Revised June 2023, March 2022, June 2020 with current title, June 2013 titled "Guidelines on the Role of Physician Assistants and Advanced Practice Registered Nurses in the Emergency Department."
Originally approved January 2007 titled "Guidelines on the Role of Physician Assistants and Nurse Practitioners in the Emergency Department", replacing "Guidelines on the Role of Physician Assistants in Emergency Departments" (2002) and "Guidelines on the Role of Nurse Practitioners in the Emergency Department" (2000)
Physician assistants (PAs) and nurse practitioners (NPs) serve as integral and valued members of the physician-led emergency department care team. They do not possess the training and expertise in emergency medicine that may only be acquired through successful completion of an ACGME accredited emergency medicine residency training program - there are no exceptions. The American College of Emergency Physicians (ACEP) believes that regardless of where a patient lives, all patients who present to emergency departments (EDs) deserve to have access to high quality, patient-centric care delivered by emergency physician-led care teams. Accordingly, ACEP endorses the following principles for EDs that utilize PAs and/or NPs in the delivery of emergency department care.
Emergency Department Physician-Led Care Teams
- Because of the nature of emergency medicine, in which patients present with a broad spectrum of acute, undifferentiated illness and injury, including critical life-threatening conditions, the gold standard for emergency department care is that provided by an emergency physician who is certified (or eligible to be certified) by the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM) in emergency medicine or pediatric emergency medicine or an equivalent international certifying body recognized by ABEM or AOBEM in emergency medicine or pediatric emergency medicine.
- EDs should have a medical director who is certified (or eligible to be certified) by the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM) in emergency medicine or pediatric emergency medicine or an equivalent international certifying body recognized by ABEM or AOBEM in emergency medicine or pediatric emergency medicine.
- The ED medical director should be responsible for the orientation and ongoing professional practice evaluation of PAs and NPs working in the ED. The individual evaluative process should be transparent and should provide PAs and NPs with constructive feedback including recommendations for clinical care delivery improvement and professional development.
- As PAs and NPs have variable training and experience, the ED medical director should have the authority to approve both departmental credentialing and for the granting of clinical privileges for PAs and NPs working in the ED.
- ACEP supports the ongoing educational efforts of PAs and NPs in order to improve their clinical and professional knowledge and skills. These ongoing educational efforts may include formal postgraduate emergency medicine training programs. However, these postgraduate training programs for PAs and NPs do not provide training comparable to that provided in an ACGME-accredited emergency medicine residency training program and will never substitute for this comprehensive, specialized, and standardized training.
- ACGME-accredited emergency medicine residency training of physicians should include training in the value and importance of the emergency physician-led care team. This training should include instruction on how to effectively supervise PAs and NPs.
Emergency Physician Supervision of PAs and NPs
- PAs and NPs should not perform independent, unsupervised care in the ED.
- The gold standard for emergency department care is that provided by an emergency physician. If PAs and NPs are utilized for providing emergency department care, the standard is onsite supervision by an emergency physician. The supervising emergency physician for a PA or NP must have the real-time opportunity to be involved in the contemporaneous care of any patient presenting to the ED and seen by a PA or NP.
- ACEP acknowledges that there are currently workforce limitations in specific CMS-designated facility types in which supervision of a PA or NP by an emergency physician may be provided “Offsite” by telehealth means as follows:
- Critical Access Hospitals (CAHs)
- Rural Emergency Hospitals (REHs)
Supervision of PAs and NPs
For all patients being cared for by a PA or NP within the ED, the on-duty emergency physician should solely determine which level of supervision is appropriate. This determination should be made based upon the clinical patient information available and an individual assessment of the PA or NP caring for the patient. Emergency physicians should always have the authority and opportunity to be involved in the care of any patient presenting to the ED and seen by a PA or NP while they are on duty. Emergency physicians must be allowed to determine their level of interaction, care, and involvement for patients seen by a PA or NP under their supervision.
The following concepts of supervision are defined as follows:
- Direct versus Indirect Supervision - defines the degree of involvement of the emergency physician in the care of a patient being seen by a PA or NP.
- Direct Supervision: When the supervising physician personally examines/evaluates the patients for which she/he is the supervisor. This is the gold standard of supervision.
- Indirect Supervision: When the supervising physician contemporaneously discusses or reviews the management of patients for which she/he is the supervising physician but does not personally examine/evaluate the patient.
- Onsite versus Offsite Supervision – delineates the location of the supervising emergency physician for patients being cared for by a PA or NP.
- Onsite: When the supervising physician is physically present in the ED and is available to examine/evaluate the patient.
- Offsite: When the supervising physician is not physically present in the ED but is available 24/7/365 for real-time consultation such as by telehealth means.
- Since the supervising emergency physician is not physically present when providing offsite supervision, the PA or NP caring for the patient must discuss all patients with the supervising physician.
- The following levels of emergency physician involvement in the care of patients seen by a PA or NP are NOT adequate for optimal patient care and are NOT considered appropriate supervision of an PA or NP in the ED.
- Oversight: When an emergency physician is available for supervision, but the PA or NP does not discuss or review the management of the patient, and the physician is not involved in real-time patient care or does not examine/evaluate the patient directly.
- Asynchronous Chart Review: Review of charts in a non-contemporaneous manner for care provided by an PA or NP. While chart review is an important quality assurance activity, it does not constitute direct or indirect supervision.
- Multiple staffing models utilizing PAs and NPs exist. The use of PAs and NPs in the ED should be determined at the site level by local ED physician leadership, who are responsible for PA/NP hiring, supervision, and credentialing of clinical privileges. These emergency physician leaders should be responsible for establishing processes and practice standards that ensure both sufficient physician availability for PA and NP supervision as well as adequate physician opportunity to supervise.
- Emergency physicians should not be required to sign the chart of a patient unless they have a real-time opportunity to be involved in the patient’s care. Though state and hospital policies may require a physician’s signature on all patient charts regardless of physician involvement or supervision, it should be clearly noted in these cases that the physician was not actively involved in the patient’s care.
- All clinical documentation should clearly reflect the role and involvement of the emergency physician and any PAs or NPs who have actively participated in the care of a patient. In particular, the physician should carefully document their independent findings and medical decision making.