Advanced Practice Provider (APP) Supervision at LLU ED:
At Loma Linda, we work closely with our APPs (PAs and NPs) to provide care to our patient population. The aim of this primer is to introduce to you the framework for which MDs supervise APPs in our emergency department, especially if you have not worked with mid-levels in the past.
Scheduled shifts with APPs:
Currently, we usually have one APP at the Main Campus ED during the afternoon from 9a-9p, however they more commonly work at the Advanced Urgent Care (AUC) with their shift times being 11a-11p and 3p-3a. The attending physician shifts that work with APPs are the MC Green Pod shifts and all AUC shifts.
APPs staffing to attending physicians:
We do ask that recently hired APPs (< 6 months) staff any patient with ESI levels 3 and up with an attending physician until they get comfortable treating our patient population. All other APPs will staff with you if they have any questions regarding the care for the patient or if they feel it is out of their scope of practice. At AUC, any patient that is getting transferred to MC, admitted, or getting consulted on, should be discussed with an attending physician before proceeding.
If at any point you feel uncomfortable working with the APP, you can ask them to staff all their patients with you. This is up to the discretion of the physician and all APPs are aware that this is a possibility.
Documentation:
APPs need to have a supervising attending physician documented in their note; this is not only a requirement by billing, but also by law. You don’t need to necessarily see the patient, that is left to the judgment of the physician and/or APP. Their note may simply state “Supervising Physician: Dr. _____” at the top. If the patient was discussed with a supervising physician they may put in their MDM, “Discussed with Dr. ____ who agrees with the plan.” Given complexity and acuity of a patient, an APP may further expand on physician involvement in their MDM.
For patients getting transferred, consulted on, or admitted, it is up to the discretion of APP and/or physician about documentation. If there is a straightforward reason for this (i.e. transfer to MC ED for ACS consult for cholecystitis), no documentation needs to be done by the physician. However, if the patient seems more complicated, the physician should evaluate the patient themselves and document appropriately.
As of 2022, new documentation guidelines have been made to determine the BILLING provider. The billing provider is determined by who provided the “substantive” portion of care. This is completed by EITHER:
The provider (APP or MD) who provided the key evaluation and management elements of caring for patient as documented in their MDM
Both the APP and MD need to document their time spent on the patient. The provider who spent > 50% of their time taking care of the patient will be the billing provider.
We believe the second option is the easiest. To use this attestation, please use .attinpatient and there will be a drop down option to choose from (SEE ATTACHMENT FOR REFERENCE). In addition, the “substantive” portion of care will be determined based only on time in 2024.
Legality:
Historically, LLU ED physicians are often not involved in lawsuits brought against APPs. In addition, rates of lawsuits of APPs at LLU are low.
In California, NPs can practice independently as they are considered “independent practitioners.” This is not the case with PAs. Our department has set up a practice agreement that specifies how our APPs (both NPs and PAs) can practice in our ED/AUC. Ultimately, the supervising physician is responsible.
Any further questions regarding the legal framework surrounding physician and APP supervision can be discussed with our legal department.
Continued Education of APPs:
We do hire recent graduates of both PA and NP schools. They are required by LLU ED to participate in the external “EM Bootcamp” course, a 4-day workshop held yearly. For continued education, all APPs are offered monthly lectures related to common EM topics tailored to their scope of practice and SIM teaching for hands-on experience.
Ongoing APP Competency and Evaluation:
As stated above, our department has a practice agreement on how our APPs can practice. Within the first year, all of our APPs undergo proctoring which requires sign off on certain procedures (wound closure, I&Ds, toenail removals) as well as chart review. This is done by the co-directors of the APPs.
Ongoing evaluations consist of periodic chart reviews of highest complexity patients to maintain competency.
Concerns/Complaints/Accolades involving APPs:
Please direct concerns, complaints, and accolades to Drs. Diandra Escamilla (DEscamilla@llu.edu) and Rachael Tena (RTena@llu.edu).