EPIC: Physician Assistant in the Emergency Department

EPIC: Physician Assistant in the Emergency Department

QA EPIC Physician Extender Guidelines

Utah DOPL Delegation of services agreement:

"Delegation of services agreement" means written criteria jointly developed by a physician assistant's supervising physician and any substitute supervising physicians and the physician assistant, that permits a physician assistant, working under the direction or review of the supervision physician, to assist in the management of common illnesses and injuries.

The agreement defines the working relationship and delegation of duties between the supervising physician and the physician assistant as specified by division rule and shall include:

(i)The prescribing of controlled substances

(ii)The degree and means of supervision

(iii)The frequency and mechanism of chart review

(iv)Procedures addressing situations outside the scope of practice of the physician assistant, and

(v)Procedures for providing backup for the physician assistant in emergency situations.

Scope of Practice

(1)A physician assistant may provide any medical services that are not specifically prohibited under this chapter or rules adopted under this chapter, and that are:

(a)Within the physician assistant's skills and scope of competence;

(b)Within the usual scope of practice of the physician assistant's supervising physician; and

(c)Provided under the supervision of a supervising physician and in accordance with a delegation of services agreement.

(2)A physician assistant, in accordance with a delegation of services agreement, may prescribe or administer an appropriate controlled substance if:

(a)The physician assistant holds a Utah controlled substance license and a Utah DEA registration;

(b)The prescription or administration of the controlled substance is within the prescriptive practice of the supervising physician and also within the delegated prescribing stated in the delegation of services agreement; and

(c)The supervising physician cosigns any medical chart record of a prescription of a Schedule 2 or Schedule 3 controlled substance made by the physician assistant.

(3)A physician assistant shall, while practicing as a physician assistant, wear an identification badge showing his license classification as a practicing physician assistant.

Areas of responsibility:

  1. Staff the ED fast track as the primary medical provider (in emergency departments with separately identified fast track)
  2. Understand the purpose and goals of the fast track in terms of overall ED structure and patient flow
  3. Support and achieve the fast track goals to ensure it is a successful business venture
  4. Float to the Non-fast track area of the ED as needed, assess patients using scope of practice guidelines listed below:
  5. Be aware of primary FT responsibilities by immediately returning to FT area if new patients arrive there
  6. Peer review
  7. Assist PHYSICIAN director with extender peer review by assessing level and quality of care provided by colleagues.

Protocols:

Physician EXTENDER specific protocols for patient therapy are not necessary. If established practice protocols exist such as critical pathways for the treatment of AMI, Asthma, DKA, etc, then the extender should be expected to follow these pathways. However, creating more detailed protocols for many of the other various presentations seen in the ED is usually not necessary and rapidly outdated.

Scope of Practice:

On a site specific basis the PHYSICIAN EXTENDER in the emergency department may care for all ED patients at the discretion of the on-site emergency PHYSICIAN.

Should a physician extender feel they have initiated care on a patient that is outside the scope of the typical fast track visit, the extender should immediately review the patient’s care with the physician on duty. At that point, the extender and the physician should determine who would continue the care of the patient.

Different levels of supervision are required based on the patient acuity.

Levels of Supervision:

  1. Direct supervision in the room
  2. Case presentation to PHYSICIAN while patient is still in the ED
  3. Case presentation to PHYSICIAN and chart review by PHYSICIAN at a later time.
  4. CME

Cases requiring face-to-face supervision with the PHYSICIAN:

(In general, tThe PHYSICIAN will be in charge of the case and the EXTENDER will assist except in rare situations with multiple unstable cases)

  1. All Resuscitations and procedures associated with resuscitation, including but not limited to:
  2. ACLS care
  3. Intubation
  4. Cardioversion, defibrillation
  5. Central Line placement
  6. Chest tube placement
  7. Thrombolytic administration
  8. Critical or potentially critical patients, including but not limited to:
  9. Acute MI
  10. Acute Stroke
  11. Any patient with unstable vital signs
  12. Status epilepsy
  13. Delivery of a baby
  14. Pediatric fever < 3 months old.
  15. Altered Mental Status
  16. Multiple trauma
  17. Patients requiring Procedural Sedation

All x-rays must be reviewed by the ED PHYSICIAN or the Radiologist prior to the discharge of the patient.

Guidelines for case presentation to the PHYSICIAN while the patient is still in the department:

A significant effort should be made to review all patients with the physician on shift prior to the discharge of the patient. The EXTENDER will give a very brief synopsis of the case and note on the chart the reviewing physician’s name. Any complex cases will be discussed in more detail. Any cases with questions regarding care will be addressed by the PHYSICIAN with the EXTENDER at that moment.

1. Pulmonary and/or other complaints, which have one of the following criteriaRepeat visit

  1. Tachycardia
  2. Hypoxia (O2 sat <92%)
  3. Hypotension
  4. Tachypnea
  1. Chest pain (non-traumatic, >30 y.o.)
  2. Admissions or transfers
  3. Abdominal pain
  4. Scheduled and unplanned follow-ups.

6Patient requiring a more extensive work-up, such as the ordering of multiple labs, x-rays, or CT scans, should have very early physician involvement in the care of the patient. It is most advisable that this patient is presented to the PHYSICIAN after the extender has evaluated the patient, and before the work-up commences.

Situations in which it is reasonable for the case presentation to the PHYSICIAN to occur after discharge:

A significant effort should be made to review all patients with the PHYSICIAN on shift prior to the discharge of the patient. However, this may not always be efficient, and can lead to significant delays in patient care. It is not unreasonable to review some patients after discharge, but before the end of the shift. Patients with simple, single focus complaints, for example ankle sprains, simple lacerations, otitis media or strep pharyngitis, can reasonably be discharged without immediate physician supervision. The PHYSICIAN should be made aware of the patient with a brief presentation as soon as possible.

The physician who is on-site is required to respond to any extender request for a consult regardless of the level of acuity. The PHYSICIAN EXTENDER should always have the ability to ask a physician to see a patient if there is any concern or question regarding the care of the patient. At that point, the EXTENDER and the PHYSICIAN should determine who would continue the care of the patient.

Documentation:

During the shift, the EXTENDER will bring completed charts ready for signature to the doctor who is responsible that day for the EXTENDER oversight. The EXTENDER will try to do this every 30 to 60 minutes so that the charts do not build up. It is the Extender’s responsibility to see that the charts are completed and get PHYSICIAN signature during their shift. The PHYSICIAN EXTENDER must document with which physician each case was reviewed. All charts must be co-signed by this physician in a timely fashion as dictated by medical staff bylaws

It is the responsibility of the PHYSICIAN EXTENDER and the supervising physician on duty in the Emergency Department to determine which patients are appropriate to the scope of practice of the mid-level provider. By presenting each patient, the physician and the mid-level provider will be in constant communication. This should minimize patient error, mal-practice risk and maximize on-going physician extender education.

Case Review:

  1. Daily review: Chart review and co-signatures: (see appendix A & TQI log)

Although Sstate law only requires co-signature for all PA cases where a Schedule 2 or 3 controlled substance was prescribed, and doesn’t require co-signature for Nurse Practitioners, it is EPIC policy that all charts be co-signed..

For this reason, the PHYSICIAN on shift will be required to sign the EXTENDER’s charts and will identify quality issues during this co-signature phase.

  1. Monthly review:
  2. QA person for each ED group will review all charts forwarded to him/her from the daily co-signature review and identify issues that need to be addressed with individual practitioners as well as with the group (EXTENDER and PHYSICIAN) as a whole. These issues will be:
  3. Discussed with the EXTENDER
  4. Discussed in the monthly staff meeting if appropriate
  5. Forwarded to the EPIC QA group for review and identification of sentinel topics that needs to be addressed system wide.
  6. Monthly PHYSICIAN meetings will also have discussion of morbidity cases and other interesting cases by PHYSICIAN’s that were found by the QA person through complaints, bad outcomes, random review, etc.
  7. The EXTENDER’s should be involved in these discussions to enhance their learning. An attendance of 75% will be required to sustain good standing in the group.
  8. These cases should also be forwarded to the EPIC QA group for review and identification of sentinel topics that need to be addressed system wide.

Quality Issues

If any physician recognizes an issue as being a quality issue, he or she will discuss the case with the EXTENDER AND do one of the following:

Fill out the TQI chart and turn it into the physician QA person at the end of the shift OR

Pull a face sheet of the chart of concern, write down their concern and put that in the QA person’s box.

The QA person for each group will review the referrals and make appropriate decisions as to which issues need to be:

  • Discussed with the EXTENDER
  • Discussed in the monthly staff meeting if appropriate
  • Forwarded to the EPIC QA group for review and identification of sentinel topics that needs to be addressed system wide.
  • Forwarded to the EPIC Compliance Committee

A monthly list of topics and issues will be forwarded to the EPIC QA director and the EPIC Compliance Committee, who will use this data to identify timely topics that impact the entire EPIC group.

EPIC QA director contact information:

Roger Perry, MD e-mail:

FAX/phone: 801-463-7341

EPIC Compliance Committee

Telephone: 801-463-7415

FAX: 801-463-7341

Appendix A: Daily EXTENDER chart review and co-signature:

State law requires all patients who receive a controlled substance to have chart co-signature. In addition, chart review is required but the type is not defined.

Chart review proposal:

1. Method:

Legal Disclaimer

It is neither the purpose nor intent of these guidelines to serve as a final authoritative source on any medical condition, treatment plan, or clinical intervention, nor should these guidelines be used to rigorously define a rigid standard of care that should be practiced by all clinicians. These guidelines provide the medical provider with a reasonable clinical guide that is composed of suggestions and opinions of EPIC. These guidelines are a general reference resource and clinical roadmap designed to assist the medical provider. These guidelines cannot replace the clinical judgment of the medical provider and cannot possibly describe every possible aberration, nuance, clinical scenario, or presentation and cannot define standards for clinical actions or procedures.

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