On June 3, 2010, Emergency Medicine News published an article titled "Midlevel Providers Aren't the Solution" (Ginde & Camargo, 2010). In this article, the authors indicated that there is currently a shortage of residency-trained emergency medicine physicians (Camargo et al., 2008). The article also stated that one potential solution discussed among emergency physicians was the use of providers such as physician assistants (PAs) and nurse practitioners (NPs) and that the introduction of NPs and PAs in emergency care settings is already occurring in great numbers. In fact, 13% of all U.S. ED visits were covered by NPs and PAs in 2005 (Ginde, Espinola, Sullivan, Blum, & Camargo, 2010).

Ginde and Camargo (2010) did concede that NP and PA providers have "helped expand the efficiency of emergency physicians, and cover some of the workforce gap. Their cost to the hospital is lower than a physician's, and at least for minor presentations, patient satisfaction appears to be high" (Counselman, Graffeo, & Hill, 2000, p. 661). However, they did take an issue with several items, including the replacement of emergency medicine physicians with NPs and PAs, the education and training of NPs and PAs, patient acuity, and the quality and safety of care provided by NPs and PAs saying "...increasing scope of practice and level of autonomy...that [sic] calls into question whether midlevel*providers are collaborating with emergency physicians or actually replacing them."

Additionally, according to American Academy of Nurse Practitioners (AANP), the term midlevel provider also implies somehow that the care provided by NPs is "less than" some other (unstated) higher standard (AANP, 2009a). In addition, NPs provide high-quality, cost-effective care and are independently licensed (i.e., an NP's scope of practice is not dependent on or an extension of care rendered by a physician; AANP, 2007a, 2007b).

Furthermore, the intent of NP providers is not to replace emergency physicians. For example, NPs and PAs with proper education and competencies can and do manage patients at all levels of acuity in emergency care. The ability to care for these patients is based on a scope of practice. Although education and attained competencies provide a model for entry-into practice, education, and competencies in and of themselves do not stipulate a scope of practice. The scope of practice for an NP within a particular state is regulated by the state board of nursing (National Council of State Boards of Nursing, 2009). Competencies are reviewed, reevaluated, and revised periodically because the science of advanced practice nursing evolves and changes. New evidence and practice patterns result in new competencies that will be added to the list of current competencies. State regulations, medical institutions, and independent parties dictate the scope of practice for these providers.

Ginde and Camargo (2010) also state, "When emergency medicine-trained physicians are unavailable or unwilling to cover some EDs, such as smaller and rural EDs, however, many non-emergency medicine-trained providers, both physicians and midlevel providers, continue to fill the void." Yes, NPs and PAs who are emergency educated and trained are available, willing, and capable to "fill the void." For more than four decades, NPs have provided cost-effective, high-quality care. The AANP states that the Office of Technology Assessment has conducted several extensive assessments of NP outcomes in various health care settings and determined that NPs provided equivalent or improved medical care at a lower total cost than physicians (AANP, 2007a).

Another concern raised by Ginde and Camargo (2010) is that "... midlevel providers, who do not have formal emergency medicine training and fewer overall years of medical training than physicians, are often embraced as a solution to the workforce shortage." First, there are many emergency department (ED) physician groups, even in tertiary academic medical centers, that currently hire MDs who are not board eligible (i.e., have no formal emergency medicine training). Second, the authors imply that NP and PA providers do not have formal emergency training. This is not uniformly accurate. Third, there are currently several university-affiliated programs in the United States that offer emergency care concentrations to NPs. In addition, competency can be achieved through other pathways, which include continuing education course completion and on-the-job instruction. Finally, many NPs were emergency nurses first. NPs and PAs have numerous years of education and experience--far more so than a physician who is fresh out of residency.

The next concern raised by Ginde and Camargo (2010) is that "Neither group [i.e., PAs or NPs (sic)] has developed accredited emergency medicine training programs for specialization in emergency care"). According to the consensus model for APRN regulation (2008), councils, commissions, colleges and universities, associations, and specialty organizations are working collaboratively to achieve standardized APRN regulation.

The Emergency Nurse Association (ENA, 2008) recently developed Competencies for Nurse Practitioners in Emergency Care. Competencies are used in academic settings as a foundation for curricula.

The Board of Certification of Emergency Nursing is presently investigating the validation mechanisms for NPs in emergency care (ENA, 2010). These validation mechanisms include, but are not limited to, examination, portfolio review, and peer review.

Currently, the National Commission on Certification of Physician Assistants' board of directors approved the design and implementation of a "certificates of added qualifications" recognition program. This certificate would be awarded rather than a specialty certification (American Academy of Physician Assistants, 2010).

Ginde and Camargo (2010) proposed that "Emergency physician workforce shortages are probably not driving this as much as practical and financial considerations; ED administrators may hire less expensive midlevel providers instead of emergency physicians." Not only are ED administrators hiring NPs, but also in many instances, physician groups are hiring NP and PA providers instead of emergency physicians.

Ginde and Camargo (2010) go on to state that "When emergency medicine-trained physicians are unavailable or unwilling to cover some EDs, such as smaller and rural EDs,...many non-emergency medicine-trained providers, both physicians and midlevel providers, continue to fill the void." Yes, that is true, and is it not a good thing that they are there to care for those patients?

In addition, Ginde and Camargo (2010) raise issues about acuity data "What about acuity?...While these acuity data are lower than those for physicians in the ED, the role of midlevel providers, who may practice without on-site physician involvement, has clearly extended beyond minor presentations." According to a recent study published in the July issue of the Journal of Emergency Nursing (van der Linden, Reijnen, & de Vos, 2010) emergency NPs (ENPs) were "on par" with physicians in the caring for emergency patients. This study demonstrated that there were no significant differences between ENPs and MDs with regard to diagnostic accuracy and management of minor injuries and illness. The researchers compared 741 patients treated by ENPs with those treated by MDs for number and severity of missed injuries (n = 741). They also examined the inappropriate management of cases. Wait times and length of stay were also reported. The authors found that injuries were missed or patients were inappropriately managed in 29 of the 1,482 cases studied (1.9%); however, there was no statistically significant difference between ENPs and MDs in relation to (1) missed injuries, (2) inappropriate management, or (3) wait time. Length of stay was significantly longer for patients treated by MDs rather than ENPs (85 min vs. 65 min). The study highlighted the fact that of the injuries that were missed, the most common error was the misinterpretation of radiographs (13 of 17 missed injuries). Emergency nurse practitioners showed diagnostic accuracy of 97.3% with no significant differences between ENP and MDs related to missed injuries and inappropriate management (van der Linden et al., 2010).

In a meta-analysis to analyze the effectiveness of NPs by Wilson, Zwart, Everett, and Kernick (2009), nine studies involved adults with minor injuries who presented to EDs. These patients were managed by NPs. The researchers reviewed data on patients' wait times, referral, readmission and representation rates, costs, and patient satisfaction. The meta-analysis revealed a reduction in wait time for patients treated by NPs when compared to traditional models of care. The meta-analysis also revealed that, in general, patients were satisfied with the care given by NPs. The authors also reported, no statistically significant differences between NPs and physicians with regard to significant clinical errors and follow-up by NPs when compared with MDs. The quality of care was similar.

Finally, Ginde and Camargo (2010) conclude by acknowledging that NP and PA providers do have a major role to play in the future of emergency care, and they support the development-continued education and accreditation of NPs and PAs. They state,

Before moving forward with a midlevel provider-based "solution" to the emergency physician workforce shortage, we encourage more thoughtful discussion about training, scope of practice, and supervision. The growing acceptance of nonemergency medicine-trained midlevel providers practicing independently in EDs is difficult to reconcile with the often heated and absolute opposition to non-emergency medicine residency trained physicians. The ultimate goal of most emergency physicians and midlevel providers, regardless of their emergency medicine training and accreditation, is to provide effective and safe care for our patients. This should stay at the forefront of the emergency medicine workforce debate. (Ginde & Camargo, 2010, p. 23)

Agreed. The goal is "teamwork" among MDs, NPs, and PAs. For example, many institutions are employing more NPs and PAs in EDs to provide "rapid" triage and care. Although the data of preliminary hospitals employing this new method of throughput report excellent patient outcomes and better patient and provider satisfaction among staff members (e.g., RNs, MDs, NPs, and PAs).

To summarize, NPs are intimately involved in the health care reforms taking place in the United States. This includes the recognition and utilization of NPs as primary and urgent care providers. Nurse practitioners have requested that the Institute of Medicine definition of primary care be used in all proposed legislations and regulations pertaining to the provision of primary care and that special attention be given to safety net providers who provide care for those who would not otherwise have an access to care (i.e., patients come to the ED for care because they have no other options). Nurse practitioners have requested inclusion in the design and development of all health care reform models (AANP, 2009b[AQ6]). There are many solutions to provider shortages; NPs are one group who can fill this void. This is the future of the health care.

K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP

Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA

Jean A. Proehl, RN, MN, CEN, CPEN, FAEN

Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH

REFERENCES