Is there a nurse in the house?

By Judi Hasson | June 30, 2016


There's something missing from the emergency department at Ellenville Regional Hospital in upstate New York.

Where are the doctors?

Seven years ago, the hospital's board of directors voted to shift from its traditional model — in which doctors oversee nurse practitioners — and instead turned the emergency department over to nurse practitioners and physician assistants.

Ellenville's emergency staffers can consult with a large physician group by phone 24/7, and six doctors attached to the hospital are reachable for questions and guidance. But the mid-level practitioners run the department round-the-clock, perform a wide spectrum of emergency care, write prescriptions, order X-rays and laboratory tests, and decide when to transfer a patient with serious conditions to another hospital.

“We have a shortage of qualified physician providers to see patients, and it turns out nurse practitioners are doing this job with a great deal of success," says Robert Donaldson, a nurse practitioner who is the hospital's clinical director of emergency medicine.

Ellenville Regional, in the heart of the Shawangunk Mountains, is designated as a critical access hospital — one of more than 1,300 in the United States that provide healthcare in rural areas. Under federal rules, nurse practitioners in critical access settings are allowed to practice with minimal supervision.

But there is a growing movement to expand nurses' privileges in more primary care settings — propelled by some demographic and economic realities.

More patients, more pressure


By 2025, the American Association of Medical Colleges predicts a shortage of between 46,000 and 90,000 primary care doctors. At the same time, the aging baby boom population is likely to increase demands on the medical system, as is a wave of newly insured patients under the Affordable Care Act.

Already, doctors are buckling under an increased workload. According to a 2014 Mayo Clinic survey, more than half of U.S. physicians are experiencing professional burnout. And a 2015 Medscape survey found the highest rates of burnout are incurred by physicians at the front lines of care: 53 percent of critical care doctors and 52 percent of emergency medicine doctors reported symptoms of burnout.

“Part of physician burnout is the workload — the sheer number of patients, the work that accompanies caring for patients, and the hours," says Peter Basch M.D., a Washington, D.C., primary care physician.

Nurse practitioners often ease that workload by seeing their own panel of patients, or by handling walk-ins or same-day appointments, Basch says.

But what burns out doctors most, Basch says, is the volume of non-reimbursable administrative and clinical work. According to athenahealth data, a typical pediatrician has to fill out more than 600 school forms and 150 camp forms in a year. Basch also cites prior authorizations and care coordination, and notes that nurse practitioners are rarely used for these tasks.

As the ranks of nurse practitioners grow — from 192,000 in the United States in 2014 to a projected 244,000 in 2025 — these nurses say they're well-positioned to help practices run more efficiently and allow doctors to work to the top of their licenses.

“We're working as primary care providers for a lot of patients," says Laurie Bond, a nurse practitioner at the Maryland Primary Care Physicians in Queenstown, Md., who sees 15 to 30 patients per day. "Having us in practice allows the doctors to focus on patients who have more complicated care and need more attention."

Resistance remains

Many states are making it easier for nurse practitioners — all of whom have masters degrees or doctorates in nursing — to take on a larger share of the primary care burden. In 21 states and the District of Columbia, nurse practitioners are legally sanctioned to work without doctor supervision. That means they can assess, diagnose, interpret diagnostic tests, and prescribe medications independently — and they're free to establish and operate their own independent practices in the same way physicians do.


Still, there remains strong opposition to expanding nurse practitioners' authority and independence. The American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association have openly opposed nurse practitioners' use as primary care providers, claiming that educational gaps render them unqualified to care for patients independently.

Some states that have passed bills expanding the scope of practice for nurse practitioners have included provisions requiring a certain number of years or hours of collaborative practice before gaining the authority to practice independently.

And in some cases, physician organizations have secured passage of state laws that require direct physician supervision of nurse practitioners; prevent nurse practitioners from practicing outside of a mileage radius of a physician; or require physician nurse practitioners to have a signed collaboration agreement with a physician before they can provide care.

Whether those restrictions are merited is a matter of vigorous debate. A new study published in the journal Annals of Internal Medicine examined treatment of upper respiratory infections, back pain, and headaches, and found that nurse practitioners and physician assistants deliver the same level of care that doctors do when it comes to antibiotic prescriptions, ordering of scans and lab tests, and referrals to other healthcare providers.

For patients, meanwhile, the use of nurse practitioners can make a palpable difference. That's been the case at Ellenville Regional Hospital, whose emergency room functions as an urgent care center for 15,000 patients per year, says Steven L. Kelley, the hospital's president and CEO.

By using three nurse practitioners and two physician assistants, Kelley says, the hospital cut the time patients spend in the emergency room — from waiting time to examination time to checkout — from 3.5 hours to 100 minutes.

“We are able to deliver healthcare on demand 24/ 7, 365 days a year in less time than most scheduled office visits," Kelley said. “That's quality from a patient's perspective."

Judi Hasson is a writer based in Washington, D.C.

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