PAs in the ED


Emergency medicine physician assistants practice medicine as members of a team with their supervising physicians.  

Qualifications | Practice Setting & Supervision | Scope of Practice | Co-signing Charts |
Compliance | Credentialing & Enrollment |Cost Effectiveness | Hiring PAs 


Qualifications

To qualify to work in the emergency department, a physician assistant must have:

  • Graduated from an accredited physician assistant training program and be certified or eligible to be certified by the National Commission on Certification for Physician Assistants (NCCPA)
  • Comply with licensure and other regulations of the PA practice act in the state in which he or she practices
  • Develop or maintain qualifications through:
    • Ongoing emergency medicine training and CME in emergency medicine
    • Experience in emergency medicine as a physician assistant
    • Graduate of emergency medicine physician assistant residency.
    • Membership in SEMPA is encouraged
     

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Practice Setting & Supervision

Emergency medicine physician assistants may provide emergency care for patients in various settings such as:

  • Emergency departments and critical care units
  • Urgent care and fast track settings, observation units, chest pain centers
  • Pre-hospital situations, ground or air transport of patients in all settings
  • Education, teaching and administrative functions pertaining to emergency medicine

PAs practice medicine with the supervision of licensed physician and, although by law PAs are dependent practitioners, they typically exercise considerable autonomy in clinical decision-making. Supervision may be provided by varied methods such as physical presence or reasonable access by telephone or electronic media. Each state will have its own supervisory requirements and it is mandatory that the physician/EMPA team follows state law where they are practicing.

There are several types of documents that are used to describe how a physician and PA will work together. These documents are often referred to as "supervision agreements", "delegation agreements", "job descriptions", "physician-PA practice agreements", or "supervision protocols." Whatever it’s called, the purpose of the document is to: describe how the supervising physician and PA will work together; outline any specific requirements the physician has for the PA; how supervision will be documented; and general expectations for the physician and the PA. Some state laws require specific information be included in the practice agreement. The best supervision agreements are general one- or two-page documents that allow flexibility and do not have to be modified every time the PA learns a new procedure or takes on a new task.

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Scope of Practice

There are four parameters that determine the scope of practice for an emergency medicine physician assistant:

  • State law and regulation (or in the case of federally employed PAs, by the federal employer)
  • Facility policy
  • Education, experience, and expertise of the PA
  • Determination of the supervising physician(s) about what will be delegated

PAs are utilized in all areas of the ED and in all settings from being the solo provider in a rural ED to providing patient care at a Level I Trauma Center. When staffing the ED, a PA typically sees the same patient acuity mix as the physician(s) with whom they work in the physician/PA team.

In emergency medicine, the ED medical director, other supervising physicians and the EMPA typically reaches decisions about delegation jointly. Because medical practice and physician/PA practice are dynamic, specific lists of approved tasks that can be applied to all facilities and to all physician PA teams are not practical. There are not any "typical" restrictions on what a PA does in the ED. The physician/PA team and the hospital should be aware of any restrictions on the PA's scope found within state law or hospital policy.

Examples of scope of practice include, but are not limited to the following:

  • Membership on the medical staff, including hospital privileges and voting privileges
  • Active and ongoing involvement in the quality improvement activities in the department of emergency medicine
  • Taking patient histories and performing physical examinations of a patient and recording or dictating the history and physical in the medical record.
  • Performing a medical screening exam
  • Performing diagnostic and therapeutic studies
  • Ordering medications; ordering and interpreting diagnostic laboratory tests, radiological studies or various other therapies. Orders may be written or verbal
  • Establishing diagnostic decision-making
  • Instructing and counseling patients regarding mental and physical health, including but not limited to the following: diet, disease, prevention, treatment and normal development
  • Referring patients to appropriate specialists, health facilities, agencies and resources. Also referring and conversing with appropriate consultants in regard to patient management.
  • Performing such other tasks, not prohibited by law, in which the physician assistant has been trained and is proficient to perform.
  • Writing admission orders as requested by the accepting or admitting physician per hospital and department policy
  • Performing diagnostic/therapeutic procedures, subject to state regulation and PA training/experience, such as, but not limited to:
    • Abscess incision and drainage
    • Administration of medications and injections
    • Advanced Cardiac Life Support including all procedures
    • Advanced Pediatric Life Support including all procedures
    • Advanced Trauma Life Support including all procedures
    • Anoscopy
    • Arterial puncture and blood gas sampling
    • Arthrocentesis
    • Cast and Splint application
    • Central line placement
    • Dislocation reduction management
    • Debridement of burns, abrasions and abscesses
    • Epistaxis management
    • Extensor tendon repair
    • Fracture Reduction
    • Foreign body removal: ears, nose, rectum, soft tissue, throat, vaginal
    • Immobilization techniques (spine, long bone, etc.)
    • Intubation - Endotracheal/Nasal
    • Interosseous needle placement
    • Laceration repair - simple intermediate, complex
    • Lumbar puncture
    • Nail trephination/removal
    • Nasogastric/Orogastric tube placement, lavage and management
    • Obstetrical patient evaluation
    • Ordering and initial interpretations of radiological studies
    • Ordering of EKGs with interpretation
    • Paracentesis
    • Procedural sedation management
    • Regional block anesthesia including double cuff method/bier block
    • Slit lamp diagnostic and rust ring removal
    • Tonometery, ocular
    • Thoracentesis
    • Thoracostomy tube insertion
    • Urethral catheter placement and management
    • Emergency ultrasonography
    • Venous access, peripheral/cutdown
    • Wound care
    • Other interventions or procedures as directed by the supervising physician
     

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Co-signing Charts

There are three factors that can determine whether a PAs chart requires as co-signature:

  • State law  
  • Hospital by-laws or regulations  
  • In some cases, requirements by third party payers  

The Medicare program does not require a PAs chart to have a co-signature. However, Medicare will defer to state law and require chart co-signature if that is a requirement of state law.

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Compliance

Many of the issues concerning the utilization PAs in the ED are the same issues that confront emergency department physicians including:

  • Assuring medical necessity for services rendered
  • Actually performing the service(s) that were billed
  • Adequately documenting the E/M CPT code(s) that are billed
  • Assuring compliance with Stark rules to avoid allegations of kick-back arrangements

Some issues that are unique to PA utilization in the ED include:

  • Assuring that the PA is providing services that are within the state scope of practice and authorized by the hospital
  • Meeting state and hospital supervision requirements Avoiding the use of "incident to" billing when treating Medicare patients in the hospital

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Credentialing & Enrollment

Each payer determines credentialing and enrollment policies for PAs. In fact, the same national payer may have different rules regarding PA credentialing and enrollment in different states. And, some private payers or Medicaid departments may enroll PAs while others will not.

It’s important to understand that enrollment and credentialing are not synonymous with coverage or payment for services. Many payers who do not separately credential PAs will cover their services when billed under the supervising physician's name or the group practice.

The term "incident to" is occasionally used to describe coverage of services performed by a PA, when those services are billed under the name of the supervising physician. That is not correct. "Incident to" is a Medicare term used to describe services billed in the office or clinic setting. The "incident to" billing concept is not utilized in the hospital (inpatient or outpatient).

Non-Medicare payer enrollment policies are made on the local payer level. The policies followed by Medicaid and Blue Cross/Blue Shield programs vary considerably by state. For example, the Medicaid program in one state may enroll PAs, while the Medicaid program in a neighboring state may only recognize physician services.

The best way to determine credentialing and enrollment policies is to contact the payers in your specific area to ascertain their policies.

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Cost Effectiveness

Utilizing PAs in the ED has proven to be both cost effective and efficient.

PAs provide similar, and in most cases identical, medical services that are being provided by their supervising physician but at a much lower cost. By adding a PA program to the ED, more patients can be seen faster, reducing patients waiting times and improving patient satisfaction. PAs can be utilized to treat lower acuity patients and those patients most likely to be discharged home from the ED, giving the physician more time to care for critical patients.

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Hiring PAs

When recruiting PAs, an emergency department should consider its needs, and it’s important to match the expectations of the ED and the PA.

Another aspect to consider is the level of experience. Any organization hiring a new graduate should be mindful that newly trained PAs require more mentoring and closer supervision than experienced PAs. A seasoned PA with emergency medicine experience will be more likely to hit the ground running, may work at a more rapid pace than a new graduate and be able to handle a higher volume of patients.

Providing rotations for PA students in an ED is an excellent way to recruit new graduates – the physicians have a chance to work with the PA student before making a hiring decision.

When looking for ED candidates, employers might wish to consider individuals with previous ED experience, either as a PA or in a previous career as a technician, paramedic, or nurse, for example. Very often, PAs who are drawn to emergency medicine have worked in emergency medicine in some capacity before they became PAs.

SEMPA has a robust Career Center designed for PAs and employers alike.

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