The first studies of midlevel providers, which include physician assistants (PA) and nurse practitioners (NP), comparing quality of care were performed not long after the primary board certification of the emergency medicine discipline itself was achieved.
A meta-analysis of 45 studies comparing PA/NP to physician care was performed to report some interesting trends.1 It found that in a significant proportion of studies, patients were at least as pleased, if not more pleased, with NP/PA than with physician provided care. Process variable analysis finds no difference in outcome between patients seen by midlevel providers compared to physicians.
The emergency nurse provider (ENP) is an RN with specific postgraduate training, who functions in conjunction with the supervision of a physician functioning in an expanded role in the ED setting. Patients responded to a questionnaire study to report that this care was prompt (78%), courteous (92%), received a good or satisfactory rating (90%), was thorough (92%) and most (94%) said they would be examined by a NP again.2
There was a subtle physician bias concerning disease complexity, where the physicians felt the NP performed adequately in 93% of nonurgent cases, 80% in urgent, but only 59% in emergent cases. Over time, the advent of critical care NP programs in addition to the primary care NP certification programs have effected a positive change in this area as well.
Since the first physician assistant graduates provided care in 1966, the advent of this service has served to increase the affordability of ED care.3 It was suggested that 62% of all ED providers could be handled by a PA, with physician consultation required in 31% of the cases and only 7% that required direct physician intervention.4
There was a resounding endorsement of this profile as the majority (97%) of patients felt they could be seen again by the PA if the need should ever arise.
This is indeed a worldwide trend, with the British system embracing midlevel care as well. However, this survey found that only 9% of patients were managed primarily by the NP alone, with the majority (86%) of cases related to trauma, and not medical illness. The suitability of care protocols for this endeavor was documented as appropriate in most cases.5
Another important consideration is the beneficial effect on customer service. A study directly comparing care by NP to physician controls found equivalent overall satisfaction rates (3.9 vs. 4.0) on a 1 (poor) to 5 (excellent) linear scale.6 Most patients (80%) were non-committal on a repeat visit assignment to a midlevel, while 10% would prefer to see a physician or midlevel exclusively.
The use of PAs in the ED has been largely successful as well, featured in 50% of EDs nationally. A recent survey found a high level of satisfaction (93%), not influenced by patient’s age, gender, or insurance status.7 Interestingly, most of patients (88%) indicated they would not be willing to wait longer to receive care from an EDP. Those willing to wait would only be delayed an additional 30 minutes for physician care.
The advantages of a midlevel provider in the ED setting include benefits on efficiency and customer service, with an associated positive financial impact. PA/NP providers are capable of evaluating and meeting a wide variety of medical and surgical conditions in the ED setting. There is a large proportion of patients that prefer the “kinder and gentler” care of the midlevel provider. Lastly, the financial benefits offer a greater proportion of potential ED patients’ access to care. As patient care reimbursement progressively declines and unfunded mandates exist to care for additional ED patients, it becomes mandatory to include these numbers in your staffing plan. Antiquated staffing models suggest midlevels can see patients in a 0.5 – 0.75: 1 ratio with physicians, resulting in 1.0 – 1.5 pph rate.
Currently, midlevels are capable of seeing 2.5 (2.0 – 3.0) pph, which at today’s reduced reimbursement rates may be required to allow the program to survive, while an exclusively physician-staffed model requires an extensive subsidy to see the same patient volume.
There is a balance, however, requiring direct physician supervision of mid-levels to care for the more critically ill or admitted patients.
1. Sox, H.C., Jr. “Quality of patient care by nurse practitioners and physician’s assistants: a ten-year prospective.” Annals of Internal Medicine 1979; 91(3): 459 – 68.
2. Alongi, S., Geolot, D., Richter, L., Mapstone, S., Edgerton, M.T., Edlich, R.F. “Physician and patient acceptance of emergency nurse practitioners.” Journal of the American College of Emergency Physicians 1979; 8(9): 357 – 9.
3. Friedman, M.M. “A physician’s assistant in your ED?” Emergency Medical Services 1979; 8(3): 68.
4. Maxfield, R.G., Lemire, M.D., Thomas, M., Wansleben, O.; “Utilization of supervised physician’s assistants in emergency room coverage in a small rural community hospital.” Journal of Trauma 1975; 15(9): 795 – 9.
5. Read, S.M., Jones, N.M., Williams, B.T. “Nurse practitioners in accident and emergency departments: what do they do?” British Medical Journal, 1992; 305(6867): 1466 – 1470.
6. Rhee, K.J., Dermyer, A.L. “Patient satisfaction with a nurse practitioner in a University Emergency Service.” Annals of Emergency Medicine 1995; 26(2): 130 – 2.
7. Counselman, F.L., Graffeo, C.A., Hill, J.T. “Patient satisfaction with physician assistants (PAs) in an ED fast track.” American Journal of Emergency Medicine 2000; 18(6): 661 – 5.