PAs, NPs in ED require careful hiring, training

Here’s how to get the most bang for your buck

Hospital administrators can expect a good return on their investment in midlevel practitioners if they follow certain guidelines.

For a start, experts say, be choosy about who you hire. Then back that with rigorous training.

"A lot of people coming straight out of an undergraduate program might not have a lot of emergency medicine skills," warns Lee Smith, MD, JD, assistant professor in the department of emergency medicine at West Virginia University and a practicing physician at West Virginia University Hospital and the Ruby Memorial Hospital in Morgantown, WV.

Smith says some physician assistants (PA) might already have worked as ED nurses or paramedics, while others might have no experience.

A PA with emergency medicine experience could begin to see patients fairly quickly, Smith says. "That type of person would be light years ahead of someone who went from high school into the PA program." [See story on writing protocols for PAs, nurse practitioners (NP), p. 115.]

Smith and other ED experts offer these guidelines on hiring and training midlevel practitioners:

1. Hire midlevel practitioners who have some medical experience or education beyond the PA or NP degrees.

The American College of Emergency Physicians in Dallas recommends that PAs have the following minimum qualifications:

• a graduate of a Class A physician assistant training program approved by the Committee on Allied Health Education and Accreditation (CAHEA);

• general experience as a PA in the evaluation and management of patients with emergent, urgent, and non-urgent medical problems;

• licensed or eligible for licensure by the state board of medicine and has the ability to work autonomously as a physician extender as well as ability to work under pressure.

Smith recommends hospitals hire midlevels who have master’s degrees, experience, or special training in emergency medicine, although he concedes these could be harder to find. (See chart, p. 113.)

Only 1.2% of PAs responding to a recent survey had specialized in emergency medicine in a post-graduate residency program.1

Also, of more than 70 accredited PA programs, only about 16 offer master’s degrees, Smith says. This includes a master’s program at Alderson-Broaddus College in Philippi, WV, which provides hands-on training for PAs at West Virginia University Hospital and hospitals in 12 other states.

"The PAs need to be involved in hospitals where they are working and undergoing training as part of clinical requirements," Smith says.

When the ED at Loma Linda (CA) University Medical Center expanded to include express care services, the department hired two nurse practitioners who had health care experience prior to becoming NPs, says Darlene Bradley, RN, MSN, MAOM, director for emergency and express care services.

One NP had four-to-five years experience in employee health, and the other had industrial medicine experience and had worked in adolescent medicine.

2. Start small, but add more midlevels as volume dictates.

Smith recommends EDs start with one or two midlevels who serve as backups to physicians during peak times.

West Virginia University Hospital, which recently started an urgent care center, has 18 residents, three PAs, and one NP in the ED, Smith says.

Midlevel practitioners are best used to overlap the physician in an ED, especially during peak hours, Smith and Bradley say.

Loma Linda’s ED is considering expanding the express care service hours to 3 a.m. The current weekday hours are 7 a.m. to 9 p.m. Bradley says she might hire two more midlevel practitioners to help cover the expanded hours.

Some medical professionals estimate that PAs can perform about 80% of the skills performed by a physician on a day-to-day basis, Smith says.

"What we have found is that on a day-to-day work basis, the physician assistants are equivalent to a perpetual second-year resident physician," Smith adds. "They function very well in that type of setting; they have good solid knowledge, and do a solid job."

3. Require additional training in emergency medicine and related skills.

Some states, such as Pennsylvania, require all practitioners who work in the ED to have training in advanced cardiac life support, trauma life support, and pediatric advanced life support, and Smith says he recommends this as an ED policy.

Loma Linda put the NPs through extensive hands-on training. The nurse practitioners were trained in sutures and X-rays under direct supervision by physicians, Bradley says.

"They were trained depending on what the nurse practitioner needed because they came with different backgrounds," she adds.

Also, their charts were reviewed, and the clinical cases were evaluated with joint decisions between the physician and NP.

Bradley says extra training was provided in the areas that gave the NPs the most difficulty:

— The NP who had trouble with pediatrics was teamed with a pediatrician for a month; she received plenty of supervision and hands-on experience.

— They were trained to read X-rays by attending an X-ray reading course and working with a radiologist reviewing all the X-rays.

— The NPs attended a course on suturing and then were observed by physicians doing sutures.

4. Set a competitive salary for midlevel practitioners.

Full-time physician assistants had a mean salary of $60,687, according to a 1996 census report by the American Academy of Physician Assistants.1

The same study showed that between 10% and 90% of the 11,212 PAs who answered the question reported earning between $45,609 and $89,972.

Physician assistants’ salaries have been high traditionally, experts say, because there has been a great demand for the workers and the supply is small.

The need for midlevels is rising nationwide, with about six positions available for each physician assistant and four available for each nurse practitioner, according to a 1994 report.2 (See table showing job growth for PAs, p. 114.)

Also, the salaries have been climbing as emergency departments in urban and rural hospitals compete for physician extenders to make up for a shortage of emergency physicians.3,4


1. American Academy of Physician Assistants. 1996 AAPA Physician Assistant Census Report. Alexandria, VA; Dec. 1996.

2. Robbins K. Non-physician providers. Business and Health 1994; 12(3 Suppl A):49-53.

3. Ehrenberg K, Salzber MD, Sturmann KM. Physician assistants in emergency medicine. Annals of Emergency Medicine 1990; 19:3,304-3,308.

4. American Academy of Physician Assistants. Physician Assistants: Statistics and Trends: 1991-1996. Alexandria, VA; 1997.