Innovative staffing in emergency departments: the role of midlevel providers

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NPs and PAs are increasingly common in US and Canadian EDs. Emergency medicine is a unique specialty with a vast knowledge base performed in a high-risk environment; therefore, supervisory models and regulatory requirements developed for lower-risk settings (e.g., primary care) and more circumscribed practices (e.g., diabetes clinic) are unlikely to be sufficient for EDs. As innovative ED staffing models evolve, specific roles and scopes of practice for midlevel providers should be based on an objective analysis of existing care gaps and system needs, local provider availability, operational efficiency, cost-effectiveness, regulatory compliance, risk management, and quality of care. Although it is tempting to reduce cost by using PAs or NPs, de-emphasis of emergency physician involvement should proceed cautiously to avoid negatively impacting patient care. Variability in midlevel provider use and the relative paucity of evidence describing optimal provider roles, scopes of practice, and care outcomes in different patient populations highlight the need for a measured approach, appropriate supervisory models, effective quality assurance programs, and cost-effectiveness analyses looking at both clinical and economic outcomes of this important health system evolution.