Many years ago, nursing was not allowed to place IVs. Now, in some places, they place ultrasound guided PICCs, and in a handful of places, ultrasound guided central lines. Nursing can titrate vasopressors, and in some facilities, they run ACLS during codes.
So…. Have you ever experienced or asked “for the doctor (or consultant)?”
Have you ever been concerned and wondered do PA’s provide appropriate care in the ED?
This study is done at the world famous Our Lady of Lourdes in Camden,NJ, with none other than the EM famous Al Sacchetti- and should aim to answer some of these concerns, at least in the pediatric population
Over a 24 month period, over 10,000 patients age 6 or younger were restrospectively evaluated for bounce back rates and broken down into 3 groups based on their provider: attending only care, PA only care, or co-evaluation by both EP and PA. Here’s the twist- in this department, policy permits PA’s to evaluate treat and discharge patients of any age independent of the attending physician. There are no specific protocols for assigning specific patients to specific providers, though they do state that PA’s do not perform LP’s in the study department, and that febrile infants <8 weeks were brought to the immediate attention of the attending physician by the triage nurse. Essentially, the PA seemingly functions at a high level and fairly autonomous.
So what’d they find? Are you more likely to “bounceback” based on who you’re seen by?
Well, as one would likely expect, a higher percentage of higher acuity patients were seen by the attending physician (85% ESI-2, 70% ESI-3, 60% ESI 4/5.), and the younger the patient, the more likely they were an “attending only” case.
Bounce backs? Only 0.4% of PA only cases vs 0.6% of attending only cases bounced back and were admitted – not statistically significant – and below the national average of 0.83%. Only 0.9% of PA only cases were admitted vs 4.1% of attending only cases (and 3.4% of PA/MD cases. This was statistically significant, and likely reflects higher acuity of the cases the MD is involved in. There was a higher rate of return visits in MD only cases – 8% vs 6.8% (statistically significant) – but the rate of return for combined MD/PA cases was highest – 9.3%.
Amongst ESI 2,3, & 4s, bounceback rates for EP only eval was consistently higher than PA only eval, and bounceback rates for MD/PA co-evaluation was consistently higher than both PA only and MD only eval.
So, what’s the take home? For one, its that PA’s can provide high level care without a significant drop off in care… and that in order for medicine to progress, we have to cognitively offload to expand our boundaries. This may include expanding services to nursing or PAs (as discussed above)…
And here is the most important message:
Dont be that person – if someone (nursing, PCA’s, PA/NP’s, etc) comes to you with a concern – go see a patient. We’re all on the same team. Take it as a compliment – as evidenced by this paper it’s likely a complex or clinically ambiguous case with a higher bounceback rate, and who doesnt like a challenge!