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Advanced Practice Providers Are Seeing High-Acuity Patients in EDs

By Stacey Kusterbeck, Special for

Clinical practice models for emergency care are changing rapidly, due in large part to surging patient volumes and staffing shortages.

“The specialty is trying to keep pace with growing demand for ED [emergency department] care that far exceeds the number of new emergency physicians,” says Arjun Venkatesh, MD, MBA, MHS, chair of the department of emergency medicine at Yale School of Medicine and chief of emergency services at Yale New Haven Hospital.

In many EDs, there has been a shift to more care delivered by nonphysician providers. Venkatesh and colleagues decided to take a closer look at this. The researchers used claims data to determine whether the bill was from an emergency physician (either working alone or with a nonphysician) or by a nonphysician who may have had some physician supervision, but not enough to warrant a physician bill.

“The proportion of patients getting critical care from a nonphysician provider, without a physician billing for the service, was an eye-opener,” Venkatesh shares.

Investigators analyzed independent billing data of 47,323 emergency medicine physicians, 10,555 nonemergency medicine physicians, and 26,599 advanced practice providers collected between 2013 and 2019. “We sought to describe how much the emergency care world has changed,” Venkatesh explains.

In 2019, advanced practice providers billed for 9.7% of all high-acuity ED encounters, compared to 5.1% in 2013. In 2019, more than one-third of the average advanced practice providers’ ED encounters were for high-acuity services.

Venkatesh and colleagues also found significant geographic differences in the use of advanced practice providers:

  • In rural areas, advanced practice providers billed for about one in six high-acuity ED encounters.
  • In urban areas, advanced practice providers billed for one in 11 high-acuity ED encounters.

“This reflects that rural areas are likely more dependent on nonphysician providers to staff EDs,” Venkatesh observes.

EDs cannot provide care to all patients with physicians alone. Also, there always will be geographic differences in the workforce distribution.

“We need to create models for care supervision, triage and care segmentation, and even care regionalization that match the skills and training of each member of our workforce to the acuity and needs of the patient in the ED,” Venkatesh says. “There are many ways this could evolve.”

Venkatesh offers these examples:

  • Payment incentives can be used to encourage emergency physicians (EPs) to practice in rural communities.
  • Nonphysicians can go through advanced training programs if they are going to provide high-acuity care in rural EDs.
  • Telehealth can be used to provide physician supervision to nonphysicians in the ED.

Some ED policies stipulate that advanced practice providers should see high-acuity patients only with an EP’s direct supervision. “Such policies need to balance the feasibility and realities of staffing to meet today’s emergency care demand,” Venkatesh says.

If advanced practice providers see high-acuity patients without direct supervision by a qualified EP, patients may not receive appropriate comprehensive care, cautions Pamela Dyne, MD, professor of clinical emergency medicine at the UCLA David Geffen School of Medicine. This could delay potentially life-saving interventions.

“Advanced practice providers generally don't have the training and experience to safely perform the breadth of invasive procedures that residency trained and board-certified emergency physicians have,” Dyne says.

Of 125 ED chairs surveyed, Dyne and colleagues learned only 2% stated advanced practice providers manage high-acuity patients in their ED without the involvement of attending physicians. To alleviate risk, Dyne, suggests the following:

  • Ensure advanced practice providers only see Emergency Severity Index (ESI) Level 4 and 5 patients without direct supervision by a qualified, board-certified EP.
  • If advanced practice providers do see ESI 3 or higher patients, direct a board-certified EP to provide real-time direct supervision.

Some advanced practice providers have accumulated an outstanding and comprehensive knowledge base and a much clinical experience. “But as a group, their supervised training is minimal compared to medical school and residency training that board-certified EPs have,” Dyne says.

For more on this and related subjects, be sure to read the latest issues of ED Management and Emergency Medicine Reports.