Best Practices: Utilizing Physician Assistants in Rural (Critical Access) Emergency Departments
As Emergency Department (ED) utilization increases, there is a growing need for more Board Certified Emergency Medicine Physicians. Many EDs across the country are suffering from shortages in ED staffing and this trend is expected to get worse over the next 10 years. Further, those EDs that are located in less desirable areas suffer from this shortage disproportionately. Although the best solution would be to train more Board-Certified Emergency Medicine physicians, this is not a realistic solution for several reasons. First, in the immediate future there is not enough capacity in EM residency programs to support this goal. Second, many EM-trained physicians do not want to relocate to rural areas or other underserved areas where shortages are greatest.
To address this, Physician Assistants (PAs) have been proposed as a viable staffing alternative provided they are well trained and have appropriate oversight by EM-trained physicians. In this article, we spoke with 2 PAs who currently staff rural access EDs. John Graykoski, MPAS, PA-C, is the Regional Supervisor of Mayo Clinic’s Northwest Region Emergency Physician Assistants group and Cary Stratford, DFAAPA, PA-C is one of the co-owners of Emergency Services of New England (ESNE), a private PA group staffing 2 critical access EDs in rural Vermont.
How did your system come into existence?
John: It began about 6 years ago; our rural ED was staffed by family practice docs and supplemented with Locum Tenens. It was difficult to recruit new people to the clinic. The family practice docs didn't want responsibility to care for ER patients. We had constant problems with call outs, etc., so we made a conscious decision to look at other options. We utilized a Six Sigma approach to evaluation. We considered different models: contracting with other groups, using a straight MD model, utilizing a mixed model of MD/PA, or using PAs as primary providers. The decision was made to utilize PAs as primary providers who would be supported by local family practice docs if needed, or Emergency Medicine docs at our tertiary facility.
Once we switched to this model, we saw a marked increase in Press Ganey scores and adherence to core measures, specifically time to analytics administration in CVA, time to ECG and time to cath lab. We were delivering high quality care, both within the Mayo system as well as by comparison to surrounding hospitals. We implemented this approach now in 3 critical access hospitals. We occasionally have docs work in the department as fill-ins but we are a predominantly PA model.
Cary: About 30 years ago, we were using retired physicians (IM/FP) with 2 PAs in the ED. The docs eventually retired and the hospital was unable to sustain coverage. It went to a contract process and the 2 PAs put together a model of PAs as the primary providers, 24/7 in the ER, with an emergency physician director for QA and supervision. The MD worked clinically and was available as required by agreement and law. We are now in our 32nd year.
How does oversight work?
John: We have a MD medical director who focuses on QA/QI, 1-on-1 training, peer review, and getting new hires on board with how the system works. He covers all 3 critical access hospitals in the system. We also have a PA supervisor who handles the administrative aspects including completing provider evaluations and interface with hospital staff and other departments within the system.
Cary: The Medical director provides QA, clinical support, medical oversight, training and peer review. He covers both hospitals. We are a PA owned-group and actually employ the clinicians. Various administrative roles fall to members of the group.
What is the volume for your respective facilities?
John: We have 3 critical access hospitals, with the following number of visits:
Hospital 1 - 7000 / yr
Hospital 2 - 3000 / yr + 1-2k urgent care visits per year (seen concurrently)
Hospital 3 - 2000 / yr + 1=2k urgent care visits per year (seen concurrently)
Hospital 1 - 18,ooo / yr
Hospital 2 - 6800 / yr
How do you compare with other hospitals in terms of quality of care provided?
Cary: We are either in the top 10 percent or at the top for both patient satisfaction scores via Press Ganey surveys as well, and core measures. We have been so for years.
John: We are also in the top tier. There are 22 hospitals in this part of the Mayo system and we are consistently near the top, both within the system and statewide. Strategically, due to the strength of the model, we are looking to implement it at other sites.
Do you ever encounter resistance from your physician colleagues or other members of the healthcare team?
John: The family practice docs have loved having us as it relieves them of having to deal with the ED. They have also worked with PAs for a long time and are well aware of our skill set and what we bring to the table. We have consistently seen with recruiting other family practice docs that most of them just aren't interested in ED practice. In our tertiary facilities, PAs haven't been used because residents were available. But with their recent introduction, we’ve been embraced by our EM physician colleagues.
Cary: We have been very well received in the hospital and the community. We have an excellent working relationship with the hospital medical staff and have a certain sense of pride and ownership that we can provide this service for them.
What educational standards do all providers in your ED have to maintain to practice?
Cary: We try to draw from EM-experienced providers as we try to target them specifically for training and eventual solo coverage. We have a rigorous set of courses that must be maintained including ACLS, PALS, ATLS, and the Advanced Airway course. We also provide significant CME funding for providers to attend several conferences a year and we are aggressively pursuing ultrasound training at this time.
John: We have 2 tracks - providers who come with experience and those without experience. We consider someone experienced if they come with 2 years full-time equivalent experience working with an EM physician in a main ED. We have all of the same course requirements as mentioned by Cary, and we also add the CALS course (comprehensive advanced life support) which everyone on staff (docs, nurses, etc) takes. It is a course designed for rural access hospitals and focuses on team building for care of critical patients. We also do the Gulf Coast ultrasound 3-day program.
The inexperienced provider, including new graduates, takes all of the above training as any other provider. But they also work with an MD directly for the first 18 months in a tertiary center building their knowledge and skills set. They then move to the rural hospitals and work with another PA and develop the rest of the skills needed to eventually move to solo coverage. We have found that we really need to train our own to make sure we are getting qualified folks as there just aren't enough experienced providers out there.
Cary: John is correct. We too are having difficulty finding experienced providers and also use a two-tiered approach to teach new graduates or less experienced providers. We don't have the tertiary facility approach, but at our 18k visit/year site, we see enough that we can train up providers. We add a new person as an "extra" for a long time and their sole purpose is to see patients and start developing the mindset necessary to function in EM. Once they are up to speed and comfortable, we put them into a double coverage scenario with senior PAs who can continue to teach and mentor them. When we think they are capable, we will let them work autonomously. We have used this approach with a couple of candidates and they have been wildly successful, but we have been selective as to whom we will consider doing this.
How do you prepare them academically?
John: There are a couple of options out there for formal post-grad academic training in EM. We have started a couple of PAs on this track to complement their in-house education and will evaluate it to see how it evolves. We are also considering utilizing the EM residency conferences and grand rounds via remote video for education as well.
Are there any drawbacks or disadvantages to your system(s)?
John: The biggest drawback is that not only is there a physician-shortage, but there is a PA shortage as well. PAs who can function at this level are highly sought after, and many times we find we make an offer and then their original employer opens the purse strings to retain them. It has not been a good employer market.
Cary: It is costly to run this system. The mentoring time requirement drives up the cost to the hospital, so retention is key to the system. Even though it’s expensive, we still represent a significant value over an all-physician group. EP workforce limitations are the major driving force for utilization of EM PAs in this model, not cost. You just can't find a complement of EPs who want to work in these low volume rural environments.
Both models presented have experienced the same challenges: identification, recruitment and retention of highly qualified PAs who desire the degree of autonomy and responsibility to staff these critical access sites. Additionally, both models have developed thorough PA training and monitoring processes in conjunction with their physician colleagues who provide the appropriate supervision. Further, these models provide high quality care to otherwise disadvantaged communities while also demonstrating cost containment. With well-trained EM PAs, who are supervised by Board Certified EM physicians, outreach to remote communities or otherwise disadvantaged areas is a viable and sustainable option for extending the reach of emergency healthcare.
Gregory Raines, MS, MMSc, PA-C - President-Elect, Society of Emergency Medicine Physician Assistants (SEMPA)
John Graykoski, MPAS, PA-C, Regional Supervisor of Mayo Clinic’s Northwest Region Emergency Physician Assistants group
Cary Stratford, DFAAPA, PA-C, co-owners of Emergency Services of New England