Date: November 19th, 2020

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.

Reference: Pines et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. AEM November 2020.

Case: You are the medical director of a medium sized urban emergency department (ED). Volumes have increased over the past few years and you’re considering adding an extra shift or two. Your hospital has asked you to consider adding some advanced practice providers (APPs) instead of physician hours.

Background: Advanced practice providers (APPs) such as nurse practitioners (NPs) and Physician Assistants (PAs) are increasingly used to cover staffing needs in US emergency departments. This is in part driven by economics, as APPs are paid less per hour than physicians.

The calculation works if APP productivities are similar enough to physicians to offset differentials in billing rates. However, little data exists comparing productivity, safety, flow, or patient experiences in emergency medicine.

The American Academy of Emergency Medicine (AAEM) has a position statement on what they refer to as non-physician practitioners that was recently updated. The American College of Emergency Physicians (ACEP) has a number of documents discussing APPs in the ED.

There has been a concern about post-graduate training of NPs and PAs in the ED. A joint statement on the issue was published in September this year by AAEM/RSA, ACEP, ACOEP/RSO, CORD, EMRA, and SAEM/RAMS. 


Clinical Question: How does the productivity of advanced practice providers compare to emergency physicians and what is its impact on emergency department operations?


Reference: Pines et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. AEM November 2020.

  • Population: National emergency medicine group in the USA that included 94 EDs in 19 states
  • Exposure: Proportion of total clinician hours staffed by APPs in a 24-hour period at a given ED
  • Comparison: Emergency physician staffing
  • Outcome:
    • Primary Outcome: Productivity measures (patients per hour, RVUs/hour, RVUs/visit, RVUs per relative salary for an hour)
    • Safety Outcomes: Proportion of 72-hour returns and proportion of 72-hour returns resulting in admission
    • Other Outcomes: ED flow by length of stay (LOS), left without completion of treatment (LWOT)

Dr. Jesse Pines

This is an SGEMHOP episode which means we have the lead author on the show. Dr. Jesse Pines is the National Director for Clinical Innovation at US Acute Care Solutions and a Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and also leads the USACS opioid programs. 

Authors’ Conclusions: In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery.

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Unsure
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? Unsure
  7. Was the follow up of subjects complete enough? Yes
  8. How precise are the results? Fairly precise
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure
  11. Do the results of this study fit with other available evidence? Unsure

Key Results: Over five years there were more than 13 million ED visits at these 94 sites.  The majority (75%) of visits were treated by physicians independently. PAs treated 18.6%, NPs 5.4% and 1.4% were treated by both a physician and an APP.


Physicians were more productive than physician assistants and nurse practitioners.


  • Effect of 10% increase in APP coverage:
    • Patients/hour: -0.12 (95% CI; -0.15 to -0.10)
    • RVUs/hour: -0.4 (95% CI; -0.5 to -0.3)
  • Safety and Outcome: No significant effect on length of stay, left without treatment, and 72-hour returns

Listen to the podcast on iTunes to hear Jesse’s responses to our five nerdy questions.

1) Surprise: These results surprise me somewhat due to personal experience where APPs see lower acuity patients, often in a “fast-track” area. I don’t know our facility data, but would be surprised if the APPs had significantly lower overall patients/hour than the doctors.

2) Physician Satisfaction: You looked at the productivity and safety as an outcome. What about physician satisfaction? I know some doctors who can’t function well without an APP and other doctors who prefer working without an APP.

3) Not All Equal: You mention that when making the schedules, one physician hour was equal to two APP hours. For your analysis, it was unclear to me if you calculated your numbers using 1:1 physician to APP hours, or if you kept the 1:2 ratio.

4) Patient Satisfaction: You had an exploratory outcome using a Press-Ganey (PG) percentile rank as a measure of patient experience. Those outside of the USA may not be familiar with the Press-Ganey patient satisfaction survey. Can you explain this metric and what did you find in your study about patient satisfaction?

5) External Validity: This was a large study with 19 states, 94 sites and 13 million ED visits. However, it represents one large national ED group. Do you think the results would apply to small groups, democratic physician-led groups, or rural sites?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions


SGEM Bottom Line: Increasing advanced practice provider coverage has minimal effect on emergency department productivity, flow and safety outcomes.


Case Resolution: You continue the discussion with hospital administration, understanding that APP hours need to be added in such a way as to utilize their skillsets best, but not as a full replacement for physician hours. You suggest considering a higher number of APP hours to replace one physician hour.

Dr. Corey Heitz

Clinical Application: APPs can be utilized to “offload” lower acuity cases, while allowing physicians to care for higher acuity patients. Physicians overall had higher levels of productivity, both as measured by patients/hour and RVUs/hour.

What Do I Tell My Patient? Not applicable

Keener Kontest: Last weeks’ winner was Dr. Daniel Walker. He is an Emergency Medicine & Critical Care registrar working in the UK. Dan knew the LAST thing you want to see happen after injecting someone with lidocaine is Local Anesthetic Systemic Toxicity.

Listen to the SGEM podcast to hear this weeks’ question. Send your answer to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers, what do you think of this episode on APPs in the ED? Tweet your comments using #SGEMHOP.  What questions do you have for Jesse and his team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. We will put the process on the SGEM blog:

  • Go to the Wiley Health Learning website
  • Register and create a log in
  • Search for Academic Emergency Medicine – “November”
  • Complete the five questions and submit your answers
  • Please email Corey (coreyheitzmd@gmail.com) with any questions or difficulties.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.


 

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