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Bay Area Hospital in Coos Bay, OR, had an ED struggling to keep up with demand for years. The ED had so many patients that its left without being seen (LWBS) statistics were about 8%, well over the industry average of 2%. The ED overcame this problem with the strategic use of physician assistants (PAs) and nurse practitioners (NPs).
The physician had all physician staffing when it contracted with CEP America, a national physician staffing company in Emeryville, CA, to manage the Bay Area Hospital ED. The staffing company suspected that a mix of physicians and PAs or NPs would make the ED more efficient, says Nancy Carlson, RN, BSN, MBA, senior practice management consultant with CEP America. The company employs more than a thousand PAs and NPs nationwide.
“They had a good number of low-acuity patients in the ED, about 40%, but every one of them was seen by a physician, and we know physicians should spend most of their time with very sick patients,” Carlson says. “We had seen from other hospital experiences that PAs are entirely capable of handling these less serious cases, as well as more complex issues.”
Up to that point the hospital had been following a basic triage procedure that ensured the sickest patients were treated first and those with minor issues had to wait — sometimes long enough that they gave up and left the ED. Even very sick patients often waited an hour to see a physician, and other patients waited much longer.
The hospital instituted several changes, including the designation of two exam rooms as “hot rooms,” each staffed with a PA, nurse, and technician. When the triage nurse determines that a patient is low acuity (at level 4 or 5 on the Emergency Services Index [ESI] ), that patient was is sent directly to a hot room to be seen by the staff there. The time to provider dropped sharply, Carlson says, as did turnaround time to discharge — the time from arrival at the ED to departure after waiting for test results.
“Those low-acuity patients were being seen by the PAs very quickly and their time to provider was 13 minutes rather than an hour or more,” she says. “The time to discharge also dropped about 30 minutes.”
Moving all patients through the ED quickly is not the goal, Carlson notes. The focus is on identifying those who can be moved through quickly and getting them treated without delay, which can leave clinicians more time to spend with the higher-acuity patients.
The LWBS ratio also has gone down significantly, to less than 1%, and patient satisfaction has improved by double digits, Carlson says. The hospital helps educate patients about PAs and NPs by handing out “We Care Team” cards during registration, and then asks for their feedback with “Patient Experience” cards afterward. (See the cards on this page.)
The hospital also implemented a rapid medical evaluation (RME) process, which emphasizes having ED patients seen quickly and tests started even if no bed is available. The process also uses a quick registration process and triage.
Such strategic use of PAs requires commitment from the hospital administration, medical staff, and nursing staff, says David Birdsall, MD, a practicing emergency physician and vice president for operations and PA/NP practice with CEP.
“We’re seeing more use of PAs but there are still hospitals that are holdouts because one or more of these groups is suspicious of the concept, and that’s the case only when they really haven’t been educated about who PAs are and what they can do,” Birdsall says. “There is a reasonable concern for patient safety and quality, but those worries can be addressed by educating people.”
Author Greg Freeman, Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Nurse Planner Kay Ball report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Patrice Spath discloses she is a stockholder of both General Electric and Johnson & Johnson, and principal of Brown- Spath & Associates.