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Advanced Practice Providers (Physician Assistant and Nurse Practitioner) Medical-Legal Issuesan Information PaperReviewed by the ACEP Board of Directors, November 2016Nurse practitioners (NP) and physician assistants (PA) are a growing part of the emergency department(ED) team. ACEP’s Medical Legal Committee has been asked to summarize the issues of working with,hiring and supervising these Advanced Practice Providers (APPs). This document will try and answerquestions related to APPs and there are attached links provided for more information.Emergency Nurse Practitioner Educational PreparationNurse practitioners must be registered nurses. The minimum education level is a master’s degree but theymay be educated to the terminal degree of DNP or PhD. Nurse practitioners are nationally certified, andmay then advance to obtain specialty knowledge and competencies in accordance with the ConsensusModel for APRN Regulation.1Emergency Nurse Practitioners (ENPs) must be prepared to provide primary care and acute resuscitation,as well as manage complex, unstable conditions in patients of all ages; therefore, current ENP educationalprograms build upon Family Nurse Practitioner (FNP) education to provide specialty knowledge acrossthe lifespan. Specialty training in emergency care is currently available through graduate academicprograms and through fellowship programs. Listings of current ENP academic programs, both graduateand post-graduate, and ENP fellowship programs are available on the AAENP website (http://aaenpnatl.org/index.php).The ENP scope of practice is based on educational preparation, state regulation and licensure, andinstitutional credentialing. Not all nurse practitioners have the same knowledge and skill sets.Competency to practice in the emergency care setting is based on academic preparation, certification in aspecific patient population (most appropriately family), and specialty education in emergency care - noton prior emergency nursing experience. Therefore, it is important to evaluate the educationalqualifications of nurse practitioners to ensure they possess specialty qualifications for emergency care.Evaluation of ENP Competencies may be assessed in several ways: Successful completion of an academic ENP program or post-graduate emergency care fellowshipprogram Organizational orientation, skill acquisition, and evaluation based on location and organizationstandards Completion of emergency-specific continuing education Individual portfolio documentation of skills, training and/or procedure log1. American Nurses Credentialing Center (2008). Consensus model for APRN Regulation: Licensure,Accreditation, Certification and Education. Retrieved from elReport.aspxPhysician Assistant Background and EducationThe physician assistant (PA) profession started in 1965 at Duke University. Well trained medics werereturning from Vietnam and there was little employment for these highly skilled individuals in civilianlife. Dr. Eugene Stead conceived and implemented the PA program which has grown to approximately110,000 certified PAs and 170 accredited programs around the country, and many more now around theworld.The PA profession emphasizes previous experience for its candidates. Many programs require over 1000hours of direct medical care for applicants. This may include paramedic, nursing, technician, medical1

assistant, scribes, and many others. Most of the programs now are master’s programs with a requiredbachelor degree with basic pre-med prerequisites. The average PA student is 24 years old with a bachelordegree and three years of healthcare experience.PA programs are all accredited by the Accreditation Review Commission on the Education of PhysicianAssistants (ARC-PA). ARC-PA is the accrediting agency that protects the interests of the public and PAprofession by defining the standards for PA education and evaluating PA educational programs within theterritorial United States to ensure their compliance with those standards.PA programs vary from 24-28 months. PAs are trained in the medical model. Many PA programs areassociated with medical schools so the physician/PA relationship starts early in training. The first year isdidactic and is mostly classroom, with some hospital-based or office-based education performingsupervised history and physicals. The second year is clinical and rotates through specialty services. Atleast 2000 hours of clinical training, supervised by physicians and PAs is required. Rotations include: Emergency Medicine Family Medicine Geriatric Medicine Internal Medicine Obstetrics/gynecology Orthopedics Pediatrics Psychiatry Radiology SurgeryAfter successful graduation from an accredited PA program, the PA must successfully pass the PhysicianAssistant National Certifying Exam (PANCE) which is given by the National Commission on theCertification of Physician Assistants (NCCPA), similar to American Board of Emergency Medicine. Thismust be passed to become certified and is a requirement for all state licenses. The PANCE exam is ageneralist exam and not specific to a specialty. There is a surgical and general medicine exam; either maybe elected.PAs must have 100 hours of CME every two years to keep their certification in most states. Theseincluded, up until recently, Category I and Category II CME, similar to physicians. Recently the NCCPAchanged to two-year cycles. During each of those two-year cycles, the PA must earn and log at least 100CME credits, including at least 50 Category 1 CME credits. Also -- new in the certification maintenancecycle -- 20 of the 50 Category I CME credits must be earned through self-assessment (SA) CME and/orperformance improvement CME (PI-CME). By the end of the first four two-year CME cycles, PAs musthave earned a total of at least 40 Category 1 CME credits through PI activities and 40 Category 1 CMEcredits through SA activities.Until recently, PAs took a recertification test every six years. This was changed to every 10 years to moreclosely mirror physician colleagues. NCCPA is now considering changes to the test which may includemore frequent smaller tests and more specialty emphasis, but this is currently in development. Anychanges will be posted on www.NCCPA.net.Over the last few years, the NCCPA has provided a Certificate of Added Qualification (CAQ). This is anoptional additional exam that can be taken and passed to prove added education and training in aspecialty. Emergency medicine is one of these specialties.2

Physician assistants seeking the Emergency Medicine CAQ must demonstrate advanced knowledge andexperience in emergency medicine, above and beyond that expected of entry-level PAs or PAs working ina generalist practice. PAs seeking eligibility for the Emergency Medicine Specialty Examination mustmeet requirements of specialty-specific CME, experience in the field, and specific knowledge and/orexperience in conducting procedures and being involved in patient cases that are deemed core to thespecialty area of practice. PAs will have six years within which to complete all four components for theCAQ, including passing the specialty exam.Physician assistants seeking the Emergency Medicine CAQ must also first satisfy two basic prerequisites: (1) current PA-C certification and (2) possession of a valid, unrestricted license to practice as aPA in at least one jurisdiction in the United States or its territories, or unrestricted privileges to practice asa PA for a government agency. NCCPA’s specialty CAQ process is predicated on a strong belief in thevalue and importance of the physician-PA team, and in support of the procedures and patient caserequirement, each applicant must provide attestation from a supervising physician who works in thespecialty and is familiar with the PA’s practice and experience. PAs may find it helpful, however, tosecure such a physician sponsor at the beginning of the process for the purpose of seeking guidance on thepursuit of the other requirements.CME RequirementIn the six years preceding the date of application for the specialty exam, candidates must earn a minimumof 150 credits of Category 1 CME focused on emergency medicine practice with a minimum of 50 ofthose credits having been earned within the two years prior to the date of exam application. The 150required CME credits must include completion of an Advanced Cardiac Life Support course. The same150 credits may also be used for maintenance of the PA-C credential.PAs are encouraged to use their best judgment when determining whether individual CME activities arerelated to emergency medicine, understanding that those credits may be subject to a CME auditingprocess.Upon fulfillment of all CME requirements, candidates must attest to their completion at NCCPA’swebsite.Recommendations for CME Activities: Physician and PA emergency medicine leaders provided input indeveloping the following CME recommendations for PAs interested in pursuing a CAQ in that specialty.Applicants should complete a comprehensive emergency medicine course that reflects the guidelines setforth in the most current version of Model of the Clinical Practice of Emergency Medicine. Applicantsshould also complete the following courses: Pediatric Advanced Life Support or Advanced Pediatric Life Support Advanced Trauma Life Support Airway courseEXPERIENCE REQUIREMENTPhysician assistants seeking the Emergency Medicine CAQ must have gained at least 3,000 hours ofexperience (the equivalent of 18 months of full-time practice) working as a PA in emergency medicinewithin six years of the date they attest to NCCPA that the experience requirement has been satisfied. Ifselected for an audit, documentation substantiating that work experience will be required.PROCEDURES/PATIENT CASE REQUIREMENTCandidates for the CAQ must be able to apply the appropriate knowledge and skills needed for practice inthe specialty, as described below. In support of this requirement, each candidate must provide attestation3

from a supervising physician who works in the specialty and is familiar with the PA’s practice andexperience. The physician attestation must indicate that the PA has performed the procedures and patientmanagement relevant to the practice setting and/or understands how and when the procedures should beperformed.Again, the PA may not have experience with each procedure, but he or she must be knowledgeable of thebasics of the procedures, in what situation the procedures should be done, and the associated managementof patients.In determining whether a PA can satisfy the Specialty Procedures and Patient Case Requirement,consideration should be given to the following areas:Airway Adjuncts: Invasive Airway Management Intubation Mechanical ventilation Capnometry Non-invasive ventilatory managementAnesthesia Local, digital Procedural anesthesia, conscious sedationAdvanced Wound Management Incision & drainage, wound debridement Superficial/deep wound closureDiagnostic/Therapeutic Procedures Soft tissue and joint aspiration Lumbar puncture Slit lamp examination Thoracentesis, thoracostomy Tonometry Control of epistaxis Electrocardiographic interpretation Cardiac pacing Defibrillation/cardioversion Clearing a cervical spine Fracture/dislocation managementHemodynamic Techniques Peripheral venous access Arterial access for diagnostics and placement of arterial lines Central venous access Intraosseous infusionRadiographic Interpretation Chest x-ray Plain films (bone, soft tissues, abdominal series, etc.) CT scans, MRIsResuscitation Cardiopulmonary FluidTHE EMERGENCY MEDICINE SPECIALTY EXAMOnce PAs have satisfied all other requirements for the Emergency Medicine CAQ, they can apply for theEmergency Medicine Specialty Exam -- 120 multiple-choice questions related to emergency medicine4

targeted for PAs with experience in the practice of that specialty. It will be based on the ContentBlueprint, developed using data gathered during the 2009-2010 PA Practice Analysis conducted Society of Emergency Medicine Physician AssistantsPost Graduate PA Training in Emergency MedicinePrimary PA education is designed to provide a generalist foundation upon which PAs can, over time,build specialty knowledge and skills. Historically this has been accomplished through on-the-job trainingalongside experienced PAs and EPs. As PAs are being utilized in ever expanding roles, the amount ofspecialty knowledge needed to continue to provide excellent patient care is increasing. Concurrently everincreasing time, fiscal, and liability pressures make it challenging for new graduate PAs to obtainspecialty education in the standard on the job system. While some practices have developed structuredorientation programs many PAs new to emergency medicine are placed in the ED to “sink or swim.” Thehigh failure or burnout rate of these PAs has caused many employers to not entertain new grads ascandidates. These factors have generated a demand for more uniform formal specialty training programs,which are now called EMPA Residencies or Fellowships.USC Medical Center LA County Hospital had the first emergency medicine residency for PAs. It was anabridged version of EM physician residencies lasting one year. This program was very popular with PAsbut there was a two-year experience requirement and they typically only took two residents a year. Theprogram started in 1990, and unfortunately, due to budget cuts, the program was discontinued. For yearsafter this, there was a void in emergency medicine post-graduate training for PAs. Many emergencymedicine groups and physician residencies looked into providing this extra training, but because it is notreimbursed through Medicare and the federal government, or were based on grants with finite limits,many of the programs were dropped.As the ED became more