Protocols for PAs ensure better patient care

Set ground rules before patients are seen

When an emergency department (ED) begins hiring midlevel practitioners, it’s crucial the administration develops protocols for how these physician extenders will be used, experts say.

Since positions for physician assistants (PA) and nurse practitioners (NP) were created in the late 1960s, hospitals and general practitioners have increasingly grown to rely on them to substitute for doctors in places where physicians are scarce.

Now there are more than 50,000 practicing midlevels in the United States, according to a recent survey.1

Several experts offer this advice on developing the protocol:

1. Consult ED physicians.

"The most important thing is you have to have a set of protocols that are accepted by the physician and have the physician’s input in how they are designed and put into practice," says Lee Smith, MD, JD, assistant professor in the department of emergency medicine at West Virginia University in Morgantown. (See sample PA description, p. 116.)

Smith says he often receives complaints from physicians that an administrator suddenly makes a decision to hire PAs or NPs to hold down costs.

2. Limit midlevels’ role to what the supervising physician can do.

Smith advises EDs to limit the midlevel practitioners skills to whatever limits the supervising physician has. For example, if the supervising physician cannot do heart surgery, then the physician assistant working with him or her would not be permitted to assist in heart surgery, he says. "But if they worked for a neurosurgeon then they could assist in neurosurgery cases," Smith adds.

3. Follow state and federal licensing requirements.

"Because there are 50 different states and licensing institutions then there are as many different regulations," Smith says.

Most states allow midlevel practitioners to write some prescriptions without being certified by a physician. However, many states limit prescription writing to certain drugs and sometimes under certain conditions. Smith recommends that you include these precise requirements in the protocol.

4. Decide whether high acuity patients must be seen by a physician.

Smith says some hospitals won’t allow a PA or NP to deal with high-acuity patients, such as those who come in with crushing chest pain.

Some midlevels treat any category

But the ED in West Virginia University Hospital has no limits on what type of patients a midlevel practitioner or resident physician can see while under supervision, he adds. "We allow our folks to go in and see all patients because they need to get the experience of seeing seriously-ill patients."

Also, West Virginia’s ED typically begins to treat high-acuity patients, such as those with chest pain, immediately upon admission, Smith says. "The minute they say ‘chest pain,’ we put them in a treatment bed, put them on an EKG monitor. We start an IV and administer oxygen or nitroglycerin if necessary, and all that’s done before the physician sees the patient," Smith explains.

5. Outline the extent of supervision required.

The protocols should address the types of patients that the midlevel provider can see without any type of supervision, Smith says.

Loma Linda (CA) University Medical Center has two nurse practitioners working in the ED’s express care area. The NPs always work with one physician, so there is constant supervision, says Darlene Bradley, RN, MSN, MAOM, director for emergency and express care services.

Likewise, the ED at the Medical College of Georgia in Augusta provides constant supervision of the midlevel providers on staff, says Larry Mellick, MD, FAAP, FACEP, chairman and professor of the Department of Emergency Medicine.

6. Make sure everyone knows what the legal responsibilities are.

"Everyone has to have a clear understanding of what the protocols are and what their limitations are," Smith states.

Smith says he advises midlevel providers to obtain their own medical malpractice insurance. "Whether you’re a resident physician, a physician assistant or nurse practitioner, you may have your own cause of medical malpractice," Smith says.

Midlevel providers traditionally have fewer medical malpractice claims than physicians. A U.S. Government Accounting Office medical malpractice study showed that physicians experienced an average of 16.5 claims per 100 physicians per year in 1984. In 1986, PAs had an average of 0.1 claims per 100 PAs.2


1. Hooker RS, McCaig L. Emergency department uses of physician assistants and nurse practitioners: A national survey. American Journal of Emergency Medicine May 1996:14,245-249.

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