Adapt use of physician extenders for your needs
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The Joint Commission’s Standard for Extenders The following, provided to ED Management by the Joint Commission on Accreditation of Healthcare Organizations, is Standard LD.3.70, governing the qualifications and use of staff, including extenders: "The leaders define the required qualifications and competence of those staff who provide care, treatment, and services, and recommend a sufficient number of qualified and competent staff to provide care, treatment, and services." One of the elements of performance for this standard states: "The leaders ensure that physician assistants and advanced practice registered nurses who practice within the hospital are credentialed and privileged and re-privileged through the medical staff process or an equivalent process that has been approved by the governing body. An equivalent process at a minimum does the following:
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State gives credentialing outline, rest is your call
Among the more challenging issues facing ED managers are those where there are no universal rules governing policies and procedures — at least none that are clearly spelled out by nationwide organizations such as the Joint Commission on Accreditation of Healthcare Organizations or the Centers for Medicare & Medicaid Services.
One such challenge is the credentialing and utilization of physician extenders [i.e., nurse practitioners (NPs) and physician assistants (PAs)] or allied practitioners, as they more formally are called.
"Every hospital would have some type of credentialing process for allied practitioners set up through the medical staff office or the medical governing body, but it is always initiated at a departmental level," notes Kathy Hendershot, RN, clinical director of the ED at Methodist Hospital in Indianapolis.
While states do outline scope of practice for each of these positions, each facility is free, for example, to restrict those activities in their hospital. "In Indiana, the scope of practice is defined by the licensing board, so the medical staff has to set up rules within that scope," notes Chuck Shufflebarger, MD, medical director of the ED at Methodist. "But if they restrict it to a greater degree than the licensing board, the ED manager has to make sure they follow the medical staff rules."
And what does the Joint Commission have to say about the use to extenders? "The most important thing from the Joint Commission’s perspective is to make sure you follow the bylaws of your medical staff," he explains. "ED managers have to know what rules have been set and follow them explicitly." (See the Joint Commission standard on extenders, to the right.)
There is flexibility concerning which extenders will be used in your facility — and in your department.
"We decided to use NPs because in our state they have prescriptive authority, while PAs do not," adds Hendershot. "Our medical ED section went to the medical staff office with a request that they be credentialed and allowed to do certain things."
There were long discussions with staff physicians to make sure the faculty members who were not ED physicians would be comfortable with these roles in the ED, she notes. "The NPs have to have a contract to work with a physician group," Hendershot says.
The NPs perform several functions at Methodist. "In Indiana, an NP under a collaborative agreement can give schedule II, III, and IV drugs [controlled substances]," she points out. "We use them in all kinds of areas of the hospital — internal medicine, neurosurgery — but our NPs suture, X-ray, prescribe, and develop the entire treatment plan."
They can’t perform procedural sedation at Methodist — for example, for putting on a splint or a cast, adds Shufflebarger. What about treating lacerations? "At the present time, middle level providers do not do that sort of thing [at Methodist]," he says.
The Methodist ED also uses what they call noncredentialed extenders, or medical assistants. "They are used as scribes, to retrieve labs — basically as gofers," Hendershot explains. "That’s one way to use a first-level extender." Every one of Methodists’ specialties has some type of extenders, she continues. "Ortho have PAs, but can they give drugs or write prescriptions? No. Can they cast? Probably."
Even with a well-planned policy for your own extenders, life can get complicated as the ED comes in contact with so many other departments. "Someone could come down here and say, I want to do conscious sedation in your department,’ but I may not know who they are," Hendershot posits. "Or there is an NP from the neurology group; what is she allowed to do?"
The problem, according to Shufflebarger, is that while that information exists, it is not always readily accessible. "The medical staff have a privileging form, which is reviewed by the credentials committee," he says. "That’s a nice document to have in the medical staff office, but we don’t know from day to day which privileges they have."
If there’s a question that arises, there is an on-line mechanism where the privileges can be reviewed through a secure web site, "but I’m honestly not sure I know how to do that," Shufflebarger concedes. The good news: "These situations come up very rarely," he says.
What usually happens is "We just call the orthopod or whatever and ask what they can do," Hendershot says.
There are variations within the realm of emergency care. For example, Shufflebarger’s group employs extenders in its fast-track area. "They will do simple suturing, for example," he says. "We have a scope of practice already defined, which includes such things as incision and drainage, uncomplicated foreign body removal, and similar minor urgent procedures."
Whatever your particular needs, however, notes Hendershot, it’s critical to comply with your state’s credentialing guidelines. "Most of the differences [in ED use of extenders] — and there are many — are based on what the state will allow an allied practitioner to do," she adds.
Source
For more information, contact:
- Kathy Hendershot, RN, ED Clinical Director, Methodist Hospital, Indianapolis. Phone: (317) 962-8880.
- Chuck Shufflebarger, MD, ED Medical Director, Methodist Hospital, I-65 at 21st Street, P.O. Box 1367, Indianapolis, IN 46206. Phone: (317) 962-8880.
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