PA Role in non-fast track EDs

[Emerson]

My group treats a fairly educated and wealthy population. This combined with the growing concept of the urgent care, we just don't have the volume to allow PA's to strictly run within a fast-track criteria. Because of this, I sense that there is somewhat of an identity crisis on how this group wishes to utilize the PA concept. We pretty much function as residents now in that we are assigned beds, see the patient, start the workup and then talk to our attending about the case who either agrees or disagrees with what we've done. In a group with 40 physicians, trying to adapt your practice constantly is both frustrating and cumbersome. Nursing is in charge of patient distribution, so I may get a 94 y/o c CP and the attending may receive a partially thick laceration as we have universal beds.

 

Needless to say, the attitude within the PA's have shifted as we no longer have the autonomy we once enjoyed. There are aspects to our job that now makes us feel like residents/scribes for the attending. Are any other PA's functioning in a similar environments? If so, I am curious about how your are utilized within the ED to ultimately optimize the PA concept.

 

Does anyone have any ideas on what the return on investment for a PA is working in the ED?

[ventana]

triage triage triage

[EMEDPA]

there is a lot of variety in non-fast track ed's from what you describe all the way to pa's and docs see alternate pts with full autonomy and consult as needed. I would not work in a place that a doc needed to see all my pts and approve every order. wouldn't do it.

[stroom]

As a student I can imagine that setup being really conducive to a new graduate like myself in the future that has a lot to learn.. That said if these are experienced PAs... it seems like a gross loss of potential productivity.

[MassPA-C]

Still a pre-PA but in my hospital (Large, Urban, academic, Level 1 trauma) PA/NP both fill and work resident shifts. All charts are signed and orders approved by whomever the attending on that shift is.... Ironically no PA/NP's work in our fast track they only work in our upstairs space (bi-level ED) where we place none-urgent complicated patients. Having worked in this environment for a few years I do not believe I would return to work these types of shifts (they have very little autonomy) but we will see how I feel once I am looking for a job...

[paporzelt]

i'm curious - I definately aspire to work the ED someday...but didnt think it was wise to get into it immediately after graduating. however - does urgent care experience help pave the way to the ER, espeically if its an UC attached to a same day surgery, and cath lab. the only thing this place doesnt really get is trauma. I guess you could say its like a level 3 trauma ER in a way. would this help/hurt my path to a career in the ER combined with ortho experience?

[Emerson]

I was hoping to generate some ideas about how other ED's utilize PA's in this capacity. For example, maybe 3 of 8 beds are setup with specific fast track criteria which don't require an attending, etc.

 

Paporzelt - i feel it really depends upon the type of ED. For example, we tried a few PA's with UC experience and it simply didn't workout. If you're transitioning into a fast-track then I think that experience will suit you well. Because of the limitations of UC (i.e. working up abdominal pain, ACLS, intubations, LPs, etc) I've found the transition into a group such as mine has been difficult. I actually went straight into ED after graduating from PA school, but I had a background in EMS and completed a 3 month ED fellowship. Even then, the learning curve was overwhelming to say the least.

[EMEDPA]

One of the facilities I work at has a pod system and the pa's staff the "intermediate acuity" and fast track pods so we get pretty much anything except multisystem trauma, stemi's , and cva's. we only have to have the docs cosign admissions and they generally just want a quick summary:

"this is a 52 yr old IV drug user with back pain, fever, leukocytosis, and an mri c/w epidural abscess. he's admitted to neurosurg."

doc: "ok, thanks". signs chart.

[medic25]

Our main ED usually functions in the traditional resident/attending model, with PA's filling many of the resident spots. We also staff a free-standing ED that uses no residents and allows a more autonomous practice model. We are free to grab any chart, and attending involvement depends on the triage level. Using the 1 through 5 scale, the attending has to at some point see any Level 1 or 2 patients; 3-5 can be seen by the PA only. It's not perfect, but I'll throw it out there as a potential model.

[EMEDPA]

M25- that's essentially what we do but at the facility I mentioned above the pa's generally don't get a crack at level 1's unless it is a mistriage.

at our satelite facility it is pa's 24/7 with a doc on days only so we see/do it all there.

[kargiver]

Where I work we run the gambit of models due to the number if institutions that fall under our groups umbrella. At the university academic ER, PAs do FT and Obs alone and see Levels 3-5 alone. 1-2s an attending has to sign off (because these usually get admitted) so at some point I let them know about the patient.

 

At the Comm Hospital in our group setup we have (there are 2), I replace an MD (that has been a political hairball I must say) so I see and do everything from running arrests to med refills (I can't do Section 12s - involuntary holds on psychs - or online medical control for EMS - that has to be an MD). I have to have an attending sign for admissions but otherwise I am autonomous. This is a very impressive role but it has been our experience that very FEW PAs can actually do this with any degree of confidence. I think this is more a Massachusetts thing than a PA thing as this level of autonomy doesn't exist elsewhere...

 

We are starting to toy with the idea of PAs in Triage as well. That would complete the known roles for PAs in the ER setting...

 

As a side note, at my 2 other per diem jobs, one is I staff a critical access ER by myself (or with another PA) so we also do everything there. The other is an MD/PA model... I see 2-5s and do my own lines, tubes, etc as needed.... I can do level 1s as well but they are few and far between so the attendings generally jump on them. That's fine though... It gets tedious after a while anyway so let them play... :)

 

A lot of urban models run on the "PA sees it and the MD oversees it" model. It makes them money and deals with perceived liability. There is a significant push coming from some in ACEP and other places that PAs need more supervision. Of course, there will be counters to this but some groups are already moving towards this...

 

Hope this helps,

G

[quirkymedic]

I work in a rural er that has a total of 20 ER beds. Our ER is divided up into the clinic side (the pa runs) and the trauma side (the doc runs.. which generally consist of multi system trauma pt's, cvas, AMI, severe SOB) we have an NP up front who deals with rapid medical evaluations (back pain, OM, etc) from 8 am to 8 pm and they have 2 of our 14 clinic rooms during that time.

 

I have rooms 3-14, (1-14 after 8pm) and the doc has the trauma rooms A-E. I work fairly autonomously, only running certain pt's by the doc.. IE pts who meet SIRS criteria, or surgical pt's that may need consult- the docs like to know if I have a possible surgical consult. Otherwise I am on my own and my treatment plan is my own. If I get backed up, the doc may wander over to "my side" and help out, but that is rare. I do not generally treat patients on the trauma side.

 

That being said, I still evaluate level 2-5 patients.. Including chest pains, appys, gi bleeds, possible cva's, LOTS of abd pain, and what not. If I have a question, I ask my SP. If my SP hears me talking to a nurse about a pt and they want to know what is going on with that pt, they ask me. I am responsible for their entire visit.. from workup to discharge or admission.

 

I should probably point out the way our er is set up... we have two hallways, the "clinic hall" and the "trauma hall" with a common nursing/work station at the end of both halls where the nursing staff, the MD and I all work together.. so its not completely divided. I have an idea of what is going on on the trauma side, and the doc has an idea of what is going on with the clinic side.

[medic25]

M25- that's essentially what we do but at the facility I mentioned above the pa's generally don't get a crack at level 1's unless it is a mistriage.

at our satelite facility it is pa's 24/7 with a doc on days only so we see/do it all there.

 

For practical purposes this is how our satellite works as well. There is no rule against us seeing Level 1's, but it's only an 8 bed ED; if we get a Level 1 (e.g. respiratory/cardiac arrest) everyone knows about it, so we usually both jump in and do what needs to be done. The attending takes lead and eventually writes the chart, I usually end up either doing the airway, getting vascular access or ultrasounding the patient.

[CAdamsPAC]

Our main ED usually functions in the traditional resident/attending model, with PA's filling many of the resident spots. We also staff a free-standing ED that uses no residents and allows a more autonomous practice model. We are free to grab any chart, and attending involvement depends on the triage level. Using the 1 through 5 scale, the attending has to at some point see any Level 1 or 2 patients; 3-5 can be seen by the PA only. It's not perfect, but I'll throw it out there as a potential model.

 

I worked in your ED 88-92 the attending let us work at our level of comfort ,then taught us more and pushed us farther. We saw whatever made it to us and did our own LPs, belly& chest taps, put in central lines.When exiled to "mini-med" we were on our own!

It's important that ED PAs be allowed to do as much as they can and be taught and allowed to do more!I'm with EMEDPA on being under the thumb of attendings or answering to residents!!!

[medic25]

I worked in your ED 88-92 the attending let us work at our level of comfort ,then taught us more and pushed us farther. We saw whatever made it to us and did our own LPs, belly& chest taps, put in central lines.When exiled to "mini-med" we were on our own!

It's important that ED PAs be allowed to do as much as they can and be taught and allowed to do more!I'm with EMEDPA on being under the thumb of attendings or answering to residents!!!

 

You'll be happy to hear that we are finally in the midst of building a new ED (although it means working in a construction site for a couple of years)! I'd like to think we are still the same way. Overall we have a great group of attendings, and I have still continue to learn from them. The ED runs with color coded teams, and the PA teams bypass the senior resident and only deal with the attending. We still do a ton of procedures, especially the aggressive folks. One of my big pet peeves is when one of our new grads has a patient needing something like a belly tap or a central line and they ask the senior resident to do it because they lack the self-confidence to attempt it themselves. Even if it means asking the senior to come walk them through their first central line, they should still be the ones doing it; it is their patient after all.

[CAdamsPAC]

You'll be happy to hear that we are finally in the midst of building a new ED (although it means working in a construction site for a couple of years)! I'd like to think we are still the same way. Overall we have a great group of attendings, and I have still continue to learn from them. The ED runs with color coded teams, and the PA teams bypass the senior resident and only deal with the attending. We still do a ton of procedures, especially the aggressive folks. One of my big pet peeves is when one of our new grads has a patient needing something like a belly tap or a central line and they ask the senior resident to do it because they lack the self-confidence to attempt it themselves. Even if it means asking the senior to come walk them through their first central line, they should still be the ones doing it; it is their patient after all.

 

This is where the Old Hand PA's need to take the younglings under their wings and guide them to the Dark Side!If they demonstrate weakness and servitude that is what will be expected of them! My PA buddy from my days always said the residents role in the section was top make us look good!