SPECIAL CONTRIBUTION
Physician Assistants in Emergency Medicine: The Impact of Their Role Roderick S. Hooker, PhD, PA, David J. Klocko, MPAS, PA-C, and G. Luke Larkin, MD, MSPH
Abstract Background: Emergency medicine (EM) in North America has been undergoing significant transformation since the new century. Recent health care reform has put it center stage. Access demand for acute care is increasing at the same time the number of qualified emergency physicians entering service has reached a plateau. Physician assistants (PAs), one alternative, are employed in emergency departments (EDs), but little is known about the impact of their role. Objectives: This was a literature review to identify the current role of PAs in patient treatment and the management of emergency services. Methods: All publications and designs from 1970 through 2009 were identified using multiple science citation indices. Each author reviewed the literature, and categories were developed based on consensus. Results: Thirty-five articles and reports were sorted into categories of interest: prevalence of PAs in EDs, efficiency and quality of care, patient satisfaction, rural emergency care, and legal issues. Each category is summarized and discussed. Evidence comparing the clinical effectiveness of PAs to mainstream management of emergency care was only fair in methodologic quality. Conclusions: The use of PAs in EDs is increasing, and this expansion is due to necessity in staffing and economy of scale. Unique uses of PAs include wound management, acute care transfer management to the wards, and rural health emergency staffing. While their role seems to be expanding, this assessment identified gaps in deployment research using appropriate outcome measures in the area of clinical effectiveness of PAs. ACADEMIC EMERGENCY MEDICINE 2011; 18:72–77 ª 2011 by the Society for Academic Emergency Medicine
T
he demand for emergency medical care has increased substantially in the new millennium.1 The number of visits to emergency departments (EDs) is rising, and the shortage of physician personnel is mounting.2 The American College of Emergency Physicians (ACEP) reaffirmed that ‘‘there is currently a significant shortage of physicians appropriately trained and certified in emergency medicine.’’3 Emergency services, physician group practices, and hospital administrators have turned to physician assistants (PAs) as a way to meet increased health care demands. Such utilization From the Department of Veterans Affairs (RSH), Dallas, TX; the Department of Physician Assistant Studies, University of Texas Southwestern Medical Center (DK), Dallas, TX; and the Department of Emergency Medicine, Yale University (GLL), New Haven, CT. Received March 29, 2010; revisions received May 27 and June 5, 2010; accepted June 7, 2010. The authors have no disclosures or conflicts of interest to report. Supervising Editor: Lowell Gerson, MD. Address for correspondence and reprints: Roderick S. Hooker, PhD, PA; e-mail:
[email protected].
72
ISSN 1069-6563 PII ISSN 1069-6563583
suggests that physicians are realizing the effectiveness of PAs in the ED. The rate of ED visits is predicted to double by 2025, while the rate of emergency physicians (EPs) entering the profession is flat. Managers of acute care services are searching for additional labor solutions.1,4,5 The American health care reform act of 2010 includes priorities to improve the delivery of health care services, along with strengthening EDs and trauma center capacity. Because more demand for ED patient care is anticipated, we set out to examine utilization and efficacy with the premise that a greater quantity of PAs will be needed to assist in the delivery of urgent care. We conducted a review of PA ED literature on contemporary staffing arrangements. Our objective was a purposive literature review, rather than a systematic review. METHODS All publications and designs about PAs in EDs from 1970 through 2009 were identified using multiple science citation indices: Google Scholar, PubMed, and CINAHL. Key search terms included ‘‘physician(s) assistant,’’ ‘‘physician(s) associate,’’ ‘‘non-physician provider,’’
ª 2010 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2010.00953.x
ACAD EMERG MED • January 2011, Vol. 18, No. 1
www.aemj.org
73
‘‘PA, physician extender,’’ ‘‘midlevel provider,’’ ‘‘emergency medicine,’’ ‘‘emergency room,’’ ‘‘fast track,’’ ‘‘workforce,’’ ‘‘manpower,’’ and ‘‘acute care.’’ The authors reviewed the literature, and categories were developed based on consensus. Each category was summarized and discussed. Background and current understanding of PA employment was added for greater usefulness. Articles addressing the efficacy of the PA role in EDs were purposely selected.
cation will include: work experience in EM, a continuing medical education requirement, a patient log, and a specialty examination.15 Implications of PA specialty certification are part of a national debate. However, other attempts to develop voluntary specialty certification examinations have failed due to lack of interest.16
•
RESULTS Thirty-five articles and reports on PAs in EDs were sorted into the following topics of interest: history and education, prevalence, efficiency, quality of care, patient satisfaction, rural emergency care, and legal issues. History, Policy, and Education of PAs The use of PAs in American medicine began in 1967. Almost from the beginning, they were recruited for emergency services.6,7 As of 2009, all PA programs teach some aspect of emergency medical care, and each PA student spends clinical time in an emergency medicine (EM) setting. PAs are employed as health professionals who practice care under physician supervision.8 Approximately 7,817 (10%) worked primarily in EDs in 2009.9 To qualify for practice, PAs must be licensed in the state where they work. Licensing (or credentialing) is mandatory in all states, the District of Columbia, and most U.S. territories. All PAs must be graduates of an educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant. In 2010, there were 154 accredited PA programs, with 88% awarding a master’s degree; the remainder a baccalaureate degree and/or a certificate.10 Upon graduation, he or she must pass a national certifying examination administered by the National Commission on Certification of Physician Assistants (NCCPA) to be eligible to work as a PA. To work clinically in a jurisdiction, the PA must obtain authorization to practice from the appropriate regulatory board.11 Since 2007, all states have sanctioned delegated prescribing, and all but two permit prescribing controlled substances as part of that authority.12 Physician assistant postgraduate programs are not part of primary PA education, but exist in some small form. Less than 2% of the PA population elects to train beyond their PA education, and the vast majority of PAs in the ED are trained on the job. A survey of 55 postgraduate PA programs in 2008 found that seven were in EM, and the duration of this specialized training was 12–18 months.13 The U.S. Army postgraduate education program in EM, at Brooke Army Medical Center in Fort Sam Houston, Texas, is a prototype residency of 18 months in length, admits four PAs a year, and awards a doctorate in health sciences (DHSc). The program is structured to expose the PA to high-trauma battlefield conditions.14 No similar program has been developed in civilian institutions. Specialty Certification. The NCCPA has developed an optional specialty certificate for EM and intends to make it available in 2011. The criteria to meet specialty certifi-
Influencing Organizations. Three professional societies influence PA roles in the EM workforce. ACEP addresses policy issues pertaining to PAs, and the Society of Emergency Medicine Physician Assistants represents specialized EM PAs, with each recognizing the other’s organization. The American Academy of Physician Assistants is an advocacy group that represents clinically active PAs in the United States (approximately 75,000 in 2010). Emergency Medical Treatment and Active Labor Act (EMTALA). In 1986, the EMTALA, Section 1867(a) of the U.S. Social Security Act, addressed emergency medical access and provider reimbursement. EMTALA law and regulations permit medical screening examinations by PAs. Written hospital policy and medical staff bylaws specify that PAs and nurse practioners (NPs) are providers that the hospital deems qualified to work in defined roles.17 Guidelines for Physician Assistants. ACEP’s policy statement, Guidelines on the Role of Physician Assistants in the Emergency Departments,8 requires PAs to work clinically within the supervision of an EP who assumes responsibility for each PA encounter. Furthermore, the PA’s scope of practice must be clearly delineated and consistent with state regulations.8 An example of a PA scope of practice as listed in the Texas medical board rules and regulations is in Table 1. Prevalence of PAs in EDs The PA role in EM began in the late 1960s, with their utilization documented at various times and in various ways. One of the first cross-sectional utilization studies of PAs used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). In 1992, PAs and NPs together managed 4% of all NHAMCS ED visits. Few differences emerged when diagnoses and patient characteristics managed by PAs or NPs and by physicians were compared. This finding suggested there was little differentiation (triage) of patients to a PA, NP, or physician.18 A similar analysis of the NHAMCS data set in 1994 found that the number of patients seen by PA and NPs in the ED had doubled.19 At that time, 8.4% of all PAs nationally reported that they were employed in EM, compared to 64 other medical and surgical disciplines.20 By 1997, the National Centers for Health Statistics (NCHS) estimated that outpatient visits had risen to 960 million per year in nonfederal ambulatory care settings, with EDs accounting for 9.9% of these visits. At this time, half of all PAs were employed in primary care, but EM was the second most commonly chosen specialty by recent PA program graduates (9.1%).21 The NHAMCS estimate of ED visits continues to rise annually. In a 10-year trend analysis of U.S. EM activity (1995–2004), an estimated 1 billion EM visits were
74
Table 1 PA Scope of Practice as Listed in a State Medical Board Rules and Regulations* 1. Obtaining patient histories and performing physical examinations. 2. Ordering or performing diagnostic and therapeutic procedures. 3. Formulating a working diagnosis. 4. Developing and implementing a treatment plan. 5. Monitoring the effectiveness of therapeutic interventions. 6. Assisting at surgery. 7. Offering counseling and education to meet patient needs. 8. Requesting, receiving, and signing for the receipt of pharmaceutical sample prescription medications and distributing the samples to patients in a specific practice setting in which the physician assistant is authorized to prescribe pharmaceutical medications and sign prescription drug orders as authorized by physician assistant board rule. 9. Signing or completing a prescription. PA = physician assistant. *Texas Medical Board, Chapter 204. Physician Assistants Occupations Code. Physician Assistant Licensing Act. Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. September 1, 1999, p 19.
aggregated. PAs were the provider of record for 5.7% of those visits and NPs for another 1.7%. Emergency visits and the employment of all three provider types increased over the 10 years as well, with PA growth doubling during this period and EP growth was almost flat.1 This work was validated by another set of researchers with similar conclusions.22 As of 2010, the American Academy of Physician Assistants (AAPA) estimated that there were 75,000 clinically active PAs; 10.5% (7,817) identified EM as their primary specialty (excluding trauma).9 A 2008 AAPA survey of 2,651 PAs in EM served as a cohort for subanalysis. The census analysis found the average age of ED PAs was 40 years, females were 52% of the cohort, 33% were employed by a single-specialty physician group practice, 37% were employed by a hospital, and 7% were self-employed or worked for agencies.12 Most worked in an urban setting (85%), and the majority (85%) worked full-time (at least 32 hours per week). Approximately one-third (36%) were salary-based; 64% were paid an hourly wage. The mean salary in 2008 was $99,635. The higher compensation, when compared with other PAs, may reflect the fact that almost one-third of EM PAs are contract and ⁄ or shift workers and tend to work more than 2,000 hours per year, on average.9 The increased use of PAs in hospitals is thought to be a response to the postgraduate workweek limitations put in force by the Accreditation Commission on Graduate Medical Education (ACGME). Although ACGME imposed physician resident work hours in 2004, many hospitals enacted the policy earlier and developed various strategies on the part of GME programs to find labor shortage alternatives. Employment trends in the early 2000s generally correlated with EDs adjusting to the reduction of their traditional source of hospital labor and the employment of PAs in greater numbers.23 Authors’ Comment. The presence of PAs in EM is increasing and appears to be serving as a medical
Hooker et al.
•
PA ED ROLES
reservoir for expanding demand. National information on staffing patterns in hospital outpatient departments such as EDs is considered reliable due to the robustness of the data collected consistently and systematically by the NCHS. Administrative data of employment among large corporations that contract ED services would help to distinguish characteristics of providers and those of patient populations for better matching of service teams. Creative Solutions to ED overcrowding Decreasing health care dollars and increasing demands for acute care services have driven managers to assess whether PAs are an appropriate alternative to provide services in ED settings. In one study, researchers analyzed 9,600 ED visits attended by physicians and PAs in an urban urgent care facility. They compared length of visit and total charges for the two providers using 14 diagnostic groups. Both providers had a similar distribution of diagnostic cases. Respiratory infection and musculoskeletal disorders accounted for 36% of visits; lacerations, gastrointestinal disorders, and otitis each accounted for 5% of visits. Overall, PA-attended visits were 8 minutes longer and total charges $8 less compared to a doctor. Differences in charges and time were considered small and clinically insignificant by the authors.24 Innovative programs to take advantage of select PA skills have been adopted in some settings. A PA laceration management program demonstrated improved care and outcomes, decreased cost, and improved patient satisfaction.25 Crowding in the ED has multiple causes, including space and staffing in both inpatient areas and the ED.26 Waiting for beds is a primary issue in the ED, because the patient requires continuing care and attention from EPs. As a managerial response, a unique role was developed for PA and NPs to provide ‘‘back-end’’ care for patients awaiting inpatient beds. After initial physician evaluation, patients without ready inpatient beds were grouped in the ED and their care was transferred to the transition team. The transition team consisted of a PA and ⁄ or NP and a nurse, all reporting to an EP supervisor. Each team assumed care for the patient and provided appropriate care to keep the patient stable until the patient was evaluated by the admitting inpatient service or until the patient left for an inpatient unit. The major transition team objectives were improved patient care and a reduction in EP labor in caring for inpatients. In the aggregate, the transition team assumed a significant patient load, an indirect measure of reduced physician work. However, this transition team did not improve patient satisfaction. While the transition team is a potentially available, incremental staffing resource for a crowded ED, the authors point out that this may not be more desirable to PAs than other traditional clinical roles in the ED.27 Authors’ Comment. Innovative uses of PAs can involve task transfer of repetitive skills such as laceration management and skill mix such as a transition team. Both activities involve low to moderate patient acuity and draw on experience and a good knowledge
ACAD EMERG MED • January 2011, Vol. 18, No. 1
www.aemj.org
75
base. These examples aside, the literature is considered inadequate to make judgments on efficiency.
needed to assess and link outcomes to patient satisfaction among all types of providers.
Quality of Care A study undertaken at two Toledo, Ohio, hospitals assessed the quality of patient care during transition from a resident trauma team to a PA-assisted trauma program that functioned without residents. The research compared support with and without PAs.28 This retrospective analysis of patient care compared a resident-assisted program at a Level II trauma center in 1998 and a PA-dedicated trauma program in 1999 in two 6-month segments. The only significant outcome was a decreased length of stay (LOS) in the hospital due to patients being transferred directly from the ED to the floor in 1999. Substitution of PAs for residents had no effect on patient mortality; however, LOS was statistically reduced by 1 day. The authors concluded that benefits in patient care improved when there was collaboration of residents and PAs in the ED. A prospective, nonrandomized, descriptive study compared traumatic wound infection rates in patients based on level of training in ED practitioners.29 Wounds were evaluated in 1,163 patients using a wound registry and a follow-up visit or phone call. No significant difference emerged in level of training or wound care rates among different types of providers: medical students had the lowest infection rate at 0 of 60 (0%), resident physicians had 17 of 547 (3.1%), PAs had 11 of 305 (3.6%), and attending physicians had 14 of 251 (5.6%). In the aggregate, delegation of wound management to PAs appeared to be safe; PA performance was similar to that of physicians in the same setting.29
Rural ED Staffing The practice of EM in rural areas is challenging. In 2006, a national telephone survey of a random sample of 408 small rural hospitals (defined as 100 or fewer beds) found that most used a mix of staffing to cover the ED. On weekdays, about one-third of the hospitals used their own medical staff physicians, one-third used a combination of medical staff and contract coverage on evenings and weekends, and 14% used PAs with a physician on call.32 In 1979, a Maine rural hospital with 92 beds compared a PA to a rotating medical staff system as a method of providing ED coverage. When a patient presented to the ED, the provider on call would be paged. There was a 105% increase in utilization on shifts covered by the PA, compared to a 19% increase seen on medical staff shifts during the same period. The financial analysis revealed that the PA generated net revenue of $260 per shift, while the medical staff system operated a net deficit of $50 per shift. Since the PA practiced without on-site supervision, the hospital administration developed alternative methods to ensure quality of care. In the retrospective analysis of cases of 564 patients spread over 1 year, the PA made no significant diagnostic or treatment errors.33
•
Authors’ Comment. Quality of care is measured in many ways, but the outcome of care is generally the standard by which it is best assessed. The literature on PA-delivered quality and outcomes of care (when compared to a physician) is limited and inadequate for any conclusions in the ED setting.
Authors’ Comment. Staffing rural hospitals appears to be an important element of stability in micropolitan communities. Krein34,35 has shown that without PAs in such communities, many hospitals would have to close. The shortcoming in the literature is the lack of depth about how PAs can improve staffing mix in these small towns.
Patient Satisfaction Probing patient satisfaction with acute care experience is a concept not often reported. Three researchers explored not only patient satisfaction, but also willingness to forgo a longer wait in the Fast Track Clinic as a tradeoff to see a physician versus a PA. All patients were seen primarily by a PA in a community hospital with an annual ED census of 48,600 patients (18% in the Fast Track Clinic). An anonymous survey at time of discharge was used to rate patient satisfaction: 111 survey returns were analyzed. Patients were ‘‘very satisfied’’ with care rendered by a PA, with a mean patient satisfaction score of 93 of 100 (95% confidence interval = 90.27 to 95.73). Overall, 12% were willing to wait longer for a physician.30
Legal Issues In outlining the credentials and accreditation process for PA programs, including ACEP guidelines for the use of PAs in the ED, Delman11 reviewed the legal literature and case histories of PAs. The author concluded that ‘‘… probably the most controversial area of practice for a physician extender (sic) is in the emergency department. Ambulatory care is the principal mode of health care in the United States. The second most common place for the provision of ambulatory care is in hospital emergency departments.’’ Klig36 was more specific when examining the legal implications of PAs in the ED. For an ED attending physician, the legal tenet of vicarious liability under respondent superior can apply to PAs as it does for physician residents. If a physician is officially designated as a supervisor for all aspects of care provided by a PA, that physician may be held directly liable for negligent supervision if a PA is held negligent in the care of the patient.
Authors’ Comment. Patient acceptance of PAs is critical, and no amount of advocacy will outweigh this. The few studies on patient satisfaction suggest that patients are generally satisfied when their needs are met regardless of who produces the care.31 More research is
Authors’ Comment. There are four major elements of malpractice risk for doctors who supervise a PA: 1) lack of adequate supervision, 2) untimely referral to a consultant or the PA’s failure to use a consultant, 3) failure of a PA to make the correct diagnosis of a patient’s
76
condition, and 4) inadequate examination of a patient by a PA.37 A 20-year analysis validated that PAs do not increase liability and in fact may even lower the liability of a medical practice.38 Whether this pertains to a cross-section of EDs has not been explored. DISCUSSION Evidence identifying how PAs fit into mainstream management of emergency care was fair in methodologic quality but lacking in comprehension of role (or defining the efficacy of these roles). Some of the studies are limited in their ability to generalize because of small sample size or unique nonrepresentative setting and circumstance. Nevertheless, a number of findings were revealed. It appears that the use of PAs in EDs can favorably affect patient care. This may be through patient flow, differentiation of patients, offloading resident work hours, or augmenting staffing patterns. Improved clinical and financial outcomes are important findings in a few studies. Other studies have demonstrated additional areas of influence such as quality of care. When comparable data were pooled, few differences arose between PAs and doctors. Innovative use of PAs included wound management, acute care management, stabilization of patients waiting for transfer, and rural health roles. Economic tradeoffs in terms of patient willingness to be seen by a PA in an ED provide an interesting perspective of satisfaction surveys showing that patient acceptance of PAs is similar to their acceptance of doctors. More work is needed in this arena, as the global expansion of PAs is occurring with little public input. LIMITATIONS There are a number of limitations to this work. Many of the cited studies are small and may not have utility in larger settings. The exceptions are the NHAMCS surveys. These are broad, cross-sectional surveys that are stratified and weighted to produce comprehensive representative ED activity in nonfederal settings. Their shortcoming is the lack of granularity needed to understand outcomes and differences in providers or patients. There are no critical studies identifying productivity of different types of providers (holding a number of variables constant), much less patient acuity. The whole notion of team effort to improve outcomes of ED care is notably absent from the literature. CONCLUSIONS Reviewing the literature and critiquing studies on the use of physician assistants in EM provides a number of important observations. The physician assistant appears to be part of a multidisciplinary effort working closely with emergency physicians across the United States. Their numbers, more than 7,000, are substantial, and efficiency in their use may be due to economy of scale and division of labor. As such, physician assistants are being used due to increasing demand for EM services in the face of a relatively flat physician replacement
Hooker et al.
•
PA ED ROLES
stock. The reports in this overview are useful in understanding some of the unique ways EM physician assistants can be deployed. However, published reports on physician assistants’ role delineation in EM provide little more than a limited guide for ED managers in making staffing decisions. This is due to substantial gaps in the literature on physician assistants in EM. Prospective studies examining outcomes of care, cost benefit of care, division of labor, and organizational efficiency are missing. These studies are needed before unequivocal recommendations can be made. Issues of safety, scope of practice, range of skills, level of acuity, and geographical setting are variables that need adjustment in studies involving physician assistants, nurse practitioners, and physicians if issues of substitution are to be addressed. Given an underperforming health care system and untenable rising costs, it is important for health care to take the path that aligns quality and value efforts with care where it matters: at the front lines with clinicians and patients. Changes in national health care access and financing will affect acute care services, in both demand and action, which will test the adaptability of ED operations. How emergency service centers will accommodate an anticipated surge requires collective planning. We suggest investment in quality improvement research at the acute care interface and the results used to transform clinician-patient dynamics. Physician assistants should be part of this planning. References 1. Hooker RS, Cipher DJ, Cawley JF, Herrmann D, Melson J. Emergency medicine services: interprofessional care trends. J Interprof Care. 2008; 22:167– 78. 2. Bodenheimer T, Pham HH. Primary care: current problems and proposed solutions. Health Aff. 2010; 29:799–805. 3. Sullivan AF, Richman IB, Ahn CJ. A profile of U.S. emergency departments in 2001. Ann Emerg Med. 2006; 48:694–701. 4. Moorhead JC, Gallery ME, Mannle T, et al. A study of the workforce in emergency medicine. Ann Emerg Med. 1998; 31:595–607. 5. Camargo CA, Ginde AA, Singer AH, et al. Assessment of emergency physician workforce needs in the United States, 2005. Acad Emerg Med. 2008; 15:1317–20. 6. Rosen RG. Symposium proceedings of the first national conference on new health practitioners. Utilization of PAs in acute general hospital settings. PA J. 1974; 4:52–54. 7. Maxfield RG, Lemire MD, Thomas M, Wansleben O. Utilization of supervised physician’s assistants in emergency room coverage in a small rural community hospital. J Trauma. 1975; 15:795–9. 8. American College of Emergency Physicians. Emergency Medicine Practice Committee. Guidelines on the role of physician assistants in the emergency department. Ann Emerg Med. 2002; 40:547–8. 9. American Academy of Physician Assistants. AAPA Physician Assistant Census Report. Alexandria, VA:
ACAD EMERG MED • January 2011, Vol. 18, No. 1
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
www.aemj.org
77
American Academy of Physician Assistants, 2009, pp 1–15. Lane S, Liang M. Twenty-fourth annual report on physician assistant educational programs in the United States, 2007-2008. Alexandria, VA: Physician Assistant Education Association, 2009, Vol 24, pp 1– 73. Delman JL. The use and misuse of physician extenders: aiding and abetting the unauthorized practice of medicine. J Leg Med. 2003; 24:249–80. Hooker RS, Cawley JF, Asprey DP. Physician Assistant: Policy and Practice. 3rd ed. Philadelphia, PA: F. A. Davis, 2010. Wiemiller MJ, Somers KK, Adams MB. Postgraduate physician assistant training programs in the United States: emerging trends and opportunities. J Physician Assist Educ. 2008; 19:58–63. Salyer SW. A clinical doctorate in emergency medicine for physician assistants: postgraduate education. J Physician Assist Educ. 2008; 19:53–56. National Commission on Certification of Physician Assistants. Summary of NCCPA Board Actions and Issues. Specialty Certification Model Approved. Available at: http://www.nccpa.net/NewsArticles/ NewsArticlesBODAug09.aspx. Accessed Oct 11, 2010. Hooker RS, Carter R, Cawley JF. The national commission on certification of physician assistants: history and role. Persp Phys Assist Educ. 2004; 15:8–15. HCPro, Inc. Clinical Privilege White Paper. Physician Assistants in the Emergency Department. Marblehead, MA: Credentialing Resource Center, 2005, pp 1–16. Hooker RS, McCaig LF. Emergency department uses of physician assistants and nurse practitioners: a national survey. Am J Emerg Med. 1996; 14:245–9. McCaig LF, Hooker RS, Sekscenski ES, Woodwell DA. Physician assistants and nurse practitioners in hospital outpatient departments, 1993–1994. Public Health Rep. 1998; 113:75–82. American Academy of Physician Assistants. 1998 AAPA Census Report. Alexandria, VA: American Academy of Physician Assistants, 1998. Hachmuth FA, Hootman JM. What impact on PA education? A snapshot of ambulatory care visits involving PAs. JAAPA: J Am Acad Physician Assistants. 2001; 14:22–4 27–38. Menchine MD, Wiechmann W, Rudkin S. Trends in midlevel provider utilization in emergency departments from 1997 to 2006. Acad Emerg Med. 2009; 16:963–9. Cawley JF, Hooker RS. The effects of resident work hour restrictions on physician assistant hospital utilization. J Physician Assist Educ. 2006; 17:41–3.
24. Arnopolin SL, Smithline HA. Patient care by physician assistants and by physicians in an emergency department. J Am Acad Physician Asst. 2000; 13:39– 40 49–50, 53–54, 81. 25. Katz HP, Cushman I, Brooks W, et al. A physician assistant laceration management program. HMO Pract. 1994; 8:187–9. 26. Brook C, Chomut A, Jeanmonod R. When the emergency department is packed can physician assistants pick up the pace? An analysis of physician assistant productivity related to patient volume [abstract]. Ann Emerg Med. 2009; 54:S5. 27. Ganapathy S, Zwemer FL Jr. Coping with a crowded ED: an expanded unique role for midlevel providers. Am J Emerg Med. 2003; 21:125–8. 28. Oswanski MF, Sharma OP, Raj SS. Comparative review of use of physician assistants in a level I trauma center. Am Surg. 2004; 70:272–9. 29. Singer AJ, Hollander JE, Cassara G, Valentine SM, Thode HC Jr, Henry MC. Level of training, wound care practices, and infection rates. Am J Emerg Med. 1995; 13:265–8. 30. Counselman FL, Graffeo CA, Hill JT. Patient satisfaction with physician assistants (PAs) in an ED fast track. Am J Emerg Med. 2000; 18:661–5. 31. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners and physicians. Permanente J. 1997; 1:38–42. 32. Casey MM, Wholey D, Moscovice IS. Rural department staffing and participation in emergency certification and training programs. J Rural Health. 2008; 24:253–62. 33. Newkirk W. Rural emergency department coverage: comparison of a physician assistant to rotating medical staff members. J Maine Med Assoc. 1980; 71:375–7. 34. Krein SL. The adoption of provider-based rural health clinics by rural hospitals: a study of market and institutional forces. Health Serv Res. 1999; 34:33–60. 35. Krein SL. The employment and use of nurse practitioners and physician assistants by rural hospitals. J Rural Health. 1997; 13:45–58. 36. Klig JE. The legal implications of physician trainees and non-physician practitioners for the emergency physician. Clin Pediatr Emerg Med. 2003; 4:243–8. 37. Gore CL. A physician’s liability for mistakes of a physician assistant. J Leg Med. 2000; 21:125–42. 38. Hooker RS, Nicholson J, Le T. Does the employment of physician assistants and nurse practitioners increase liability? J Med Licensure Disc. 2009; 95:6–16.
•
