PA in hospitals and their role

[rn undisclosed name]

I'm just wondering what the PA role is in your hospital. Where I am they can write orders which the nurse implements, do h&p, and discharging of patients. Although depending on which group they are in they won't do an actual d/c until the doc sees the patient. I'm sure there are other things they do but that was a brief overview. We can also call them during the day for other things that come up so we are not bothering the docs as much for orders (not that I think calling docs for orders is bothering them).

I had a recent experience where a PA wanted me to get a consent for an invasive procedure which he was going to do and then told me which doc name to put down. I refused to do this and got my manager, director, and medical director involved. In addition the group of doctors was called to notify them of the situation and my refusal to get consent for this. I just think if a procedure is invasive and has the potential for a poor outcome it should be a doc performing the procedure. In addition we would have to give Versed or an anesthesia and the PA is not permitted to order this according to his priviledges at this hospital.

How are things where you are at?

[caldje]

The hospital is who decides who is qualified to perform what procedures. It is completely unfair for you to decide, arbitrarily, without any information on the training and background of PAs in general and especially this specific PA that he is not qualified to perform a procedure. Your personal opinions, especially when biased, should not interfere with the PA's patient's care or the care the physician was providing by having his/her PA do the invasive procedures. Chances are, in order for the PA to be credentialed to do the procedure in the state you are in and, definately in the hospital you are in, he had to do MULTIPLE one's in front of the very physician you were "telling on him" to.. under that physician's direct supervision while discussing and showing knowledge of the contraindications, complications, etc.

It is VERY, VERY common for PAs to put in art lines, central lines, do large portions of surgeries independently (such as harvesting a vein for bypass) etc. and they only do it if they can prove their competence.

As you have made evident, people should be very comfortable that of ALL providers, PAs are qualified to do what they are doing. Why? Because they have to prove to every patient, doctor, nurse, nurse's aid, resp therapist in the hospital they know what they are doing. The fact a doc or nurse knows what they are doing is often taken for granted. Unfortunantly, there are people who cause a LOT of trouble for PAs who are just doing what they were trained to do.. making their patient healthier in the process, and allowing the doc to do something that requires their level of expertise. I know it sounds strange, but MOST procedures aren't that hard and certainly dont require a high level of decision making.

Best of luck to you, and I hope you take this into consideration next time you keep someone from doing their job. It really isnt fair, and you would be pissed if a nurse's aid did the same thing to you as you were about to drop an NG tube or something.

[Crux1024]

Best of luck to you, and I hope you take this into consideration next time you keep someone from doing their job. It really isnt fair, and you would be pissed if a nurse's aid did the same thing to you as you were about to drop an NG tube or something.

It sounded like the OP was saying the PA was telling her which Doc to put down as doing the procedure even though it was really him. In which case, I would completely agree with her not getting the consent, Nothing like falsifying records to lose your license..

Maybe you can clarify what you meant, OP?

[caldje]

I just think if a procedure is invasive and has the potential for a poor outcome it should be a doc performing the procedure. In addition we would have to give Versed or an anesthesia and the PA is not permitted to order this according to his priviledges at this hospital.

This is what I was responding to mostly.

By the way, peripheral IV access is invasive and if you accidentally withraw the needle over the cath you can create an embolism right? phlebitis? extravasation of tissue toxic meds?

I guess a doc should be doing that too.???

[rn undisclosed name]

The hospital is who decides who is qualified to perform what procedures. It is completely unfair for you to decide, arbitrarily, without any information on the training and background of PAs in general and especially this specific PA that he is not qualified to perform a procedure. Your personal opinions, especially when biased, should not interfere with the PA's patient's care or the care the physician was providing by having his/her PA do the invasive procedures. Chances are, in order for the PA to be credentialed to do the procedure in the state you are in and, definately in the hospital you are in, he had to do MULTIPLE one's in front of the very physician you were "telling on him" to.. under that physician's direct supervision while discussing and showing knowledge of the contraindications, complications, etc.

It is VERY, VERY common for PAs to put in art lines, central lines, do large portions of surgeries independently (such as harvesting a vein for bypass) etc. and they only do it if they can prove their competence.

As you have made evident, people should be very comfortable that of ALL providers, PAs are qualified to do what they are doing. Why? Because they have to prove to every patient, doctor, nurse, nurse's aid, resp therapist in the hospital they know what they are doing. The fact a doc or nurse knows what they are doing is often taken for granted. Unfortunantly, there are people who cause a LOT of trouble for PAs who are just doing what they were trained to do.. making their patient healthier in the process, and allowing the doc to do something that requires their level of expertise. I know it sounds strange, but MOST procedures aren't that hard and certainly dont require a high level of decision making.

Best of luck to you, and I hope you take this into consideration next time you keep someone from doing their job. It really isnt fair, and you would be pissed if a nurse's aid did the same thing to you as you were about to drop an NG tube or something.

I agree it is the hospital is who decides who does the procedure and it is NOT permitted under his priviledges at the hospital. All I was doing was clarifying to make sure it was permitted and not preventing him from doing his job. The procedure was a cardioversion and he is only permitted to do them under an emergent situation and this was not an emergent situation. I was advocating for my patient and if the hospital states he is not permitted to do this then that should be the way it is. It is my license and I don't feel comfortable getting a consent with a certain docs name when they are not the one doing the procedure. In addition he wanted to do this at the bedside and in my hospital we don't do these at the bedside they go down to a special procedure where they perform TEEs and cardioversions. I am not trained in giving conscious sedation and we don't do that up on the floor.

Sorry but I don't see how I was permitting him from doing his job and didn't decide he wasn't qualified to perform this procedure. I have heard of this specific PA doing things only a cardiologist should be doing and all I did was ask my manager/director if this was ok. Even the medical director said he was not to do this. I also wanted to clarify the PA role because I am not familiar with them doing more than the rounding/writing orders. Maybe their role differs by state also and I was just wondering that also. I tried finding their practice act online but am having difficulty locating that.

[EmmaG, RN]

I agree it is the hospital is who decides who does the procedure and it is NOT permitted under his priviledges at the hospital. All I was doing was clarifying to make sure it was permitted and not preventing him from doing his job. The procedure was a cardioversion and he is only permitted to do them under an emergent situation and this was not an emergent situation. I was advocating for my patient and if the hospital states he is not permitted to do this then that should be the way it is. It is my license and I don't feel comfortable getting a consent with a certain docs name when they are not the one doing the procedure. In addition he wanted to do this at the bedside and in my hospital we don't do these at the bedside they go down to a special procedure where they perform TEEs and cardioversions. I am not trained in giving conscious sedation and we don't do that up on the floor.

Sounds like you did the right thing, and he has some 'splainin' to do...

[caldje]

I agree it is the hospital is who decides who does the procedure and it is NOT permitted under his priviledges at the hospital. All I was doing was clarifying to make sure it was permitted and not preventing him from doing his job. The procedure was a cardioversion and he is only permitted to do them under an emergent situation and this was not an emergent situation. I was advocating for my patient and if the hospital states he is not permitted to do this then that should be the way it is. It is my license and I don't feel comfortable getting a consent with a certain docs name when they are not the one doing the procedure. In addition he wanted to do this at the bedside and in my hospital we don't do these at the bedside they go down to a special procedure where they perform TEEs and cardioversions. I am not trained in giving conscious sedation and we don't do that up on the floor.

Sorry but I don't see how I was permitting him from doing his job and didn't decide he wasn't qualified to perform this procedure. I have heard of this specific PA doing things only a cardiologist should be doing and all I did was ask my manager/director if this was ok. Even the medical director said he was not to do this. I also wanted to clarify the PA role because I am not familiar with them doing more than the rounding/writing orders. Maybe their role differs by state also and I was just wondering that also. I tried finding their practice act online but am having difficulty locating that.

Maybe I was too harsh, and MAYBE the PA was out of line but I wonder why someone would be capable of doing something in an emergency situation when things are hectic and crazy but NOT able to do something routinely?? that doesnt make much sense. I have cardioverted people as an EMT-CT, after giving them 2 of versed. no doctors, no nurses, no PAs..

What did the PA do or say when you confronted him? Did you confront him? What kind of things are we talking about that "only a cardiologist should be doing?" and yes, practice acts vary from state to state. for info on your state go to http://www.aapa.org/gandp/state-law-summaries.html

www.aapa.org is a good resource for info on PAs.

Again i appologize if i was too harsh but I have seen things like this cause patients serious harm. Also, you are not liable for the PAs actions, they are licensed providers and liable for themselves. If he is acting out of his scope he should be fired and possibly lose his license. I doubt he was going to cardiovert someone without his attending knowing though. At least I hope so.

[rn undisclosed name]

Thanks for the links.

I also don't agree with why he can do something in an emergent situation but not at other times. I do believe I would be liable if he performed the procedure and I put another docs name on the consent and I had previous knowledge of this. The other cardiologist in the group knew he was scheduled for this but the particular doc who wrote the order may not have known the PA was intending on doing this procedure.

[core0]

Thanks for the links.

I also don't agree with why he can do something in an emergent situation but not at other times. I do believe I would be liable if he performed the procedure and I put another docs name on the consent and I had previous knowledge of this. The other cardiologist in the group knew he was scheduled for this but the particular doc who wrote the order may not have known the PA was intending on doing this procedure.

You are correct that a PA cannot do something in urgent situations that they cannot do at other times. There are disaster rules but they deal more with loosening the supervisory rules than procedure rules.

I am presuming you are from Illinois. Illinois' scope of practice rules for PAs are pretty straightforward. PAs are limited by the scope of practice of their supervising supervision and the PAs training and experience. Basically they can do what their supervising physician can do and what the supervising physician says they can do.

In the hospital it is a little more complicated and a little easier. In the hospital each provider is credentialled to do certain procedures and medical acts. For example you can be credentialled to do admissions, discharges and orders. Or you could only be credentialled to do consults. That would mean that you could not order tests but could suggest things. This applies to both physicians and NPPs (non-physician providers). So under that rule most invasive procedures can be preformed by PAs (even those that some physicians believe should only be done by other physicians). For example there are PAs that do endoscopy, cardiac catheterization and a number of other fairly invasive procedures (there are NPs and CNS that are doing these also). Central lines and chest tubes are bread and butter procedures for most inpatient PAs.

As far as anesthesia. What you seem to be describing is sedation. PAs are allowed to do conscious sedation depending on the institution and state law. This is not considered anesthesia.

On permits. PAs frequently obtain permits for the physicians. Depending on the institution this is perfectly cosher. Our institution has a place for a signature of the physician or designated clinician. For example when I do a pre-op H&P I explain the risks of the surgery and consent the patient. I put the physician's name who will do the surgery on the form. If I am doing the procedure I put my name on the form. Our institution has a place for the physicians name if the NPP (or resident) is doing the procedure.

It is hard to know what exactly happened without being there. It sounds like you did the right thing. This is no different than if a physician had you put another physicians name on the consent even though they were going to do the procedure.

I am curious why they had you do the consent. Every place I have worked the provider had to do the consent. If you do a phone consent you can have the nurse witness it but I have never had a nurse do a consent.

David Carpenter, PA-C

[rn undisclosed name]

You are correct that a PA cannot do something in urgent situations that they cannot do at other times. There are disaster rules but they deal more with loosening the supervisory rules than procedure rules.

I am presuming you are from Illinois. Illinois' scope of practice rules for PAs are pretty straightforward. PAs are limited by the scope of practice of their supervising supervision and the PAs training and experience. Basically they can do what their supervising physician can do and what the supervising physician says they can do.

In the hospital it is a little more complicated and a little easier. In the hospital each provider is credentialled to do certain procedures and medical acts. For example you can be credentialled to do admissions, discharges and orders. Or you could only be credentialled to do consults. That would mean that you could not order tests but could suggest things. This applies to both physicians and NPPs (non-physician providers). So under that rule most invasive procedures can be preformed by PAs (even those that some physicians believe should only be done by other physicians). For example there are PAs that do endoscopy, cardiac catheterization and a number of other fairly invasive procedures (there are NPs and CNS that are doing these also). Central lines and chest tubes are bread and butter procedures for most inpatient PAs.

As far as anesthesia. What you seem to be describing is sedation. PAs are allowed to do conscious sedation depending on the institution and state law. This is not considered anesthesia.

On permits. PAs frequently obtain permits for the physicians. Depending on the institution this is perfectly cosher. Our institution has a place for a signature of the physician or designated clinician. For example when I do a pre-op H&P I explain the risks of the surgery and consent the patient. I put the physician's name who will do the surgery on the form. If I am doing the procedure I put my name on the form. Our institution has a place for the physicians name if the NPP (or resident) is doing the procedure.

It is hard to know what exactly happened without being there. It sounds like you did the right thing. This is no different than if a physician had you put another physicians name on the consent even though they were going to do the procedure.

I am curious why they had you do the consent. Every place I have worked the provider had to do the consent. If you do a phone consent you can have the nurse witness it but I have never had a nurse do a consent.

David Carpenter, PA-C

Thanks for you input. It sounds like they can do a lot more than I thought but I guess it just depends on the hospital and mine does not permit the more invasive procedure and only wants the doc doing them. I don't know why they set up those limits but they need to be followed.

I do get the consent after the doctor or PA talks to the patient about the procedure because I am needed as a witness for the document. I would love to not be the one to get it though. If the patient has not been talked to about the procedure you better believe I am not giving consent. And yes the PA wanted me to get the consent with another docs name and then he would be doing the procedure. I agree with putting down the person's name who will be doing the procedure.

[core0]

Thanks for you input. It sounds like they can do a lot more than I thought but I guess it just depends on the hospital and mine does not permit the more invasive procedure and only wants the doc doing them. I don't know why they set up those limits but they need to be followed.

I do get the consent after the doctor or PA talks to the patient about the procedure because I am needed as a witness for the document. I would love to not be the one to get it though. If the patient has not been talked to about the procedure you better believe I am not giving consent. And yes the PA wanted me to get the consent with another docs name and then he would be doing the procedure. I agree with putting down the person's name who will be doing the procedure.

It depends on your hospital but the only signatures that have to be on the consent are the patients and the provider (or their representative). The witness line is there if the patient is unable to consent and you have to get a phone consent. I only get the nurse involved to witness if I have to do a phone consent. I would check your hospital policy, but it sounds like you are doing something that you don't have to do.

David Carpenter, PA-C

[caldje]

You are correct that a PA cannot do something in urgent situations that they cannot do at other times. There are disaster rules but they deal more with loosening the supervisory rules than procedure rules.

David, Im sorry... but she was saying the exact opposite of what you said she was right about. If you review her post she said the PA could ONLY do the procedure during an emergency.