Rural EMPA Guidelines

Guidelines for the Rural Emergency Medicine
Physician Assistant

The emergency medicine physician assistant (EMPA) plays a critical role in providing emergency care as a member of the physician-led health care team in rural communities throughout the United States. The gold standard of emergency medical care utilizes “The Model of the Clinical Practice of Emergency Medicine,” and is traditionally provided by a team of medical clinicians led by a board-certified, residency-trained emergency physician. Recruiting an emergency medicine board-certified physician in many rural locations is a challenge and is cost prohibitive. Alternatively, many facilities utilize family practice physicians, physician assistants and other practitioners. EMPAs with appropriate physician supervision/collaboration, education, training and other skills provide this care in many of our communities.

PAs in rural America working at critical-access hospitals require special skills, training and ex-perience that are unique in this environment. The challenges of low volumes combined with occasional high acuity of critical care medicine present unique stresses that, at times, can overwhelm the critical access hospital. The rural EMPA must be properly armed with advanced education and training as well as knowledge of local resources to employ in these moments of critical care emergencies. Many EMPAs have taken their advanced education and training to the rural area to provide high-quality care to the patients they serve. SEMPA’s goal is to estab-lish a benchmark by which a physician assistant can obtain appropriate education and training with the appropriate skills to thrive in this environment and provide the highest quality emer-gency medicine care for these patients.

I. Role of the EMPA in Rural Emergency Medicine and the Critical Access Setting

Many rural and critical access hospitals with very low volume EDs utilize EMPAs as solo provid-ers. Appropriately trained EMPAs provide advanced care, ideally with the supervi-sion/collaboration of a board-certified emergency physician. This, however, is not available in many rural facilities. Administration of patient care with telemedicine access to emergency physicians (when available) and/or consultation from various internal medicine, surgery, criti-cal-care, OB, and other specialists can be helpful. The initial role of the rural EMPA is to exam-ine, diagnose, and recognize critical illness and injury, and begin resuscitation and treatment. Patients presenting to rural EDs require admission to the hospital as often as patients present-ing to their urban counterparts, and the need for referral to a hospital with capabilities of a higher level of care is commonplace. The EMPA in the rural setting is often caring for patients admitted in the hospital as well. Ideally, care is managed in conjunction with a hospitalist and physicians of appropriate specialty. Communication, ongoing personal assessment, and evalua-tion are key in this environment. Follow-up and feedback are helpful to the many EMPAs, with advanced training and skills, who are successfully practicing in this environment throughout the country.

II. Job Description and Scope of Practice for the Rural EMPA

There are four parameters that determine the scope of practice for an emergency medicine physician assistant:

• State law and regulation (or in the case of federally employed PAs, by the federal em-ployer)
• Practice site policy
• Education, experience, and expertise of the PA
• Determination by the supervising/collaborating physician(s) about what will be dele-gated

In rural emergency medicine, the ED medical director, supervising/collaborating physician, and the EMPA together reach decisions about scope of practice. Because medical practice and phy-sician/PA practice relationship requirements (or agreements) are dynamic, specific lists of ap-proved tasks applied to all facilities and to all physician/PA teams are not practical. There are not any "typical" restrictions regarding PA practice in the ED. The physician/PA team and the hospital should be aware of any restrictions on the PA's scope of practice found within state law or hospital policy.

Examples of scope of practice for the EMPA practicing in rural or critical access hospital in-clude, but are not limited to:

1. Membership on the medical staff, including hospital privileges and voting privileges
2. Active and ongoing involvement in the quality improvement activities in the department of emergency medicine
3. Taking patient histories and performing physical examinations of a patient and record-ing or dictating the history and physical in the medical record
4. Performing a medical screening exam
5. Ordering and performing diagnostic and therapeutic procedures
6. Ordering medications; ordering and interpreting diagnostic laboratory tests, radiological studies or various other therapies
7. Establishing diagnostic decision-making for each patient.
8. Instructing and counseling patients regarding mental and physical health, including but not limited to the following: diet, disease, prevention, treatment and normal develop-ment
9. Referring patients to appropriate specialists, health facilities, agencies and resources. Also referring and conversing with appropriate consultants in regard to patient man-agement
10. Performing such other tasks, not prohibited by law, in which the EMPA has been trained and is proficient and credentialed to perform
11. Writing admission orders as requested by the accepting or admitting physician per hos-pital and department policy
12. Performing diagnostic/therapeutic procedures, subject to state regulation and PA train-ing and experience, to include, but not limited to:
    a) Abscess incision and drainage
    b) Administration of medications and injections
    c) Advanced Cardiac Life Support including all procedures
    d) Advanced Pediatric Life Support including all procedures
    e) Advanced Trauma Life Support including all procedures
    f) Anoscopy
    g) Arterial puncture and blood gas sampling
    h) Arthrocentesis
    i) Cast and Splint application
    j) Central line placement
    k) Dislocation reduction management
    l) Debridement of burns, abrasions and abscesses
    m) Epistaxis management
    n) Extensor tendon repair
    o) Fracture Reduction
    p) Foreign body removal: eyes, ears, nose, rectum, soft tissue, throat, and vaginal
    q) Hemorrhage control
    r) Immobilization techniques (spine, long bone, etc.)
    s) Intubation - Orotracheal/Nasotracheal/cricothyrotomy
    t) Intraosseous needle placement
    u) Laceration repair – simple, intermediate, complex
    v) Lumbar puncture
    w) Nail trephination and removal
    x) Nasogastric/Orogastric tube placement, lavage and management
    y) Obstetrical patient evaluation
    z) Ordering and initial interpretations of radiological studies
    aa) Ordering of EKGs with interpretation
    bb) Paracentesis
    cc) Procedural sedation management
    dd) Local and Regional block anesthesia including double cuff method/bier block
    ee) Slit lamp diagnostic and rust ring removal
    ff) Tonometry, ocular
    gg) Thoracentesis
    hh) Thoracostomy
    ii) Bladder catheter placement and management
    jj) Emergency ultrasonography
    kk) Venous access, peripheral and central
    ll) Wound care
    mm) Other interventions or procedures as directed by the supervis-ing/collaborating physician

III. Recommended Training for the Rural EMPA

There are a number of ways in which an EMPA can obtain the appropriate skills to thrive in the rural environment or in a solo practice environment. Most ideally, the EMPA can attend a post-graduate training program to develop the necessary skills. These are formal supervised post-graduate programs modeled after emergency medicine residencies and the Accreditation Council for Graduate Medical Education (ACGME) guidelines, with required didactic education, clinical rotations, competencies, and oversight. Alternatively, the EMPA can obtain their origi-nal training and, under close mentorship, learn and develop the skills by working closely with an emergency physician. Working over two years in a high acuity system in conjunction with repeatedly attending CME courses specifically designed to develop critical care skills, technical skills (like airway management, venous access, point of care ultrasound (POCUS)), and other procedures, the EMPA can develop the experience, comfort level, judgment, and technical skill to manage critical care patients in the rural emergency department. There are several courses continuously available to obtain these skills. The competency of the rural EMPA must be estab-lished by a board-certified emergency physician to ensure quality of care. NCCPA EM-CAQ is also valuable to establish a benchmark of EMPA skills required in the emergency department. Below are the recommended minimum qualifications required for an EMPA practicing in the rural setting with potentially critically ill or injured patients.

1. NCCPA Certified PA
2. Valid Medical License in State(s) of Practice
3. Current Certifications
a) BLS
b) ACLS
c) PALS
d) ATLS
e) NRP
4. Minimum of two (2) years of full-time experience managing patients in a high-acuity, high-volume main ED managing patients
5. Extensive emergency medicine related CME with documentation of training and proficiency

Additional recommended training qualifications:

a. EM Fellowship
b. NCCPA EM CAQ
c. CALS
d. ENLS (neuro)
e. RTTDS (Rural Trauma Team Development)
f. APLS
g. Fundamental Pediatric Fundamental Critical Care Support  (PFCCS)Critical Care Support (FCCS) course
h. Emergency OB workshop

Below is a list of resources available for the EMPA to obtain additional education, training and skills.

SEMPA Emergency Medicine Resources

A. SEMPA 360 Annual Conference – multiple lectures and procedural and   interactive practice-based workshops
B. EM Academy Lecture Series
C. SEMPA Live! Events and SEMPA Live! On Demand Lectures
D. Emergency Medicine Toolkit for Practicing PAs
E. Free Open-Access Medical Education recommendations
F. SEMPA Procedures Course
G. SEMPA Ultrasound Course

Other resource include, but are not limited to:

A. EM Boot Camp
B. Emergency Medicine Core Training
C. Difficult Airway Course: https://www.airwaycam.com or https://www.theairwaysite.com/

IV. Skills and competencies required to prepare for this arena

A. Documented procedural competencies:

• Intubation and difficult airway management
• Emergency cricothyroidotomy
• Chest tube insertion
• Ventilator management
• Procedural sedation
• Rapid sequence induction
• Fracture and dislocation management
• Slit lamp and tonometry
• Intraosseous placement
• Central line placement
• Capnography
• Advanced EKG interpretation
• Radiographs, Computerized Tomography, Magnetic Resonance Imag-ing, ultrasound basic interpretation
• Simple and advanced wound closure
• Cardiac resuscitation (to include cardio-version and cardiac pacing)
• Arterial access for blood gas and monitoring
• Lumbar puncture
• Bedside ultrasound
• Arthrocentesis and injection
• Additional skills as determined by collaborating/supervising physician

B. Demonstrate and document team leadership, knowledge and skills in the management of the following presentations through patient, cadaver or simulation laboratory teaching:

• Cardiac arrest and dysrhythmias
• Shock
• Sepsis
• Stroke and altered mental status
• Respiratory arrest and respiratory failure
• Acute Care Trauma
• Unresponsive patient
• Overdose and toxicological emergencies
• Diabetic ketoacidosis and other endocrine and metabolic emergencies
• Obstetric and gynecologic emergencies
• Pediatric emergencies
• Febrile neonate and child
• Oncologic emergencies
• Hazardous material exposures
• Mass casualty events
• Other situations as determined by practice site