Systematic review of the the literature on the use of physician assistants in emergency medicine.

1. SPECIAL CONTRIBUTION
Physician Assistants in Emergency Medicine:
The Impact of Their Role
Roderick S. Hooker, PhD, PA, David J. Klocko, MPAS, PA-C, and G. Luke Larkin, MD, MSPH
Abstract
Background: Emergency medicine (EM) in North America has been undergoing significant transforma-
tion since the new century. Recent health care reform has put it center stage. Access demand for acute
care is increasing at the same time the number of qualified emergency physicians entering service has
reached a plateau. Physician assistants (PAs), one alternative, are employed in emergency departments
(EDs), but little is known about the impact of their role.
Objectives: This was a literature review to identify the current role of PAs in patient treatment and the
management of emergency services.
Methods: All publications and designs from 1970 through 2009 were identified using multiple science
citation indices. Each author reviewed the literature, and categories were developed based on consensus.
Results: Thirty-five articles and reports were sorted into categories of interest: prevalence of PAs in
EDs, efficiency and quality of care, patient satisfaction, rural emergency care, and legal issues. Each cat-
egory is summarized and discussed. Evidence comparing the clinical effectiveness of PAs to mainstream
management of emergency care was only fair in methodologic quality.
Conclusions: The use of PAs in EDs is increasing, and this expansion is due to necessity in staffing and
economy of scale. Unique uses of PAs include wound management, acute care transfer management to
the wards, and rural health emergency staffing. While their role seems to be expanding, this assessment
identified gaps in deployment research using appropriate outcome measures in the area of clinical
effectiveness of PAs.
ACADEMIC EMERGENCY MEDICINE 2011; 18:72–77 ª 2011 by the Society for Academic Emergency
Medicine
T
he demand for emergency medical care has suggests that physicians are realizing the effectiveness of
increased substantially in the new millennium.1 PAs in the ED.
The number of visits to emergency departments The rate of ED visits is predicted to double by 2025,
(EDs) is rising, and the shortage of physician personnel while the rate of emergency physicians (EPs) entering
is mounting.2 The American College of Emergency Phy- the profession is flat. Managers of acute care services
sicians (ACEP) reaffirmed that ‘‘there is currently a sig- are searching for additional labor solutions.1,4,5 The
nificant shortage of physicians appropriately trained and American health care reform act of 2010 includes prior-
certified in emergency medicine.’’3 Emergency services, ities to improve the delivery of health care services,
physician group practices, and hospital administrators along with strengthening EDs and trauma center capac-
have turned to physician assistants (PAs) as a way to ity. Because more demand for ED patient care is antici-
meet increased health care demands. Such utilization pated, we set out to examine utilization and efficacy
with the premise that a greater quantity of PAs will be
From the Department of Veterans Affairs (RSH), Dallas, TX; needed to assist in the delivery of urgent care. We con-
the Department of Physician Assistant Studies, University of ducted a review of PA ED literature on contemporary
Texas Southwestern Medical Center (DK), Dallas, TX; and the staffing arrangements. Our objective was a purposive
Department of Emergency Medicine, Yale University (GLL), literature review, rather than a systematic review.
New Haven, CT.
Received March 29, 2010; revisions received May 27 and June 5, METHODS
2010; accepted June 7, 2010.
The authors have no disclosures or conflicts of interest to All publications and designs about PAs in EDs from
report. 1970 through 2009 were identified using multiple science
Supervising Editor: Lowell Gerson, MD. citation indices: Google Scholar, PubMed, and CINAHL.
Address for correspondence and reprints: Roderick S. Hooker, Key search terms included ‘‘physician(s) assistant,’’
PhD, PA; e-mail: rodhooker@msn.com. ‘‘physician(s) associate,’’ ‘‘non-physician provider,’’
ISSN 1069-6563 ª 2010 by the Society for Academic Emergency Medicine
72 PII ISSN 1069-6563583 doi: 10.1111/j.1553-2712.2010.00953.x

2. ACAD EMERG MED • January 2011, Vol. 18, No. 1 • www.aemj.org 73
‘‘PA, physician extender,’’ ‘‘midlevel provider,’’ ‘‘emer- cation will include: work experience in EM, a continuing
gency medicine,’’ ‘‘emergency room,’’ ‘‘fast track,’’ medical education requirement, a patient log, and a spe-
‘‘workforce,’’ ‘‘manpower,’’ and ‘‘acute care.’’ The cialty examination.15 Implications of PA specialty certifi-
authors reviewed the literature, and categories were cation are part of a national debate. However, other
developed based on consensus. Each category was sum- attempts to develop voluntary specialty certification
marized and discussed. Background and current under- examinations have failed due to lack of interest.16
standing of PA employment was added for greater
usefulness. Articles addressing the efficacy of the PA Influencing Organizations. Three professional socie-
role in EDs were purposely selected. ties influence PA roles in the EM workforce. ACEP
addresses policy issues pertaining to PAs, and the Soci-
RESULTS ety of Emergency Medicine Physician Assistants repre-
sents specialized EM PAs, with each recognizing the
Thirty-five articles and reports on PAs in EDs were other’s organization. The American Academy of Physi-
sorted into the following topics of interest: history and cian Assistants is an advocacy group that represents
education, prevalence, efficiency, quality of care, patient clinically active PAs in the United States (approximately
satisfaction, rural emergency care, and legal issues. 75,000 in 2010).
History, Policy, and Education of PAs Emergency Medical Treatment and Active Labor Act
The use of PAs in American medicine began in 1967. (EMTALA). In 1986, the EMTALA, Section 1867(a) of
Almost from the beginning, they were recruited for the U.S. Social Security Act, addressed emergency
emergency services.6,7 As of 2009, all PA programs teach medical access and provider reimbursement. EMTALA
some aspect of emergency medical care, and each PA law and regulations permit medical screening examina-
student spends clinical time in an emergency medicine tions by PAs. Written hospital policy and medical staff
(EM) setting. PAs are employed as health professionals bylaws specify that PAs and nurse practioners (NPs)
who practice care under physician supervision.8 Approx- are providers that the hospital deems qualified to work
imately 7,817 (10%) worked primarily in EDs in 2009.9 in defined roles.17
To qualify for practice, PAs must be licensed in the
state where they work. Licensing (or credentialing) is Guidelines for Physician Assistants. ACEP’s policy
mandatory in all states, the District of Columbia, and statement, Guidelines on the Role of Physician Assis-
most U.S. territories. All PAs must be graduates of an tants in the Emergency Departments,8 requires PAs to
educational program accredited by the Accreditation work clinically within the supervision of an EP who
Review Commission on Education for the Physician assumes responsibility for each PA encounter. Further-
Assistant. In 2010, there were 154 accredited PA pro- more, the PA’s scope of practice must be clearly delin-
grams, with 88% awarding a master’s degree; the eated and consistent with state regulations.8 An
remainder a baccalaureate degree and/or a certificate.10 example of a PA scope of practice as listed in the Texas
Upon graduation, he or she must pass a national certi- medical board rules and regulations is in Table 1.
fying examination administered by the National Com-
mission on Certification of Physician Assistants Prevalence of PAs in EDs
(NCCPA) to be eligible to work as a PA. To work clini- The PA role in EM began in the late 1960s, with their uti-
cally in a jurisdiction, the PA must obtain authorization lization documented at various times and in various
to practice from the appropriate regulatory board.11 ways. One of the first cross-sectional utilization studies
Since 2007, all states have sanctioned delegated pre- of PAs used data from the National Hospital Ambulatory
scribing, and all but two permit prescribing controlled Medical Care Survey (NHAMCS). In 1992, PAs and NPs
substances as part of that authority.12 together managed 4% of all NHAMCS ED visits. Few
Physician assistant postgraduate programs are not differences emerged when diagnoses and patient char-
part of primary PA education, but exist in some small acteristics managed by PAs or NPs and by physicians
form. Less than 2% of the PA population elects to train were compared. This finding suggested there was little
beyond their PA education, and the vast majority of differentiation (triage) of patients to a PA, NP, or physi-
PAs in the ED are trained on the job. A survey of 55 cian.18 A similar analysis of the NHAMCS data set in
postgraduate PA programs in 2008 found that seven 1994 found that the number of patients seen by PA and
were in EM, and the duration of this specialized train- NPs in the ED had doubled.19 At that time, 8.4% of all
ing was 12–18 months.13 The U.S. Army postgraduate PAs nationally reported that they were employed in EM,
education program in EM, at Brooke Army Medical compared to 64 other medical and surgical disciplines.20
Center in Fort Sam Houston, Texas, is a prototype resi- By 1997, the National Centers for Health Statistics
dency of 18 months in length, admits four PAs a year, (NCHS) estimated that outpatient visits had risen to
and awards a doctorate in health sciences (DHSc). The 960 million per year in nonfederal ambulatory care set-
program is structured to expose the PA to high-trauma tings, with EDs accounting for 9.9% of these visits. At
battlefield conditions.14 No similar program has been this time, half of all PAs were employed in primary
developed in civilian institutions. care, but EM was the second most commonly chosen
specialty by recent PA program graduates (9.1%).21
Specialty Certification. The NCCPA has developed an The NHAMCS estimate of ED visits continues to rise
optional specialty certificate for EM and intends to make annually. In a 10-year trend analysis of U.S. EM activity
it available in 2011. The criteria to meet specialty certifi- (1995–2004), an estimated 1 billion EM visits were

3. 74 Hooker et al. • PA ED ROLES
Table 1 reservoir for expanding demand. National information
PA Scope of Practice as Listed in a State Medical Board Rules on staffing patterns in hospital outpatient departments
and Regulations* such as EDs is considered reliable due to the robust-
ness of the data collected consistently and systemati-
1. Obtaining patient histories and performing physical cally by the NCHS. Administrative data of employment
examinations. among large corporations that contract ED services
2. Ordering or performing diagnostic and therapeutic would help to distinguish characteristics of providers
procedures.
3. Formulating a working diagnosis. and those of patient populations for better matching of
4. Developing and implementing a treatment plan. service teams.
5. Monitoring the effectiveness of therapeutic interventions.
6. Assisting at surgery. Creative Solutions to ED overcrowding
7. Offering counseling and education to meet patient needs. Decreasing health care dollars and increasing demands
8. Requesting, receiving, and signing for the receipt of
pharmaceutical sample prescription medications and for acute care services have driven managers to assess
distributing the samples to patients in a specific practice whether PAs are an appropriate alternative to provide
setting in which the physician assistant is authorized to services in ED settings. In one study, researchers ana-
prescribe pharmaceutical medications and sign prescription lyzed 9,600 ED visits attended by physicians and PAs in
drug orders as authorized by physician assistant board rule.
9. Signing or completing a prescription.
an urban urgent care facility. They compared length of
visit and total charges for the two providers using 14
PA = physician assistant. diagnostic groups. Both providers had a similar distri-
*Texas Medical Board, Chapter 204. Physician Assistants bution of diagnostic cases. Respiratory infection and
Occupations Code. Physician Assistant Licensing Act. Acts musculoskeletal disorders accounted for 36% of visits;
1999, 76th Leg., ch. 388, Sec. 1, eff. September 1, 1999, p 19. lacerations, gastrointestinal disorders, and otitis each
accounted for 5% of visits. Overall, PA-attended visits
were 8 minutes longer and total charges $8 less com-
aggregated. PAs were the provider of record for 5.7% pared to a doctor. Differences in charges and time were
of those visits and NPs for another 1.7%. Emergency considered small and clinically insignificant by the
visits and the employment of all three provider types authors.24
increased over the 10 years as well, with PA growth Innovative programs to take advantage of select PA
doubling during this period and EP growth was almost skills have been adopted in some settings. A PA lacera-
flat.1 This work was validated by another set of tion management program demonstrated improved
researchers with similar conclusions.22 care and outcomes, decreased cost, and improved
As of 2010, the American Academy of Physician patient satisfaction.25
Assistants (AAPA) estimated that there were 75,000 clin- Crowding in the ED has multiple causes, including
ically active PAs; 10.5% (7,817) identified EM as their space and staffing in both inpatient areas and the ED.26
primary specialty (excluding trauma).9 A 2008 AAPA Waiting for beds is a primary issue in the ED, because
survey of 2,651 PAs in EM served as a cohort for sub- the patient requires continuing care and attention from
analysis. The census analysis found the average age of EPs. As a managerial response, a unique role was
ED PAs was 40 years, females were 52% of the cohort, developed for PA and NPs to provide ‘‘back-end’’ care
33% were employed by a single-specialty physician for patients awaiting inpatient beds. After initial physi-
group practice, 37% were employed by a hospital, and cian evaluation, patients without ready inpatient beds
7% were self-employed or worked for agencies.12 Most were grouped in the ED and their care was transferred
worked in an urban setting (85%), and the majority to the transition team. The transition team consisted of
(85%) worked full-time (at least 32 hours per week). a PA and ⁄ or NP and a nurse, all reporting to an EP
Approximately one-third (36%) were salary-based; 64% supervisor. Each team assumed care for the patient and
were paid an hourly wage. The mean salary in 2008 was provided appropriate care to keep the patient stable
$99,635. The higher compensation, when compared with until the patient was evaluated by the admitting inpa-
other PAs, may reflect the fact that almost one-third of tient service or until the patient left for an inpatient
EM PAs are contract and ⁄ or shift workers and tend to unit. The major transition team objectives were imp-
work more than 2,000 hours per year, on average.9 roved patient care and a reduction in EP labor in caring
The increased use of PAs in hospitals is thought to be for inpatients. In the aggregate, the transition team
a response to the postgraduate workweek limitations assumed a significant patient load, an indirect measure
put in force by the Accreditation Commission on Grad- of reduced physician work. However, this transition
uate Medical Education (ACGME). Although ACGME team did not improve patient satisfaction. While the
imposed physician resident work hours in 2004, many transition team is a potentially available, incremental
hospitals enacted the policy earlier and developed vari- staffing resource for a crowded ED, the authors point
ous strategies on the part of GME programs to find out that this may not be more desirable to PAs than
labor shortage alternatives. Employment trends in the other traditional clinical roles in the ED.27
early 2000s generally correlated with EDs adjusting to
the reduction of their traditional source of hospital Authors’ Comment. Innovative uses of PAs can
labor and the employment of PAs in greater numbers.23 involve task transfer of repetitive skills such as lacera-
tion management and skill mix such as a transition
Authors’ Comment. The presence of PAs in EM team. Both activities involve low to moderate patient
is increasing and appears to be serving as a medical acuity and draw on experience and a good knowledge

4. ACAD EMERG MED • January 2011, Vol. 18, No. 1 • www.aemj.org 75
base. These examples aside, the literature is considered needed to assess and link outcomes to patient satisfac-
inadequate to make judgments on efficiency. tion among all types of providers.
Quality of Care Rural ED Staffing
A study undertaken at two Toledo, Ohio, hospitals The practice of EM in rural areas is challenging. In
assessed the quality of patient care during transition 2006, a national telephone survey of a random sample
from a resident trauma team to a PA-assisted trauma of 408 small rural hospitals (defined as 100 or fewer
program that functioned without residents. The resea- beds) found that most used a mix of staffing to cover
rch compared support with and without PAs.28 This the ED. On weekdays, about one-third of the hospitals
retrospective analysis of patient care compared a resi- used their own medical staff physicians, one-third used
dent-assisted program at a Level II trauma center in a combination of medical staff and contract coverage
1998 and a PA-dedicated trauma program in 1999 in on evenings and weekends, and 14% used PAs with a
two 6-month segments. The only significant outcome physician on call.32
was a decreased length of stay (LOS) in the hospital In 1979, a Maine rural hospital with 92 beds com-
due to patients being transferred directly from the ED pared a PA to a rotating medical staff system as a
to the floor in 1999. Substitution of PAs for residents method of providing ED coverage. When a patient pre-
had no effect on patient mortality; however, LOS was sented to the ED, the provider on call would be paged.
statistically reduced by 1 day. The authors concluded There was a 105% increase in utilization on shifts cov-
that benefits in patient care improved when there was ered by the PA, compared to a 19% increase seen on
collaboration of residents and PAs in the ED. medical staff shifts during the same period. The finan-
A prospective, nonrandomized, descriptive study cial analysis revealed that the PA generated net revenue
compared traumatic wound infection rates in patients of $260 per shift, while the medical staff system oper-
based on level of training in ED practitioners.29 ated a net deficit of $50 per shift. Since the PA prac-
Wounds were evaluated in 1,163 patients using a ticed without on-site supervision, the hospital
wound registry and a follow-up visit or phone call. No administration developed alternative methods to ensure
significant difference emerged in level of training or quality of care. In the retrospective analysis of cases of
wound care rates among different types of providers: 564 patients spread over 1 year, the PA made no signifi-
medical students had the lowest infection rate at 0 of cant diagnostic or treatment errors.33
60 (0%), resident physicians had 17 of 547 (3.1%), PAs
had 11 of 305 (3.6%), and attending physicians had 14 Authors’ Comment. Staffing rural hospitals appears
of 251 (5.6%). In the aggregate, delegation of wound to be an important element of stability in micropolitan
management to PAs appeared to be safe; PA perfor- communities. Krein34,35 has shown that without PAs in
mance was similar to that of physicians in the same such communities, many hospitals would have to close.
setting.29 The shortcoming in the literature is the lack of depth
about how PAs can improve staffing mix in these small
Authors’ Comment. Quality of care is measured in towns.
many ways, but the outcome of care is generally the
standard by which it is best assessed. The literature on Legal Issues
PA-delivered quality and outcomes of care (when com- In outlining the credentials and accreditation process
pared to a physician) is limited and inadequate for any for PA programs, including ACEP guidelines for the
conclusions in the ED setting. use of PAs in the ED, Delman11 reviewed the legal liter-
ature and case histories of PAs. The author concluded
Patient Satisfaction that ‘‘… probably the most controversial area of practice
Probing patient satisfaction with acute care experience for a physician extender (sic) is in the emergency depart-
is a concept not often reported. Three researchers ment. Ambulatory care is the principal mode of health
explored not only patient satisfaction, but also willing- care in the United States. The second most common
ness to forgo a longer wait in the Fast Track Clinic as a place for the provision of ambulatory care is in hospital
tradeoff to see a physician versus a PA. All patients emergency departments.’’
were seen primarily by a PA in a community hospital Klig36 was more specific when examining the legal
with an annual ED census of 48,600 patients (18% in implications of PAs in the ED. For an ED attending
the Fast Track Clinic). An anonymous survey at time of physician, the legal tenet of vicarious liability under
discharge was used to rate patient satisfaction: 111 sur- respondent superior can apply to PAs as it does for
vey returns were analyzed. Patients were ‘‘very satis- physician residents. If a physician is officially desig-
fied’’ with care rendered by a PA, with a mean patient nated as a supervisor for all aspects of care provided
satisfaction score of 93 of 100 (95% confidence inter- by a PA, that physician may be held directly liable for
val = 90.27 to 95.73). Overall, 12% were willing to wait negligent supervision if a PA is held negligent in the
longer for a physician.30 care of the patient.
Authors’ Comment. Patient acceptance of PAs is criti- Authors’ Comment. There are four major elements of
cal, and no amount of advocacy will outweigh this. The malpractice risk for doctors who supervise a PA: 1) lack
few studies on patient satisfaction suggest that patients of adequate supervision, 2) untimely referral to a con-
are generally satisfied when their needs are met regard- sultant or the PA’s failure to use a consultant, 3) failure
less of who produces the care.31 More research is of a PA to make the correct diagnosis of a patient’s

5. 76 Hooker et al. • PA ED ROLES
condition, and 4) inadequate examination of a patient stock. The reports in this overview are useful in under-
by a PA.37 A 20-year analysis validated that PAs do not standing some of the unique ways EM physician assis-
increase liability and in fact may even lower the liability tants can be deployed.
of a medical practice.38 Whether this pertains to a However, published reports on physician assistants’
cross-section of EDs has not been explored. role delineation in EM provide little more than a limited
guide for ED managers in making staffing decisions.
DISCUSSION This is due to substantial gaps in the literature on phy-
sician assistants in EM. Prospective studies examining
Evidence identifying how PAs fit into mainstream man- outcomes of care, cost benefit of care, division of labor,
agement of emergency care was fair in methodologic and organizational efficiency are missing. These studies
quality but lacking in comprehension of role (or defin- are needed before unequivocal recommendations can
ing the efficacy of these roles). Some of the studies are be made. Issues of safety, scope of practice, range of
limited in their ability to generalize because of small skills, level of acuity, and geographical setting are vari-
sample size or unique nonrepresentative setting and ables that need adjustment in studies involving physi-
circumstance. Nevertheless, a number of findings were cian assistants, nurse practitioners, and physicians if
revealed. It appears that the use of PAs in EDs can issues of substitution are to be addressed.
favorably affect patient care. This may be through Given an underperforming health care system and
patient flow, differentiation of patients, offloading resi- untenable rising costs, it is important for health care to
dent work hours, or augmenting staffing patterns. take the path that aligns quality and value efforts with
Improved clinical and financial outcomes are important care where it matters: at the front lines with clinicians
findings in a few studies. Other studies have demon- and patients. Changes in national health care access
strated additional areas of influence such as quality of and financing will affect acute care services, in both
care. demand and action, which will test the adaptability of
When comparable data were pooled, few differences ED operations. How emergency service centers will
arose between PAs and doctors. Innovative use of PAs accommodate an anticipated surge requires collective
included wound management, acute care management, planning. We suggest investment in quality improve-
stabilization of patients waiting for transfer, and rural ment research at the acute care interface and the
health roles. Economic tradeoffs in terms of patient results used to transform clinician-patient dynamics.
willingness to be seen by a PA in an ED provide an Physician assistants should be part of this planning.
interesting perspective of satisfaction surveys showing
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