NPs in the Emergency Department

[dee789]

Hi all, I am a new graduate RN (since May) and have been working in a high-volume Level I academic ED setting, where we have tons of residents, attendings and a few NPs and PAs. I haven't been on the floor for long so I am not yet 100% clear on the role of the PAs and NPs, although I have been told they do not just work the fast-track that is where I see most of them so far and I have never seen them in the "critical" section.

I absolutely love the ED and love my job, despite the fact that it is very stressful, and since beginning to work as a nurse I have become pretty sure that one day I will want to advance and be the person creating a differential diagnosis and ruling out most likely causes. I never really understood the MD role in school but now that I work closely with them and see what they do their job seems very interesting. It's something I never ever considered either before of during nursing school.

I haven't 100% ruled out going to med school at some point but I feel I am too old (29) and going into that much debt terrifies me. It's also a very long time commitment and would probably require a lot of relocating and sacrifice from my boyfriend.

I would much rather go to NP (or possibly PA) school, but my dilemma is that I think I want to stay in the ED, if not forever then at least for a long time. The RNs in my department who are going for their NP all seem to be interested in working outpatient and are very negative about the role of NPs in the hospital, referring to them as "perpetual residents" and other similar comments. I don't really see myself working in a clinic, I love the hospital setting.

So, I have some questions for any NPs who work in the ED and what your role is. I am wondering:

- What level ESIs do you see? Do you see only 4/5s? Or all acuities?

- Does every patient who walks through your door have to be seen by an attending physician or are there some patients who are handled 100% independently by the PA/NP?

- Are you happy with your scope in the ED?

- What procedures do you do? I have heard that there are very few NPs/PAs who intubate, run codes, place central lines etc but I know there are "residency" programs that teach this so it must be done in some places? I don't care so much about being able to do procedures but I would like to be involved in the decision-making process for complex patients.

- Do you work in a teaching or community hospital? Does scope of practice vary by setting and do you feel that NPs/PAs in community hospitals have more independence?

- Are you certified as an ACNP or FNP? What kind of post-masters training did you get at your hospital?

- What are your hours like? Do you work rotating shifts like MDs or strictly days/nights?

- Is there anything a PA can do at your facility that an NP cannot, or vice versa?

And any other general insight would be great. Sorry about the length of this post ... am very curious!

[JeanettePNP, MSN, RN, NP]

I do not work in an ER but I did do clinical rotations in an ER so I will try to answer some of your questions.

- What level ESIs do you see? Do you see only 4/5s? Or all acuities?

As a student I only saw 4-5's but I shadowed on more acute patients as well. There is a collaborative approach in the ED so basically the next available provider takes the next patient, and if a patient is more acute then it's "all hands on deck." The physicians and NPs work together, consult with each other on cases or call in specialists as needed. Defniitely the NPs I shadowed took care of higher acuity patients as well.

- Does every patient who walks through your door have to be seen by an attending physician or are there some patients who are handled 100% independently by the PA/NP?

The NPs/PAs handle their cases independently. If they decide they want a consultation/referral they will initiate that on their own.

- What procedures do you do? I have heard that there are very few NPs/PAs who intubate, run codes, place central lines etc but I know there are "residency" programs that teach this so it must be done in some places? I don't care so much about being able to do procedures but I would like to be involved in the decision-making process for complex patients.

All depends on your training/comfort level but generally they are happy to train you in these skills. I was just talking to a critical care MD who told me that a child needed a central line placed. The parents said they were not sure if they wanted an NP to place the central line. The MD said, trust me, you want this NP to place your child's central line.

- What are your hours like? Do you work rotating shifts like MDs or strictly days/nights?

The NPs in the particular site I was in with were either straight days or straight nights but that can differ depending on the hospital. I interviewed for a different job where they had rotating shifts.

And any other general insight would be great. Sorry about the length of this post ... am very curious!

[WIBound]

Worked as a nurse in an ED that typically staffed with 2 MDs, 3-4 mid-levels (PAs and NPs). Typically there was a midlevel in triage with the nurse to to a quick eval and put in initial orders. The nurse determined the ESI and the midlevel could pull sone 3s to handle in fast track depending on the flow of the ED.

The fast-track was always staffed by a mid-level and mostly 4s and 5s with a few easy-breezy 3s thrown in for good measure.

In the main ED usually 1-2 midlevels at different parts of the day and they saw 3s and on occasion involved with some 2s (usually given to them by the MD). The MDs would take the more complicated patients and there were times where the mid-level was the one initiating the process of turning over the patient to the MD. Only the physicians covered the trauma/resus beds and they signed off on all the patients (except for 4s and 5s). Only the physical intubated.

I know quite a few brand new NPs who have taken jobs in local EDs and none are limited fast track

[Rocknurse, MSN, APRN, NP]

Following this thread as I'd love to work in the ED. Just out of interest, does anyone know any Acute Adult NPs who work in the ED? I'd love to but I can't see kids.