Diagnostic accuracy of emergency nurse practitioners versus physicians related t

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Taurus

Taurus

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What's that sound I hear? It's the NP's sharpening their knives and licking their lips as they work to undermine emergency physicians. Who needs an emergency doc when you can get an NP for a quarter of the price and the same level of diagnostic accuracy according the NP's? It's just another example of how the NP's are using propaganda by publishing garbarge studies to advance their agenda.

Diagnostic accuracy of emergency nurse practitioners versus physicians related to minor illnesses and injuries.

J Emerg Nurs. 2010 Jul;36(4):311-6. Epub 2009 Dec 8.
van der Linden C, Reijnen R, de Vos R.

Accident and Emergency Department, Medical Center Haaglanden,, The Hague, The Netherlands.

Abstract

INTRODUCTION: Our objectives were to determine the incidence of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses and to evaluate diagnostic accuracy of the emergency nurse practitioners (ENPs) compared with junior doctors/senior house officers (SHOs).

METHODS: In a descriptive cohort study, 741 patients treated by ENPs were compared with a random sample of 741 patients treated by junior doctors/SHOs. Groups were compared regarding incidence and severity of missed injuries and inappropriately managed cases, waiting times, and length of stay.

RESULTS: Within the total group, 29 of the 1,482 patients (1.9%) had a missed injury or were inappropriately managed. No statistically significant difference was found between the ENP and physician groups in terms of missed injuries or inappropriate management, with 9 errors (1.2%) by junior doctors/SHOs and 20 errors (2.7%) by ENPs. The most common reason for missed injuries was misinterpretation of radiographs (13 of 17 missed injuries). There was no significant difference in waiting time for treatment by junior doctors/SHOs versus ENPs (20 minutes vs 19 minutes). The mean length of stay was significantly longer for junior doctors/SHOs (65 minutes for ENPs and 85 minutes for junior doctors/SHOs; P < .001; 95% confidence interval, 72.32-77.41).

DISCUSSION: ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected.​
 
Our group employs NP's and PA's, and I think they do a great job. We allow our guys and gals to manage pretty much anything that comes through the door that they're comfortable with, and if they ever get in a bind or have any questions, they come and ask.

I know a lot of people don't like the NP's and PA's because some of them want to be called 'doctor', but when you have properly trained NP's or PA's, they're an invaluable asset.

And plenty of doctors fail their boards (good and bad), so you can't use that as an example.
 
More than double the error rate is insignificant? but an increase in the length of visit by 33 % is significant? Also correct me if im wrong but by senior house officer/junior doctor are they referring to residents? who cost half as much as an NP?

Taurus said:
What's that sound I hear? It's the NP's sharpening their knives and licking their lips as they work to undermine emergency physicians. Who needs an emergency doc when you can get an NP for a quarter of the price and the same level of diagnostic accuracy according the NP's? It's just another example of how the NP's are using propaganda by publishing garbarge studies to advance their agenda.
Diagnostic accuracy of emergency nurse practitioners versus physicians related to minor illnesses and injuries.

J Emerg Nurs. 2010 Jul;36(4):311-6. Epub 2009 Dec 8.
van der Linden C, Reijnen R, de Vos R.

Accident and Emergency Department, Medical Center Haaglanden,, The Hague, The Netherlands.

Abstract

INTRODUCTION: Our objectives were to determine the incidence of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses and to evaluate diagnostic accuracy of the emergency nurse practitioners (ENPs) compared with junior doctors/senior house officers (SHOs).

METHODS: In a descriptive cohort study, 741 patients treated by ENPs were compared with a random sample of 741 patients treated by junior doctors/SHOs. Groups were compared regarding incidence and severity of missed injuries and inappropriately managed cases, waiting times, and length of stay.

RESULTS: Within the total group, 29 of the 1,482 patients (1.9%) had a missed injury or were inappropriately managed. No statistically significant difference was found between the ENP and physician groups in terms of missed injuries or inappropriate management, with 9 errors (1.2%) by junior doctors/SHOs and 20 errors (2.7%) by ENPs. The most common reason for missed injuries was misinterpretation of radiographs (13 of 17 missed injuries). There was no significant difference in waiting time for treatment by junior doctors/SHOs versus ENPs (20 minutes vs 19 minutes). The mean length of stay was significantly longer for junior doctors/SHOs (65 minutes for ENPs and 85 minutes for junior doctors/SHOs; P < .001; 95% confidence interval, 72.32-77.41).

DISCUSSION: ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected.​
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Greenbbs said:
Our group employs NP's and PA's, and I think they do a great job. We allow our guys and gals to manage pretty much anything that comes through the door that they're comfortable with, and if they ever get in a bind or have any questions, they come and ask.

I know a lot of people don't like the NP's and PA's because some of them want to be called 'doctor', but when you have properly trained NP's or PA's, they're an invaluable asset.

And plenty of doctors fail their boards (good and bad), so you can't use that as an example.
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I don't think anyone disputes that midlevels add value to a busy practice or ED. As part of a team that is headed by an emergency physcian, I and many people have no problem with that.

But you would be extremely naive to believe that NP's have no desire to run the ED without you or that they want to decrease the supervision ratio from 1:4 to 1:8 so that it increases their employability. And the NP's use propaganda, lies, garbage studies, and lobbying to achieve their goals. That's the issue everyone has with NP's. We should all do everything to kick NP's out of the ED and replace them with PA's in my opinion.
 
1. Study is not done in our ED system
2. Nurses likely receive a different type of schooling with a different degree in the Netherlands
3. STudy is restritced to minor illnesses and minor injuries.

So I'm not sure how this really would impact us in anyway considering that this is how we already tend to use NP's and PA's.
 
The use of underpowered studies to prove equivalence is fascinating. I look forward to the J Emerg Nurs publishing my n=2 study showing no significant difference (0% vs 100% but p > 0.05) between an NP and my cat Fluffy in the correct diagnosis of pneumothorax.
 
There's such a lack of EP's that i really don't feel as though NP's/PA's are out for our jobs. I find them absolutely invaluable in delivering efficient care. And personally, I'd prefer not to see all the fast-track cases primarily.... they really help speed things up in a busy FT department, at least in my ED.
 
Ha! This is pretty much the same thing the anesthesiology discussion board is always talking about. Don't kid yourself, nurses want to take over. I hope EM doesn't go down the anesthesia path. 🙁
 
Taurus said:
Abstract

INTRODUCTION: Our objectives were to determine the incidence of missed injuries and inappropriately managed cases in patients with minor injuries and illnesses and to evaluate diagnostic accuracy of the emergency nurse practitioners (ENPs) compared with junior doctors/senior house officers (SHOs).

METHODS: In a descriptive cohort study, 741 patients treated by ENPs were compared with a random sample of 741 patients treated by junior doctors/SHOs. Groups were compared regarding incidence and severity of missed injuries and inappropriately managed cases, waiting times, and length of stay.

RESULTS: Within the total group, 29 of the 1,482 patients (1.9%) had a missed injury or were inappropriately managed. No statistically significant difference was found between the ENP and physician groups in terms of missed injuries or inappropriate management, with 9 errors (1.2%) by junior doctors/SHOs and 20 errors (2.7%) by ENPs. The most common reason for missed injuries was misinterpretation of radiographs (13 of 17 missed injuries). There was no significant difference in waiting time for treatment by junior doctors/SHOs versus ENPs (20 minutes vs 19 minutes). The mean length of stay was significantly longer for junior doctors/SHOs (65 minutes for ENPs and 85 minutes for junior doctors/SHOs; P < .001; 95% confidence interval, 72.32-77.41).

DISCUSSION: ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected.[/INDENT]
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1. Define "minor injuries"
2. What is the average years of experience for the ENP cohort compared to the physician cohort? Are we comparing apples to apples?
3. p values and some other basic stats please.

This is silly.
 
Antibodies said:
Ha! This is pretty much the same thing the anesthesiology discussion board is always talking about. Don't kid yourself, nurses want to take over. I hope EM doesn't go down the anesthesia path. 🙁
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Considering that emergency physicians carved out a niche based on being better then other physicians at what we do, the idea that our jobs are going to be replaced by NPs is laughable.
 
Taurus said:
compared with junior doctors/senior house officers (SHOs).
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If the system in the Netherlands is anything like here in the UK, these doctors are not in fact Emergency Physicians, but most are rotating through the department, usually on their way to GP (FP) or other specialty training. It isn't until "Registrar (SpR)" level that you're considered destined to be an EP.
 
The amazing thing will be that NP's will extrapolate from being able to suture a lac as well as a doc to being able to do everything as well as docs.

"you get the medical knowledge of a physician, with the added skills of a nursing professional."

That's the danger of these garbage studies. Individually, they are junk studies. Collectively, they are like a thousand little knives that the NP's use to undermine physicians and hope to convince lawmakers, insurance companies, and hospitals that they are competent enough to work independently or run the entire ED (you're a fool if you don't think that this isn't one of their goals).

How do you think the NP's were able to gain autonomy in so many states? Lies, propaganda, garbage studies, and lobbbying. Some people are predicting eventually all 50 states will give them complete autonomy like physicians. It's our job to make sure that prediction doesn't come true.

I say kick every NP out of the ED and replace them with physicians or PA's.
 
Taurus said:
The amazing thing will be that NP's will extrapolate from being able to suture a lac as well as a doc to being able to do everything as well as docs.

"you get the medical knowledge of a physician, with the added skills of a nursing professional."

That's the danger of these garbage studies. Individually, they are junk studies. Collectively, they are like a thousand little knives that the NP's use to undermine physicians and hope to convince lawmakers, insurance companies, and hospitals that they are competent enough to work independently or run the entire ED (you're a fool if you don't think that this isn't one of their goals).

How do you think the NP's were able to gain autonomy in so many states? Lies, propaganda, garbage studies, and lobbbying. Some people are predicting eventually all 50 states will give them complete autonomy like physicians. It's our job to make sure that prediction doesn't come true.

I say kick every NP out of the ED and replace them with physicians or PA's.
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Taurus, out of curiousity ar eyou an ED resident or one in a different field?
 
It seems that three issues are being muddled together here:

1) Should NP's be able to treat minor care injuries in a supervised capacity?
2) Should NP's be able to function unsupervised and see all comers (which is what would have to be accepted were they to "replace" the docs)?
3) Does the quoted study actually tell us anything?

I think that most of us would answer "yes" to question 1. Question 2 is just what the study claims to answer with a yes: ENPs showed high diagnostic accuracy, with 97.3% of the patients being correctly diagnosed and managed. No significant differences between nurse practitioners and physicians related to missed injuries and inappropriate management were detected.

However, even a brief review of the abstract reveals this to be a worthless study. There was more than double the rate of missed injuries in the NP group, but they're claiming non-inferiority. No doubt, this study was under-powered, and thus claiming non-inferiority is completely unfounded. Furthermore, the study compares NP's to non-specialty trained "junior" doctors! So even if the stats were good (and they aint) the results are not applicable to ED's staffed by board certified EM docs.

The NP in my ED is one of my favorite people to supervise, she's absolutely fantastic at her job. But the Journal of Emergency Nursing is willing to use this offensively bad study to conclude that there is "No significant difference" between doctors and NP's. All these flaws get lost in the meta-analysis, so when Congress is lobbied all they'll likely hear is that study after study have showed no difference between NP's and ER Docs. Taurus is right to cry foul, and we should all join in to make the cry louder.
 
Emergency training is still embryonic in the Netherlands; they barely have established Emergency Medicine as a specialty. The house officers to which these NPs are being compared are interns and junior residents awaiting specialty training in another specialty.

And, as others have pointed out, statistical significance and clinical significance require an intelligent mind to correctly interpret each.
 
I think there's a lot that emergency physicians can learn about midlevels given the CRNA debacle going on in the anesthesia camp.

People coming in for an emergency don't get to pick who treats them, much like how you generally don't get a choice of who your anesthesiologist is. Just as it did in anesthesiology, that leaves the emergency physician vulnerable to job encroachment as patients don't have a long-lasting and durable bond to EPs as they do with other physicians.

Additionally, just as in anesthesiology, when things are going fine the ED, any house officer or equivalent midlevel can handle the situation. But when bad things happen and quick action is needed, experience and training matter.

I see no problem hiring PAs and having them work as the equivalent of residents ad infinitum. An attending-midlevel partnership could be just as good as an attending-resident team, in theory. But just as the seasoned attending keeps a vigilant eye over residents, the same needs to be done for PAs.

Nurse practicioners are a different story. They are not trained like MDs or PAs, and they want to practice independently. The anesthesiologists are really up a creek now that CRNAs can practice independently and are gaining momentum. Emergency physicians should learn from the anesthesiologists and partner with PAs almost exclusively to make sure that if we want to promote a physician-midlevel partnership that we don't wind up with a physician-non-physician adversarial arrangement where we're engaged in NYTimes Op-Ed public debates over quality and who should be providing emergency care.

So much of the struggle of ACEP, AAEM, and emergency medicine in general in the last 50 years has been about providing access to high quality emergency care by residency trained specialists to the general public. We shouldn't let progress slide and let midlevels undo so much of the hard work that's been done by the EM legends.
 
Arcan57 said:
Considering that emergency physicians carved out a niche based on being better then other physicians at what we do, the idea that our jobs are going to be replaced by NPs is laughable.
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Just become EM docs are better than NP doesn't mean NP won't push for independent work. NPs are cheaper, so congress and the general public will like that. The study "proves" that NPs are just as good.
See the CRNA vs Anesthesiologist discussions. Anesthesiologist are better than CRNA but it doesn't stop the CRNA from wanting to practice solo (and achieving it in certain places).
 
mlw47 said:
Additionally, just as in anesthesiology, when things are going fine the ED, any house officer or equivalent midlevel can handle the situation. But when bad things happen and quick action is needed, experience and training matter.
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Of course, things go sideways in emergency medicine far more commonly than in anethesia. Things "going fine" is not the natural state of the ED. I understand your argument, I just think it's wrong.
 
Arcan57 said:
Of course, things go sideways in emergency medicine far more commonly than in anethesia. Things "going fine" is not the natural state of the ED. I understand your argument, I just think it's wrong.
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Yeah, I guess "going fine" isn't the right phrase. What I meant was that when the ddx and the work up is relatively clear, when things are "Plan A" and not "Plan B" as my surgery attending used to say.
 
Arcan57 said:
Of course, things go sideways in emergency medicine far more commonly than in anethesia. Things "going fine" is not the natural state of the ED. I understand your argument, I just think it's wrong.
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Are you kidding? Stuff hits the fan all the time, especially in higher risk operations. Do you really understand the risk of noctors? Taurus, thanks for pointing out this incredible study...The noctors won't stop until they have us all out of medicine.

Anesthesiology has been hit by the "marines" of the noctor movement. Do not follow our path.
 
This might be a little naive, but to take the contrary position....

I say let them practice independently. Anyone who is willing to shoulder the burden of misdiagnosis and malpractice and see patients without supervision by a board-certified Emergency Physician...by all means, have fun! Let them try to find a group willing to hire them, let them try to find affordable malpractice insurance, let them see the cost-savings dry up as they mismanage patients and over-order diagnostic tests to cover for their lack of knowledge and experience. You'd have to put them in the fast-track, like in this study, and then I don't really know what anyone gains by hiring an NP into a PA position.

I can't imagine them providing competition for EM physicians - but, well, that's probably what anesthesia thought, too....
 
xaelia said:
This might be a little naive, but to take the contrary position....

I say let them practice independently. Anyone who is willing to shoulder the burden of misdiagnosis and malpractice and see patients without supervision by a board-certified Emergency Physician...by all means, have fun! Let them try to find a group willing to hire them, let them try to find affordable malpractice insurance, let them see the cost-savings dry up as they mismanage patients and over-order diagnostic tests to cover for their lack of knowledge and experience. You'd have to put them in the fast-track, like in this study, and then I don't really know what anyone gains by hiring an NP into a PA position.

I can't imagine them providing competition for EM physicians - but, well, that's probably what anesthesia thought, too....
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I think the problem is that you are approaching this from an educated point of view. The people who will make the decision to let them practice will approach this from a bottom line view. All congress will see is one sentence in the study that says they are "equal" and that they cost less money.
 
Wrong, wrong, wrong.

Naive.

Fight this.

xaelia said:
This might be a little naive, but to take the contrary position....

I say let them practice independently. Anyone who is willing to shoulder the burden of misdiagnosis and malpractice and see patients without supervision by a board-certified Emergency Physician...by all means, have fun! Let them try to find a group willing to hire them, let them try to find affordable malpractice insurance, let them see the cost-savings dry up as they mismanage patients and over-order diagnostic tests to cover for their lack of knowledge and experience. You'd have to put them in the fast-track, like in this study, and then I don't really know what anyone gains by hiring an NP into a PA position.

I can't imagine them providing competition for EM physicians - but, well, that's probably what anesthesia thought, too....
Click to expand...
 
I hate to break it to some of the clueless people on here, but after primary care and anesthesiology, the ED is the most likely and next logical place that the NP's will eye to fully infiltrate and claim as their own. Even Mundinger said as much in her piece.

First, they will claim that they are equivalent to ED physicians for urgent care. Next, they will claim, maybe with a year of "residency" they are fully equivalent to ED physicians for any case. After all, most of ED medicine is following protocols and cookbook medicine. No group follows protocols as well as the nurses because they are from day 1 of nursing school taught to not think but to instead follow a recipe. That is why they have done so well in protocol-driven fields like primary care and anesthesiology.
 
Taurus said:
I hate to break it to some of the clueless people on here, but after primary care and anesthesiology, the ED is the most likely and next logical place that the NP's will eye to fully infiltrate and claim as their own. Even Mundinger said as much in her piece.

First, they will claim that they are equivalent to ED physicians for urgent care. Next, they will claim, maybe with a year of "residency" they are fully equivalent to ED physicians for any case. After all, most of ED medicine is following protocols and cookbook medicine. No group follows protocols as well as the nurses because they are from day 1 of nursing school taught to not think but to instead follow a recipe. That is why they have done so well in protocol-driven fields like primary care and anesthesiology.
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Yeah, good luck with the smooth-'talkin.
 
I've read a lot of Taurus' stuff, and I think he's on target. I agree that we do a lot of cookbook medicine (I mean, how many ways can you do chest pain?), and I don't take that as an insult. Hell, most appys, GBs, and childbirths are cookbook - it's the 5 to 10% when it isn't when the doctor's skill comes into play.

We would be fools to say, "oh no, not us!" I am mucho fortunante to have only worked with NPs that know their "property line" (and who knew what they didn't know), so I wasn't put in a bind, and, also, none of the junior nurse BS where a suggestion which they already know is received is "I know that - do you think I'm stupid?" (don't ask questions where you aren't ready for the answer) - instead, despite me being younger, my opinion was well-received and acted upon reasonably.
 
Arcan57 said:
Considering that emergency physicians carved out a niche based on being better then other physicians at what we do, the idea that our jobs are going to be replaced by NPs is laughable.
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lol, wake up - everybody wants to be a doctor but few want to go through the grind that all of us do.
 
Since nursing runs most hospitals, it is only a matter of time until they will take over all aspects of patient care, including emergency room care. You will have 1 or 2 ED M.D. "supervising" 30 RNs/PAs. That is the future my friend. You are blind if you don't see it. I know you are laughing. It is called the DNP program and there are "residencies" in every field of medicine; including "minor surgery"
 
sevo85288 said:
Since nursing runs most hospitals, it is only a matter of time until they will take over all aspects of patient care, including emergency room care. You will have 1 or 2 ED M.D. "supervising" 30 RNs/PAs. That is the future my friend. You are blind if you don't see it. I know you are laughing. It is called the DNP program and there are "residencies" in every field of medicine; including "minor surgery"
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Heck, with this DNP thing, nurses need not bother with any kind of physician supervision. Shoot, why should we limit ourselves to medicine, it's all a protocol anyway. Why not shoot for the stars and for a few online courses and some hands on experience, we can have nurse engineers, nurse chemists and nurse physicists. I'm sure we can fabricate...I mean develop non-biased studies to prove our effectiveness in these fields.
 
Taurus said:
...taught to not think but to instead follow a recipe. That is why they have done so well in protocol-driven fields like primary care...
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Excuse me? Are you implying I just follow a "protocol" during my patient visits? I'm done reading this crap.

I'm back to the real world where I can at least try to make a difference (and yes, I am active in the political process of my home state in issues like these).

I encourage everyone that feels strongly about this issue of NPs expanding their scope of practice to become active politically at least at the state level, instead of venting in an internet forum.

Be warned, though: most politicians I know give us a lot of lip service, but when the powerful nursing lobby shows up with bags of money they change their tune. They do it in sneaky ways. Instead of putting "physician" in their bills, they put "provider" so it's open to interpretation (heck, even chiropractors want to be "providers" now).
 
University of Southern Florida in fact is offering a "residency" to DNP's in emergency medicine, among other fields including derm, cards, pain medicine.

Dermatology
Cardiovascular
Family Practice
Occupational Health
Internal Medicine
Endocrinology
Neurology/Pain Management
Psychiatry
Pediatrics
Neonatology
Emergency Medicine
Acute Care

They took their website down after people (like folks on SDN) started to complain.

I'm not talking in the hypothetical. This is the new reality and it is only growing unless physicians put their foot down and say no to it. By teaching NP's, you're training your future competitors and replacements. Just ask the anesthesiologists what happened with CRNA's. The saving grace of EM is that there seems to be a preference for PA's in the ED over NP's. If you're in a position to influence hiring, then it is your responsibility to not just make it a preference but make it an extreme bias to hire PA's over NP's.

Continue to look for such garbage studies. Then watch the NP's use them to lobby the politicians to advance their agenda.
 
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Actually, going off of this thread, USF is still moving forward with it:
http://forums.studentdoctor.net/showthread.php?t=718880&page=19
Here is a link provided from the one of the posts on the last page.
http://health.usf.edu/nocms/nursing/AdmissionsPrograms/dnp_residency.html

From that initial derm 'residency' posting, they removed it to replace it with a more broad "minimum of 1000 post-baccalaureate supervised clinical hours in their area of practice certification". It sounds like that really didn't listen to complaints or concerns.
 
Taurus said:
After all, most of ED medicine is following protocols and cookbook medicine. No group follows protocols as well as the nurses because they are from day 1 of nursing school taught to not think but to instead follow a recipe.
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What makes Emergency Medicine protocol-driven? I'd like to hear you develop this idea. How is that different than other fields?
 
WOW. Those "residencies" keep expanding, huh?

Taurus is one of the most valuable resources on SDN for his/her constant fight and monitoring of the situation. Keep it up. 👍

Taurus said:
University of Southern Florida in fact is offering a "residency" to DNP's in emergency medicine, among other fields including derm, cards, pain medicine.

Dermatology
Cardiovascular
Family Practice
Occupational Health
Internal Medicine
Endocrinology
Neurology/Pain Management
Psychiatry
Pediatrics
Neonatology
Emergency Medicine
Acute Care

They took their website down after people (like folks on SDN) started to complain.

I'm not talking in the hypothetical. This is the new reality and it is only growing unless physicians put their foot down and say no to it. By teaching NP's, you're training your future competitors and replacements. Just ask the anesthesiologists what happened with CRNA's. The saving grace of EM is that there seems to be a preference for PA's in the ED over NP's. If you're in a position to influence hiring, then it is your responsibility to not just make it a preference but make it an extreme bias to hire PA's over NP's.

Continue to look for such garbage studies. Then watch the NP's use them to lobby the politicians to advance their agenda.
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I think a lot of us here are missing the point due to some inflammatory things Taurus has posted and our tender egos as EP's. If you read this forum with any regularity you must have noticed that I'm an EP and I like a good fight with anyone who wants to slam our specialty, so understand that's where I'm coming from.

I don't think Taurus' point is that we're expendible protocol-driven overpaid triage nurses. The point is that NP's are working hard, and with a decent chance of succeess, towards convincing administrators and legislators that we can and should be replaced with NP's. If we get in a cat fight with someone who is trying to warn us of this danger, then the NP's will quietly side-step that fight on their way to the hospital administrator's office.

Do not stand for these terribly performed, heavily-biased studies. Write ACEP, write the journal's editors, write your paper. Just write something other than an SDN post.
 
WilcoWorld said:
I think a lot of us here are missing the point due to some inflammatory things Taurus has posted and our tender egos as EP's. If you read this forum with any regularity you must have noticed that I'm an EP and I like a good fight with anyone who wants to slam our specialty, so understand that's where I'm coming from.

I don't think Taurus' point is that we're expendible protocol-driven overpaid triage nurses. The point is that NP's are working hard, and with a decent chance of succeess, towards convincing administrators and legislators that we can and should be replaced with NP's. If we get in a cat fight with someone who is trying to warn us of this danger, then the NP's will quietly side-step that fight on their way to the hospital administrator's office.

Do not stand for these terribly performed, heavily-biased studies. Write ACEP, write the journal's editors, write your paper. Just write something other than an SDN post.
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I think you have it exactly right. And the same thing seems to be happening in a sister thread on the forum.

No one (to my awareness) is implying that EM is soldiered by "expendible protocol-driven overpaid triage nurses" in either thread. Rather, we're questioning and worrying over mid-level providers' invasion of multiple medical specialties.

And it seems that it's past time for alot of us to start taking a much more active role in this subject.
 
" Originally Posted by emedpa
the emerging trend is to staff these places either 24/7 with a pa with an on-call fp available to come in within 20 min or staff pa 24/7 with a doc on day shift only(and available for after hrs call.) lots of small/rural critical access hospitals in the northeast(maine/VT/NH) and west(washington and a few in montana and wyoming) have gone to this model. there may be an in house physician managing inpts available for consults but this is not always the case.
I work at a facility that has 24/7 pa coverage with a doc on days only. most pts we can manage at that facility. those needing more significant evaluations( cath, multi-system trauma, subspecialty eval, stroke team, etc) we transfer to a regional ctr that has formal agreements with us to always take our transfers. this ctr also always has specialty consults available to us by phone and we have pacs teleradiology so they can remotely view our studies. those of us who do the most solo nights have significant prior experiences as military or civilian medics and all of the em merit badge courses( atls, apls, fccs, difficult airway, etc).
the pa's make 30 dollars less/hr than the fp docs so this is a significant cost savings for the facility and in the 15 yrs we have staffed this model there have been no significant problems.
__________________
Emergency/Disaster/Global Medicine P.A., EMT-P
23 Years working in EM "
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Looks like the rural hospitals have already started the advance. And you know to hospital admin the $30/hr saving is going to count more than outcome "studies".
 
Well, the "cookbook" medicine is an asinine comment. I spent a month on neurology and I found it very cookbook. MRI and an aspirin, that is all you get out of a neurology consult 95% of the time. ER is no more cookbook that any other branch of medicine. Cardiology- stress and cath, stress and cath, B-block them until they are orthostatic and then pawn them off on their PCP. Surgery, when in doubt, cut it out and let the pathologist give you the diagnosis.

EVERY branch of medicine is now cookbook, if you want to describe the protocols driven by evidence-based medicine, standard of care combined with the wisdom of individual academic attendings teaching through experience as cookbook medicine.

The truth is, we have become the diagnostic center for the hospital. PCPs are losing their own ability to work up chest pain and abdominal pain because of how good we are at our job. PCPs don't even try to diagnose appendicitis anymore in my neck of the woods. Abdominal pain- to the ER, chest-pain- to the ER, neurologic symptoms- to the ER, vomiting to the ER, etc.

Do we tend to order a battery of tests that go along with a specific diagnosis? Yes, because the current ER patient wants a diagnosis within a couple hours and we've got to shot-gun labs and diagnostic procedures to immediately rule out every concievable diagnosis. I don't have a "chest pain protocol" that I follow. The tests that guide my test-ordering are dictated by me brain-storming the most life-threatening and most-likely diagnoses based on physical exam and history, and then ruling those conditions out ASAP through imaging and laboratory methods.

If you make a comment like that, and are asked to explain yourself, you either clarify your point, apologize, or you offer up proof of your opinion.
 
Last edited by a moderator:
Hell, lately we've had a rash of GI bleeds sent from the GI office to the ED for "evaluation, workup, and possible admission". And these people aren't hemorrhaging or hypotensive. The GI doc just wants us to babysit and get the labs before we admit to primary with GI consult for scope in the morning.
 
The future I'm describing is coming, like it or not. ED is definitely in the cross-hairs of nursing. Now is the time to step up or watch your field become another branch of nursing.

IOM Report Says Nurses Need More Training, Independence

By Katherine Hobson

Nurses need increased training, more opportunity to assume leadership roles and an end to barriers that prevent them from practicing “to the full extent of their education and training,” says a new report from the Institute of Medicine.

The report, by the IOM’s Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, says the health-care overhaul legislation will increase demand for medical services as more people have insurance coverage — and that nurses will play a key role in meeting that demand. (The Association of American Medical Colleges recently said health-care overhaul legislation will exacerbate a projected shortage of physicians.)

The most controversial recommendations of the committee — which includes nurses, doctors, academics and other health industry participants and is chaired by former HHS head Donna Shalala — are likely to be those that deal with so-called “scope of practice,” i.e. the authority nurses have to order tests, prescribe medicine and perform other medical services. As Kaiser Health News writes, the report “calls for states and the federal government to remove barriers that restrict what care advanced practice nurses — those with a master’s degree — provide and includes many examples of nurses taking on bigger responsibilities.”

Advanced practice nurses include nurse practitioners, certified nurse midwives and certified registered nurse anesthetists (CRNAs). (The latter will be familiar to Health Blog readers — we’ve followed the heated debate about whether anesthesia services provided by a CRNA working independently of a physician should be reimbursed by Medicare. States can opt out of this requirement by petitioning CMS.)

This report says CMS should reimburse advanced practice nurses the same as a physician if the same care is being provided, and calls for the FTC to make sure scope of practice rules aren’t anti-competitive, KHN points out. Efforts to expand the scope of what a nurse can do are often met with pushback by physicians, who argue even advanced practice nurses don’t have the same education and training as doctors.

The IOM report also calls for the establishment of residency training programs for nurses, an increase in the percentage of nurses who get at least a bachelor’s degree to 80% by 2020 and an increase the number of nurses who obtain doctorates.​
 
Wow...gotta love that. My favorite part is "Efforts to expand the scope of what a nurse can do are often met with pushback by physicians, who argue even advanced practice nurses don’t have the same education and training as doctors.".

Obviously, education and training is not measured by years in school...or the IOM is using "fuzzy math"....
 
Taurus said:
The future I'm describing is coming, like it or not. ED is definitely in the cross-hairs of nursing. Now is the time to step up or watch your field become another branch of nursing.

IOM Report Says Nurses Need More Training, Independence

By Katherine Hobson

Nurses need increased training, more opportunity to assume leadership roles and an end to barriers that prevent them from practicing “to the full extent of their education and training,” says a new report from the Institute of Medicine.

The report, by the IOM’s Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, says the health-care overhaul legislation will increase demand for medical services as more people have insurance coverage — and that nurses will play a key role in meeting that demand. (The Association of American Medical Colleges recently said health-care overhaul legislation will exacerbate a projected shortage of physicians.)

The most controversial recommendations of the committee — which includes nurses, doctors, academics and other health industry participants and is chaired by former HHS head Donna Shalala — are likely to be those that deal with so-called “scope of practice,” i.e. the authority nurses have to order tests, prescribe medicine and perform other medical services. As Kaiser Health News writes, the report “calls for states and the federal government to remove barriers that restrict what care advanced practice nurses — those with a master’s degree — provide and includes many examples of nurses taking on bigger responsibilities.”

Advanced practice nurses include nurse practitioners, certified nurse midwives and certified registered nurse anesthetists (CRNAs). (The latter will be familiar to Health Blog readers — we’ve followed the heated debate about whether anesthesia services provided by a CRNA working independently of a physician should be reimbursed by Medicare. States can opt out of this requirement by petitioning CMS.)

This report says CMS should reimburse advanced practice nurses the same as a physician if the same care is being provided, and calls for the FTC to make sure scope of practice rules aren’t anti-competitive, KHN points out. Efforts to expand the scope of what a nurse can do are often met with pushback by physicians, who argue even advanced practice nurses don’t have the same education and training as doctors.

The IOM report also calls for the establishment of residency training programs for nurses, an increase in the percentage of nurses who get at least a bachelor’s degree to 80% by 2020 and an increase the number of nurses who obtain doctorates.​
Click to expand...

Wow, I can't believe that. To see the IOM come up with what is basicially an AANP position paper is deeply disturbing. Where's the part about how they need to open up far more residency spots to fit the growing number of patients? This is bull----
 
Cliff Notes of this article:

Nurse Practitioners are 97% as good as Emergency residents in the Netherlands.

Looking back at my training days, I was probably 30% as good as my attending.
 
danielmd06 said:
To echo the above...wow. Why would a medical group make a statement like this?
Click to expand...

It's a medical group run by leaders appointed by the President of the US.

Obama supports the nurses. The IOM is trying to please the boss.
 
If they have the same knowledge base they should take all of our licensing exams. From all the steps of the USMLE to the written and oral EM boards.
 
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