The American Academy of Emergency Medicine took a firm stance against the independent practice of nurse practitioners and physician assistants in the emergency department, convening a task force on the role of advanced practice professionals, issuing a statement that it does not “support the independent practice of APPs and other non-physician clinicians,” and in January, dissolving its allied health membership category. (http://bit.ly/AAEM-APP.) The American College of Emergency Physicians likewise has had a policy against the independent practice of NPs and PAs since 2001. (http://bit.ly/ACEP-APP.)
Since the Emergency Nurse Practitioner Certification examination was first offered in January 2017, more than 560 NPs have passed the exam. Twelve training programs offer subspecialty courses and post-master's certificates in emergency nurse practitioner specialization, according to the American Academy of Emergency Nurse Practitioners (AAENP). (http://bit.ly/AAENP-ENP-C.)
ACEP supported developing the new ENP-C certification, even providing a grant to the AAENP and the Academy of Nurse Practitioners Certification Board to create it. ACEP leaders said ENP-Cs are not meant to practice independently or replace emergency physicians. “It's been ACEP policy since 2001 that nurse practitioners and physician assistants should not work unsupervised in the ED, and that position was just reaffirmed in January,” said Sandra Schneider, MD, the college's director of emergency medicine practice.
“ENP certification does not authorize ‘independent practice;’ rather, it provides a mechanism for validating emergency-specific knowledge and competencies,” she said. “AAENP endorses team-based care in emergency department settings with consultation and collaboration with emergency physicians. Collaborative practice is embedded in the ENP certification competency domains.”
ACEP's guidelines for the role of physician assistants and advanced practice registered nurses in the emergency department include the statement that the college “believes that advanced practice registered nurses or physician assistants should not provide unsupervised emergency department care.” (http://bit.ly/ACEP-APP.)
The certification program was needed, Dr. Schneider said, because of the variability of nurse practitioner training. A lot of programs allow nurses to acquire their credentials almost entirely online, with relatively small numbers of required clinical care hours, she said, adding that she knew of a program that required only 500 hours of clinical care, less than what is required for paramedics. “It's almost impossible to know if the nurse you're hiring can sew up a laceration or drain an abscess,” Dr. Schneider said. “We hope that this certification will help emergency physicians make a reasonable decision about the NPs they choose to hire, and identify those who have knowledge and experience you might not find in a general NP.”
Vidor Friedman, MD, the president of ACEP and an emergency physician with FEP of TeamHealth, said improving the education of APPs was important to help develop the team. “Emergency nurses already have a certification program that recognizes special knowledge, the CEN, so this is simply another mechanism like that. There was never any intention to develop a certification exam as a means of stating that an APP is independently qualified to practice emergency medicine.”
APPs in many states, however, are allowed to practice independently. NPs have full practice authority and can work without physician supervision in nearly two dozen states. (http://bit.ly/AANP-States.) “We know that there are settings in which advanced practice professionals are practicing emergency medicine without any real supervision by a board-certified emergency physician,” said Lisa Moreno-Walton, MD, a professor of emergency medicine at Louisiana State University Health Sciences Center and the president-elect of AAEM. “We have no difficulty with NPs being part of the health care team, but they should be directly supervised by board-certified emergency physicians to ensure that patients are getting the best care.”
Dr. Moreno-Walton also noted that APPs aren't necessarily filling the gaps where the need exists for more emergency physicians. “Yes, there are areas where there is a shortage of emergency physicians, but this need predominantly exists in rural areas and smaller cities where it's just not as desirable for young people to live,” she said. “The idea was that APPs would go to the places where physicians didn't want to go. But so far, that hasn't happened.”
Evie Marcolini, MD, an assistant professor of emergency medicine and neurology at the University of Vermont Medical Center and a member of the AAEM board of directors, chaired the AAEM Task Force on Advanced Practice Providers. “Some people may have read our new position statement as saying that we don't like NPs or PAs and are trying to get rid of them,” she said. “That is far from the truth. We value and need PAs and NPs in emergency medicine in the system that has always been in place, which has been as a dependent practice.”
Although the AAEM allied health membership for NPs and PAs was dissolved, APPs are still involved in all the same AAEM activities as before the change, including attending and being involved with the scientific assembly and participating in writing groups, said Dr. Marcolini, also the director of critical care education, emergency medicine, and the fellowship director for neurocritical care at UVMC. “We haven't looked at the ENP-C certification in detail, and can't say whether it will push nurse practitioners toward independent practice or not. I know that ACEP does not support independent practice either, so hopefully this certification does not support independent practice.”
She acknowledged the importance of excellent training for all professionals in the ED and noted that she has encountered inexperienced APPs in the ED. “I've had to do on-the-job training for inexperienced NPs in a busy ED before, and it's challenging. Their ability to tell sick from not sick, assess patients, and have what it takes that you get from experience, it's just not there,” she said. “When you graduate a physician, you know that he or she has 4,000 hours or more of clinical experience, but some NPs come to us with very little clinical experience. To throw them into a busy ED and expect them to do the job of someone who's been an NP for 20 years, that's untenable.”
Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.