Great variation exists in emergency departments (EDs) across the United States with regard to scope of practice, expectations, team dynamics, and training requirements for physician assistants (PAs) and nurse practitioners (NPs), according to a study published in JAAPA.

Andrew W. Phillips, MD, MEd, FAAEM, from the Department of Emergency Medicine at the University of North Carolina, Chapel Hill, and colleagues, sought to establish a baseline record of current PA and NP staffing models, practice patterns, and practice scope as the first step to inform future policy recommendations at a national level. The researchers used the American College of Emergency Physicians (ACEP) council as a nationally representative sampling frame and created two surveys using the data. Survey construction was informed by interviews and evaluated with validity and reliability studies.

All ACEP councilors as of October 2015 were invited to participate. Respondents were asked to provide responses with respect to their current primary clinical location. Of the 364 councilors, 331 were signed in to the meeting at the time of the audience response system survey and responded, yielding a response rate of 90.1%. For the online survey, 208 of 371 registered councilors responded, yielding a 56.1% response rate. About 72% of respondents were male, and the mean age was 47.7 years.

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About 51% of the 327 respondents to the audience response system survey reported that they generally regarded PAs and NPs as subordinate in relation to attending physicians. Nearly 12% considered the relationship equivalent, 0.92% considered it similar to that of a medical student, 22.9% liked working with a resident, and 13.2% reported an unspecified relationship not described by the previously mentioned categories.

In about 30% of represented EDs, PAs and NPs see patients who are ESI level 1 (most urgent, requiring resuscitation). More than 90% of PAs and NPs see patients who are ESI levels 3 (urgent) to 5 (nonurgent). Supervisory models vary, with some EDs requiring realtime physician presentation for every patient and others not requiring any physician knowledge of the patient’s presence for the same ESI level.

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No statistically significant difference was found in the type of provider (PA or NP) hired between different ED settings. Slightly more than 63% of councilors reported that their institutions hired PAs with less than 5 years’ experience and 58.1% reported hiring less-experienced NPs. The ED setting was not significantly associated with hiring less-experienced PAs (yes for 64.3% rural, 60.8% suburban, and 65.4% urban of 117 respondents), nor for less experienced NPs (yes for 71.4% rural, 54.9% suburban, 57.7% urban of 117 respondents). NPs were reported to have inadequate supervision more frequently than PAs, based on 128 responses (42.2% inadequate, 57% adequate, 0.8% too much supervision for NPs; 31.3% inadequate, 68% adequate, 0.8% too much supervision for PAs).

“Differences in resource use and autonomy in practice were noted between PAs and NPs,” the authors concluded. “Our findings provide a foundation on which further evaluation can inform policy recommendations for the most appropriate training and experience standards, scope of practice, and levels of supervision for NPs and PAs in US EDs.”


Phillips AW, Klauer KM, Kessler CS. Emergency physician evaluation of PA and NP practice patterns. JAAPA. 2018;31:38-43. doi: 10.1097/01.JAA.0000532118.98379.f1