The Case 

Community emergency departments have seen volumes increase over the years. Previously, departments responded to increases in patient volume by adding more physician coverage. Lately, hospital administrations have looked to advanced practice providers (APPs) such as physician assistants (PAs) or nurse practitioners (NPs) to meet volume demands. Your hospital is considering hiring some APPs. 

Clinical Question

What is the impact of APP staffing on ED productivity, flow, and safety?

Background

There has been an increased use of APPs in staffing U.S. emergency departments in recent years, justified in part on economic considerations. Advocates claim APPs can be just as productive as physicians and provide safe ED care while costing less money. This financial calculation could work if APP productivities are similar enough to that of physicians to offset differentials in billing rates and compensation. However, there are few data comparing productivity, safety, flow, or patient experiences in emergency medicine.

ACEP has published a number of documents discussing various issues around APPs in the emergency department. Recent concerns about postgraduate training of APPs in the emergency departments led to a joint statement issued in September 2020 by multiple organizations, including ACEP, that said the terms “resident,” “residency,” “fellow,” and “fellowship”​ in a medical setting must be limited to postgraduate clinical training of medical school physician graduates within GME training programs.1 

The debate is only heating up. 

Reference: Pines JM, Zocchi MS, Ritsema T, et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. Acad Emerg Med. 2020;27(11):1089-1099.

• Population: 13 million ED visits from 94 hospitals in 19 states from one national emergency medicine group 
• Exposure: Proportion of total clinician hours staffed by APPs in a 24-hour period at a given emergency department
• Comparison: Emergency physician staffing
• Outcomes:
  • Primary Outcome: Productivity (patients/hour, relative value units [RVUs]/hour, RVUs/visit, RVUs/relative salary for an hour)
  • Secondary Outcomes: Proportion of 72-hour returns and proportion of 72-hour returns resulting in admission, length of stay (LOS), and left without completion of treatment (LWOT)

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.”