagree completely to 5 = agree completely). Both NPs and PAs demonstrated increase in knowledge scores in posttest 1 vs pretest (p < .001) and did not show a significant decline in posttest 2 (p = .073). The mean ratings of components of the online lecture series, workshops, and simulation scenarios were 4.5-4.7, 4.4-4.8, and 4.5-4.7, respectively, with positive comments. This novel curriculum meets the educational needs of NPs and PAs at our institution and can be used as a model to train them at other tertiary care pediatric EDs.

Insights into the physician assistant profession in Canada

Physician assistants (PAs) have been used for decades in the Canadian military. Now, PAs are being introduced in various clinical settings to provide patient care for the general population. This article reviews major developments in the PA profession across Canada over the last decade. Nearly 541 PAs are employed in Canada or work for a Canadian agency. Growing evidence demonstrates the positive effect of PAs; however, key issues challenge the extent to which the PA movement will continue to build momentum.

Forecasting the effect of physician assistants in a pediatric ED

BACKGROUND

Most pediatric ED visits are for nonemergent problems. Physician assistants are well trained to manage these patients; however, their effect on patient flow in a pediatric ED is unknown.

OBJECTIVES

To compare the effect on key pediatric ED efficiency indicators of extending physician coverage versus adding PAs with equivalent incremental costs.

METHODS

We used discrete event simulation modeling to compare the effect of additional physician coverage versus adding PAs on wait time, length of stay (LOS), and patients leaving without being seen.

RESULTS

Simulation of extended physician coverage reduced wait times, LOS, and rates of leaving without being seen across acuity levels. Adding PAs reduced wait times and LOS for high-acuity visits, and slightly increased the LOS for low-acuity visits.

CONCLUSIONS

With restricted autonomy, PAs mainly benefitted the high-acuity patients. Increasing the level of PA autonomy was critical in broadening the effect of PAs to all acuity levels.

Improving health care efficiency through the integration of a physician assistant into an infectious diseases consult service at a large urban community hospital

Physician assistants have recently been introduced into the Canadian health care system. The impact of the integration of physician assistants into various health care fields in the United States has been studied in detail; however, there is a lack of Canadian data regarding this topic. Accordingly, this study compared outcomes related to health care efficiency in the two-year period before the integration of a physician assistant at an infectious diseases consult service with the two-year period after integration.

BACKGROUND:

Physician assistants (PAs) have recently been introduced into the Canadian health care system in some provinces; however, there are little data demonstrating their impact.

METHODS:

A retrospective case-control study was conducted between January 2010 and December 2013. Length of stay (LOS) and mortality were examined in the infectious diseases consult service (IDCS) compared with hospital-wide controls. The two-year period before the introduction of the PA to the IDCS of a large urban community hospital in Canada (2010 to 2011) was compared with the two-year period following the introduction of the PA (2012 to 2013).

RESULTS:

Following the introduction of a PA to the IDCS, there was a decrease in time to consultation from 21.4 h to 14.3 h (P<0.0001). LOS was significantly decreased among IDCS patients by 3.6 days more than that seen in matched hospital-wide controls (P=0.0001). Mortality did not significantly change after PA introduction in either cases or controls.

DISCUSSION/CONCLUSION:

PAs can improve health efficiencies in the Canadian health care setting, leading to reduction in LOS.

Clinical research priorities in emergency medicine

OBJECTIVE

To determine the clinical research priorities of Fellows of the Australasian College for Emergency Medicine (ACEM) in order to inform the strategic research agenda specific to multicentre clinical research.

METHODS

An anonymous survey of all ACEM Fellows (FACEMs) listed on the ACEM researcher database was conducted between January and March 2013.

RESULTS

Of 108 FACEMs invited to participate, 54 (50%) responded. Over half of respondents (61%) had a higher research degree but only a minority (24%) had funded research positions. The top research categories identified as priorities were resuscitation, trauma, cardiology, ED ultrasound, acute behavioural disturbance and geriatrics. The most common specific sub-categories included anterior chest pain, fluid resuscitation in trauma, and drug therapy for both atrial fibrillation and acute behavioural disturbance. Several specific research questions related to chest pain, resuscitation/sepsis, stroke, paediatrics and pulmonary embolus.

CONCLUSION

The findings provide guidance and support for research areas amenable to collaborative multicentre clinical research within emergency medicine. Discussion rounds are planned to translate these perceived research priorities to actual priorities.