Guidelines Regarding the Role of Physician Assistants and Advanced Practice Registered Nurses in the Emergency Department

Revised and approved by the ACEP Board of Directors titled, ‘Guidelines Regarding the Role of Physician Assistants and Advanced Practice Registered Nurses in the Emergency Department” June 2013
Revised and approved by the ACEP Board of Directors January 2007 by replacing two policy statements, “Guidelines on the Role of Physician Assistants in Emergency Departments” approved February 2002 and “Guidelines on the Role of Nurse Practitioners” in the Emergency Department” approved June 2000

Physician assistants (PAs) and advanced practice registered nurses (APRNs) provide services in various roles in emergency departments (EDs), including out-of-hospital patient care, patient triage, patient care in the ED, and administrative functions. The American College of Emergency Physicians (ACEP) endorses the following guidelines for EDs that utilize PAs and APRNs.

  • PAs and APRNs do not replace the medical expertise and patient care provided by emergency physicians.
  • PAs and APRNs working in EDs should have or acquire specific experience or specialty training in emergency care, and should receive continuing education in providing emergency care.
  • Credentialing procedures for PAs and APRNs in the ED must be specifically stated and approved by the facility governing body with input from the medical staff and must meet the requirements of the federal or state jurisdictions in which they practice.
  • PAs and APRNs must be appropriately certified by their respective certifying bodies.
  • Due to variations in state laws and regulations, it is imperative that emergency physicians, PAs and APRNs are aware of their scope of practice as well as physician supervision responsibilities and requirements.
  • The PAs and APRNs scope of practice must be clearly delineated and must be consistent with federal and state laws and regulations.
  • PAs and APRNs working in EDs should participate in a supervised orientation program, including demonstrating knowledge of specific ED policies and procedures and the requisite knowledge base to function safely and appropriately in the ED.
  • The medical director of the ED or a designee has the responsibility of providing the overall direction of activities of the PA or APRN in the ED. In EMS, this is the role of the physician EMS medical director.
  • PAs may function in various capacities and with varying degrees of supervision. However, as dependent practitioners, they must always function with a supervisory agreement with a physician.
  • APRNs supervisory requirements (collaborative agreements) vary and independent practice is authorized in some states.
  • ACEP believes that advanced practice registered nurses or physician assistants should not provide unsupervised emergency department care.
  • Each supervising physician should retain the right to determine his/her degree of involvement in the care of patients provided by PAs and APRNs in accordance with the defined PA or APRN scope of practice, state laws and regulations, and supervisory or collaborative agreement. When such is required, the supervising physician for each PA or APRN encounter should be specifically identified.
  • The ED medical director should define the number of PAs and/or APRNs whose clinical work can be simultaneously supervised by one emergency physician, guided by ED clinical needs and state laws.
  • ED medical directors are encouraged to develop guidelines for PAs and APRNs outlining the types of conditions PAs and APRNs may or may not routinely evaluate and treat:
    • With indirect supervision: Verbal supervising physician consultation and/or chart review/signature.
    • With direct supervision: In conjunction with a supervising physician physically attending to the patient, providing face-to-face time.
  • PAs and APRNs must be aware of and participate in performance improvement activities of the ED or EMS agency.
  • The ED medical director should be responsible for ongoing professional practice evaluation of each PA and APRN utilizing focused professional practice evaluation, as appropriate.
  • PAs and APRNs may fulfill clinical and administrative roles in which they will supplement and assist emergency physicians.
  • Multiple staffing models utilizing PAs and APRNs exist. It is the responsibility of the ED medical director to identify the most appropriate staffing model to achieve operational efficiency, while maintaining clinical quality.


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