Physician Assistants in the ED

Dr Ben Close – ED Director

The Townsville Hospital Emergency Department

Healthcare Improvement Unit, Department of Health

What is a Physician Assistant (PA)

• Mature, experienced Health professional

• Trained in the Medical Model

• Direct/Indirect/Remote Supervision

• Tasks, including but not limited to;

– Patient history & physical examination,

– Procedures e.g. IVC, suturing

– Ordering pathology & imaging

– Prescribing medications & fluids

History

• Originated in the USA in the 1960’s

• Currently 108,500 PA’s certified in the

USA • Up to 20% of this group work in ED

• 77% of ED’s use them (2006 data)

• National certification (NCCPA) that

individual states rely on for

licensure/regulation requirements

• Specialty qualification program added in

2009

Role in US ED’s

• Majority used in Fast Track models of

care

• Triage

• Trauma

• Administration

• Rural

How are PA’s Trained

• Pathway to PA; Pre-Hospital Care, Nursing,

Military, Allied Health i.e. Pharmacy,

Physiotherapy, Podiatry

• University of Queensland – Masters Degree

• James Cook University – Bachelors degree (3

years)

How are PA’s employed

• QLD Health – Clinical Governance

Guideline 16Oct14

• QLD Health (Drugs and Poisons)

Regulation 1996 – 01Oct15

• Hospital & Health Service PA Practice

Plan

• Townsville Hospital – Senior Intervention

From Triage (SIFT) model

40 0

17th March 2016

The Townsville Hospital

• Tertiary trauma hospital for North Queensland

• Adults & Paediatrics

• Inter-hospital transfers (no advanced burns care

or organ transplant)

• > 580 beds

• 78,000 ED presentations last year

• NEAT 88%

The Townsville Hospital

• PA trial commenced in March 2015

• 3 Physician Assistants

• PO4 $93,298 p.a.

• Aim was to use the PA’s in a senior

medical driven, front loaded model to

target at risk patients

SIFT at TTH ED

• Senior Intervention From Triage (SIFT)

• 1000 to 2230 7 days a week

• Team

– Emergency Physician, Registrar, PA and often a RN

• Role

– Early intervention to improve outcome and speed up

pt journey

– Dynamic role, targeted higher risk or disadvantaged

groups

– Surge capacity & mobile response

SIFT at TTH ED

• 53 year old male

• ‘Severe L sided abdominal pain, 10/10, can’t get comfortable,

blood in urine, on irbesarten for high BP’

• PA picks up patient immediately after triage

• Inserts 18G IV cannula

• Administers IV morphine

• Sends FBC, E/LFT, Lipase

• Takes history, examines patient

• Confirms frank haematuria on WTU

• Discusses case with FACEM

• CT KUB ordered

• Patient admitted to the SSU on regular analgesia to await CT

• Adds clinical notes on eMR

Progress

• Audits

• Medical imaging & pathology requests,

medication prescribing and medical

record entries

• Patient Satisfaction Survey

• Medical feedback

• Staff feedback

Average

waiting times

(min)

Admitted

NEAT (%)

Discharged

NEAT (%)

Did Not Wait

(%)

Left after

treatment

commenced

(%)

ATS3 29 ➤ 24 37 ➤ 70 83 ➤ 94 1 ➤ 0.46 3.3 ➤ 2

ATS4 45 ➤ 36 45 ➤ 76 88 ➤ 96 6.3 ➤ 3.7 1.8 ➤ 1.5

• 1466 pathology requests ordered over a 3

month period. ‘No test’ rate in line with the

ED average of 3.83%.

• Random audit against the first time quality

request form mandatory data requirements

for medical imaging. 99-100% (best in ED).

• Random pharmacy prescribing audits.

Standard higher than Dr’s.

• Patient satisfaction survey. 9.4 out of 10

(n=52).

Monster 4m crocodile caught on The Strand

in Townsville needs a new home February 4, 2016

Next step

• Prescribing

• Routine medical clearances

• Direct admission pathways

• Inter-hospital transfers

• Model of care changes

• ED specific training

• AHPRA recognition

• Health aligned award system

Controversies & Challenges

• Impact on training of medical students &

junior medical staff

• Impact on Nurse Practitioners & other

expanded nursing roles

• Confusion around scope of practice

• Safety

• Cost

• Role substitution

Questions?